Etiopathogenesis of otosclerosis

Factors Associated With Hearing Outcomes After Stapedotomy in Taiwanese Patients With Clinical Otosclerosis

OBJECTIVE

To examine the clinical factors associated with the effectiveness of stapedotomy in improving hearing sensitivity in Taiwanese patients with otosclerosis.

METHODS

In this retrospective study, we reviewed the medical records of 31 patients (36 ears) with otosclerosis undergoing stapedotomy performed by a single surgeon. Preoperative and postoperative hearing results were analyzed to identify factors associated with hearing outcomes after stapedotomy in the Taiwanese population with clinical otosclerosis.

RESULTS

Compared with preoperative pure tone averages (PTAs), stapedotomy significantly improved postoperative air conduction (AC) thresholds (P < .0001), bone conduction (BC) thresholds (P = .025), and air-bone gaps (ABGs; P < .0001). Postoperative closure of ABGs less than 10 or 20 dB was achieved in 16 (44.4%) and 33 (91.7%) of 36 surgical ears. Improvement in postoperative AC thresholds and ABGs and the size of preoperative ABGs were significantly correlated (r = .650, P < .001 and r = .745, P < .001, respectively). Gender-stratified analysis indicated a stronger correlation between improvement in postoperative AC thresholds and preoperative ABGs in male patients than in female patients (r = .893, P < .001 and r = .476, P = .014, respectively), and in postoperative and preoperative ABGs (r = .933, P < .001 and r = .626, P < .001, respectively). With the more stringent criteria for surgical success, factors including age (≤50 years), type (conductive, BC ≤25 dB), and degree (PTA ≤55 dB) of preoperative hearing loss led to more favorable outcomes.

CONCLUSIONS

We reported evidence supporting a potential gender difference on hearing outcomes after stapedotomy in Taiwanese patients with otosclerosis. Age, type, and degree of preoperative hearing loss may affect the surgical success rate.

Genetic variants and altered expression of SERPINF1 confer disease susceptibility in patients with otosclerosis

Otosclerosis (OTSC) is a focal and diffuse bone disorder of the human middle ear characterized by abnormal bone growth and deposition at the stapes' footplate. This hinders the transmission of acoustic waves to the inner ear leading to subsequent conductive hearing loss. The plausible convections for the disease are genetic and environmental factors with yet an unraveled root cause. Recently, exome sequencing of European individuals with OTSC revealed rare pathogenic variants in the Serpin Peptidase Inhibitor, Clade F (SERPINF1) gene. Here, we sought to investigate the causal variants of SERPINF1 in the Indian population. The gene and protein expression was also evaluated in otosclerotic stapes to ameliorate our understanding of the potential effect of this gene in OTSC. A total of 230 OTSC patients and 230 healthy controls were genotyped by single-strand conformational polymorphism and Sanger sequencing methods. By comparing the case controls, we identified five rare variants (c.72 C > T, c.151 G > A, c.242 C > G, c.823 A > T, and c.826 T > A) only in patients. Four variants c.390 T > C (p = 0.048), c.440-39 C > T (p = 0.007), c.643 + 9 G > A (p = 0.035), and c.643 + 82 T > C (p = 0.005) were found to be significantly associated with the disease. Down-regulation of SERPINF1 transcript level in otosclerotic stapes was quantified by qRT-PCR, ddPCR and further validated by in situ hybridization. Similarly, reduced protein expression was observed by immunohistochemistry and immunofluorescence in otosclerotic stapes that corroborate with immunoblotting of patients' plasma samples. Our findings identified that SERPINF1 variants are associated with the disease. Furthermore, reduced expression of SERPINF1 in otosclerotic stapes might contribute to OTSC pathophysiology.

A retrospective study on the outcomes of stapedotomy with vein graft interposition and vein graft surround techniques

OBJECTIVE

This study evaluated audiological outcomes of stapedotomy using two different techniques, vein graft interposition and vein graft surround, for sealing the stapes fenestra.

METHOD

A retrospective study of 130 patients who underwent stapedotomy for otosclerosis was performed. A total of 84 patients underwent the vein graft surround procedure and 46 underwent the vein graft interposition procedure. Post-operative hearing outcome was compared between them.

RESULTS

A total of 55 of 130 patients had a post-operative air-bone gap of less than 10 dB. A total of 57 patients had an air-bone gap within 20 dB. The average air-bone gap was 13.16 dB at 3 months with a mean improvement of 22.06 dB (11.98 dB for vein graft interposition and 13.80 dB for vein graft surround; p = 0.79).

CONCLUSION

There was no significant difference in hearing outcome between the two techniques. The vein graft interposition technique is preferred for large fenestra or stapedectomy cases and in cerebrospinal fluid gusher cases. The vein graft surround technique is easier to perform and preferred in small fenestra stapedotomy.

Association between Otosclerosis and Rubella in Taiwan: A Nationwide Case-Control Study

Otosclerosis is an early adult-onset disease that is associated with 5-9% and 18-22% of all cases of hearing and conductive hearing loss, respectively, and it is suspected to have a viral etiology. However, the role of viral infection in otosclerosis is still inconclusive. This study aimed to investigate whether rubella infection was associated with otosclerosis risk. We conducted a nationwide case-control study in Taiwan. Data were retrospectively analyzed from the Taiwan National health Insurance Research Database. Cases consisted of all patients who were aged ≥6 years and had a first-time diagnosis of otosclerosis for the period between 2001 and 2012. The controls were exact matched to cases in a 4:1 ratio by birth year, sex, and must survive in the index year of their matched cases. Adjusted odds ratio (OR) and 95% confidence interval (CI) were estimated by using conditional logistic regression. We examined 647 otosclerosis cases and 2588 controls without otosclerosis. Among the 647 patients with otosclerosis, 241 (37.2%) were male and 406 (62.8%) were female, with most aged between 40 and 59 years, with a mean age of 44.9 years. After adjusting for age and sex, conditional logistic regression revealed that exposure to rubella was not associated with a significant increase in otosclerosis risk (adjusted OR, 2.0; 95% CI, 0.18-22.06, p = 0.57). In conclusion, this study did not show that rubella infection was associated with the risk of otosclerosis in Taiwan.

Comparison of endoscopic and microscopic methods in stapedotomy: a retrospective analysis

PURPOSE

The goal of the present study was to compare the audiologic results, complications, and advantages/disadvantages of endoscopic and microscopic stapedotomy.

METHODS

Patients who experienced stapedotomy surgery in the Ear Nose Throat Clinic (ENT) of Selcuk University Faculty of Medicine between September 2011 and January 2018 were included in the study. The data of all patients were analyzed and divided into two groups. Those who underwent endoscopic stapedotomy were included in group I, and patients who underwent microscopic stapedotomy formed group II. Surgical findings, complications, and operation times were compared for the two groups. Air and bone conduction thresholds were evaluated at the frequencies of 500, 1000, 2000, and 4000 Hz pre- and postoperatively at 1, 3, and 6 months, and the mean (± SD) air-bone gap value was recorded.

RESULTS

While the mean pre- and postoperative air-bone gaps were 34.38 ± 7.47 dB (23-53 dB) and 9.69 ± 4.43 dB (0-19 dB), respectively, in group I, 34.32 ± 7.57 dB (23-6 dB) and 9.62 ± 4.25 dB (2-23 dB) were the respective means calculated in group II (p < 0.05). When the mean postoperative air-bone gap was compared, there was no statistically significant difference between the two groups (p = 0.774). The mean operative times for groups I and II were 57.22 ± 4.37 min and 63.70 ± 7.34 min, respectively (p < 0.001). The requirement for chorda tympani nerve manipulation and scutum curettage was significantly less in group I compared to group II (p = 0.003). Postoperative dysgeusia and postoperative pain were found to be higher in group II than group I, but they were not statistically significant (p > 0.05).

CONCLUSION

Endoscopic stapedotomy displayed similar audiological results, shorter operation times, and similar complication rates, as well as being a less invasive surgery, compared to the microscopic approach.

Conservative Otosclerosis Treatment With Sodium Fluoride and Other Modern Formulations: A Systematic Review

Otosclerosis, also known as otospongiosis, is a primary osteodystrophy of the otic capsule of the inner ear and one of the leading causes of deafness in adults. The rationale for medical therapy for otospongiosis is to slow down and eventually stop the phase of bone resorption. Conservative treatments include sodium fluoride (NaF), bisphosphonates, and other modern medicines. A systematic review of the existing and published articles and books until April 2021 has been conducted in Medscape, Google Scholar, PubMed, and other databases using appropriate terms. According to the results of the research, the administration of NaF for a period of at least six months stabilizes hearing thresholds (HTs), improves vestibular symptoms, and delays the worsening of tinnitus. The administration of bisphosphonates for a period of at least six months showed significant percentage differences in the improvement of hearing loss, dizziness, and tinnitus remission. In the already existing double-blind studies that were evaluated, groups of patients treated with bisphosphonates for at least 24 months showed greater stabilization of the mean air and bone conduction thresholds than groups of patients treated with a placebo. The new modern medications have not yet been widely administered clinically to draw useful conclusions, although the test results of some of their use are quite encouraging.

Otopathologic and Computed Tomography Correlation of Internal Auditory Canal Diverticula in Otosclerosis

INTRODUCTION

Internal auditory canal (IAC) diverticula, also known as IAC cavitary lesions or anterior cupping of the IAC, observed in otopathologic specimens and high-resolution computed tomography (CT) scans of the temporal bone are thought to be related to otosclerosis. Herein, we examined the usefulness of CT scans in identifying diverticula and determined whether IAC diverticula are associated with otosclerosis on otopathology.

METHODS

One hundred five consecutive specimens were identified from the National Temporal Bone Hearing and Balance Pathology Resource Registry. Inclusion criteria included the availability of histologic slides and postmortem specimen CT scans. Exclusion criteria included cases with severe postmortem changes or lesions causing bony destruction of the IAC.

RESULTS

Ninety-seven specimens met criteria for study. Of these, 42% of the specimens were from male patients, and the average age of death was 77 years (SD = 18 yr). IAC diverticula were found in 48 specimens, of which 46% were identified in the CT scans. The mean area of the IAC diverticula was 0.34 mm 2 . The sensitivity and specificity of detecting IAC diverticula based on CT were 77% and 63%, respectively. Overall, 27% of specimens had otosclerosis. Histologic IAC diverticula were more common in specimens with otosclerosis than those without (37.5% versus 16%; p = 0.019). Cases with otosclerosis had a greater mean histologic diverticula area compared with nonotosclerosis cases (0.69 mm 2 versus 0.14 mm 2 ; p = 0.001).

CONCLUSION

IAC diverticula are commonly found in otopathologic specimens with varied etiologies, but larger diverticula are more likely to be associated with otosclerosis. The sensitivity and specificity of CT scans to detect IAC diverticula are limited.

Whether cochlea involvement on CT in otosclerosis patients impacts the effect of stapedotomy

BACKGROUND

The success rate of stapedotomy in otosclerosis patients with cochlea involvement was unknown.

AIMS/OBJECTIVES

To determine the difference of surgical outcomes and symptomatology in otosclerosis patients with or without cochlea involvement on CT.

MATERIAL AND METHODS

79 otosclerosis patients were included and grouped by HRCT, including cochlear-involved otosclerosis (C-group) or non-cochlear-involved otosclerosis (NC-group, control group). Patients were defined as NC-group in the presence of normal or solely fenestral involvement, or C-group if the hypodensities involve other parts of the labyrinthine bone Patients in the control group were collected at a 2:1 ratio to the C-group with similar follow-up times. Detailed complaints and surgical outcomes were compared between these groups.

RESULTS

Chief complaints were similar in the C-group and NC-group. Although postoperative AC, BC, and ABG decreased significantly in both groups, the success rate was significantly higher in C-group regarding the postoperative ABG ≤10 dB. Furthermore, diffuse lesions may indicate a more severe disease and a poorer prognosis.

CONCLUSIONS AND SIGNIFICANCE

Stapedotomy was effective for clinical otosclerosis. The surgical outcome was inferior favorable for cochlea involvement patients, especially for cases with widely involvement. There was no difference in chief complaints among patients with different CT degree of otosclerosis.

Personalized Proteomics for Precision Diagnostics in Hearing Loss: Disease-Specific Analysis of Human Perilymph by Mass Spectrometry

Despite a vast amount of data generated by proteomic analysis on cochlear fluid, novel clinically applicable biomarkers of inner ear diseases have not been identified hitherto. The aim of the present study was to analyze the proteome of human perilymph from cochlear implant patients, thereby identifying putative changes of the composition of the cochlear fluid perilymph due to specific diseases. Sampling of human perilymph was performed during cochlear implantation from patients with clinically or radiologically defined inner ear diseases like enlarged vestibular aqueduct (EVA; n = 14), otosclerosis (n = 10), and Ménière's disease (n = 12). Individual proteins were identified by a shotgun proteomics approach and data-dependent acquisition, thereby revealing 895 different proteins in all samples. Based on quantification values, a disease-specific protein distribution in the perilymph was demonstrated. The proteins short-chain dehydrogenase/reductase family 9C member 7 and esterase D were detected in nearly all samples of Ménière's disease patients, but not in samples of patients suffering from EVA and otosclerosis. The presence of both proteins in the inner ear tissue of adult mice and neonatal rats was validated by immunohistochemistry. Whether these proteins have the potential for a biomarker in the perilymph of Ménière's disease patients remains to be elucidated.

Association Between the Duration of Hearing Loss and Hearing Outcomes in Surgery for Otosclerosis

INTRODUCTION

Hearing loss due to otosclerosis is effectively treated with surgery. The association between duration of hearing loss and surgical outcomes is unknown.

STUDY DESIGN

Retrospective review.

SETTING

Large otology referral center.

METHODS

Patients undergoing primary stapes surgery for otosclerosis from 2005 to 2017 were evaluated according to their self-reported duration of hearing loss. Closure of the air-bone gap (ABG) was the primary outcome measure.

RESULTS

A total of 580 stapes operations were included. Sixteen percent of patients reported hearing loss for ≤1 year; 25%, >1 to ≤5 years; 24%, >5 to ≤10 years; 24%, >10 to ≤20 years; and 12%, >20 years, respectively. Average pre- and postoperative ABGs were 26.1 and 9.6 dB (P < .0005). Patients with longer duration of hearing loss had worse preoperative ABGs (P < .0005). After surgery, patients with longer duration of hearing loss had a greater reduction in their ABGs (P < .0005) such that the remaining ABG was not associated with duration of hearing loss (P > .05). There were no significant associations between the duration of hearing loss and complication rates or the need for revision surgery.

CONCLUSION

Otosclerosis is effectively treated with surgery even after a long duration of hearing loss, provided that sensorineural hearing and word recognition are favorable. Although far-advanced otosclerosis has known poorer hearing outcomes after stapes surgery, a long duration of hearing loss is an unreliable surrogate for this.

Otosclerosis and Measles: Do Measles Have a Role in Otosclerosis? A Review Article

Otosclerosis is a common cause of conductive hearing loss which is an autoimmune inflammatory disorder related to abnormal bone remodeling of the human otic capsule that has complex etiopathogenesis attributed to genetics, autoimmunity, viral infection, inflammation, hormonal factor, environmental factor, and disturbed bone metabolism. It has a prevalence of 0.3%-0.4% in Caucasians, which makes up 5-9% of all hearing loss and 18-22% of all conductive hearing loss. This review article aims to study the postulated role of sustained measles virus infection in the etiopathogenesis of otosclerosis, among others. A PubMed search of the related topic identified 97,990 articles. After we applied the inclusion and exclusion criteria, it was determined that 52 articles were relevant, which included 38 observational studies, 13 review articles, and a systematic review. Among them, 33 observational studies, 13 review articles and a systematic review spotted a positive association between persistent measles virus infection and otosclerosis. On the contrary, five observational studies reported no evidence of the association. The majority of the current literature supported the presence of the measles virus component in the otosclerotic stapes samples and its role in the etiopathogenesis of otosclerosis. Measles virus infection may have the amplitude to initiate a pathological process, which in the presence of other factors like autoimmunity and genes plays a significant role in causing otosclerosis. However, other studies have failed to show the presence of the measles virus component in otosclerotic stapes. So, more studies are needed to probe the role of persistent measles virus infection in the etiopathogenesis of otosclerosis.

Effect of CO2 laser for the management of primary otosclerosis: A protocol for systematic review and meta-analysis

BACKGROUND

This study will explore the effect and safety of CO2 laser (COL) for the management of patients with primary otosclerosis (PO).

METHODS

The following electronic databases will be searched from inception to the present: PUBMED, EMBASE, The Cochrane Library, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, VIP, WANGFANG, and China National Knowledge Infrastructure. No language limitation will be applied. All relevant randomized controlled trials using COL to treat patients with PO will be included. Two researchers will identify studies, collect data and evaluate the risk of bias of each included study independently. Any different views between 2 researchers will be resolved by a third researcher via discussion. Data analysis will be carried out using RevMan 5.3 software.

RESULTS

This study will evaluate the effect and safety of COL for the treatment of PO through hearing gain, tinnitus severity, incidence of intraoperative, health-related quality of life, other morbidities, and adverse events.

CONCLUSION

This study will provide evidence for the effect and safety of COL in patients with PO.

STUDY REGISTRATION NUMBER

INPLASY202040110.

Diagnostic utility of labyrinth capsule bone density in the diagnosis of otosclerosis with high resolution tomography

OBJECTIVE

The aim of this study is to compare the bone density around the otic capsule in otosclerotic patients with a control group, and find the cut-off values of bone density from which we can diagnose the disease.

MATERIAL AND METHODS

A retrospective case-control study was performed. Bone densities in Hounsfield units (HU) from 28 otosclerotic ears were compared to the densities of 33 non otosclerotic capsules. These densities were measured in eight regions of interest (ROI) where the otosclerotic foci are usually found. The mean density of these regions (PROMED) was taken. Furthermore, the ROC curves of each ROI and the mean density (PROMED) were calculated.

RESULTS

All radiological densities in HU of each ROI and the mean density in otosclerotic patients were lower compared to non otosclerotic ears. The area under the ROC curve of each ROI and the mean density showed that the areas with greater accuracy for the diagnosis of otosclerosis were mean density, the fissula ante fenestram, and precochlear region, with cut-off values of 1980HU, 1750HU and 2114HU, respectively.

CONCLUSION

The mean density of the otic capsule (PROMED), the density in the fissula ante fenestram (ROI1) and in the precochlear region (ROI3) seem to be the most useful parameters to make a diagnosis of otosclerosis.

Comparison of surgical and audiological outcomes of endoscopic and microscopic approach in stapes surgery

Objective:

The main objectives of the present study were to compare the surgical and audiological outcomes of endoscopic and microscopic approach in stapes surgery.

Methods:

Sixty-one patients who underwent the stapes surgery with the endoscopic and microscopic approach between January 2012-November 2018 were included in the study. Patients were divided into two groups as a Group-I (endoscopic) and Group-II (microscopic). The audiometric measurements, duration of surgery, intraoperative findings and complications were recorded and evaluated retrospectively.

Results:

Mean operative time for the Group-I and II was 45.1±8.4 minutes and 48.7±5.6 minutes, respectively (p>0.05). The preoperative and postoperative average air-bone gap in the Group-I was 27.8±7.2 dB and 8.7±3.4 dB and these values in Group-II were 30.2±5.1 dB and 7.4±4.8 dB, respectively (p<0.001). The requirement of chorda tympani nerve manipulation and scutum curettage were significantly less in Group-I as compared Group-II (p<0.05). Dysgeusia and postoperative pain were observed significantly higher ratios in Group-II relative to Group-I (p<0.05). There was no significant difference between endoscopic and microscopic approach in stapes surgery in terms of difficulty of prosthesis insertion (p>0.05).

Conclusion:

Endoscopic stapes surgery provides comparable audiological outcomes, shorter operative times, fewer complications rates, and more minimally invasive surgery, relative to the microscopic approach.

Small Fenestra Stapedotomy Versus Large Fenestra Stapedectomy in Improving Hearing Ability in Patients with Otosclerosis: Our 10 Years Experience

The aim of this study was to review the experience with surgical treatment of otosclerosis over the last 10 years at Amrita Institute of Medical Sciences and Research Centre and to compare it with reported outcomes. A total of 125 patients who had reported between January 2008 and June 2018 were selected for the study. The inclusion criteria for the study included the age group 15-60 years, conductive hearing loss with intact tympanic membrane and an air-bone-gap (ABG) of more than 30 dB. The exclusion criteria included patients below 15 years of age and above 60 years of age, patients with chronic otitis media and the cases of revision stapes surgery. Audiological evaluation was conducted prior to the surgery and post operative audiological evaluation was also performed after 1 month to understand the difference in hearing. In all cases the same surgical technique was used, only the dimension of the foot plate removed varied. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) (version windows base system, SPSS Inc. Chicago IL USA) software. Mean age in years who underwent surgery is 37.8 ± 11.4 and duration of disease in months median 36 months (range 1-120 months). Of the 125 patients (42% males and 58% females), 73 patients underwent large fenestra stapedotomy, and 52 patients underwent small fenestra stapedotomy. There was significant improvement in the following hearing parameters studied (puretone average of air conduction thresholds-PTA, ABG) in both the groups after surgery. There was no significant difference between the small fenestra and large fenestra groups with respect to improvement in PTA and ABG. On comparison of SDS (pre and post surgery) statistically significant difference was noted only in small fenestra group. However, this difference of SDS was not significant in between group comparison (stapedotomy versus stapedectomy). In summary both techniques are safe and effective treatment for conductive hearing loss in otosclerosis patients. There appears to be no deleterious effects of either procedures on hearing function. Similar results can be obtained in experienced hands using either technique. The absence of serious complications makes it reasonable to perform stapes surgery in both ears in patients with bilateral otosclerosis with conductive hearing loss.

Assessment of inflammatory markers in otosclerosis patients

Introduction

Otosclerosis is an idiopathic disease characterized by new bone formation in foci of the human otic capsule. It is more common in Caucasian populations; affecting females twice as often as males. Its etiopathogenesis has not yet been fully elucidated.

Objective

The aim of this study was to investigate the relationship between otosclerosis and white blood cell and thrombocyte counts, mean platelet volume, neutrophil lymphocyte ratio, and the platelet lymphocyte ratio.

Methods

This retrospective case-control study was conducted in the outpatient clinic Mustafa Kemal University, in the department of otolaryngology, between 2015 and 2018. A total of 30 patients with an established diagnosis of otosclerosis were compared to a control group of 30 healthy subjects, matched for age, gender and body mass index. The white blood cell, thrombocyte, mean platelet volume, neutrophil lymphocyte ratio and platelet lymphocyte ratio values were calculated for all participants.

Results

There was no statistically significant difference between the groups with respect to age, gender, or body mass index, or for the mean neutrophil lymphocyte ratio, platelet lymphocyte ratio, white blood cell, or thrombocyte values (p > 0.05). A statistically significant difference was determined between the groups for the mean platelet volume values. The mean platelet volume values were lower in the otosclerotic patients (p = 0.047).

Conclusion

These results show that neutrophil lymphocyte ratio, platelet lymphocyte ratio, white blood cell and thrombocytes should not be used to predict otosclerosis, but suggest that mean platelet volume may be a negative predictive marker.

Clinically important change in tinnitus sensation after stapedotomy

Background

When measuring the treatment effect in tinnitus with multi-item outcome instruments, it is crucial for both clinical and research purposes to take into consideration clinical importance of the outcome scores. The aim of the present study is to determine minimal important change (MIC) in tinnitus which is clinically meaningful to patients with otosclerosis.

Methods

The study population was 95 patients with otosclerosis, suffering from tinnitus. They completed the Tinnitus Functional Index before stapedotomy and 3 months after the surgery. The minimal important change was estimated with the Clinical Global Impression Scale as the external criterion (anchor). The mean change method and the receiver operating characteristic (ROC) method were used to determine minimal important change in tinnitus sensation.

Results

The improvement in tinnitus after stapedotomy was reported by 69.4% of the patients with otosclerosis. Minimal important change in tinnitus was estimated as reduction of 8.8 points in the Tinnitus Functional Index.

Conclusions

The anchor-based approach using an external criterion (anchor) allows to determine change in tinnitus sensation which is meaningful to patients after stapedotomy. The value of 8.8 points in Tinnitus Functional Index could be used as benchmark of stapedotomy effectiveness in otosclerosis patients suffering from tinnitus. Hearing difficulties comorbid with tinnitus could affect the perception of tinnitus change.

Update From the 4th Edition of the World Health Organization Classification of Head and Neck Tumours: Tumours of the Ear

The 2017 fourth edition of the World Health Organization Classification of Tumours, specifically as it relates to the ear (Chap. 9), has several changes. Importantly, the number of entities has been significantly reduced by omitting tumors or lesions if they do not occur exclusively or predominantly at this site or if they are discussed in detail elsewhere in the book. These entities include: embryonal rhabdomyosarcoma, osteoma, exostosis, angiolymphoid hyperplasia with eosinophilia, Schneiderian papilloma, inverted papilloma, lipoma of the internal auditory canal, hemangioma, hematolymphoid tumors, and secondary tumors. Paraganglioma was included in the neck chapter. New entries include otosclerosis and cholesteatoma, while refinements to nomenclature, classification and criteria were incorporated into the ceruminous gland tumors and epithelial tumors of the middle and inner ear. Specifically, the middle and inner ear were combined, as practical limitations of origin and imaging make a definitive separation artificial. The classification reflects the state of current understanding for these uncommon entities, with this update only highlighting selected entities that were the most significantly changed.

Juvenile otosclerosis: a case presentation and review of the literature

Otosclerosis in childhood and adolescence or juvenile otosclerosis is a rare disorder resulting in conductive hearing loss. A 9-year-old boy presented to our clinic, suffering from moderate hearing loss. According to his parents, his hearing acuity had progressively deteriorated over the past 2 years. Otoscopy and tympanometry revealed bilateral secretory otitis media and the patient underwent bilateral grommet insertion. However, he continued to report of hearing loss and a right exploratory tympanotomy was performed. Stapedial fixation was confirmed, being compatible with juvenile otosclerosis, and we proceeded to a right stapedotomy. One year later, follow-up showed satisfactory outcome with an air-bone gap closure to 10 dB. Juvenile otosclerosis with the coexistence of persistent secretory otitis media can be overlooked. Affected children from 9 years of age are strongly motivated to undergo stapes surgery for juvenile otosclerosis, following parental consent.

Vestibular Disorders after Stapedial Surgery in Patients with Otosclerosis

Introduction and Objectives. Vertigo is a described complication of stapedial surgery. Many studies have been conducted to assess the improvement of hearing loss, but there are few studies that assess vestibular function after stapedial surgery. The aim of this study was to evaluate the presence and characterize the vertigo after stapedial surgery. Methods. We conducted a prospective observational study. Patients undergoing stapedial surgery in our hospital between October 2013 and December 2014 were invited to participate. The vertigo was assessed before and 4 months after surgery, using the Dizziness Handicap Inventory. Results. We included 140 patients in the study. 12 patients (8.6%) reported vertigo before surgery, and all of them denied vertigo after surgery. 36 patients (25.7%) reported vertigo four months after surgery, and none of them had vertigo before surgery. Postoperative total scores in patients with vertigo ranged between 2 and 18 points. Conclusion. The study shows that vestibular disorders may remain after the immediate postoperative period and reinforces the need for clarification of the patient in the informed consent act.

3D-Flair sequence at 3T in cochlear otosclerosis

PURPOSE

To assess the capability of three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequences in detecting signal alterations of the endolabyrinthine fluid in patients with otosclerosis.

MATERIALS AND METHODS

3D-FLAIR before and after (-/+) gadolinium (Gd) administration was added to the standard MR protocol and acquired in 13 patients with a clinical/audiological diagnosis of severe/profound hearing loss in otosclerosis who were candidates for cochlear implantation and in 11 control subjects using 3-T magnetic resonance imaging (MRI) equipment. The MRI signal of the fluid-filled cochlea was assessed both visually and calculating the signal intensity ratio (SIR = signal intensity cochlea/brainstem).

RESULTS

We revealed no endocochlear signal abnormalities on T1-weighted -/+ Gd images for either group, while on 3D-FLAIR we found bilateral hyperintensity with enhancement after Gd administration in eight patients and bilateral hyperintensity without enhancement in one patient. No endocochlear signal abnormalities were detected in other patients or the control group.

CONCLUSION

Using 3-T MRI equipment, the 3D-FLAIR -/+ Gd sequence is able to detect the blood-labyrinth barrier (BLB) breakdown responsible for alterations of the endolabyrinthine fluid in patients with cochlear otosclerosis. We believe that 3D-FLAIR +/- Gd is an excellent imaging modality to assess the intra-cochlear damage in otosclerosis patients.

KEY POINTS

• Gd-enhanced T1-weighted MRI has limited application to detect intra-cochlear damage. • 3D-FLAIR is less sensitive to flux artefacts and allows multiplanar reconstruction. • Post-Gd 3D-FLAIR is advantageous as it may highlight the BLB breakdown. • Using 3D-FLAIR -/+ Gd, we were able to identify intra-cochlear signal hyperintensities. • 3D-FLAIR might be applied for monitoring disease progression and treatment response.

Otolaryngological manifestations of Measles (Rubeola): A case report and brief review

Measles is an acute viral respiratory illness caused by a virus of the Paramyxoviridae family. Despite being eliminated from the United States, small outbreaks across the country continue to occur. The United States experienced a record number of cases in 2014, with 668 cases seen across the country, a record since its elimination in 2000. Here, we present a case of an acute presentation of measles illness and discuss the otolaryngologic manifestation of the disease. Laryngoscope, 126:1481-1483, 2016.

Bone mineral density measurements in otosclerosis using dual-energy X-ray absorptiometry

OBJECTIVES

This study aims to evaluate patients with otosclerosis with respect to bone mineral density (BMD) at different regions of interest (ROI), using dual-energy X-ray absorptiometry (DXA).

DESIGN

Cross-sectional controlled study.

SETTING

Tertiary referral hospital.

PARTICIPANTS

The patients with a definite diagnosis of otosclerosis confirmed intra-operatively were defined as the study group (n = 30). The control group consisted of volunteer, healthy subjects with normal hearing (n = 43).

MAIN OUTCOME MEASURES

Following an audiometric evaluation, a venous blood sample was obtained and a single BMD measurement using DXA was applied to each participant.

RESULTS

The mean BMD, T and Z scores were higher in the otosclerosis group than in the control group in all the regions considered, but not significantly; only the L2-L3 lateral BMD and its T and Z scores were significant (P = 0.036, P = 0.029 and P = 0.036, respectively).

CONCLUSION

This study shows that the BMD does not decrease in the presence of otosclerosis despite its genetic and metabolic relevance with osteoporosis. Concerning the L2-L3 lateral BMD measurements, the BMD increased in otosclerosis.

Experimental in vitro infection of rat osteoblasts with measles virus stimulates osteogenic differentiation

In this work we characterized the infection of a primary culture of rat osteoblastic lineage cells (OBCs) with measles virus (MeV) and the effect of infection on cell differentiation and maturation. Infection of OBCs with MeV led to high titers of infectivity released early after infection. Also, analysis of mRNAs corresponding to osteogenic differentiation markers like alkaline phosphatase (ALP), bone sialo-protein (BSP) and bone morphogenetic proteins (BMPs) 1-4-5-7 in OBCs revealed higher values (2-75-fold of increment) for infected cells in comparison with uninfected controls. Differentiation of OBCs in osteogenic medium prior to infection influenced the level of stimulation induced by MeV. Furthermore, treatment of OBCs with Ly294002, a PI3K/AKT inhibitor, increased viral titers, whereas treatment with 10μM or 100μM ATPγS diminished MeV multiplication. In addition, increments of osteogenic differentiation markers induced by MeV infection were not modified either by treatment with Ly294002 or ATPγS. These data provide the first evidence demonstrating that MeV can infect osteoblasts in vitro leading to osteoblastic differentiation, a key feature in bone pathogenic processes like otosclerosis.

Exclusion of TNFRSF11B as Candidate Gene for Otosclerosis in Campania Population

The etiology of otosclerosis is unknown. The etiopathogenesis of otosclerosis seems similar to that occurring in Paget's disease of bone, for which mutations or polymorphisms in several genes have been identified. Among these, TNFRSF11B gene encoding the osteoprotegerin is produced at high levels in the normal inner ear and at low level in active otosclerotic stapes footplates. The aim of this work was to verify the presence of a correlation between the rs2073618 (N3K) polymorphism in the TNFRSF11B gene and otosclerosis. Mutational screening in the TNFRSF11B gene was performed by direct sequencing. SNPs analysis was performed by PCR and by specific restriction enzyme assay with HpaI. The significance of the association was analyzed by statistical specific software. No causative mutation has been identified but the data suggested a strong correlation between the rs2073618 (N3K) polymorphism and otosclerosis. This correlation, however, has been excluded in a case-control study. This study excluded the association between the N3K polymorphism and otosclerosis in Campania region population.

Otosclerosis and vitamin D receptor gene polymorphism

OBJECTIVE

The possible genetic relationship between otosclerosis and Vitamin D Receptor (VDR) gene polymorphism is uncertain. The aim of this study is to assess association between otosclerosis and VDR gene polymorphisms.

STUDY DESIGN

Case-control Studies.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

Clinical diagnosis of stapes fixation was based on otoscopic, audiometric, tympanometric and surgical findings. We identified 25 eligible patient and 60 controls to investigate the association of the VDR gene polymorphisms FokI, BsmI, ApaI, and Taq I with otosclerosis. The patient and control DNA was genotyped for; VDR Bsm I (rs1544410), VDR Apa I (rs7975232), VDR Taq I (rs731236) and VDR Fok I (rs2228570) gene. Primer, simple probe sequences was genotyped by RT-PCR restriction fragment length polymorphism.

RESULTS

There was a statistically significant association between VDR gene and otosclerosis in polymorphism Taq I, Apa I and Bsm I. There was no significant association between VDR gene and otosclerosis in polymorphism Foq I.

CONCLUSION

Three polymorphisms (Taq I, Apa I and Bsm I) in the VDR gene appear to be associated to susceptibility to otosclerosis disorder with otosclerosis patients.

Avascular necrosis of stapes crura in one case of operated otosclerosis

Unilateral otosclerosis combined with avascular necrosis of stapes crura is a rare entity. It should be considered in a case of high grade otosclerosis. Symptoms are the same as in patients who suffer from common otosclerosis. Patients complain on progressive hearing loss and tinnitus. The diagnosis is made clinically by conventional audiologic evaluation and radiologically by x-ray mastoid Schuller's view and CT scan. HRCT scan makes visible all parts of ossicular chain and gives surgeon some information about ossicular chain damage. Surgery with stapedotomy and stapes prosthesis implantation in a case of otosclerosis with avascular necrosis of stapes crura can be success therapy to improve patient's hearing

Stapedectomy in sheep: an animal model for surgical training

HYPOTHESIS AND BACKGROUND

Stapedectomy is a surgical technique that requires progressive training. The external and middle ear of sheep have a close resemblance to the human and have been previously used as surgical training models. In our project we describe the anatomy of the middle and external ear in sheep focusing on surgical landmarks and technique in order to determine whether the sheep's ear is an adequate model for stapedectomy training.

MATERIALS AND METHODS

We reviewed the literature on sheep anatomy and use of sheep as an otologic surgical model. Macroscopic sections as well as temporal bone computed tomography were obtained. Stapedectomy was performed on 40 sheep, using 4 mm platinum piston prosthesis, by first year residents.

RESULTS

Most of the structures in the sheep's middle ear are similar to those in humans although their size is about two thirds smaller. Incus long process is shorter, thicker, and closer to the malleus body, making the piston insertion and adjustment more difficult. The median surgical time of stapedectomy was reduced from 70 (52.5-100.3) minutes to 39.5 (35.5-48) minutes after completing training. There was also a reduction in rate of complications (flap disruption, incus dislocation, and footplate mobilization).

CONCLUSION

Sheep ears constitute a cheap, easy to obtain and anatomically adequate model for stapedectomy training.

The differential diagnosis of hearing loss

BACKGROUND

According to the World Health Organization, hearing loss is one of the six leading contributors to the global burden of disease. It is becoming an ever more important problem in society at large, not just because the population is aging, but also because young people increasingly spend their leisure time in activities that expose them to excessive noise. On the other hand, the treatment of hearing loss is improving, as the result of technical developments in otological surgery, hearing aids, and cochlear implants. For nearly every type of hearing loss, there is now some type of rehabilitative treatment. The prerequisite to effective care is timely and accurate diagnosis.

METHOD

Review of the pertinent literature and national guidelines.

RESULTS AND CONCLUSION

The available epidemiological data on hearing loss in Germany are inadequate. It is roughly estimated that 13 to 14 million people in Germany are in need of treatment for hearing loss. The most common types of permanent hearing loss are those associated with old age, chronic otitis media, and acoustic trauma. Transient hearing loss is particularly common in childhood as a result of inadequate ventilation of the middle ear. The further technical development of cochlear implants has now widened their indications to include severe congenital deafness and presbycusis.