Otitis media in neonatal intensive care unit graduates: a 1-year prospective study.

A group of 46 high-risk infants (graduates of a neonatal intensive care unit) and 19 full-term infants were observed prospectively for middle ear status beginning at 40 weeks' postconceptional age. All infants were born to families living in low socioeconomic urban neighborhoods. Pneumootoscopy was used to determine the presence or absence of middle ear effusion during periodic medical and nonmedical visits throughout a 1-year period. Of all infants studied, 91% had at least one episode of otitis media with effusion during the observation interval. There were no differences in the percentages of visits during which high-risk and full-term infants experienced either normal middle ears bilaterally or otitis media with effusion in one or both ears. Furthermore, the age of onset of otitis media with effusion was similar for the two groups of babies. No differences were found between boys and girls in the age of onset for otitis media or in the percentage of visits at which otitis media with effusion was detected. Hispanic infants experienced their initial episode at significantly younger ages than did black infants in the sample. Both groups had similar percentages of visits attributable to otitis media with effusion during the observation period. The results indicate a high incidence among the infants studied and similar otologic courses for neonatal intensive care unit graduates and full-term infants during the first year of life.

Efficacy of ofloxacin and other otic preparations for otitis externa.

Ofloxacin otic is as effective in curing otitis externa in children (<12 years of age) as is the preparation combining polymyxin/neomycin plus hydrocortisone and as ciprofloxacin otic. Furthermore ofloxacin otic, as it requires less frequent dosing, is likely to encourage greater patient adherence and consequently to achieve a better cure rate than both of these treatment options. Because a number of cases of otitis externa are complicated by an undiagnosed tympanic membrane perforation, the lack of ototoxicity associated with ofloxacin otic makes it a particularly safe option for use in these patients.

Round window membrane delivery of L-methionine provides protection from cisplatin ototoxicity without compromising chemotherapeutic efficacy.

Cisplatin (cis-diamminedichloroplatinum(II) (CDDP)) is a widely used, highly effective, oncolytic agent that has serious ototoxic side-effects. To test the effectiveness of local delivery, of L-methionine (L-Met) as an otoprotective agent against CDDP ototoxicity, we used a rat model of a highly metastatic breast cancer tumor, i.e. Fisher 344 rats implanted with MTLn3 breast cancer cells. Four experimental groups were evaluated--I: untreated; II: CDDP-treated (three dosages); III: systemically-delivered L-Met + CDDP-treated; IV: locally delivered L-Met + CDDP-treated. The integrity of the outer hair cells (OHCs) was determined using scanning electron microscopy (SEM); hearing was assessed by recording auditory brainstem responses (ABRs) at multiple frequencies. The chemotherapeutic effectiveness of CDDP was quantified by measuring changes in tumor mass and the presence of tumor metastasis. L-Met provided otoprotection of the OHCs against CDDP toxicity in the cochleae of rats following either systemic (III) or local (IV) administration. The ABRs were unchanged in each of the L-Met protection Groups (III and IV) and in the untreated animals of Group I. Treatment with CDDP only (II) induced significant hearing losses at both 16 and 18 kHz when compared to ABRs of untreated rats(I). CDDP was effective in controlling the MTLn3 initiated breast cancer tumors in the CDDP-treated (II) and the local L-Met protection, CDDP-treated (IV) Groups. In contrast, the tumors in the systemic L-Met protection, CDDP-treated Group (III) were not controlled by the CDDP treatment regime. This study demonstrates that local delivery of L-Met to the scala tympani of the cochlea via the round window membrane (IV) provides effective protection against CDDP ototoxicity without compromising its ability to control a highly metastatic form of cancer.

The fate mapping of the eleventh and twelfth day mouse otocyst: an in vitro study of the sites of origin of the embryonic inner ear sensory structures.

An experiment was undertaken to determine which sensory structures of the mouse embryo inner ear developed from what portion of the mouse otocyst. Otocysts of gestation days 10, 11, 12, and 13 were divided by surgical dissection into six anatomical groups: dorsal, ventral, anterior, posterior, medial and lateral halves. They were organ cultured separately. After a period of ten days, the explanted tissues were harvested and processed histologically for microscopic analysis. The surgical control specimens fixed at the time of explantation were composed of undifferentiated ectodermal cells for tissues of gestation days 10, 11, and 12. Otocysts of gestation days 11, and 12 showed, during the course of their subsequent growth, that the three semicircular ducts and their associated cristae developed from the dorsal and lateral halves. Only the anterior and posterior canals and cristae originated from the medial portion. The posterior half gave rise to the posterior crista and the anterior half provided for the development of the anterior and lateral cristae. The cochlear duct and its sensory epithelium developed in all the anatomical groups except the dorsal half. The utricle developed in the dorsal section of the middle third of the otocyst, while the utricular macula developed in the anterior half of the same section of the otocyst. The saccule and its macula differentiated from the ventral section of the middle third of the anterior half.

Redefining the survival of the fittest: communication disorders in the 21st century.

OBJECTIVES: To determine the economic effect on the US economy of the cost of caring for people with communication disorders as well as the cost of lost or degraded employment opportunities for people with such disorders, including disorders of hearing, voice, speech, and language. STUDY DESIGN: Survey of available historical and contemporary governmental and scholarly data concerning work force distribution and the epidemiology of disorders of hearing, voice, speech, and language. METHOD: Analysis of epidemiological and economic data for industrialized countries, North America, and the United States. RESULTS: Communication disorders are estimated to have a prevalence of 5% to 10%. People with communication disorders may be more economically disadvantaged than those with less severe disabilities The data suggest that people with severe speech disabilities are more often found to be unemployed or in a lower economic class than people with hearing loss or other disabilities. Communication disorders may cost the United States from $154 billion to $186 billion per year, which is equal to 2.5% to 3% of the Gross National Product. CONCLUSIONS: Communication disorders reduce the economic output of the United States, whose economy has become dependent on communication-based employment. This trend will increase during the next century. The economic cost and the prevalence rates of communication disorders in the United States indicate that they will be a major public health challenge for the 21st century.

Serous otitis media associated with sensorineural hearing loss in children.

The effect of a conductive hearing loss secondary to serous otitis media in children with sensorineural hearing loss was seen to be an increase in threshold and in one case a decrease in speech discrimination. The diagnosis of the conductive component can be made by means of measurement of impedance, middle ear pressure, the recording of a tympanogram and otoscopy. It is likely that a conductive component can lead to delay in the diagnosis of an underlying sensorineural hearing loss in some children which could result in exacerbation of speech and language deficits. Correction of the conductive component can convert a profound hearing loss to a severe hearing loss, or a severe hearing loss to a moderate hearing loss, and it may also increase speech discrimination.

Patterns of anomalies in children with malformed ears.

Sixteen children with anomalies of the auricle and/or middle ear who presented malformations of the face, mouth, upper airway, spine, limbs, heart, gastrointestinal (GI), and/or genitourinary (GU) systems, were described. While clusters of anomalies suggested syndromes such as the oculo-auriculo-vertebral syndrome of Goldenhar, hamifacial microsomia, mandibulo-facial dysostosis (Treacher Collins syndrome), Pierre Robin, Klippel-Feil, Moebius, Duane, and/or VATER syndromes, many children did not fit what are usually considered even minimal criteria for these syndromes. Several children had malformations which fit the description of more than one syndrome. The importance of investigating the children for unsuspected anomalies, especially of the GU system, was emphasized. Life threatening problems in this group consisted of airway problems, congenital heart disease, and major anomalies of the GI and GU systems. Better management of sucking, swallowing and airway problems might have decreased the early morbidity and mortality (3/16) in this group. Children with multiple defacing anomalies may not be mentally retarded so that aggressive management of their visceral anomalies and hearing problems, and early educational intervention are mandatory. Delay in development may be due to hearing loss, vestibular impairment, ataxia, the consequences of early malnutrition, and multiple hospitalizations rather than to mental retardation. A pessimistic attitude in infancy is unwarranted since it is impossible to predict which children will end up competitive individuals.

Radiation induced carcinoma of the temporal bone.

This report presents a case of squamous cell carcinoma of the temporal bone induced by high dose radiation therapy. Several important surgical techniques are stressed which serve to make this procedure far safer in the avoidance of catastrophic hemorrhage.

Assessment of efficacy of intervention in hearing impaired children with speech and language deficits.

The diagnosis of hearing loss in children with speech and language deficits by the otorhinolaryngologist involves a large allocation of sources. The ability to assess the efficacy of intervention in order to minimize speech and language deficits is an aspect in the care of these children which has not been generally considered as part of the child's ongoing medical care. These children have speech and language deficits predominantly from hearing impairment and occasionally from a primary language disorder. The effect of intervention (usually a hearing aid), the special education program for the hearing impaired child, and the language therapy for the child with a primary language disorder are seldom measured. The ability to assess and monitor the child's progress is essential for the care of these patients. The continual monitoring of the child's progress is accomplished by periodic assessment of the child's speech and language. An instrument to do this has been developed and used by the Department of Otorhinolaryngectomy at the Albert Einstein College of Medicine for a number of years. The utilization of this instrument, as demonstrated by a series of case reports, will be presented. These will include children in which intervention was successful and those for whom it was unsuccessful, with an analysis of the reasons underlying the effectiveness for each child. It is recommended that every child with a speech and language deficit should be monitored periodically so that the child's progress, or lack of progress, can be determined. If the child is not progressing, additional remediation can be instituted to attempt to prevent a permanent speech and language deficiency.

Otitis media, auditory sensitivity, and language outcomes at one year.

The relationship among otitis media, auditory sensitivity, and emerging language was examined in a group of 1-year-old children who were prospectively followed since birth. Pneumatic otoscopy was used to document the otologic status of the children's ears at each medical visit. There were 13 babies with normal ratings in each ear at 80% more of their visits (designated as "otitis free") and 12 babies with bilaterally positive otoscopy results at 30% or more of their first year visits (designated "otitis positive"). In comparison to the otitis free infants, the group of otitis positive babies demonstrated reduced auditory sensitivity as measured by auditory brain stem response (ABR) and poorer expressive language abilities. However, differences in receptive language were not detected. These results suggest that otitis media may have an impact on auditory sensitivity and developing language as early as 1 year of age.

Language screening as a factor in the management of the pediatric otolaryngic patient. Effectiveness and efficiency.

The Early Language Milestone Scale, a screening test for language in children from birth to 36 months of age, was applied to the total population of pediatric otolaryngic patients. Ninety-seven percent of the patients were found to have a completed screen. Thirty percent of the patients failed one or more portions of the Early Language Milestone screen. Practice management was modified by the results of the Early Language Milestone in all the patients who failed the screen. The Early Language Milestone was found to be efficient and effective in contributing to the management of the children with pediatric otolaryngic disorders and diseases.

Evidence of abnormal stromelysin mRNA expression in suspected carriers of otosclerosis. A possible molecular marker.

OBJECTIVE: There is strong evidence that otosclerosis is a genetic disease affecting bone remodeling. We propose that, if otosclerosis is genetic, it will manifest itself universally, particularly at the mRNA transcription level. DESIGN: Skin biopsy specimens were taken in a single blind from human subjects who had been clinically and surgically identified as having otosclerosis. SETTING: Subjects were volunteers from the community, identified through hospital records. All procedures were carried out in a clinical research facility. PATIENTS: Twenty-one volunteers underwent a biopsy, including those positively identified as having otosclerosis (n = 4), their blood relatives (n = 8), or nonrelatives with normal hearing and no known history of otosclerosis (n = 9). INTERVENTION: Three connective tissue remodeling factors, procollagenase, prostromelysin, and tissue inhibitor of metalloprotease, were analyzed. The mRNA was extracted from each biopsy specimen, hybridized against radiolabeled cDNA, and quantitatively measured by radioautography. MAIN OUTCOME MEASURE: We expected to see significant differences in the pattern of mRNA expression for one or more of the three measured bone remodeling factors in otosclerotics, compared with age- and sex-matched negative controls. RESULTS: Two of the otosclerotic subjects had abnormally low levels of mRNA for prostromelysin and two had higher than normal levels. In three (75%) of the four, variability of mRNA expression among procollagenase, prostromelysin, and metalloprotease tissue inhibitor was higher than normal. Three (38%) of the eight relatives showed a similar pattern and two (22%) of the nine control subjects also tested as abnormal. CONCLUSION: This observed variability in otosclerotic subjects might be a manifestation of a genetic control defect, and abnormal stromelysin mRNA expression could serve as a genetic marker for otosclerosis.

Acute Streptococcus pneumoniae meningogenic labyrinthitis. An experimental guinea pig model and literature review.

OBJECTIVE: To create an experimental model of Streptococcus pneumoniae type 3 meningogenic labyrinthitis (a leading cause of deafness) similar to that in human disease. DESIGN: Cohort analytic study of guinea pigs that were inoculated intrathecally with varying dilutions of S pneumoniae type 3; the progress of the disease was compared with that in saline solution-inoculated control animals. SUBJECTS: Healthy adult Hartley guinea pigs without clinical evidence of middle ear disease that were conveniently sampled. INTERVENTIONS: Intrathecal inoculation of 10(4) to 10(6) colony-forming units of S pneumoniae type 3 into 13 guinea pigs; signs and symptoms of meningitis/labyrinthitis were observed for 15 days and compared with those in two saline solution-inoculated control animals. MAIN OUTCOME MEASURES: Morbidity--labyrinthitis, meningitis; end point--death. RESULTS: The 10(4) to 10(6) colony-forming units of S pneumoniae type 3 caused inflammation that extended from the meninges to the inner ear via the cochlear aqueduct within 3 days after inoculation; a dose of 10(7) killed animals within 12 hours after inoculation. Three of five animals that were inoculated with a 10(6) dose died 3 days after inoculation; two of three animals that were inoculated with a 10(5) dose lived to 15 days after inoculation. One of two animals that were inoculated with a 10(4) dose did not become infected. Inflammation extended to the middle ear by round-window destruction. Reactive bone formation simulated labyrinthine osteosclerosis. Observers assessed histologic slides "blindly." CONCLUSION: Guinea pigs can survive 15 days after intrathecal inoculation of a 10(5) dose, with morphologic features similar to those in human disease. This is an effective model for this study of meningogenic labyrinthitis.

Communicative disorders. The first year of life.

Disorders of communication have high incidence and prevalence in the fetus, neonate, and infant, and optimal care is dependent on early recognition and intervention. This article reviews receptive disorders, expressive disorders, and their diagnoses.

Rhinorrhea and pneumocephalus after cerebrospinal fluid shunting. The role of lateral extensions of the sphenoid sinus.

Pneumocephalus is usually seen after trauma or neurologic surgery. A rare presentation is after cerebrospinal fluid (CSF) shunting for rhinorrhea. This may be a manifestation of shunt malfunction or of the failure to close a preexisting fistulous tract. A common site of failure is the sphenoid sinus, where CSF may leak from a dehiscence in the middle cranial fossa floor. These dehiscences often communicate with lateral extensions of the sphenoid. This complication is best managed by craniotomy with direct inspection of the floor of the middle cranial fossa and correction of deranged CSF dynamics.

Cerebrospinal fluid dynamics and rhinorrhea: the role of shunting in repair.

CSF rhinorrhea can have many causes: traumatic, neoplastic, and iatrogenic origins are common. Most traumatic rhinorrhea ceases after a trial of conservative management. While obvious erosion or traumatic destruction of vital structures may be the underlying cause, other pathophysiologic mechanisms may be working in the formation of CSF rhinorrhea, which may require the combined skills of the otolaryngologist and the neurosurgeon. Leakage of CSF is seen in "high-pressure rhinorrhea," a pathophysiologic state wherein the underlying problem is poor CSF resorption. The result is increased intracranial pressure and eventual rhinorrhea or otorrhea. Areas of CSF leakage correspond to sites of congenital weakness in the cribriform plate region, the parasellar region, or the temporal bone. Weak areas in old base-of-skull fracture sites may leak with increased intracranial pressure. The initial management should stress correction of the deranged pathophysiology, namely shunting. Surgical repair is secondary to controlling the abnormal CSF dynamics.

Hypernasal speech following adenotonsillectomy.

Extensive study of 120 patients with hypernasal speech following adenotonsillectomy showed that 48 had no evidence of abnormal speech prior to surgery and 41 had minor speech anomalies exacerbated postoperatively. Thirty-five patients had the classical stigma of submucous cleft palate and another 20 had occult submucous clefts. Fifty-seven of the patients had adenotonsillectomies because of recurrent middle ear effusions, but in the majority of these cases, recurrent middle ear disease continued even after surgery, probably secondary to palatal abnormalities.

Effects of recurrent middle ear effusion in preschool years on language and learning.

Eighteen healthy 8- to 11-year-old children with normal hearing and histories of recurrent middle ear effusion (MEE) before the age of 5 years were evaluated by a battery of audiologic, psychologic, language, and achievement tests. Each of these children was compared to a non-MEE sibling who was tested at the same age. None of the children had been diagnosed as learning disabled. Both groups tested in the bright normal range of verbal ability on the WISC-R. Paired comparison of sibling data revealed that the MEE subjects had deficits in verbal ability, auditory decoding, and spelling skills compared with control siblings. Significant strength in visual sequential memory in the MEE subjects suggests that the availability of compensatory strategies for auditory deficits in these subjects. Sex and/or birth order differences did not explain the differences observed between siblings.

Otitis media, communication style of primary caregivers, and language skills of 2 year olds: a preliminary report.

The association between early otitis media, styles of primary caregivers, and language development was prospectively examined in 26 2-year-old children from lower socioeconomic backgrounds (of mixed perinatal status) followed prospectively since birth. Based on otoscopic evaluations during the first year of life, there were 14 children who were classified as bilaterally otitis-free (OM-) and 12 children who were classified as bilaterally otitis-positive (OM+). At 2 years of age, all children were administered standardized measures of cognitive and language function along with a 20-minute videotaped play session with one of their primary caregivers. The language of both the children and caregivers was analyzed. Results indicate that caregivers of OM+ and OM- children used language nearly identically when interacting with their children. However, caregivers of OM+ children whose communication style was marked by a high percentage of directives and a corresponding low percentage of both questions and information-giving had the children with the lowest scores on all measures of naturalistic language. Controlling for neonatal illness did not alter the relationships found. The results suggest that caregiver language may compensate for some of the auditory deprivations associated with otitis media.

Auditory brain stem responses to bone-conducted tones in infants.

The auditory brain stem responses (ABRs) to 500- and 2,000-Hz bone-conducted (BC) tones were recorded from 48 infants with ears exhibiting various external and middle ear states (normal, otitis media, auditory meatal atresia). Amplitudes were greater, wave V latencies longer, and detectability better for responses to 500-Hz BC tones compared to 2,000-Hz BC tones. Overall, most (94% to 100%) infants with normal cochlear sensitivity demonstrate ABRs to 20-dB normal hearing level (nHL) 500-Hz BC tones and 30-dB nHL 2,000-Hz BC tones. In cases in which masking is difficult (eg, bilateral atresia), infant ipsilateral/contralateral ABR asymmetries may help determine from which cochlea a response to the BC tones originates. In conclusion, two-channel ABR recordings to BC tones appear to be feasible for demonstrating normal cochlear sensitivity in infants.