Tophaceous Gout of the Middle Ear

Tophaceous gout can rarely present in the middle ear as a mass-like lesion, causing conductive hearing loss. Noncontrast high-resolution computed tomography (HRCT) of the temporal bone plays a significant role in the diagnosis. Awareness of this condition among radiologists is important since it presents a distinctive appearance on HRCT. We present a case of tophaceous gout of the middle ear diagnosed with photon-counting computed tomography (PCCT). Teaching point: The presence of a partially calcified mass with a semolina-like appearance within the middle ear is highly suggestive of tophaceous gout, even in the presence of normal serum uric acid levels.

Optimizing vestibular implant electrode positioning using fluoroscopy and intraoperative CT imaging

PURPOSE

 Vestibular implant electrode positioning close to the afferent nerve fibers is considered to be key for effective and selective electrical stimulation. However, accurate positioning of vestibular implant electrodes inside the semicircular canal ampullae is challenging due to the inability to visualize the target during the surgical procedure. This study investigates the accuracy of a new surgical protocol with real-time fluoroscopy and intraoperative CT imaging, which facilitates electrode positioning during vestibular implant surgery.

METHODS

 Single-center case-controlled cohort study with a historic control group at a tertiary referral center. Patients were implanted with a vestibulocochlear implant, using a combination of intraoperative fluoroscopy and cone beam CT imaging. The control group consisted of five patients who were previously implanted with the former implant prototype, without the use of intraoperative imaging. Electrode positioning was analyzed postoperatively with a high-resolution CT scan using 3D slicer software. The result was defined as accurate if the electrode position was within 1.5 mm of the center of the ampulla.

RESULTS

With the new imaging protocol, all electrodes could be positioned within a 1.5 mm range of the center of the ampulla. The accuracy was significantly higher in the study group with intraoperative imaging (21/21 electrodes) compared to the control group without intraoperative imaging (10/15 electrodes), (p = 0.008).

CONCLUSION

 The combined use of intraoperative fluoroscopy and CT imaging during vestibular implantation can improve the accuracy of electrode positioning. This might lead to better vestibular implant performance.

Risk Factors for Natural Hearing Evolution in Newborns With Congenital Cytomegalovirus Infection

Importance

Congenital cytomegalovirus (cCMV) is the major cause of congenital nonhereditary sensorineural hearing loss in children. Currently, criteria to identify infants at increased risk for unfavorable hearing outcome are lacking.

Objective

To identify risk factors associated with cCMV-related hearing improvement, hearing deterioration, and late-onset hearing loss.

Design, Setting, and Participants

This multicenter cohort study included patients from 6 secondary and tertiary hospitals enrolled in the Flemish CMV registry (Belgium). Newborns with untreated cCMV infection with at least 4-year audiological follow-up were included. Patients who presented with other possible causes of sensorineural hearing loss were excluded. Data were collected for 15 years (January 1, 2007, to February 7, 2022) and analyzed from September 26, 2022, to January 16, 2023.

Main Outcomes and Measures

Primary outcome was hearing evolution (per-ear analysis; described as stable hearing, improvement, or deterioration). The association of gestational characteristics, clinical findings, timing of seroconversion, viral load, and hearing status at birth with hearing evolution was investigated using effect sizes (Cramer V, odds ratio [OR], or Hedges g).

Results

Of the 387 children, 205 of 385 with nonmissing data were male (53.2%), 113 (29.2%) had a symptomatic infection, and 274 (70.8%) had an asymptomatic infection. Every child was 4 years or older at final hearing evaluation. A total of 701 of 774 ears (90%) showed stable hearing (normal hearing or stable hearing loss since birth) over time. Late-onset hearing loss (normal hearing at birth followed by hearing loss) was present in 43 of 683 ears (6.3%). Among children with hearing loss present at birth, 24 of 34 ears (70.6%) had hearing deterioration, and 6 of 91 ears (6.6%) had hearing improvement. Prematurity was associated with a higher chance of hearing improvement (OR, 12.80; 95% CI, 2.03-80.68). Late-onset hearing loss was more prevalent in a first trimester infection (OR, 10.10; 95% CI, 2.90-34.48). None of the 104 ears of children with a third trimester seroconversion developed late-onset hearing loss.

Conclusions and Relevance

Findings of this cohort study support that ongoing audiological follow-up for untreated children with congenital hearing loss is important, as the majority of patients had hearing deterioration. The timing of seroconversion was associated with the risk of developing late-onset hearing loss. These insights can aid in parental counseling, patient stratification, and follow-up. Future research should focus on the effect of treatment, the influence of determined risk factors, and the study of eventual new risk factors in patients at high risk to develop hearing loss.

Early cochlear implantation supports narrative skills of children with prelingual single-sided deafness

Prelingual single-sided deafness (SSD) not only affects children's hearing skills, but can also lead to speech-language delays and academic underachievement. Early cochlear implantation leads to improved spatial hearing, but the impact on language development is less studied. In our longitudinal study, we assessed the language skills of young children with SSD and a cochlear implant (CI). In particular, we investigated their narrative skills in comparison to two control groups: children with SSD without a CI, and children with bilateral normal hearing. We found that children with SSD and a CI performed in line with their normal-hearing peers with regard to narrative and verbal short-term memory skills. Children with SSD without a CI had worse narrative (group difference = - 0.67, p = 0.02) and verbal short-term memory (group difference = - 0.68, p = 0.03) scores than the implanted group. Verbal short-term memory scores and grammar scores each correlated positively with narrative scores across all groups. Early grammar scores (at 2-3 years of age) could partially predict later narrative scores (at 4-6 years of age). These results show that young children with prelingual SSD can benefit from early cochlear implantation to achieve age-appropriate language skills. They support the provision of a CI to children with prelingual SSD.

Risk Factors for Hearing Loss at Birth in Newborns With Congenital Cytomegalovirus Infection

Importance

With a prevalence between 0.2% and 6.1% of all live births, congenital cytomegalovirus (cCMV) infection is a major cause of congenital nonhereditary sensorineural hearing loss. Despite the large amount of research on cCMV-related hearing loss, it is still unclear which newborns are at risk of hearing loss.

Objective

To identify independent risk factors for cCMV-related congenital hearing loss and predictors of hearing loss severity at birth.

Design, Setting, and Participants

This cross-sectional study of newborns with cCMV infection used data included in the Flemish CMV registry that was collected from 6 secondary and tertiary hospitals in Flanders, Belgium, over 15 years (January 1, 2007, to February 7, 2022). Data were analyzed March 3 to October 19, 2022. Patients were included in the study after confirmed diagnosis of cCMV infection and known hearing status at birth. Patients who presented with other possible causes of sensorineural hearing loss were excluded.

Main Outcomes and Measures

Primary outcome was hearing status at birth. Clinical, neurological, and laboratory findings along with the timing of seroconversion and blood viral load were separately considered as risk factors. Binary logistic regression was performed to identify independent risk factors for congenital hearing loss in newborns with cCMV. Effect sizes were measured using Hedges g, odds ratio, or Cramer V.

Results

Of the 1033 newborns included in the study (553 of 1024 [54.0%] boys), 416 (40.3%) were diagnosed with symptomatic cCMV infection and 617 (59.7%) with asymptomatic cCMV infection. A total of 15.4% of the patients (n = 159) presented with congenital hearing loss; half of them (n = 80 [50.3%]) had isolated hearing loss. The regression model revealed 3 independent risk factors for congenital hearing loss: petechiae at birth (adjusted odds ratio [aOR], 6.7; 95% CI, 1.9-23.9), periventricular cysts on magnetic resonance imaging (MRI; aOR, 4.6; 95% CI, 1.5-14.1), and seroconversion in the first trimester (aOR, 3.1; 95% CI, 1.1-9.3). Lower viral loads were seen in patients with normal hearing compared with those with congenital hearing loss (median [IQR] viral load, 447.0 [39.3-2345.8] copies per milliliter of sample [copies/mL] vs 1349.5 [234.3-14 393.0] copies/mL; median difference, -397.0 [95% CI, -5058.0 to 174.0] copies/mL).

Conclusions and Relevance

Findings of this cross-sectional study suggest that newborns with cCMV infection and petechiae at birth, periventricular cysts on MRI, or a seroconversion in the first trimester had a higher risk of congenital hearing loss. Clinicians may use these risk factors to counsel parents in the prenatal and postnatal periods about the risk of congenital hearing loss. Moreover, linking clinical features to hearing loss may provide new insights into the pathogenesis of cCMV-related hearing loss. The importance of viral load as a risk factor for congenital hearing loss remains unclear.

Three Years of Vestibular Infant Screening in Infants With Sensorineural Hearing Loss

OBJECTIVES

Although vestibular deficits are more prevalent in hearing-impaired children and can affect their development on many levels, a pediatric vestibular assessment is still uncommon in clinical practice. Since early detection may allow for timely intervention, this pioneer project has implemented a basic vestibular screening test for each six-month-old hearing-impaired infant in Flanders, Belgium. This study aims to report the vestibular screening results over a period of three years and to define the most important risk factors for abnormal vestibular screening results.

METHODS

Cervical Vestibular Evoked Myogenic Potentials with bone-conduction were used as a vestibular screening tool in all reference centers affiliated to the Universal Newborn Hearing Screening Program in Flanders. From June 2018 until June 2021, 254 infants (mean age: 7.4 months, standard deviation: 2.4 months) with sensorineural hearing loss were included.

RESULTS

Overall, abnormal vestibular screening results were found in 13.8% (35 of 254) of the infants. The most important group at risk for abnormal vestibular screening results were infants with unilateral or bilateral severe to profound sensorineural hearing loss (20.8%, 32 of 154) (P < .001, odds ratio = 9.16). Moreover, abnormal vestibular screening results were more prevalent in infants with hearing loss caused by meningitis (66.7%, 2 of 3), syndromes (28.6%, 8 of 28), congenital cytomegalovirus infection (20.0%, 8 of 40), and cochleovestibular anomalies (19.2%, 5 of 26).

CONCLUSIONS

The vestibular screening results in infants with sensorineural hearing loss indicate the highest risk for vestibular deficits in severe to profound hearing loss, and certain underlying etiologies of hearing loss, such as meningitis, syndromes, congenital cytomegalovirus, and cochleovestibular anomalies.

Assessment of Receptive and Expressive Language Skills Among Young Children With Prelingual Single-Sided Deafness Managed With Early Cochlear Implantation

IMPORTANCE

Pediatric single-sided deafness (SSD) can seriously affect development, causing impaired spatial hearing skills, speech-language delays, and academic underachievement. Early cochlear implantation likely improves hearing-related outcomes, but its association with language development remains unclear.

OBJECTIVE

To investigate whether early cochlear implantation is associated with language outcomes for children with prelingual SSD.

DESIGN, SETTING, AND PARTICIPANTS

The Cochlear Implant for Children and One Deaf Ear study was initiated in 2015 and recruited participants at 4 academic hospitals in Flanders, Belgium, through 2019. This cohort study included 3 groups of children aged 2 to 5 years: children with SSD and a cochlear implant, children with SSD without a cochlear implant, and a control group with normal hearing. Language and hearing skills were assessed 1 to 2 times per year until the age of 10 years. Study completion rates were high (82%). Data analysis was performed from October to December 2020.

EXPOSURE

Unilateral cochlear implant.

MAIN OUTCOMES AND MEASURES

Longitudinal vocabulary, grammar, and receptive language scores. The implanted group was hypothesized to outperform the nonimplanted group on all language tests.

RESULTS

During the recruitment period, 47 children with prelingual SSD without additional disabilities were identified at the participating hospitals. Fifteen of the 34 children with an intact auditory nerve received a cochlear implant (44%, convenience sample). Sixteen of the remaining children were enrolled in the SSD control group (50%). Data from 61 children (mean [SD] age at the time of enrollment, 2.08 [1.34] years; 26 girls [42%]) were included in the analysis: 15 children with SSD and a cochlear implant, 16 children with SSD without a cochlear implant, and 30 children with normal hearing. Children with SSD and a cochlear implant performed in line with their peers with normal hearing with regard to grammar. In contrast, children with SSD without a cochlear implant had worse grammar scores than the group with implants (-0.76; 95% CI, -0.31 to -1.21; P = .004) and the group with normal hearing (-0.53; 95% CI, -0.91 to -0.15; P = .02). The 3 groups had similar vocabulary and receptive language abilities.

CONCLUSIONS AND RELEVANCE

These findings suggest that early cochlear implantation is associated with normal grammar development in young children with prelingual SSD. Although further follow-up will reveal the long-term outcomes of the cochlear implant for other skills, the current results will help clinicians and policy makers identify the best treatment option for these children.

Prevalence of Otological Disease in Turner Syndrome: A Systematic Review

INTRODUCTION

Girls and women with Turner syndrome (TS) present with multiple ear and hearing problems, ranging from external morphologic abnormalities to sensorineural or conductive hearing loss. The exact pathophysiology behind these otological diseases is not yet completely understood. The aim of this study is to provide a systematic review on the prevalence of otological disease in TS.

METHODS

We conducted a systematic review according to the PRISMA guidelines. A database search was performed in PubMed, Embase, Web of Science, and Cochrane library.

RESULTS

The prevalence of otological disease as external ear deformities (20-62%), recurrent otitis media (24-48%), and hearing loss (36-84%) is high in TS. The auditory phenotype in TS is complex and seems to be dynamic with CHL due to middle ear disease at young age and sensorineural hearing loss later in life.

CONCLUSION

This systematic review of the literature confirms that otological disease is definitely part of the widely variable phenotype in Turner patients. Strong evidence is lacking on the exact prevalence numbers, emphasizing the need for more prospective data gathering. Growing insights in its pathophysiology will help in the understanding and management of hearing problems in TS across lifespan.

Unilateral congenital hearing loss in children: Challenges and potentials

The estimated incidence of sensorineural hearing impairment (>40 dB HL) at birth is 1.86 per 1000 newborns in developed countries and 30-40% of these are unilateral. Profound sensorineural unilateral hearing impairment or single sided deafness (SSD) can be treated with a cochlear implant. However, this treatment is costly and invasive and unnecessary in the eyes of many. Very young children with SSD often do not exhibit language and cognitive delays and it is hard to imagine that neurocognitive skills will present difficulties with one good ear. In the current paper we review the most recent evidence on the consequences of unilateral hearing impairment for auditory and neurocognitive factors. While data of both adults and children are discussed, we focus on developmental factors, congenital deafness and a window of opportunity for intervention. We discuss which etiologies qualify for a cochlear implant and present our multi-center prospective study on cochlear implants in infants with one deaf ear. The large, state-of-the art body of research allows for evidence-based decisions regarding management of unilateral hearing loss in children.

High-resolution frequency tuning but not temporal coding in the human cochlea

Frequency tuning and phase-locking are two fundamental properties generated in the cochlea, enabling but also limiting the coding of sounds by the auditory nerve (AN). In humans, these limits are unknown, but high resolution has been postulated for both properties. Electrophysiological recordings from the AN of normal-hearing volunteers indicate that human frequency tuning, but not phase-locking, exceeds the resolution observed in animal models.

The coding of sounds by the cochlea depends on two primary properties: frequency selectivity, which refers to the ability to separate sounds into their different frequency components, and phase-locking, which refers to the neural coding of the temporal waveform of these components. These properties have been well characterized in animals using neurophysiological recordings from single neurons of the auditory nerve (AN), but this approach is not feasible in humans. As a result, there is considerable controversy as to how these two properties may differ between humans and the small animals typically used in neurophysiological studies. It has been proposed that humans excel both in frequency selectivity and in the range of frequencies over which they have phase-locking. We developed a technique to quantify these properties using mass potentials from the AN, recorded via the middle ear in human volunteers with normal hearing. We find that humans have unusually sharp frequency tuning but that the upper frequency limit of phase-locking is at best similar to—and more likely lower than—that of the nonhuman animals conventionally used in experiments.

A Role for Acoustic Stimulation in Advanced Otosclerosis: Direct Acoustic Cochlear Implant versus Cochlear Implant

Recent findings support the efficacy of the direct acoustic cochlear implant (DACI) in patients with advanced otosclerosis whose rehabilitation is very challenging. Standard treatment consists of stapes surgery combined with hearing aids or a cochlear implant (CI). CI surgery, however, is often challenging depending on the grade of otosclerosis. This study aims to compare speech perception scores in quiet and noise of 6 DACI and 12 CI patients with advanced otosclerosis at 3 and 12 months after fitting. Preoperative computed tomographic scans of all patients were scored by experts using an existing otosclerosis grading system (stages 1–3). Speech perception in quiet was significantly better for DACI compared to CI users at 3 months after fitting. At 12 months, no difference was found between DACI and CI patients. Speech perception scores in noise were significantly better in the DACI group. In summary, a DACI system seems to provide an effective treatment option as the acoustic component can be preserved in patients with advanced otosclerosis.

Prevalence and Nature of Hearing Loss in 22q11.2 Deletion Syndrome

PURPOSE

The purpose of this study was to clarify the prevalence, type, severity, and age-dependency of hearing loss in 22q11.2 deletion syndrome.

METHOD

Extensive audiological measurements were conducted in 40 persons with proven 22q11.2 deletion (aged 6-36 years). Besides air and bone conduction thresholds in the frequency range between 0.125 and 8.000 kHz, high-frequency thresholds up to 16.000 kHz were determined and tympanometry, acoustic reflex (AR) measurement, and distortion product otoacoustic emission (DPOAE) testing were performed.

RESULTS

Hearing loss was identified in 59% of the tested ears and was mainly conductive in nature. In addition, a high-frequency sensorineural hearing loss with down-sloping curve was found in the majority of patients. Aberrant tympanometric results were recorded in 39% of the ears. In 85% of ears with a Type A or C tympanometric peak, ARs were absent. A DPOAE response in at least 6 frequencies was present in only 23% of the ears with a hearing threshold ≤30 dB HL. In patients above 14 years of age, there was a significantly lower percentage of measurable DPOAEs.

CONCLUSION

Hearing loss in 22q11.2 deletion syndrome is highly prevalent and both conductive and high-frequency sensorineural in nature. The age-dependent absence of DPOAEs in 22q11.2 deletion syndrome suggests cochlear damage underlying the high-frequency hearing loss.

Hearing in Children with Congenital Cytomegalovirus Infection: Results of a Longitudinal Study

OBJECTIVES

To evaluate hearing outcome, to characterize the nature of symptomatic and asymptomatic congenital cytomegalovirus (cCMV) infection and associated hearing loss, and to compare results with data from previous studies.

STUDY DESIGN

A prospective multicenter registry was set up in 2007. Six centers participated in the development of a standardized protocol for diagnosis, treatment, and follow-up. Data were gathered in an online registry. Children (n = 379) with a documented cCMV infection and at least 2 separate audiologic evaluations were included. Audiometric results from a multicenter cohort study of children with cCMV infection with longitudinal observation were examined.

RESULTS

Results from 123 children with a symptomatic and 256 children with an asymptomatic cCMV infection were analyzed. In the group with symptomatic cCMV, 63% had hearing loss, compared with 8% in the group with asymptomatic cCMV. Delayed-onset hearing loss occurred in 10.6% of symptomatic cCMV and in 7.8% of asymptomatic cCMV. In the group with symptomatic cCMV, 29.3% of children used some kind of hearing amplification; 1.6% in the group with asymptomatic cCMV used hearing amplification.

CONCLUSIONS

Symptomatic and asymptomatic cCMV infections are a major cause of hearing loss in childhood. Reliable estimates of the long-term outcome of cCMV infection are mandatory to increase vigilance, especially among pregnant women and to draw attention to preventive measures, vaccine development, and prenatal and postnatal therapy. Universal screening of newborns for cCMV infection should be initiated and combined with longitudinal audiometric follow-up.

Predictive factors of speech understanding in adults with cochlear implants

OBJECTIVE

The aim of this study was to analyse the factors that influenced speech recognition scores in quiet conditions and speech reception threshold levels (SRT) in fixed noise conditions, after cochlear implant (CI) surgery in adults with postlinguistic deafness.

STUDY DESIGN

Combined retrospective and prospective study in a tertiary referral centre.

METHODS

We included 66 patients that received implants between 2002 and 2013. We retrospectively collected speech recognition scores and 14 demographic, audiological, and technical factors, including gender, age at implantation, aetiology, hearing loss progression, preoperative Pure Tone Average (PTA), hearing loss onset age and duration, duration and use of hearing aids (HAs); implantation in the best or worst ear; implantation on the right or left side; use of HA after implantation; and the duration and type of CI. We prospectively tested a subgroup of 21 patients for SRT in fixed noise.

RESULTS

The hearing loss duration significantly affected speech recognition scores in quiet conditions (H (4) = 10.567, p =0.032) and SRTs in fixed noise conditions (rs = 0.466, p = 0.033). The PTA of the better ear significantly affected only the SRT in fixed noise conditions (rs = 0.57 1, p = 0.007).

CONCLUSION

The duration of hearing loss and the PTA of the best ear had significant effects on the outcomes of speech recognition and SRT in quiet and fixed noise conditions, respectively. These findings are important for counselling CI candidates. Further studies in larger study populations are warranted.

Speech-in-noise testing as a marker for noise-induced hearing loss and tinnitus

Speech-in-noise testing as a marker for noise-induced hearing loss and tinnitus. Noise-induced hearing loss and tinnitus are auditory complaints that often co-occur. Often, there is no immediate indication of changes in the pure tone audiogram. Patients can still have clinically normal hearing thresholds while clearly experiencing reduced speech comprehension. This might be explained by the process of neurodegeneration of the innervated dendrites of the auditory nerve fibres and secondary degeneration of spiral ganglion neurons. Subsequent maladaptive neuronal plasticity of the central auditory system can induce tinnitus. Standard hearing testing is no longer sufficient in these patients. Therefore more complex tasks, such as speech-in-noise tests, might be valuable extensions to the standard hearing tests. We carried out a prospective investigation of the influence of tinnitus upon speech comprehension in noise and the effectiveness of speech-in-noise testing, using the Flemish version of the digit triplet test (DTT). Thirty-seven patients with mild noise-induced hearing loss, tinnitus complaints and clinically normal pure tone thresholds completed the DTT and filled in two tinnitus enquiries. A statistically significant (p=0.026) correlation between the averaged high PTA, 2,z and the averaged SRT across ears on the DTT was found. There also seems to be a slight influence of tinnitus onset on the SRT score.

Auditory neuropathy/dyssynchrony revisited

Auditory neuropathy/dyssynchrony (AN/AD) is a relatively, recently described diagnostic term. It describes a disorder characterised by detectable otoacoustic emissions and/or cochlear microphonics, combined with abnormal or absent auditory brainstem responses and deficient speech understanding. Consequently, the patient's cognitive responses are inconsistent with a behavioural tone audiogram. This review describes the epidemiology, pathogenesis, diagnosis, and treatment of AN/AD. We have focused on the diagnostic pathway, because diagnosis is sometimes difficult, and recent research has provided important insights into the aetiopathology of the disease. The diagnostic tools for AN/AD currently used in our department will be demonstrated in a clinical case. It is very important to recognise AN/AD and provide patient counselling and support as early as possible, due to the potentially major influence of this disorder on a patient's social life and language acquisition.

Aetiology of congenital hearing loss: a cohort review of 569 subjects

OBJECTIVE

Newborn hearing screening was implemented in Flanders about fifteen years ago. The aim of this study was to determine the aetiology of hearing loss detected by the Flemish screening programme.

METHODS

From 1997 to 2011, 569 neonates were referred to our tertiary referral centre after failed neonatal screening with Auditory Brainstem Responses. In case hearing loss (HL) was confirmed, further diagnostic testing was launched. A retrospective chart review was performed analysing the degree of HL, risk factor and aetiology.

RESULTS

Metabolic disorders (0.5%), infectious diseases (35.8%), congenital malformations (6.1%) and genetic abnormalities (19.8%), whether or not syndromic, were retained. In 35% of the subjects no obvious aetiology could be determined in the current study.

CONCLUSION

In contrast to the literature findings, this series shows a genetic syndromic cause in 80% of the genetic bilateral HL cases. On the other hand connexin positive diagnoses were mostly underrepresented in this study, showing the need for better screening.

Noise exposure of care providers during otosurgical procedures

OBJECTIVE

To monitor the noise exposure of care providers during otological surgery due to drilling and suction in the operating room.

METHODS

A clinical study monitoring different standard otosurgical procedures was conducted; cochlear implantation (CI), mastotympanoplasty, and mastoidectomy alone. Noise exposure to the surgeon and assistant were monitored with wireless personal noise dosimetry and stationary sound monitoring. Both maximum peak level in dBC (Lpeak) and time-average sound pressure level in dBA (equivalent level or Leq) were measured during drilling episodes. Frequency analysis in one third octaves covering the frequency bands 6.3 Hz to 20 k Hz was performed using a sound analyzing program.

RESULTS

When averaged over the entire procedure, the sound pressure level was highest for the surgeon and the assistant with values of 76.0 dBA and 72.5 dBA, respectively, during CI. Lpeak was 135.9 dBC. Leq for the stationary sound measurement was 74.2 dBA. During cortical bone work using a cutting burr, 84.6 dBA was measured. Mean values of L95% (estimation of the background noise) were between 55.8 dBA and 61.2 dBA. Frequency analysis showed the highest sound pressure level for all procedures was between 2.5 kHz and 3.15 kHz.

CONCLUSION

This is the first study to use personal sound dosimetry to monitor noise exposure during otosurgical drilling. In accordance with other studies, the results presented show sound levels below international occupational noise level regulations. However, the measured noise exposure during drilling could have negative effects on care providers based on unfavorable acoustical comfort.

Fifteen years of early hearing screening in Flanders: impact on language and education

OBJECTIVES

To assess the impact of fifteen years of universal neonatal hearing screening in Flanders on language development and the educational setting.

METHODOLOGY

An analysis of the database of Kind en Gezin from 1997 to 2012 and a long-term evaluation of the children referred to our centre after failed neonatal hearing screening. The CELF and PPVT language tests were performed.

RESULTS

Between 1997 and August 2012, bilateral hearing loss was confirmed in 2393 children in Flanders, of whom 11.4% were referred to our tertiary centre. The educational setting and language development of 84 children older than 5 years was evaluated and 54% of them had additional disabilities. Of the children without additional disabilities, 84% attended mainstream schools; 42% of children with additional disabilities entered mainstream education with additional support. There was a significant correlation between the number of additional disabilities and the education level (p < 0.001) and between the degree of hearing loss and educational placement (p < 0.001). Data on language development were available for 76% of the children and a significant correlation could be demonstrated only between the results of the PPVT language and the number of additional handicaps (p < 0.008).

CONCLUSIONS

The majority of children receiving early treatment after neonatal hearing screening enter mainstream education. The number of additional disabilities has a significant effect on education level and language development.

Long-term audiological follow-up of children with congenital cytomegalovirus

OBJECTIVE

To evaluate the audiological outcome of children with congenital cytomegalovirus infection.

METHODOLOGY

In a prospective study, the hearing of 98 congenitally cytomegalovirus-infected children born between January 2003 and July 2009 was systematically evaluated until the age of six using the Flemish CMV protocol. Symptomatic children with hearing loss at birth were treated with ganciclovir, if parents consented.

RESULTS

Seventy children passed initial screening, 28 had unilateral or bilateral hearing loss. In the normal hearing group, one asymptomatic and two symptomatic children developed late-onset hearing loss. Eight children in the group with hearing loss at birth received ganciclovir. Nine symptomatic and 11 asymptomatic children did not receive ganciclovir. In the treated group, 37.5% of the children had stable hearing loss, and 37.5% had progressive and/or fluctuating hearing loss. First progression or fluctuation always occurred after the age of one year. The hearing threshold improved in 25.0%. The improvement took place during or shortly after treatment. Hearing loss remained stable in 33.3% of the untreated symptomatic children, while progression or fluctuation occurred in 55.5%. In the asymptomatic group, hearing loss was most commonly stable (63.6%). The first change in the hearing threshold was almost always detected before the age of one year in both untreated groups.

CONCLUSIONS

Hearing loss caused by congenital cytomegalovirus infection cannot be defined unequivocally either with respect to the level of hearing loss or its evolution over time. Treating symptomatic children with ganciclovir leads to a better prognosis during the first year of life, after which progression or fluctuation again becomes more likely. However, overall, progression is more common in the untreated symptomatic group. Asymptomatic children with SNHL are more likely to have a stable hearing status.

Syndromic disorders in congenital hearing loss

OBJECTIVES

To investigate the aetiology of congenital hearing loss detected by the universal neonatal hearing screening programme (Algo) that was introduced in Flanders 15 years ago, and, more specifically, to investigate genetic causes.

METHODOLOGY

Diagnostic work-up of all children with confirmed hearing loss after referral by the Algo screening programme and screening at the neonatal intensive care unit (NICU) of our university hospital.

RESULTS

A hearing loss was confirmed in 505 of the 569 neonates (18% from NICU) referred between 1997 and 2011. After further examination, a genetic origin was identified in 84 (17%) of 100 children with a syndromic hearing loss. The most frequent syndromes are discussed.

CONCLUSION

A higher percentage of syndromic hearing loss was found than in the literature. This could be explained by the good cooperation with the human genetics department and the proportion of children retrieved from the neonatal intensive care unit.

Prevalence of risk factors for sensorineural hearing loss in NICU newborns

OBJECTIVES

The aim of this study was to determine the prevalence and significance of traditional risk factors associated with sensorineural hearing loss (SNHL) in a population of 615 neonates who attended the neonatal intensive care unit (NICU) of the University Hospital in Leuven, Belgium between January 2005 and December 2007.

METHODOLOGY

Auditory brainstem response (ABR) audiometry using 40 dB stimuli was performed in all 615 neonates. A retrospective medical database analysis was performed to evaluate the influence of 14 predetermined risk factors. The evaluated risk factors were ototoxic medication, hyperbilirubinemia, in utero infections (including CMV, rubella, syphilis, herpes, and toxoplasmosis), craniofacial anomalies, syndromes associated with SNHL, low birth weight (< 1,500 g), low Apgar score, mechanical ventilation lasting for 5 days or longer, bacterial meningitis, family history of hereditary childhood SNHL, endocranial hemorrhage, hypoxic ischemic encephalopathy, convulsions, and sepsis

RESULTS

Uni- or bilateral hearing impairment was diagnosed in 25 out of 615 neonates (4.1%). In utero infections (especially CMV), craniofacial anomalies, and syndromes known to include SNHL were significant risk factors. For the remaining risk factors, no significant correlation with SNHL was found.

CONCLUSIONS

In this study, only in utero infections (especially CMV), craniofacial anomalies, and syndromes known to include SNHL were significant risk factors associated with SNHL. Adequate management of hyperbilirubinemia and ototoxic drug administration may eliminate some of the major historical risk factors associated with SNHL in NICU neonates.

Intratympanic lidocaine instillation for Menière's disease

OBJECTIVES

We studied the role of intratympanic lidocaine instillation as part of the treatment for vertigo in Menière's disease.

METHODOLOGY

We retrospectively analyzed 40 patients who underwent 74 labyrinth anaesthesias in our center between 1996 and 2006. We studied the attack-free period after instillation, the effect of repetitive procedures and the efficacy according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (1995) criteria.

RESULTS

Labyrinth anaesthesia was effective in 70% of the studied procedures. If effective, the mean duration of the attack-free period was 12.6 months. Repetition was effective in 80.7% of the procedures if the previous procedure was effective as well. Two years after treatment 21 patients had AAO-HNS functional levels of 1 or 2 and 23 patients were class A or B.

CONCLUSION

Labyrinth anaesthesia is an effective treatment for Menière's disease and a useful tool for the control of symptoms. Repetitive instillation is effective especially when the previous instillation was also effective.

Latencies of auditory steady-state responses recorded in early infancy

Multiple-stimulus auditory steady-state responses (ASSRs) were assessed in 111 ears of 70 infants between -4 and 19 weeks of age at risk for hearing loss. ASSR thresholds obtained in infants with normal hearing (n = 69 ears) were compared with normal adult ASSR thresholds (n = 32 ears), and the linear relation between ASSR thresholds and behavioral thresholds (BHTs) was investigated in normal-hearing and hearing-impaired infants (n = 79 ears). Furthermore, latency estimates of significant responses to stimuli of 50 dB SPL were compared between the normal-hearing infants (n = 171 data points) and adults (n = 124 data points) and developmental changes in latency were evaluated within the infant group. Normal ASSR thresholds were on average 12 dB higher in infants compared with adults. Correlations between ASSR thresholds and BHTs were 0.75, 0.87, 0.87 and 0.79 for 500, 1000, 2000 and 4000 Hz, respectively. There was a significant effect of carrier frequency on ASSR latency, with higher carrier frequencies evoking shorter latencies in both infants and adults. Mean latencies in adults were 24.3 +/- 1.5, 22.3 +/- 1.1, 19.4 +/- 1.0 and 18.0 +/- 1.1 ms for 500, 1000, 2000 and 4000 Hz, respectively. Depending on the data fit of the infant latency estimates, mean latencies were 1.0 ms shorter or 9.5 ms longer in infants compared with adults. In infants, latencies were on average 2.0 ms longer in the youngest infant group (< or =0 weeks) relative to the oldest infant group (3-8 weeks). These age-related trends, together with other arguments, point to longer latencies in infants compared with adults. The results of this study are valuable as a clinical reference for interpreting ASSR results obtained in high-risk infants within their first months of life and indicate that developmental changes occur regarding ASSR latency.

Three-Year Postimplantation Auditory Outcomes in Children with Sequential Bilateral Cochlear Implantation

Objectives:

We report on the auditory abilities and speech performance in quiet and noise of 35 children with sequential bilateral cochlear implantation after 3 years of bilateral implant use.

Methods:

Testing was done in bilateral and both unilateral listening conditions. The assessments took place before the second implantation and at several time intervals after fitting. As different auditory tests were used, the children were categorized by their age at the second implantation: Younger or older than 6 years.

Results:

The pure tone averages for the bilateral condition were significantly better than those for either unilateral condition after 12 months of bilateral implant use and remained so from that test interval onward. The speech recognition outcomes in quiet and noise also improved significantly for almost all children after 36 months, although a linear regression analysis showed a beneficial effect of younger age at first implantation on the speech-in-noise results.

Conclusions:

Bilateral cochlear implantation offered advantages to all children in comparison with the first implant — Even the children who received the second implant after the age of 6 years. Compared to the younger children, the older children needed a longer adjustment period to gain bilateral benefit. However, they obtained similar results after 2 years of bilateral implant use.

Functional outcome of sequential bilateral cochlear implantation in young children: 36 months postoperative results

OBJECTIVE

To examine the effects of sequential bilateral cochlear implantation (CI) on the life of young children after 36 months of bilateral implant use.

METHOD

Thirty-five children were assessed prior to and 3 until 36 months after activation of the second CI. Main outcome measures were: the Categories of Auditory Performance (CAP), Speech Intelligibility Rating (SIR), communication mode, classroom placement, parent reports and the Würzburg questionnaire. Results were analysed separately for children younger and older than 6 years at the time of the second implantation.

RESULTS

At the 3-year test interval, 80% of the younger children attended mainstream schools and were comprehensible for all listeners. They all used oral communication and almost 70% of them could have a conversation over the telephone. After 3 years of bilateral implant use less than 50% of the older children obtained the highest score on the SIR and CAP. Approximately 70% of them was integrated in mainstream schools and used oral communication. All parents reported a more natural communication and an improved quality of life.

CONCLUSIONS

Sequential bilateral implantation seems to offer a wide range of participation benefits to all children and facilitates the social intercourse with their hearing environment.

Hearing benefits of second-side cochlear implantation in two groups of children

OBJECTIVE

To investigate the additional bilateral benefits of a second cochlear implant (CI) in a group of young children (<6 years of age) and a group of older children (>6 years of age).

METHOD

This is a Belgian tertiary multi-centre study in which 33 CI-children with a second implant between the age of 2 and 12 participated. Assessments took place pre-second implant and at several time intervals post-fitting on pure tone audiometry and speech recognition in quiet and noise (+10 dBSNR). Testing was done with the first and second implant alone and bilaterally. Results were analysed separately for children younger and older than 6 years at the time of implantation of the 2nd CI.

RESULTS

After 18 months of bilateral implant use all children obtained significantly higher hearing thresholds in the bilateral condition in comparison to both the unilateral conditions (p(CI1)=0.035/p(CI2)=0.042 for the younger children and p(CI1)=0.021/p(CI2)=0.007 for the older children). The speech recognition scores in quiet were for all children superior in the bilateral condition (p(CI2)=0.011 for the younger children and p(CI1)=0.016/p(CI2)=0.003 for the older children). In the noisy condition only significant bilateral better results were obtained in the group of younger children (p(CI1)=0.028/p(CI2)=0.034).

CONCLUSIONS

Bilateral cochlear implantation offers advantages to all children. Even for the children who received a second implant after the age of 6 a progress is determined after 18 months. However, the data appear to show a beneficial performance for those children who received their second implant before the age of 6, especially in the more challenging conditions.

Hyperbaric oxygen therapy for tinnitus

OBJECTIVE

To assess the effect of hyperbaric oxygenation on tinnitus.

METHODOLOGY

A Medline search from 1960-2007 yielding 22 studies.

RESULTS

No significant effect could be demonstrated in four prospective studies. Retrospective studies indicate greater improvement in tinnitus in acute cases (49-85%) compared with tinnitus episodes exceeding three months (34-38%). One study, however, showed significantly more improvement in patients with positive expectations before therapy (60.3%) compared with those with negative expectations (19%).

CONCLUSIONS

There are no significant data about the effect of hyperbaric oxygenation for tinnitus, but there are indications of a better effect in acute cases. However, a major psychological component and a low risk of enhancement of the tinnitus should be considered.

2′,5′-Oligoadenylate synthetase activity analysis and human papilloma virus typing as prognostic factors in patients with recurrent respiratory papillomatosis

Objective: Determination of early prognostic factors in patients with recurrent respiratory papillomatosis is extremely important, so the major goal of our prospective, multicentre study was to evaluate (1) the feasibility of various factors to determine prognosis of the clinical course,as well as (2) the response to interferon-alpha therapy in recurrent respiratory papillomatosis.

Methods: Forty-two patients with recurrent respiratory papillomatosis were treated with interferon-alpha (3 MU/m2 three times per week; mean therapy duration was 2.7 ± 1.8 years)in 1983–1994 and followed-up until 2003. Human papilloma virus (HPV) type, recurrent respiratory papillomatosis severity and 2′,5′-oligoadenylate synthetase activity were determined by standard methods and analysed for correlation with the results of long-term clinical outcome.

Results and conclusion: Patients with HPV type 11, a severity score >4, a high number of surgical procedures prior to interferon-alpha therapy and a high basal 2′,5′-oligoadenylate synthetase activity should be considered at high risk of an aggressive clinical course, often with spread to lower airway passages, malignant transformation and death. Human papilloma virus type, score for recurrent respiratory papillomatosis severity, number of surgical procedures and 2′,5′-oligoadenylate synthetase activity showed significant association with response to interferon-alpha therapy and the long-term clinical course, so these factors have value in predicting prognosis in recurrent respiratory papillomatosis.

Hyperbaric oxygen therapy after failure of conventional therapy for sudden deafness

PROBLEMS/OBJECTIVES

We investigated the effect of secondary hyperbaric oxygen therapy (HBO) for patients with idiopathic sudden sensorineural hearing loss after unsuccessful conventional treatment.

METHODOLOGY

We retrospectively evaluated 3 groups: 100 patients without further treatment (group 1), 160 patients with secondary HBO at 1.5 ATA (group 2), and 56 patients with secondary HBO at 2.5 ATA (group 3).

RESULTS

In group 1, a mean hearing gain (MHG) of 2.6 +/- 15 dB was found at the end of the follow-up period. After HBO, a MHG of 3.1 +/- 9 dB in group 2 and 19.7 +/- 23 dB in group 3 was achieved. The results in group 3 were statistically significant in comparison to group 1 (p < 0.007) and to group 2 (p < 0.009). With HBO after initial therapy failure, there is a significant correlation of MHG with time delay before HBO (p < 0.03).

CONCLUSIONS

HBO at 2.5 ATA in patients with idiopathic sudden sensorineural hearing loss after unsuccessful conventional treatment yields significant improvement of hearing. MHG is higher when time delay before HBO is shorter.

The middle ear of cleft palate patients in their early teens: a literature study and preliminary file study

OBJECTIVES

Middle ear disease is a frequent problem in young children with cleft palate (CP). Less is known about otological status in the adolescent CP population. The aim of this study is to provide an overview of current knowledge in the literature concerning the aetiology of middle ear disease in CP patients and the middle ear status of older children with CP, and to compare the situation in our centre to this background through an assessment of the otological status of patients in our CP population.

MATERIAL AND METHODS

A literature review was conducted to summarise current knowledge about middle ear status in CP patients. A retrospective analysis was performed of the medical records of 20 CP patients between the ages of 10 and 15 who were treated and followed at the University Hospitals Leuven. The available otological data, otoscopic findings, information about hearing and surgery performed was collected for each patient when aged three and above ten years.

RESULTS

Current knowledge indicates that middle ear function improves as CP patients get older. In our study, otoscopic appearance was acceptable in 63% of ears of children aged over ten years of age. Otitis media with effusion (OME) was far less frequent above this age than around the age of 3, with a decrease from 50% to 13% of all ears. Above the age of 10, tympanic perforations were present in 13% of ears and retraction of the tympanic membrane in 23%.

CONCLUSIONS

Despite a very high incidence of OME in young CP patients, the long-term otological prognosis is not necessarily sinister. A favourable natural evolution, diligent otological follow-up, early diagnosis and treatment of middle ear disease with the use of tympanostomy tubes are the likely contributors to the acceptable otological result in older CP patients.

Clinical application of dichotic multiple-stimulus auditory steady-state responses in high-risk newborns and young children

Experience with dichotic multiple-stimulus auditory steady-state responses (ASSRs) in clinical practice is described. ASSR thresholds were assessed in a sample of 60 high-risk newborns and young children between birth and 4 years of age. Amplitudes and signal-to-noise ratios (SNRs) of the ASSR were compared between normal-hearing infants and adults. Age-related changes within a group of infants younger than 3 months of age were investigated. A comparison was made between ASSR, the click-evoked auditory brainstem response and behavioral hearing thresholds in infants with a wide range of hearing threshold levels. Mean ASSR thresholds for normal-hearing infants at an average corrected age of 12 days were 42 +/- 10, 35 +/- 10, 32 +/- 10 and 36 +/- 9 dB SPL for 0.5, 1, 2 and 4 kHz, respectively. Compared to adults, these thresholds were elevated by on average 11 dB and SNRs were 1.7 times smaller. However, based on ASSRs, reasonably accurate estimations could be made of behavioral hearing thresholds obtained at a later age (median delay of 7 months). The predicted thresholds were in 61% of the cases within 10 dB of the corresponding behavioral thresholds, and in 83% of the cases within 15 dB. In less than 1 h, thresholds at four frequencies per ear could be obtained. The optimal age of testing is between 1 week and 3 months corrected age. The dichotic multiple-stimulus ASSR technique is a valuable extension of the clinical test battery for hearing-impaired children, as a follow-up diagnostic after the neonatal hearing screening.

Management of otitis media with effusion in children

Otitis media with effusion in children: B-ENT Guidelines. OME is highly prevalent among young children, with peak prevalences at around two and five years of age. Although serious complications are rare, the burden of OM is large with impaired quality of life and high direct and indirect socio-economic costs. To date, medical treatment of OME is not recommended because of the limited scientific evidence that this treatment is effective in the long term. Surgical candidacy for OME depends largely on hearing status, associated symptoms, the child's developmental risk and the anticipated chance of spontaneous resolution of the effusion. Ultimately, the recommendation for surgery must be individualized.

Jugular foramen schwannoma: surgical experience in six cases

PURPOSE

Schwannomas of the lower cranial nerves are rare tumours. We have surgical experience in six patients.

MATERIAL AND METHODS

We have retrospectively reviewed the files of the six patients with jugular foramen schwannomas that were treated in multidisciplinary collaboration in the departments of neurosurgery and ENT.

RESULTS

From a clinical point of view, the most important finding was that these tumours usually mimic a vestibular schwannoma. The imaging findings however always allowed the differentiation. The surgical technique included in all cases a suboccipital approach for the intracranial part. When large, the extracranial extension had to be removed through a lateral cervical or transfacial approach. There was no mortality and minor morbidity, with good functional outcome. In subtotally removed tumours, recurrence occurred.

CONCLUSION

A combined neurosurgical and ENT approach allows for safe removal of these often large skull base tumours.

Objective assessment of frequency-specific hearing thresholds in babies

OBJECTIVE

To report on clinical experience using dichotic multiple-stimulus auditory steady-state responses (ASSRs) as an objective technique to estimate frequency-specific hearing thresholds in hearing-impaired infants.

METHODS

A comparison was made between the click-evoked auditory brainstem response (ABR), auditory steady-state responses and behavioral hearing thresholds (BHTs). Both ears of 10 infants between 3 and 14 months of age were tested. ABR and ASSRs were recorded during the same test session. ABR was evoked by 100 micros clicks. ASSRs were evoked by amplitude- and frequency-modulated tones with carrier frequencies of 0.5, 1, 2 and 4 kHz and modulation frequencies ranging from 82 to 110 Hz. Eight signals (four to each ear) were presented simultaneously. ASSR thresholds were derived after separate recordings of approximately 5, 7.5 and 10 min to compare the influence of test duration. BHTs were defined in later test sessions as soon as possible after the ASSR test, dependent on medical and developmental factors.

RESULTS

For the subjects tested in this study 60% of ABR thresholds and 95% of ASSR thresholds for 1, 2 and 4 kHz were found at an average age of 7 months. Only 51% of frequency-specific BHTs could be obtained but on average 5 months later. The correlation of ABR thresholds and ASSR thresholds at 2 kHz was 0.77. The correlation of ASSRs and BHTs was 0.92. The mean differences and associated standard deviations were 4 +/- 14, 4 +/- 11, -2 +/- 14 and -1 +/- 13 dB for 0.5, 1, 2 and 4 kHz, respectively. The average test duration was 45 min for ABR (one threshold in both ears) and 58 min for ASSR (four thresholds in both ears). By reducing the duration of the separate recordings of ASSR, the precision of the hearing threshold estimate decreased and the number of outlying and missing values increased. Correlation coefficients were 0.92, 0.89 and 0.83 for recordings of maximum 10, 7.5 and 5 min, respectively. A compromise between test duration and precision has to be sought.

CONCLUSIONS

Multiple-frequency ASSRs offer the possibility to estimate frequency-specific hearing thresholds in babies in a time-efficient way.

Anxiety and mood disorders in otorhinolaryngology outpatients presenting with dizziness: validation of the self-administered PRIME-MD Patient Health Questionnaire and epidemiology

The aims of the study were to: 1) assess the validity of the mood and anxiety modules of the PRIME-MD Patient Health Questionnaire (PHQ) in otorhinolaryngology outpatients consulting with dizziness; and, 2) the prevalence of anxiety and mood disorders in these patients and in 3 subgroups based on of the cause of dizziness (Functional group, with psychogenic or hyperventilation factor; Organic group with an organic cause; Unspecified group without indication of organic or psychogenic cause). The PRIME-MD PHQ was completed by 268 consecutive outpatients. In 97 patients a psychiatric interview was performed. Operating characteristics indicated good criterion validity for the assessed modules of the PRIME-MD PHQ. Thirty five percent of the patients were diagnosed with "Any Anxiety or Depressive Disorder". In the Functional group, the prevalence of "Any Anxiety or Depressive Disorder" was significantly higher than in the Organic group (P<.0001) and than in the Unspecified group (P<.0001). In the Unspecified group, the prevalence of "Any Anxiety or Depressive Disorder" was significantly lower than in the Organic group (P =.007). Our findings support the criterion validity of the PRIME-MD PHQ for anxiety and depressive disorders in otorhinolaryngology outpatients with dizziness. Psychiatric disorders were highly prevalent and differences in psychiatric status between the different subgroups were demonstrated.