Cochlear implantation in children with large vestibular aqueduct syndrome and a review of the syndrome

Long-term outcomes and electrophysiological measures of children with inner ear malformations and cochlear implants

OBJECTIVES

To compared auditory and speech performance outcomes of children with cochlear implants (CI), between those with inner ear malformations (IEMs) and with normal ear anatomy; and to describe differences in electrophysiological measurements.

STUDY DESIGN

A retrospective study.

SETTING

A tertiary care pediatric medical center.

PATIENTS

Forty-one children with IEMs who underwent CI during 2003-2017, and 41 age-matched CI recipients with normal ear anatomy (control group).

MAIN OUTCOME MEASURES

Post-CI auditory performance outcomes including educational setting, Categories of Auditory Performance (CAP), and Speech Intelligibility Rating (SIR); and electrophysiological measurements, Including maximal comfortable electrical levels (CLs) and impedances along CI electrodes.

RESULTS

The ANOVA on ranks revealed lower CAP scores in the study than control group: H3 = 18.8, P < 0.001. Among children with IEMs, CAP scores were better in children with enlarged vestibular aqueduct (EVA) (P < 0.04). SIR scores of the control group did not differ from those with isolated EVA; however, SIR scores of the IEMs without EVA subgroup were lower than all the other study subgroups (P < 0.01). The proportion of the control group that was integrated with full inclusion educational settings into the regular mainstream schools was higher than for those with IEMs without EVA (47 % vs. 15 %, P < 0.05), but similar to those with isolated EVA. For the study group versus control group, maximal comfortable electrical levels (CLs) were higher)P > 0.03) while impedance measurements were similar.

CONCLUSIONS

Outcomes of pediatric recipients with normal anatomy were better than those with IEMs. Among pediatric recipients of CI with IEMs, auditory performance was better and CLs were lower among children with isolated EVA than all other IEM subgroups.

A Long-Term Follow-Up Study on the Auditory Performance and Speech Intelligibility of Mandarin-Speaking Prelingually Deaf Children With Isolated Large Vestibular Aqueduct Syndrome After Cochlear Implantation

PURPOSE

The purpose of this study was to evaluate the auditory performance and speech perception of 104 children with isolated large vestibular aqueduct syndrome (LVAS) and 523 children with no inner ear malformation (IEM) for 5 years after cochlear implantation, in order to explore whether isolated LVAS can affect the long-term hearing and speech rehabilitation of deaf children after cochlear implantation.

METHOD

A cohort study was established consisting of 627 children who underwent cochlear implantation at Beijing Tongren Hospital from 1999 to 2016. The children were examined at 0, 6, 12, 24, 36, 48, and 60 months after cochlear implantation to assess their auditory performance and speech perception using the Categories of Auditory Performance (CAP) and Speech Intelligibility Rating (SIR) questionnaires.

RESULTS

The CAP scores of the isolated LVAS group increased significantly during the baseline to the 24th month, after which they gradually rose until reaching the plateau during the 24th to the 60th month. The CAP scores of the non-IEM group increased significantly during the baseline to the 36th month and then increased steadily. The SIR scores went up significantly during the baseline to the 48th month, and increased in a gradual manner in other stages of isolated LVAS evaluation. In comparison, The SIR scores of non-IEM group grew remarkably from the baseline to the 60th month. There were no significant differences in the CAP or SIR scores between isolated LVAS and non-IEM groups in each stage of evaluation, with the only exception being the CAP score at baseline month after cochlear implantation.

CONCLUSIONS

The CAP and SIR questionnaires are helpful tools for quantifying the early hearing and speech skills of younger prelingually deafened cochlear implant recipients. This long-term follow-up study shows that the speech and hearing development of children in isolated LVAS and non-IEM groups follow similar patterns, and isolated LVAS does not affect the long-term rehabilitation of deaf children after cochlear implantation.

Cochlear implantation in adults and pediatrics with enlarged vestibular aqueduct: a systematic review on the surgical findings and patients' performance

PURPOSE

Cochlear implantation (CI) has been considered a safe and effective management option for patients with severe to profound hearing loss. Patients with enlarged vestibular aqueduct (EVA) could be challenging with some variations in surgical approaches, intraoperative surgical notes, and clinical outcomes. This study aimed to  review the surgical and clinical outcomes of cochlear implantation among patients with EVA.

MATERIALS AND METHODS

A systematic literature search was carried out in five major databases. All original studies reporting cochlear implantation in patients with EVA were included for qualitative data synthesis. The risk of bias was independently assessed through the National Intuitional of Health tool. The review protocol was registered in PROSPERO (reference number: CRD42021225900).

RESULTS

A total of 34 studies with 4035 subjects were included. Of them, 853 (21.14%) had EVA and underwent CI. Mondini malformation was the most frequently associated anomaly (n = 78, 11.1%). Unilateral implantation was performed in 258 cases while bilateral in 119 subjects. Postoperative complications included CSF/perilymph gusher (n = 112), CSF oozing (n = 18), and partial electrode insertion (n = 6). Closing the cochleostomy with temporalis fascia, muscle, connective tissue, or fibrin glue was the most frequently reported approach to manage CSF/perilymph gusher (n = 67, 56.7%) while packing was performed in six patients.

CONCLUSION

Patients with EVA demonstrated audiometric and speech performance improvement after CI. However, many patients had intra- or postoperative complications. Further research is needed as the outcomes may be affected by associated temporal bone pathology, the timing of implant, and hearing condition.

Cochlear Implantation in Children with Enlarged Vestibular Aqueduct: A Systematic Review of Surgical Implications and Outcomes

OBJECTIVES

This study investigated age at implantation, improvement in hearing and speech perception outcomes, as well as surgical complications in pediatric cochlear implant recipients with Pendred Syndrome (PS) or non-syndromic enlarged vestibular aqueduct (NSEVA).

DESIGN

A systematic review of the literature between 1984 and 2021 was performed. Two independent reviewers performed abstract and full-text screening using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The inclusion criteria were: English language, cochlear implant, age at implantation available, age <18 years, PS, Mondini malformation, and enlarged vestibular aqueduct. Full-text analysis was completed using the National Institute of Health assessment tool for case series and case-control studies. Studies were also graded according to the Oxford Centre for Evidence-Based Medicine grading system.

RESULTS

In total, 198 studies were identified and screened, and 55 studies were included for analysis. Audiological outcomes were available in 46 studies, and the four-frequency pure-tone audiogram average improved by 60 to 78 dB HL due to cochlear implantation. Auditory performance and speech intelligibility scores increased by 44%. The overall average implantation age was 60 months. The implantation age was 21 months lower in the studies where individuals were implanted after the year 2000 compared with those implanted before the year 2000. Perilymph gusher/oozing was the most common surgical incident reported, occurring in 187 of 1572 implantations.

CONCLUSIONS

In children with PS/NSEVA, cochlear implantation improves pure-tone average by 60 to 78 dB HL and capacity of auditory performance/speech intelligibility by 44%. The implantation age for these children has decreased during the last two decades but is still somewhat higher than reported for unselected pediatric cochlear implantation. Perilymph gusher/oozing is the most common surgical complication.

A case of Landau-Kleffner syndrome with SLC26A4-related hearing impairment

Background

Landau-Kleffner syndrome (LKS) is an acquired aphasia and electroencephalogram (EEG) abnormalities mainly in temporoparietal areas. SLC26A4 mutations can cause hearing loss associated with enlarged vestibular aqueduct (EVA).

Case presentations

We report a case of LKS in a 5-year-old boy with non-syndromic EVA due to homozygous mutations of c.919-2A>G (IVS7-2A>G) in SLC26A4. He had normal language development before 2 years old. At the age of 2.5 years, he was admitted to the hospital due to remarkable language delay, and diagnosed with hearing loss with EVA. The seizures started at 4.4 years of age and EEG recording showed electrical status epilepticus during sleep (ESES) with a posterior-temporal predominance. He received cochlear implantation in the right ear at 4.7 years of age, which improved his hearing and language skills. The nocturnal focal motor seizures recurred at 4.9 years of age. Then a remarkable inability to respond to calls and reduction in spontaneous speech were noticed. He was treated with methylprednisolone at 5 years old, which controlled the seizures, suppressed ESES, and remarkably improved the language ability. The absence of seizures maintained until the last follow-up at 5.3 years of age, with further improvements in EEG recording and language ability.

Conclusions

The co-existence of LKS and hearing loss caused by SLC26A4 mutations increases the difficulty of LKS diagnosis, especially in the presence of hearing loss and impaired language skills. EEG discharges predominantly in temporoparietal areas, the occurrence of ESES, and language improvement after antiepileptic medications are potential indicators for LKS diagnosis.

Outcomes of Cochlear Implantation in Patients with Pendred syndrome: A Systematic Review and Narrative Synthesis

Establish outcomes following cochlear implantation (CI) in patients with Pendred syndrome. Systematic review and narrative synthesis. Databases searched: Medline, Pubmed, Embase, Web of Science, Cochrane Collection and ClinicalTrials.gov. No limits placed on language or year of publication. Review conducted in accordance with the PRISMA statement. Searches identified 251 abstracts and 242 full texts. Of these, 22 studies met inclusion criteria reporting outcomes in 231 patients with at least 234 implants. Hearing outcomes were generally good with patients experiencing useful functional improvement. A total of 46 minor complications were reported in 78 cases. The methodological quality of included studies was modest, predominantly consisting of case reports and non-controlled case series with small numbers of patients. All studies were OCEBM grade III-IV. Hearing outcomes following CI in Pendred syndrome are generally good with useful functional improvement. However, outcomes reported in published studies lack long term follow up.

Cochlear Implantation in Pediatric Patients With Enlarged Vestibular Aqueduct: A Systematic Review

OBJECTIVE(S)

To describe cochlear implantation (CI) outcomes, with speech perception, auditory, language, and parent-reported auditory and speech behaviors, in children with an enlarged vestibular aqueduct (EVA) and incomplete partition type 2 (IP-II) and compare to control children without inner ear malformations (IEMs) and to determine cerebrospinal fluid gusher rates and effect on outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

MEDLINE, Embase, Cochrane, and CINAHL databases were searched from inception to February 2020. Studies reporting relevant outcomes in children with EVA or EVA + IP-II and controls without IEMs undergoing CI were included. Mean differences in speech perception, auditory, and language scores between cases and controls were meta-analyzed. Gusher rates were determined by proportion meta-analyses.

RESULTS

Of 214 identified articles, 42 met inclusion criteria, evaluating 775 cases and 2,191 controls. Of -cases, 578 (74.6%) had EVA and 197 (25.4%) had EVA + IP-II. Cases showed a significant improvement in speech perception, auditory and language performance, comparable to controls. Parent-reported auditory and speech production behaviors outcomes were positive among cases and comparable to controls. Pooled gusher proportions in EVA and EVA + IP-II cases were 27.7% (95% CI: 17.6-39.1) and 48.6% (95% CI: 28.6-69.0), respectively, with a proportion difference of 20.9% (95% CI: 11.0-30.1). Gusher occurrence did not impact speech perception or language outcomes.

CONCLUSION

Outcomes in children with EVA or EVA + IP-II undergoing CI are favorable and largely comparable to outcomes in children with hearing loss undergoing CI without IEMs. Intraoperative gusher is more prevalent among children with EVA + IP-II as compared to iEVA. Gusher does not influence speech perception and language development outcomes.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

The Diagnostic Efficacy of MRI in the Evaluation of the Enlarged Vestibular Aqueduct in Children with Hearing Loss

Objective

The aim of our study is to evaluate the diagnostic effectiveness of magnetic resonance imaging (MRI) compared to computed tomography (CT) in the detection of enlarged vestibular aqueduct (EVA) in childhood.

Methods

One hundred twenty-three children who underwent temporal bone CT and MRI examinations for hearing loss between 2013 and 2020 were evaluated retrospectively. All CT and MRI images were examined by two pediatric radiologists, according to the Valvassori and Cincinnati criteria for EVA. Imaging findings on CT and MRI of the vestibular aqueduct were recorded. Two pediatric radiologists performed the measurements for EVA on CT and MRI. In addition, an otolaryngologist performed the measurements independently. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI compared to CT were calculated to detect EVA. The difference between the measurements on CT and MRI was investigated. The inter-observer agreement was evaluated for measurements.

Results

The mean age of 123 children (65 boys and 58 girls) was 50.18±50.40 months. Two hundred forty-six ears were evaluated in 123 children. On CT images, EVA was present in 28 (11.3%) of 246 ears according to Cincinnati criteria and 27 (10.9%) of 246 ears according to Valvassori criteria, respectively. While sensitivity, specificity, PPD, and NPD rates of MRI were 100%, 99%, 92.8%, and 100%, respectively, for Cincinnati criteria, for Valvassori criteria, they were 100%, 97.3%, 77.7%, and 100%, respectively. According to the visual evaluation performed without using measurement, the enlarged appearance of the vestibular aqueduct was significant for the diagnosis of EVA (p<0.001), while the absence of this appearance was significant for the exclusion of EVA (p<0.001). There was no significant difference between the measurements on CT and MRI. There was a perfect correlation between the observers for measurements.

Conclusion

MRI can be used as an initial imaging technique in children with suspicion of EVA to reduce radiation exposure.

Vestibular impairment in cochlear implanted children presenting enlarged vestibular aqueduct and enlarged endolymphatic sac

Enlarged vestibular aqueduct (EVA) is a common finding in tomodensitometry. When cranial MRI is performed, enlarged endolymphatic sac (EES) can also be found. Profound hearing loss is a common finding in these patients but a few studies have investigated vestibular function after cochlear implantation (CI) in EVA and EES patients. Our main objective was to find out whether in EVA children candidates to CI, a higher endolymphatic sac (ES) volume was predictive for higher rates of postsurgical vestibular complications.

METHODS

We retrospectively included EVA children who benefited from CI, during the last 2 years. Two groups were constituted according to the presence or not of a vestibular impairment (decrease in the VOR gain on the VHIT test on one of the semicircular canals and/or a loss of cVEMPs) 6 months after CI. Endolymphatic volume of both VA and ES was measured for each patient.

RESULTS

Fifteen patients were included. The mean endolymph volume was significantly higher in the impaired group (0.40 cm³ ± 0.23, range 0.08-0.70) than in the non-impaired group (0.11 cm³ ± 0.07, range 0.04-0.29; p = 0.029). Four children of the impaired group were followed during one year. At the end of vestibular rehabilitation, all children recovered a lateral canal function and a saccular function.

CONCLUSION

In EVA children, a combined EES appears to increase the risk of severe post CI vestibular impairment. To minimize this risk prior CI surgery, besides tomodensitometry, MRI measurement of the ES volume should be systematically performed.

Cochlear Implant Outcomes in Large Vestibular Aqueduct Syndrome-Should We Provide Cochlear Implants Earlier?

OBJECTIVE

Examine postoperative speech perception outcomes in a large vestibular aqueduct syndrome (LVAS) patients at a major cochlear implantation center.

STUDY DESIGN

Retrospective analysis of the Sydney Cochlear Implant Centre (SCIC) database and medical records from January 1994 to December 2015 was performed.

SETTING

Tertiary referral center.

PATIENTS

Patients with a diagnosis of LVAS who received a cochlear implant (CI). Only those with speech perception outcomes recorded at least 12 months post implant were included in our analysis.

INTERVENTION(S)

Therapeutic.

MAIN OUTCOME MEASURE(S)

Postoperative speech perception scores.

RESULTS

Between 1994 and 2015, 176 adult and pediatric patients with a diagnosis of LVAS underwent cochlear implantation at SCIC. Postoperative Bamford-Kowal Bench (BKB) sentence test scores were obtained for 97 patients. The postoperative median BKB score was 93% with a lower quartile score of 85% and an upper quartile score of 98%. Smaller numbers were available for post-CI City University of New York (CUNY) and Consonant-Nucleus-Consonant (CNC) word scores yet similar excellent results were seen.

CONCLUSIONS

Our study results suggest the CI should be considered when BKB scores have dropped to 85%. We suggest that rather than LVAS cases representing a challenge to cochlear implantation, they are amongst the best candidates for surgery, and should receive a CI at an earlier stage in hearing loss, when they have better speech perception. This allows stable hearing to be established earlier along with excellent speech perception outcomes.

CSF Gusher and Its Management in Cochlear Implant Patient with Enlarged Vestibular Aqueduct

Aim is to share our experience of CSF gusher and its management during cochlear implant surgery in patients with enlarged vestibular aqueduct. All cases underwent classic cochlear implant surgeries via Veria technique. It is a retrospective study done at Civil Hospital Ahmedabad from January 2013 to March 2018 with 415 patients. The study includes 39 children between age groups 2-8 years who have enlarged vestibular aqueduct. In all 39 patients with enlarged vestibular aqueduct during cochleostomy there was CSF gusher which was managed by the covering the cochleostomy site with temporalis fascia. There was no need for use of fibrin glue in any case. But it was kept in standby mode in case needed. And there was no post operative CSF otorrea in any patients. While preparing the patient for cochlear implant whenever you come across enlarged vestibular aqueduct via HRCT temporal bone and MRI of cochlea, be prepared for CSF gusher while doing the cochleostomy. Csf gusher is intra operative challenge rather than a bad prognostic determine for post operative audiologic out come. Keeping fibrin glue in stand by helps if major CSF leaks happens. Finally, we achieved a simple stepwise algorithm for the management of gusher during cochlear implantation.

Morphology and cochlear implantation in enlarged vestibular aqueduct

PURPOSE

The purpose of this work is to explore audiometry following cochlear implantation (CI) in patients with enlarged vestibular aqueduct (EVA) and to investigate the effects of inner ear morphological variation on post CI audiometry.

METHODS

This was a retrospective review of both natural and cochlear-implant-aided audiometry results, using all available measurements in a mixed-effects model accounting for longitudinal change and the grouping structure of ears. Patients who visited our tertiary academic medical center between 2000 and 2016 were identified as having EVA according to Cincinnati criteria on radiological examination; patients eligible for CI were then selected for analysis.

RESULTS

Multivariable modeling showed a statistically significant hearing improvement in ears with EVA undergoing CI with regards to pure tone average (-64.0 dB, p < 0.0001), speech reception threshold (-57.90 dB, p < 0.0001), and word score (34.8%, p > 0.0001). Vestibular aqueduct midpoint size and the presence of incomplete partition type II (IP II) did not have significant independent associations with audiometric findings. However, multivariable modeling revealed a statistically significant interaction between IP II and CI such that IP II ears demonstrated a decrease in WS improvement of 30.2% (p = 0.0059) compared to non-IP II ears receiving CI.

CONCLUSION

There is a statistically significant audiometric benefit to ears with EVA receiving CI. Morphology, specifically the presence of IP II, may hinder CI benefit in terms of word score however this finding needs clinical validation. This data improves personalization of surgical counseling and planning for patients with EVA considering CI.

Cerebrospinal Fluid Leak in Cochlear Implantation: Enlarged Cochlear versus Enlarged Vestibular Aqueduct (Common Cavity Excluded)

Objective. To share our experience of cerebrospinal fluid gusher in cochlear implantation in patients with enlarged cochlear or vestibular aqueduct. Study Design. Case series with comparison and a review of the literature. Methods. A retrospective study was performed. Demographic and radiological results of patients with enlarged cochlear aqueduct or enlarged vestibular aqueduct in 278 consecutive cochlear implant recipients, including children and adults, were evaluated between January 2000 and December 2015. Results. Six patients with enlarged cochlear aqueduct and eight patients with enlarged vestibular aqueduct were identified. Cerebrospinal fluid gusher occurs in five subjects with enlarged cochlear aqueduct and in only one case of enlarged vestibular aqueduct. Conclusion. Based on these findings, enlarged cochlear aqueduct may be the best risk predictor of cerebrospinal fluid gusher at cochleostomy during cochlear implant surgery despite enlarged vestibular aqueduct.

Cochlear Implantation in Isolated Large Vestibular Aqueduct Syndrome: Report of Three Cases and Literature Review

Introduction Large vestibular aqueduct syndrome (LVAS) is characterized by the enlargement of the vestibular aqueduct associated with sensorineural hearing loss. It is the most common radiographically detectable inner ear anomaly in congenital hearing loss. LVAS may occur as an isolated anomaly or in association with other inner ear malformations.

Objective To report three cases of isolated LVAS with a focus on preoperative assessment, surgical issues, and short-term postoperative follow-up with preliminary auditory habilitation outcomes.

Resumed Report One girl and two boys with LVAS were assessed and cochlear implantation was performed for each. Various ways of intraoperative management of cerebrospinal fluid gusher and postoperative care and outcomes are reported.

Conclusion Cochlear implantation in the deaf children with LVAS is feasible and effective.

Diagnostic yield of MRI for pediatric hearing loss: a systematic review

OBJECTIVE

To perform a systematic review to analyze the diagnostic yield of magnetic resonance imaging (MRI) for pediatric hearing loss, including comparison to computed tomography (CT) and subgroup evaluation according to impairment severity and specific diagnostic findings (cochlear anomalies, enlarged vestibular aqueduct, cochlear nerve abnormalities, and brain findings).

DATA SOURCES

Pubmed, EMBASE, and the Cochrane library were assessed from their inception through December 2013. Manual searches were also performed, and topic experts were contacted.

REVIEW METHODS

Data from studies describing the use of MRI with or without comparison to CT in the diagnostic evaluation of pediatric patients with hearing loss were evaluated, according to a priori inclusion/exclusion criteria. Two independent evaluators corroborated the extracted data. Heterogeneity was evaluated according to the I(2) statistic.

RESULTS

There were 29 studies that evaluated 2434 patients with MRIs and 1451 patients with CTs that met inclusion/exclusion criteria. There was a wide range of diagnostic yield from MRI. Heterogeneity among studies was substantial but improved with subgroup analysis. Meta-analysis of yield differences demonstrated that CT had a greater yield than MRI for enlarged vestibular aqueduct (yield difference 16.7% [95% CI, 9.1%-24.4%]) and a borderline advantage for cochlear anomalies (4.7% [95% CI, 0.1%-9.5%]). Studies were more likely to report brain findings with MRI.

CONCLUSIONS

These data may be utilized in concert with that from studies of risks of MRI and risk/yield of CT to inform the choice of diagnostic testing.

Timing of surgical intervention with cochlear implant in patients with large vestibular aqueduct syndrome

Objectives

(1) To report the speech perception and intelligibility results of Mandarin-speaking patients with large vestibular aqueduct syndrome (LVAS) after cochlear implantation (CI); (2) to compare their performance with a group of CI users without LVAS; (3) to understand the effects of age at implantation and duration of implant use on the CI outcomes. The obtained data may be used to guide decisions about CI candidacy and surgical timing.

Methods

Forty-two patients with LVAS participating in this study were divided into two groups: the early group received CI before 5 years of age and the late group after 5. Open-set speech perception tests (on Mandarin tones, words and sentences) were administered one year after implantation and at the most recent follow-up visit. Categories of auditory perception (CAP) and Speech Intelligibility Rating (SIR) scale scores were also obtained.

Results

The patients with LVAS with more than 5 years of implant use (18 cases) achieved a mean score higher than 80% on the most recent speech perception tests and reached the highest level on the CAP/SIR scales. The early group developed speech perception and intelligibility steadily over time, while the late group had a rapid improvement during the first year after implantation. The two groups, regardless of their age at implantation, reached a similar performance level at the most recent follow-up visit.

Conclusion

High levels of speech performance are reached after 5 years of implant use in patients with LVAS. These patients do not necessarily need to wait until their hearing thresholds are higher than 90 dB HL or PB word score lower than 40% to receive CI. They can do it “earlier” when their speech perception and/or speech intelligibility do not reach the performance level suggested in this study.

The prediction of CSF gusher in cochlear implants with inner ear abnormality

CONCLUSION

The incidence rate of the cerebrospinal fluid (CSF) gusher in cochlear implant with inner ear abnormality is 30%. Bony defect in the fundus of the internal acoustic meatus is most often responsible for the occurrence of CSF gusher. This feature of the CT scan can be used to predict the occurrence of a CSF gusher.

OBJECTIVE

To predict the occurrence of CSF gusher in cochlear implants with inner ear abnormality.

METHODS

This was a retrospective analysis of 442 patients with inner ear abnormality who underwent cochlear implantation from February 1998 to July 2011. The patients were reviewed for the findings on temporal high resolution computed tomography (HRCT) scans and the complication of CSF gusher in cochlear implantation.

RESULTS

Among the 422 cases, 134 (30%) suffered from the complication of CSF gusher during the operation. They were all found to have a bony defect in the fundus of the internal acoustic meatus on the CT scans.

Dilated dysplastic vestibule: a new computed tomographic finding in patients with large vestibular aqueduct syndrome

OBJECTIVE

Large vestibular aqueduct syndrome (LVAS) is one of the most common anomalies of the inner ear. The purpose of our study was to evaluate the vestibule for associated aberrations. In particular, we assessed the vestibular volume in patients with LVAS, compared it to an age-matched control population, and evaluated the relationship between the size of the vestibular aqueduct and the vestibule.

METHODS

We reviewed studies of high-resolution computed tomography of temporal bone of 24 consecutive patients with LVAS (15 girls and 9 boys; average age, 8.1 years). Of these, 21 patients had bilateral LVAS and 3 patients had unilateral LVAS. Each ear was evaluated for the size of the vestibular aqueduct and the volume of the vestibule. Similar measurements were obtained in an age-matched control population (28 girls and 18 boys; average age, 8.3 years).

RESULTS

The volume of the vestibule was found to be significantly enlarged in patients with LVAS compared to the control population (right ear, P < 0.0001; left ear, P < 0.0001). A linear correlation could be established between an enlarged vestibular aqueduct and corresponding increase in the volume of the vestibule (right side, P < 0.01; left side, P < 0.01).

CONCLUSION

A dilated dysplastic vestibule is a consistently associated finding in patients with LVAS.

The development of auditory skills in infants with isolated Large Vestibular Aqueduct Syndrome after cochlear implantation

OBJECTIVE

The purpose of this study was to investigate the auditory performance of infants with isolated Large Vestibular Aqueduct Syndrome (LVAS) after cochlear implantation, compare their performance with those of infants with a normal inner ear, and establish a database of auditory development.

METHOD

435 infants with congenital severe to profound hearing loss participated in this study. 62 infants in group A were diagnosed with isolated LVAS. 373 infants in group B had a normal inner ear. Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS) was used to evaluate the development of auditory skills.

RESULTS

The mean scores for auditory ability showed no significant difference between groups A and B. The mean scores for the three different auditory skills increased significantly over time. The differences were statistically significant in mean scores among the three different auditory skills for group B.

CONCLUSION

Auditory skills of infants with isolated LVAS developed rapidly after cochlear implantation, in a similar manner to those of infants with a normal inner ear. Cochlear implantation is an effective interventional approach and an established therapeutic option for infants with isolated LVAS.

Therapeutic approach in managing patients with large vestibular aqueduct syndrome (LVAS)

OBJECTIVE

To discuss the clinical approach in managing patients with large vestibular aqueduct syndrome.

METHODS

Over the period from November 1997 to March 2005, 106 children have been fitted with cochlear implants in Antwerp University Hospital (UZA). The Hospital University of Maastricht (azM) had implanted 36 children since 1999 to March 2005. The present study focuses on nine children and one adult patient with large vestibular aqueduct syndrome (LVAS). The medical, report and radiology report were retrospectively analysed.

RESULTS

Eight out of nine children with LVAS had been implanted and one child was on the waiting list. One adult patient was implanted with Nucleus 24M at the age of 22 years old. Nine out of 10 patients had bilateral large vestibular aqueduct. There were no intraoperative or postoperative complications encountered.

CONCLUSION

Cochlear implantation is a safe operation for patients with LVAS.

[Large endolymphatic duct and sac syndrome : part 2: clinical manifestations]

OBJECTIVE

The aim of this study was to clarify the clinical course of large endolymphatic duct and sac syndrome (LEDS). Although LEDS is the most common form of radiologically detectable inner ear malformation associated with sensorineural hearing loss (SNHL), it is relatively unknown in the German-speaking countries. We hoped to derive useful pointers for clinical care.

METHODS

We evaluated the clinical audiometric records and imaging findings of 169 patients with clinically suspected inner ear malformation seen between 1994 and 2003. Following identification of all LEDS cases, we serially investigated the anamnestic and functional data with regard to severity and course.

RESULTS

Among 169 patients, 17 (median age 12 years; 12 females) showed LEDS. A total of 28 ears were affected. Clinically, most cases were of prelingual or perilingual onset and displayed steady or fluctuatingly progressive severe SNHL with emphasis on the high frequencies or deafness. Episodes of sudden hearing loss were relatively frequent. No correlation could be demonstrated between the severity of morphological changes and the degree of SNHL.

CONCLUSION

Progression of SNHL and episodes of sudden hearing loss were seen mainly in late childhood or adolescence. This should be taken into account when informing and advising patients and planning therapy.

Vestibular symptoms in children with enlarged vestibular aqueduct anomaly

OBJECTIVE

The objective of this study is to describe the vestibular symptoms in pediatric patients with enlarged vestibular aqueduct (EVA) anomaly.

METHODS

Retrospective chart review of pediatric and adult patients with EVA anomaly who were treated at the University of Utah Hospital or Primary Children's Medical Center, between 1995 and 2005. Radiographs were reviewed to confirm the diagnosis. Comparisons were made between adult and pediatric patients.

RESULTS

Thirty-two patients were included in the study, 17 females and 15 males. Twenty-one patients were under the age of 18 and 11 patients were age 18 or older. On initial audiometric evaluation at a tertiary hospital, the pure tone average in the right ear was 75.0 dB and the pure tone average in the left ear was 80.4 dB. The incidence of vestibular symptoms in adult patients was 45.5% and in pediatric patients was 48.0%. Fourteen patients underwent cochlear implantation. Four patients (28.6%) who previously denied vestibular symptoms experienced post-operative vertigo after cochlear implantation.

CONCLUSIONS

About half of the patients with EVA in our series experienced vestibular symptoms. Pediatric patients in our series experienced vertigo and vestibular symptoms with equal frequency when compared to adult patients. Some patients with EVA undergoing cochlear implantation experienced vestibular symptoms in the post-operative period.

Management of Cerebrospinal Fluid Leakage From Cochleostomy During Cochlear Implant Surgery

OBJECTIVES

The objectives of this retrospective review were to determine the incidence of cerebrospinal fluid (CSF) otorrhea from the cochleostomy during cochlear implant surgery, to recognize patients at risk, and to determine the appropriate preoperative, postoperative and intraoperative management.

METHODS

A chart review from two cochlear implant centers was performed to determine the incidence of CSF otorrhea, patients at risk, and appropriate management.

RESULTS

The incidence of CSF gusher is low, encountered in approximately 1% of patients undergoing cochlear implant surgery, and is seen in equal incidence in children and adults in our series. Preoperative imaging was predictive in only 50% of cases. Mechanisms for otorrhea in specific cochlear malformations and in those in which no apparent malformation exists are discussed. Successful implantation is expected in most cases. Intraoperative management may require complete packing of the middle ear space in addition to the cochleostomy to control CSF leak. Lumbar drain is rarely necessary. Outpatient management is possible in the majority of cases. Vaccination and antibiotic prophylaxis is essential.

CONCLUSIONS

CSF otorrhea can be encountered in cochlear malformations and in cochleas without apparent malformation. Successful implantation without short-term or long-term complications is expected.

The large vestibular aqueduct--case report and review of the literature

Patients with a large vestibular aqueduct (LVA) suffer from a loss of hearing in childhood at an early onset. An acute loss of hearing can be precipitated by minor head trauma. Until now there seems to be no sufficient therapy for stopping the progression of a loss of hearing. It has been shown that a cochlear implantation is a worthwhile procedure if the patient is almost deaf. We report the case of a patient with a bilateral LVA. A loss of hearing was confirmed at the age of 16 months. Exposure to loud noise triggered an acute progression of the hearing loss. At the age of 18 years, LVA was confirmed radiologically, revealing an enlarged endolymphatic duct and sac in MRI scans and an enlarged vestibular aqueduct in the CT scan. We successfully performed a cochlear implant (MED-EL, Combi 40+ flex). Proceeding from this case report, the paper reviews the literature on LVA.

Imaging and clinical findings in large endolymphatic duct and sac syndrome

OBJECTIVE

Large endolymphatic duct and sac syndrome (LEDS) is known as the most common kind of inner ear malformations, which is radiologically detectable. Nevertheless, nowadays many questions are not fully cleared and LEDS is relatively unknown among general radiologists. The aim of this study was to evaluate the incidence of LEDS in the own patient population and to present our experiences regarding imaging findings, clinical presentation and follow up.

MATERIALS AND METHODS

Based on a complete recording of all patients, sent from ENT department to radiology, we identified all radiological diagnosed cases of inner ear malformations including LEDS and all patients in whom an inner ear malformation was clinically suspected. The retrospective study included clinical records, HR-CT and MRI performed between 1994 and 2002.

RESULTS

Among 169 patients (338 ear), 17 of patients (median age: 12 years) and 28 ears, respectively, had enlarged endolymphatic structures. In 10 patients - 6% - (15 ears), no other abnormalities were detected, called isolated LEDS, seven patients showed additional inner ear abnormalities. One patient showed a labyrinthine hemorrhage after sudden hearing loss. Audiometric data revealed sensorineural hearing loss in 22 ears, deafness in 5 ears and normal hearing in 1 case of 28 ears. In 10 (67%) of 15 ears with isolated LEDS, the hearing loss was downward-fluctuating progressive. Twelve patients (eight with isolated LEDS) had partly repeated sudden hearing losses. A trigger for worsening of hearing was found in five patients. A correlation between the severity of morphological changes on imaging and the degree of hearing disturbances could not be detected. Only four young patients underwent a radiological examination within the first or second year after onset of hearing loss. Three patients received a cochlear implant.

CONCLUSIONS

LEDS might be the cause of progressive hearing loss and repeated acute hearing losses in children and young adults. Imaging plays an important role in making the diagnosis.

The remediation of hearing deterioration in children with large vestibular aqueduct syndrome

Based on imaging findings, large vestibular aqueduct syndrome (LVAS) in early childhood is the most common cause of sensorineural hearing loss. Children with LVAS are at a high risk of suffering sudden deteriorations in hearing. This study was to review treatment of sudden hearing deterioration in children with LVAS who underwent corticosteroid therapy. We conducted a retrospective study of patients presenting to an academic tertiary medical center. Sixteen children of LVAS were evaluated. Corticosteroid therapy (prednisolone 1-2 mg/(kg day) or equal titer's dexamethasone) was administered as soon as sudden hearing loss developed. The pure tone audiometric result improved more than 10dB at two or more consecutive frequencies and was regarded as a significant response to corticosteroid therapy. Sixteen cases comprising 12 boys and 4 girls were retrospectively analyzed in this study. The mean age at which LVAS was diagnosed was 2.3 years. Mean follow-up for the 16 cases from the first clinic visit to November 2003 was 4.2 years. The initial audiograms varied from down-sloping, valve or rising patterns. In addition, bilateral enlargement of the vestibular aqueduct was found to all children and the mean diameter of right and left ears were 7.23 and 6.83 mm, respectively. Seven children had totally experienced 13 episodes of sudden hearing deterioration. After receiving corticosteroid therapy in time, 11 of 13 episodes had indicated significant responses to treatment, a response rate of 85%. Early detection of LVAS and the timing of treatment are crucial for preventing the residual hearing from deteriorating. As soon as the hearing deterioration of a child with LVAS is recognized, aggressive intervention such as corticosteroid therapy should be performed in no time.

Predicting speech perception outcomes following cochlear implantation using Nottingham children's implant profile (NChIP)

BACKGROUND/OBJECTIVE

Nottingham children's implant profile (NChIP) is a systematic framework to assess deaf children before implantation taking into account not only the well-known factors (age, duration of deafness) but also family and support services, expectations, children's cognitive abilities and learning style. The aim of the present paper is to assess the predictive value of the NChIP in the long-term outcomes of implanted children.

PATIENTS

This prospective and longitudinal study involved 51 profoundly deaf children, implanted within the same paediatric cochlear implant programme. All children were pre-lingually deaf with age at onset of deafness <2 years and age at implantation <6 years. Three and 4 years following implantation all children were assessed using two measures of speech perception. No child was lost to follow-up and no child was excluded from the study for any reason.

RESULTS

The most constant predictor of the outcomes was children's learning style explaining upto 29% of the variance. Other significant predictors of the outcome were shorter duration of deafness, young age at implantation and family structure/support.

CONCLUSIONS

Intrinsic factors in children and how well they communicate with their environment are of paramount importance to the outcome following implantation. The predictive value of NChIP has been demonstrated and the most important predictors of the outcome were children's learning style, short duration of deafness, young age at implantation, and family structure/support.