Progressive hearing loss in children: hearing aids and other factors

A sample of 20 children monitored for progressive hearing loss combined with 25 progressive loss cases were obtained. The effects of hearing aid use on progressive loss were examined in the context of etiology and other factors, particularly the time relations between hearing aid application and the period of progression. Results indicate a limited role played by hearing aids in progressive hearing loss. Hearing aid use was not implicate in 30 (69%) of the progressive loss subjects, questionably implicated in nine (20%), and probably implicated in five (11%). In the identification and monitoring of progressive hearing loss, it is unwise to conclude that hearing aid use is the cause of the deterioration without considering all other plausible factors.

Primary malleus fixation: diagnosis and treatment

Primary malleus fixation occurs in an otherwise normal middle ear without evidence of congenital deformity and without chronic inflammatory changes. It occurs in the latter decades of life and is frequently associated with sensorineural presbycusis. We believe it is a ligament ankylosis with osteoarthritis related to the aging process. The diagnosis of malleus fixation is facilitated through the use of a modified Siegle pneumatic otoscope in conjunction with the Zeiss binocular microscope. The literature pertaining to this subject as well as the more historical reports are reviewed. Goodhill has written extensively on malleus fixation. The audiologic test results in the fixed malleus cases reviewed for this study often presented a misleading picture, sometimes mimicking stapedial otosclerosis with a characteristic Carhart's notch and sometimes indistinguishable from sensorineural presbycusis. Usually speech discrimination scores fell in the very good to excellent range. Weber tests, whether performed by tuning forks or audiometrically, almost always lateralized to the suspect ear. Impedance frequently failed to conform to the expected fixed malleus pattern of low static compliance and absent acoustic reflexes; there was an equal number of low compliance and normal range compliance tympanograms and 15% of the total number of our cases had abnormally high compliance tympanograms. Stapedial reflexes are normally expected to be absent with lateral ossicular fixation, but this was not a consistent finding with contralateral test stimulation. The decision for surgical treatment is dependent on the audiological findings and the potential hearing gain. The technique described consists of the removal of the incus and the head of the malleus and the reconstruction of a sound conducting pathway from the handle of the malleus to the mobile stapes or from the mobile stapes to the under surface of the tympanic membrane using a prosthesis-ossicle arrangement. Malleus fixation occurs far more often than it is diagnosed. Surgical correction can result in a worthwhile hearing gain even when the air-bone gap is narrow or nonexistent. The technique of ossicular reconstruction is dictated by the anatomical findings. Some form of autograft ossicular reconstruction from the malleus handle to the stapes is most frequently utilized. Otosclerosis with stapes fixation sometimes causes a lateral ossicular fixation due to degenerative disease and fibrosis. In this instance a stapedectomy is performed as the primary procedure with subsequent revision as necessary to eliminate the lateral obstruction.

Hearing loss

Defective hearing is the most prevalent chronic health problem in the United States, making it a primary concern of the physician. Failure to diagnose, misdiagnose, and delay of diagnosis of hearing loss are common errors that have serious implications. However, they can be avoided. If children exhibiting the symptoms of delayed language, articulation defects, and academic problems (especially with reading or a medical history of certain diseases) are referred for audiological testing, most cases of hearing impairment will be promptly detected. With adults the implications of hearing loss are different, both medically and psychosocially. After 30 years of age the prevalence of hearing defects increases rapidly. Some major causes are noise, otosclerosis, otitis media, and presbycusis. Surgery and amplification are the principle treatments. Management of nonmedical aspects should involve programs such as the Division of Vocational Rehabilitation, state schools for the deaf, and sign language classes.

Ear deformities associated with the Klippel-Feil syndrome

Congenital spinal fusion, constituting the Klippel-Feil anomaly, has long been known to be associated with severe deafness in many patients. Ten such cases are described, with audiometric and tomographic assessment of the ear lesions. Of the 20 ears examined, 12 showed evidence of severe hearing loss and of these, 11 had evidence of significant inner ear dysplasia on tomography. Middle and external ear abnormalities were also demonstrated. The significance of these findings and the relation to other syndromes is discussed.

Hearing, speech, and language in survivors of severe perinatal asphyxia

Hearing, speech, and language were studied in 26 children who survived severe perinatal asphyxia. The results of hearing tests showed that most children had a favourable outcome. Only 1 child had sensorineural deafness. Hearing loss in 6 others was due to middle-ear disease which resolved after treatment, and on retesting was found to be normal. The study also showed that neither gentamicin treatment nor incubator noise seemed to affect hearing. The results of speech and language assessment were less encouraging and about one-third of the children without serious mental or physical handicap had deficits in speech and language. It is suggested that the quality of life in such children could be improved if these deficits were detected early and adequately treated.

Hearing loss of Down syndrome adults

Audiological hearing-test data were obtained for 51 Down syndrome adults. Depending upon hearing-loss criteria, from 51 to 74 percent of the subjects had some degree of hearing impairment. Correlation coefficients between these hearing-acuity measurements and receptive hearing vocabulary scores suggest a moderate relationship. These data indicate that Down syndrome adults are prone to a wide variety of hearing difficulties that may reflect a variety of ear pathologies. These data and other studies have shown that both Down syndrome adults and children need frequent hearing screening and, when indicated, otological and/or audiological management. When otological treatment will be of long duration, aural rehabilitation, including prescription amplification, may be indicated as an adjunctive therapeutic procedure.

Tutorial on the potential deterioration in hearing due to hearing aid usage

This manuscript examines the issue of potential decline in hearing sensitivity due to hearing aid usage through an analysis of data obtained from the temporary threshold shift (TTS) paradigm. Following a critique of the traditional measures of TTS, the concept of integrated TTS (ITTS) is reviewed and data on hearing-aid-induced ITTS are presented. In addition, a series of equations relating permanent threshold shift (PTS) to a recently developed measure of noise dose (Dn) is derived and predictions for hearing-aid-induced PTS are made. Recommended gain settings established to protect the hearing of a person wearing a hearing aid from further decline following various durations of hearing aid usage are also provided.

Heredity hearing losses with delayed onset: mechanisms of expression

Inherited hearing loss with a delayed onset is a feature of an intriguing group of disorders. The mechanisms whereby delayed hearing loss develops may be grouped as primary degenerative (abiotrophic) disorders, secondary degenerative disorders, dysgenerative disorders, and disorders of inappropriate response. Illustrative examples within these four groups are discussed. The difficulties in determining the preclinical latent state in inherited disorders are briefly outlined.

Retreatment of recurrent nasopharyngeal carcinoma

Thirty patients with recurrent primary nasopharyngeal carcinoma were reirradiated between 1949 and 1976. Twenty eventually demonstrated recurrence at or near the primary site, involving the nasopharynx in 4 and the central nervous system in 16. Long-term palliation was often achieved, and there were no severe complications except for one patient who died of necrosis of the base of the skull. The most frequent problems were hearing loss and trismus; necrosis of the nasopharynx was seen in only 2 patients. With therapy in the range of 18-25 MeV, significant palliation and an occasional cure can be achieved without excessive risk. Recurrent disease involving the skull may be controlled for several years using current techniques.

Unrecognized infantile Meniere's disease

We have described two patients who, from early infancy, suffered attacks of vomiting associated with fluctuating hearing loss, which ended in bilateral severe sensorineural hearing loss. The patients were treated by pediatricians as suffering from gastroenteritis or meningitis. Meniere's disease was not suspected. We want to point out that Meniere's disease, though it usually begins in middle age, may well start in childhood, as well as in infancy, and should be suspected whenever vomiting without diarrhea is associated with some hearing loss at any age--no matter how young the patient is. It is also quite possible that some sensorineural hearing losses in late childhood or adulthood are in effect the result of early burnt-out Meniere disease, as in our second case.

Neurologic perspectives of otosclerosis

Of 500 patients with roentgenographically verified otosclerosis, 230 had vestibular manifestations. Because of its frequency in general practice, otosclerosis has a major impact on the differential diagnosis of vertigo and related symptoms. The vestibular syndrome encompasses the full symptomatic spectrum common to diseases of the vestibular system, from episodic violent rotational vertigo to a sense of almost continuous imbalance, and cannot usually be distinguished from idiopathic endolymphatic hydrops. Otosclerosis is easy to diagnose when vestibular symptoms occur in conjunction with conductive or mixed hearing loss and a normal tympanic membrane that excludes middle ear disease. However, in approximately one-third of patients with a hearing loss that is purely sensorineural, the diagnosis can be confirmed only by compound-motion tomography of the petrous bones.

Acoustic neuroma surgery. Translabyrinthine-transtentorial approach via the middle cranial fossa

In our approach for acoustic tumors, the method of Morrison and King and that of Bochenek and Kukwa have been modified into one method. This modified method is basically a neuro-otological-neurosurgical team approach, extending the operative field by drilling the temporal bone and cutting the superior petrosal sinus, tentorium, and posterior fossa dura according to the size of the tumor. Therefore, for tumors slightly protruding into the posterior fossa from the prous of the internal auditory canal, only the bone adjacent to it is removed (Bochenek et al's method). For larger tumors, labyrinthectomy and mastoidectomy with the separation of the superior petrosal sinus and the tentorium and posterior fossa dura are also performed. In Morrison et al.'s method, the translabyrinthine approach is done first and the middle cranial fossa approach is performed thereafter. In contrast, in the modified method, drilling the bone from the middle cranial fossa to the tip of the mastoid--labyrinthectomy and mastoidectomy--is the first thing done after elevating the temporal lobe and revealing the middle cranial fossa, and the internal auditory canal is opened thereafter. Thirty-five cases of acoustic tumors and other cerebello-pontine angle tumors were operated on during the past 3.5 years through the middle cranial fossa. Among 30 cases of acoustic tumors, eight cases in which the tumors were confined to the internal auditory canal were operated on through the middle cranial fossa. In four cases, Bochenek et al's method was performed in which bones adjacent to the internal auditory canal and a part of the labyrinth are removed without cutting the superior petrosal sinus. In 23 cases including five cerebellopontine angle tumors, the modified translabyrinthine-transtentorial approach through the middle cranial fossa was done. This modification has the advantage that severe postoperative complications are less frequent. The surgical technique and the results are discussed.

Hearing loss from hemodialysis

A 47-year-old man with normal hearing had chronic progressive renal failure. He experienced hearing loss in additive increments with peritoneal dialysis and hemodialysis, until he was profoundly deaf in both ears. Postmortem studies showed collapse of the endolymphatic system and edema and atrophy of most of the specialized cell types of the auditory and vestibular sense organs. It is our interpretation that the alterations were caused by osmotic disequilibrium associated with hemodialysis.

Cerebrospinal fluid otorrhea

Cerebrospinal fluid (CSF) otorrhea is a dangerous and potentially life threatening occurrence for which the otolaryngologist is often consulted. CSF otorrhea occurs on the basis of skull fracture, tumor, infections, congenital anomalies, and operative trauma. Forty-three patients with CSF otorrhea of varied etiology are reviewed in this paper. Eight cases are of congenital or labyrinthine origin confirming at surgery the probable connection between the subarachnoid and perilymphatic spaces. Eleven cases had spinal fluid otorrhea due to infection. All cases presented with symptoms of chronic infection: 4 cases had a history of previous surgery for chronic ear disease; 7 cases had temporal lobe abscess; 1 case had a cerebellar abscess; 8 had tegmen defects secondary to cholesteatoma; in 1 case the tegmen defect was due to previous surgery for chronic infection. Nine of 11 cases have serviceable hearing postoperatively. Fourteen cases of spinal fluid otorrhea resulted from trauma: 1 case was due to traumatic stapes footplate fracture in a congenitally malformed ear; 4 were due to transverse temporal bone fracture; and 9 were due to longitudinal temporal bone fractures. All transverse fractures resulted in nonhearing ears. Three cases were due to a combination of temporal bone fracture and infection. In 2 of these cases chronic infection preceded the fracture; in 1 case the fracture led to chronic ear disease with spinal fluid leakage. One patient required 1 surgical procedure for closure of the otorrhea, 1 patient 2 procedures, and 1 patient 3 procedures. Ten cases are due to translabyrinthine acoustic neuroma removal: 7 cases had resolution of the spinal fluid leakage after conservative nonsurgical treatment; and 3 required surgical intervention using muscle, fat and fascia obliteration of the spinal fluid pathway.

Outcome of symptomatic congenital cytomegalovirus infection: results of long-term longitudinal follow-up

Thirty-four patients with congenital cytomegalovirus infection who were symptomatic as newborns were followed in a special clinic providing periodic medical and visual examinations as well as psychometric testing and audiometry. All patients had symptoms of congenital infection by 2 weeks of age, and 31 of 34 had virus isolated from urine within the first month of life. Age at latest follow-up varied from 9 months to 14 years with a mean of about 4 years. Ten patients died and 23 surviving patients had adequate follow-up examinations; all but two had evidence of central nervous system or auditory handicaps. Microcephaly was present in 16 (70%), mental retardation in 14 (61%), hearing loss in seven (30%), neuromuscular disorders in eight (35%), and chorioretinitis or optic atrophy in five (22%). Children with symptomatic congenital cytomegalovirus infection are at very high risk for handicaps that will significantly impair development.

Auditory brainstem response and eighth nerve lesions: a review and presentation of cases

A review of salient features in the use of auditory brainstem response for the detection of eighth nerve lesions is presented. Three cases of acoustic tumors are discussed. These cases represent a normal pure-tone audiogram, one with a moderate loss, and one with no measurable hearing on the affected side. Interpretation of the auditory brainstem response in these cases is discussed in light of the various auditory brainstem response measures presented and the pure-tone audiometric data.

Electrocochleography and auditory brainstem electric responses in patients with pontine angle tumors

In 45 patients with surgically proven pontine angle tumors, compound action potential (AP) and summating potential (SP) were recorded with transtympanic electrocochleography (ECochG) together with brainstem electric responses (BSER). The aims were to quantify the mechanism by which tumors cause hearing loss and evaluate the diagnostic potentials of ECochG and BSER for detecting eighth nerve and brainstem tumors. Except for AP latency and narrow band AP waveform, response parameters recorded by ECochG are uncorrelated. Four uncorrelated parameters were abnormal in only 10% of the cases, three in 25%, two in 40%, and one in 90%. The BSER criterion was the latency delay between waves I and IV and resulted in about 90% detection, improving to 95% when used in combination with ther interaural wave V delay criterion. ECochG results provide evidence that, for hearing losses up to 60 dB HL, the origin is cochlear, resembling that caused by Meniere's disease. Evidence is presented that the increase in I-V delay in the BSERs is caused by differential action of the tumor upon low and high frequency fibers in the auditory nerve and that desynchronization of the firings of the nerve fibers is of more importance than an increase in neural conduction time. ECochG as the sole test for detection of pontine angle tumors appears to be of limited value. Brainstem response on its own has great merits; however, it should be emphasized that no wave I was detected in about 30% of the cases. The 95% detection score obtained with BSER depends on specifying the latency of wave I. For these cases, we substituted the latency of the AP recorded by ECochG.