Five-Year Hearing Outcomes in Bilateral Simultaneously Cochlear-Implanted Adult Patients.

OBJECTIVE: To report the speech performance and sound localization in adult patients 5 years after bilateral simultaneous cochlear implantation and to evaluate the change in speech scores between 1 and 5 years. DESIGN: In this prospective multicenter study, 26 patients were evaluated 5 years after implantation using long straight electrode arrays (MED-EL Combi 40+, standard electrode array, 31 mm). Speech perception was measured using disyllabic words in quiet and noise, with the speech coming from the front and a cocktail party background noise coming from 5 loudspeakers. Speech localization measurements were performed in noise under the same test conditions. These results were compared to those obtained at 1 year reported in a previous study. RESULTS: Five years after implantation, an improvement in speech performance scores compared to 1 year after implantation was found for the poorer ear both in quiet and in noise (+12.1 ± 2.6%, p < 0.001). The lower the speech score of the poorer ear at 1 year, the greater the improvement at 5 years, both in quiet (r = -0.62) and at a signal-to-noise ratio of +15 dB (r = -0.58). The sound localization on the horizontal plane in noise provided by bilateral implantation was better than the unilateral one and remained stable after the results observed at 1 year. CONCLUSION: In adult patients simultaneously and bilaterally implanted, the poorest speech scores improved between 1 and 5 years after implantation. These findings are an additional element to recommend bilateral implantation in adult patients. The use of both cochlear implants and speech training sessions for patients with poor performance should continue in the period after 1 year following implantation, since the speech scores will improve over time.

Clinical evaluation of the xDP output compression strategy for cochlear implants.

Technological advances in the domain of digital signal processing adapted to cochlear implants (CI) are partially responsible for the ever-improving outcomes observed with this neural prosthesis. The goal of the present study was to evaluate audiometric outcomes with a new signal processing strategy implemented in Oticon Medical-Neurelec cochlear implant systems, the xDP strategy. The core of this approach is a preset-based back-end output compression system, modulating a multi-channel transfer function depending on the intensity and information content of input sounds. Twenty adult CI patients, matched for age and CI experience, were included in this study. Pure-tone thresholds and vocal audiometry scores were measured with their former signal processing strategy and with xDP. Speech perception was assessed using dissyllabic words presented in quiet, at different intensity levels: 40, 55, 70, and 85 dB SPL, and in a cocktail party noise at a signal-to-noise ratio of +10 dB. Results with the xDP strategy showed, as awaited, no major modification of pure-tone thresholds. A global increase of speech perception scores was observed after a 1-month habituation period, with significant improvements for speech perception in quiet for moderate (55 dB SPL), loud speech sounds (85 dB SPL), and speech-in-noise comprehension. Subjective signal quality assessment showed a preference for Crystalis(xDP) over the former strategy. These results allow the quantification of improvements provided by the xDP signal processing strategy.

The Voice Track multiband single-channel modified Wiener-filter noise reduction system for cochlear implants: patients' outcomes and subjective appraisal.

OBJECTIVE: The aim of this study was to evaluate the potential improvements of speech perception and sound quality provided by a multiband single channel noise-reduction algorithm based on the modified Wiener-filter adapted to cochlear implant sound processing. DESIGN: This study was a longitudinal trial with a repeated-measures design. Outcome measures were performed on the first day when the noise reduction feature was provided and after a one month habituation period. Objective measures included pure-tone thresholds and vocal audiometry assessments. Speech perception was measured in quiet and in the presence of two types of noise: a stationary speech shaped noise and a two-talker cocktail noise. Subjective sound quality was assessed using a ten item questionnaire. STUDY SAMPLE: Thirteen post-lingual deaf adults, experienced users of a cochlear implant system, took part in this study. RESULTS: The noise-reduction algorithm provided a benefit for the perception of speech presented in a stationary speech shaped noise and an overall improvement in subjective sound quality ratings. CONCLUSIONS: It was shown that a single channel noise reduction system based on a modified Wiener-filter approach can improve speech in noise perception performance and subjective sound quality in cochlear implant patients.

Predictive factors of cochlear implant outcomes in the elderly.

OBJECTIVE: To analyze predictive factors of cochlear implant outcomes and postoperative complications in the elderly. STUDY DESIGN: Prospective, longitudinal study performed in 10 tertiary referral centers. METHODS: Ninety-four patients aged 65-85 years with a profound, postlingual hearing loss were evaluated before implantation, at time of activation, and 6 and 12 months after cochlear implantation. Speech perception and lipreading were measured using disyllabic word recognition in quiet and noise, and lipreading using disyllabic words and sentences. The influence of preoperative factors on speech perception in quiet and noise at 12 months was tested in a multivariate analysis. Complications, presence of tinnitus and of vestibular symptoms were collected at each evaluation. RESULTS: The effect of age was observed only in difficult noisy conditions at SNR 0 dB. Lipreading ability for words and sentences was negatively correlated with speech perception in quiet and noise. Better speech perception scores were observed in patients with shorter duration of hearing deprivation, persistence of residual hearing for the low frequencies, the use of a hearing aid before implantation, the absence of cardiovascular risk factors, and in those with implantation in the right ear. General and surgical complications were very rare, and the percentage of vestibular symptoms remained stable over time. CONCLUSION: This study demonstrates that cochlear implantation in the elderly is a well-tolerated procedure and an effective method to improve communication ability. Advanced age has a low effect on cochlear implant outcome. Analyses of predictive factors in this population provide a convincing argument to recommend treatment with cochlear implantation as early as possible in elderly patients with confirmed diagnosis of a severe-to-profound hearing loss and with only limited benefit from hearing aid use in one ear.

Comparison between bilateral cochlear implants and Neurelec Digisonic(®) SP Binaural cochlear implant: speech perception, sound localization and patient self-assessment.

An alternative to bilateral cochlear implantation is offered by the Neurelec Digisonic(®) SP Binaural cochlear implant, which allows stimulation of both cochleae within a single device. The purpose of this prospective study was to compare a group of Neurelec Digisonic(®) SP Binaural implant users (denoted BINAURAL group, n = 7) with a group of bilateral adult cochlear implant users (denoted BILATERAL group, n = 6) in terms of speech perception, sound localization, and self-assessment of health status and hearing disability. Speech perception was assessed using word recognition at 60 dB SPL in quiet and in a 'cocktail party' noise delivered through five loudspeakers in the hemi-sound field facing the patient (signal-to-noise ratio = +10 dB). The sound localization task was to determine the source of a sound stimulus among five speakers positioned between -90° and +90° from midline. Change in health status was assessed using the Glasgow Benefit Inventory and hearing disability was evaluated with the Abbreviated Profile of Hearing Aid Benefit. Speech perception was not statistically different between the two groups, even though there was a trend in favor of the BINAURAL group (mean percent word recognition in the BINAURAL and BILATERAL groups: 70 vs. 56.7% in quiet, 55.7 vs. 43.3% in noise). There was also no significant difference with regard to performance in sound localization and self-assessment of health status and hearing disability. On the basis of the BINAURAL group's performance in hearing tasks involving the detection of interaural differences, implantation with the Neurelec Digisonic(®) SP Binaural implant may be considered to restore effective binaural hearing. Based on these first comparative results, this device seems to provide benefits similar to those of traditional bilateral cochlear implantation, with a new approach to stimulate both auditory nerves.

Multicenter evaluation of Neurelec Digisonic® SP cochlear implant reliability.

Over the past decade, the adoption of universal hearing screening in newborns has led to earlier detection of hearing problems and significant lowering of the age of first cochlear implantation. As a consequence, recipients are now expected to keep their cochlear implants (CIs) for a longer period of time. Comprehensive longitudinal information on CI reliability is essential for device choice. The aim of this study was to assess the reliability (in children and adults) of the latest generation of the Digisonic(®) SP CI launched in 2006 by Neurelec. Failure rate (FR) and cumulative survival rate (CSR) for a 5-year period were calculated. This survey is a multicenter retrospective study. A questionnaire was sent to nine CI centers requesting information about patients implanted with Neurelec Digisonic(®) SP CIs. FR and CSR over a 5-year period were calculated on this group. Collaborating centers collected data on 672 patients (362 children and 310 adults) implanted between March 2006 and March 2011. The overall rate of explantation was 2.23 % (15 cases): six devices were explanted due to device failure (0.89 %) and nine were explanted for medical reasons (1.34 %). Four patients were lost to follow-up. The CSR at 5 years was 98.51 % on all patients, 98.48 % for children and 98.57 % for adults. FR was 0.97 % for adults and 0.83 % for children. This first independent study that assesses FR and CSR on the current generation of Digisonic(®) SP CI represents an important resource that can help clinicians and patients during their device choice.

Speech performance and sound localization abilities in Neurelec Digisonic® SP binaural cochlear implant users.

In this prospective study the outcome of the Digisonic® SP Binaural cochlear implant (CI), a device enabling electric stimulation of both cochleae by a single receiver, was evaluated in 14 postlingually deafened adults after 12 months of use. Speech perception was tested using French disyllabic words in quiet and in speech-shaped noise at +10 dB signal-to-noise ratio. Horizontal sound localization in quiet was tested using pink noise coming from 5 loudspeakers, from -90 to +90° along the azimuth. Speech scores in quiet were 76% (±19.5 SD) in the bilateral condition, 62% (±24 SD) for the better ear alone and 43.5% (±27 SD) for the poorer ear alone. Speech scores in noise were 60% (±27.5 SD), 46% (±28 SD) and 28% (±25 SD), respectively, in the same conditions. Statistical analysis showed a significant advantage of the bilateral use in quiet and in noise (p < 0.05 compared to the better ear). Significant spatial perception benefits such as summation effect (p < 0.05), head shadow effect (p < 0.0001) and squelch effect (p < 0.0005) were noted. Sound localization accuracy improved significantly when using the device in the bilateral condition with an average root mean square of 35°. Compared with published outcomes of usual bilateral cochlear implantation, this device could be a valuable alternative to two CIs. Prospective controlled trials, comparing the Digisonic SP Binaural CI with a standard bilateral cochlear implantation are mandatory to evaluate their respective advantages and cost-effectiveness.

Multicenter evaluation of the digisonic SP cochlear implant fixation system with titanium screws in 156 patients.

OBJECTIVES: We describe and evaluate the process of fixation of the Digisonic SP cochlear implant with two titanium screws. METHODS: The characteristics of this implant allow cochlear implantation using a minimal incision, a subperiosteal pocket, and fixation with two titanium screws, without drilling a custom-fitted seat or creating suture-retaining holes in the skull. The fixation system relies on two tailfins for use of osseo-integratable screws, incorporated into the cochlear implant housing. The first version of this fixation system was modified after a case of device migration: the size of the titanium insert inside the silicone tailfin was increased. Data on 156 patients (8 months to 86 years of age) from a 4-year period in 6 cochlear implantation centers were retrospectively evaluated. Ten patients have undergone bilateral implantation. RESULTS: Of 166 implantations, 4 postoperative infections and 1 device failure after head trauma were reported. No cerebrospinal fluid leaks or epidural hematomas were reported. One device migration was observed in the first series; no device migrations occurred in the second series. CONCLUSIONS: The fixation system with screws embedded in the Digisonic SP involves a fast and simple surgical technique that seems to efficiently prevent implant migration.

Speech performance and sound localization in a complex noisy environment in bilaterally implanted adult patients.

OBJECTIVE: To evaluate speech performance, in quiet and noise, and localization ability in adult patients who had undergone bilateral and simultaneous implantation. STUDY DESIGN: Prospective multi-center study. METHODS: Twenty-seven adult patients with profound or total hearing loss were bilaterally implanted in a single-stage procedure, and simultaneously activated (Med-El, Combi 40/40+). Subjects were assessed before implantation and at 3, 6 and 12 months after switch-on. Speech perception tests in monaural and binaural conditions were performed in quiet and in noise using disyllabic words, with speech coming from the front and a cocktail party background noise coming from 5 loudspeakers. Sound localization measurements were also performed in background noise coming from 5 loudspeakers positioned from -90 degrees to +90 degrees azimuth in the horizontal plane, and using a speech stimulus. RESULTS: There was a bilateral advantage at 12 months in quiet (77 +/- 5.0% in bilateral condition, 67 +/- 5.3% for the better ear, p < 0.005) and in noise (signal-to-noise ratio +15 dB: 63 +/- 5.9% in bilateral condition, 55 +/- 6.9% for the better ear, p < 0.05). Considering unilateral speech scores recorded in quiet at 12 months, subjects were categorized as 'good performers' (speech comprehension score > or =60% for the better ear, n = 19) and 'poor performers' (n = 8). Subjects were also categorized as 'asymmetrical' (difference between their 2 unilateral speech scores > or =20%, n = 11) or 'symmetrical' (n = 16). The largest advantage (bilateral compared to the better ear) was obtained in poor performers: +19% compared to +7% in good performers (p < 0.05). In the group of good performers, there was a bilateral advantage only in cases of symmetrical results between the 2 ears (n = 10). In the group of poor performers, the bilateral advantage was shown in both patients with symmetrical (n = 6) and asymmetrical results (n = 2). In bilateral conditions, the sound localization ability in noise was improved compared to monaural conditions in patients with symmetrical and asymmetrical performance between the 2 ears. No preoperative factor (age, duration of deafness, use of hearing aids, etiology, etc.) could predict the asymmetrical performance, nor which ear would be the best. CONCLUSION: This study demonstrates a bilateral advantage (at 12 months after the implantation) in speech intelligibility and sound localization in a complex noisy environment. In quiet, this bilateral advantage is shown in cases of poor performance of both ears, and in cases of good performance with symmetrical results between the 2 ears. No preoperative factor can predict the best candidates for a simultaneous bilateral implantation.

Zinc protection against pneumolysin toxicity on rat cochlear hair cells.

Streptococcus pneumoniae can induce local and systemic diseases such as meningitis, otitis media, and pneumonia. One third of these meningitis cases can be associated with irreversible sensorineural hearing loss whose mechanisms likely involves the exotoxin pneumolysin (PLY) that irreversibly damages cochlear hair cells (HCs). In the respiratory system and in neuron it has been demonstrated that zinc deficiency increases severity and mortality of such infections in animal models and in children. Moreover, zinc supplementation can decrease the severity of pneumococcal respiratory infections. The aim of our study was to assess the potential protective effect of zinc against PLY toxicity on HCs in culture. Our results showed that in the presence of zinc at concentration as low as 1 microM, the toxicity of PLY was largely reduced by about 50% for both inner and outer HCs. At 300 microM of zinc, protection significantly increased with 62 and 55.2% for IHCs and OHCs, respectively. Our results suggest that the protective effect of zinc is likely due to an inhibition of the toxin incorporation and aggregation into the plasma membrane, thus preventing calcium influx through the toxin pores. Our findings raise the possibility that treatments with zinc may help to prevent debilitating otological sequelae from pneumococcal infection.

Antibodies to myelin protein zero (P0) protein as markers of auto-immune inner ear diseases.

BACKGROUND/AIMS: The inner ear can be the target of autoimmune disorders. Recognition of autoimmune inner ear disease is important, as it is one of the very few forms of sensorineural hearing loss (HL) that can be successfully treated by medical therapy. The aim of this study was to evaluate whether the detection of antibodies to myelin protein P0 (MPZ) could be a diagnostic test for inner ear disease of autoimmune cause. METHODS: This multicentric prospective study included 129 patients: patients with progressive sensorineural HL or with Menière's disease, together with their control group corresponding to patients with similar symptoms, but of presumably known origin. Detection of antibodies to myelin P0 protein was performed by using western blots. NORMAL: The prevalence of antibodies to myelin P0 protein in patients with rapidly progressive HL was not statistically different from that of the control group corresponding to genetic HL patients (30 versus 28%). In patients with Menière's disease, the prevalence was lower than that of the control group corresponding to patients with benign paroxysmal positional vertigo (5.4 versus 18.7%). No patient with auto-immune disease had antibodies to myelin P0 protein. CONCLUSIONS: The sole presence of antibodies to myelin P0 may not be used as a marker of inner ear disease of autoimmune origin.

Translation of the international outcome inventory for hearing aids into Portuguese from Portugal.

OBJECTIVE: To translate the International Outcome Inventory for Hearing Aids (IOI-HA) Questionnaire from English to Portuguese (from Portugal) and to validate this instrument of study on the Portuguese population. DESIGN: In this prospective study, a translation from English into Portuguese of the IOI-HA was performed, and linguistic adaptation and counter translation were also accomplished. The data were analysed for internal consistency testing for correlations between each individual item and the total score of the IOI-HA, assessing the Cronbach α and performing test-retest analysis. SETTING AND PARTICIPANTS: 80 hearing aid users aged 18 years or older were recruited from an ear, nose and throat (ENT) appointment in Coimbra's hospital, Portugal. 84% of the participants were unilateral hearing aid users, whereas 16% were bilateral users. INTERVENTIONS: The patients volunteered to answer the questionnaire during an ENT appointment. All of the patients had been using the hearing aids for more than 3 years.After the first application of the questionnaire, a new appointment was planned for retesting, within at least 7 days to no more than 60 days. 29 participants answered the questionnaire again according to the same procedure. RESULTS: The mean IOI-HA total score in the study population was 27.33±4.93 (9-35). The mean values obtained for each item of the questionnaire ranged from 3.19 to 4.54. The Cronbach α was 0.838 and the Cronbach α values when the item was removed, were also significantly strong. The test-retest analysis revealed no differences between the paired groups. CONCLUSIONS: In the present study a valid and reliable translation and adaptation of the IOI-HA into Portuguese from Portugal is proposed. This tool will be available for clinical assessment of hearing aid users.

Twenty years' experience in the treatment of acoustic neuromas with fractionated radiotherapy: a review of 45 cases.

PURPOSE: To evaluate very long-term results of fractionated radiotherapy (FRT) of acoustic neuromas (AN). METHODS AND MATERIALS: From January 1986 to January 2004, FRT was performed in 45 consecutive patients (46 AN). Indications were as follows: poor general condition contraindicating surgery, hearing preservation in bilateral neuromas, partial resection, nonsurgical recurrence. A 3-field to 5-field technique with static beams was used. A mean total dose of 51 Gy was given (1.80 Gy/fraction). The median tumor diameter was 31 mm (range, 11-55 mm). The median follow-up from FRT was 80 months (range, 4-227 months). RESULTS: The particularity of our series consists of a very long-term follow-up of FRT given to selected patients. Nineteen patients died, two with progressive disease, and 17 from non-AN causes. A serviceable level of hearing was preserved in 7/9 hearing patients. No patient had facial or trigeminal neuropathy. Tumor shrinkage was observed in 27 (59%) and stable disease in 16 (35%). Tumor progression occurred in three patients, 12 to 15 months after FRT. Two additional tumors recurred after shrinkage 20 and 216 months after treatment and were operated on. Actuarial local tumor control rates at 5 and 15 years were 86%. For the patient who had a tumor recurrence at 216 months, histologic examination documented transformation to a low-grade malignant peripheral nerve sheath tumor. CONCLUSION: Very long-term efficacy of FRT is well documented in this series. However, our results suggest that malignant transformation can occur many years after FRT so we advocate caution when using this treatment for young patients.

Outcome-based assessment of endolymphatic sac decompression for Ménière's disease using the Ménière's disease outcome questionnaire: a review of 90 patients.

OBJECTIVE: To evaluate the quality of life (QOL) of patients treated by endolymphatic sac decompression (ELSD) for Ménière's disease (MD) with a dedicated questionnaire, while recording the results of this surgery on vertigo attacks using the American Academy of Otolaryngology-Head and Neck Surgery criteria. STUDY DESIGN: Retrospective case review in a tertiary referral care center. MATERIAL AND METHODS: Ninety patients who have MD were treated by ELSD at our institution between 1986 and 2004. They were sent a 40-question Ménière's Disease QOL dedicated questionnaire (Ménière's Disease Outcome Questionnaire) concerning physical, mental, and social well-being. Five scores out of 100 were calculated (S1-S5): S3 for preoperative QOL score, S4 for postoperative QOL score, S5 for change in QOL score (S5 = S4 - S3), and S1 and S2 representing the answers to two other paired questions about the "overall" feeling of the patients. In parallel, results of ELSD on vertigo attacks and hearing were evaluated using the Academy of Otolaryngology-Head and Neck Surgery criteria. RESULTS: Fifty-nine interpretable answers (65.6%) to the Ménière's Disease Outcome Questionnaire were obtained from 28 men and 31 women (mean age, 56 yr and 9 mo), all suffering from "definite" MD. The mean S3 was 32.5 (range, 9.7-84.7), and the mean S4 was 60.8 (range, 0-98.6). Consecutively, S5 score was 28.3 (range, -34.7 to 77.4). QOL improved in 81.4% of cases with an average duration of follow-up of 57.5 months (range, 4-156 mo) (p < 0.001), worsened in 11.9% and was stable in 6.8%. There was no statistically significant difference as a function of sex (p = 0.7) or length of follow-up (p = 0.6). There was a significant correlation between S1 and S3 (p < 0.0001), and S2 and S4 (p < 0.0001), validating the whole questionnaire. In addition, 71% of satisfactory control of vertigo at 2 years postoperatively was noted. Hearing was improved or unchanged in 79% of cases at 3 months postoperatively. CONCLUSION: These results show that ELSD significantly improves the health of patients. It represents a first-line procedure that preserves the vestibular and afferent structures, unlike vestibular neurotomy and chemical labyrinthectomy, which may be indicated as a second line.

Validity and Reliability of the Hearing Handicap Inventory for Elderly: Version Adapted for Use on the Portuguese Population.

BACKGROUND: The use of the Hearing Handicap Inventory for the Elderly (HHIE) questionnaire enables us to measure self-perceived psychosocial handicaps of hearing impairment in the elderly as a supplement to pure-tone audiometry. This screening instrument is widely used and it has been going through adaptations and validations for many languages; all of these versions have kept the validity and reliability of the original version. PURPOSE: To validate the HHIE questionnaire, translated into Portuguese of Portugal, on the Portuguese population. RESEARCH DESIGN: This study is a descriptive correlational qualitative study. The authors performed the translation from English into Portuguese, the linguistic adaptation, and the counter translation. STUDY SAMPLE: Two hundred and sixty patients from the Ear, Nose, and Throat (ENT) Department of Coimbra University Hospitals were divided into a case group (83 individuals) and a control group (177 individuals). INTERVENTION: All of the 260 patients completed the 25 items in the questionnaire and the answers were reviewed for completeness. DATA COLLECTION AND ANALYSIS: The patients volunteered to answer the 25-item HHIE during an ENT appointment. Correlations between each individual item and the total score of the HHIE were tested, and demographic and clinical variables were correlated with the total score, as well. The instrument's reproducibility was assessed using the internal consistency model (Cronbach's alpha). RESULTS: The questions were successfully understood by the participants. There was a significant difference in the HHIE-10 and HHIE-25 total scores between the two groups (p < 0.001). Positive correlations can be seen between the global question and HHIE-10 and HHIE-25. In the regression study, a relationship was observed between the pure-tone average and the HHIE-10 (p < 0.001). Reliability of the instrument was proven by a Cronbach alpha index of 0,79. CONCLUSIONS: The HHIE translation into Portuguese of Portugal maintained the validity of the original version and it is useful to assess the psychosocial handicap of hearing impairment in the elderly.

Improvement of cognitive function after cochlear implantation in elderly patients.

IMPORTANCE: The association between hearing impairment and cognitive decline has been established; however, the effect of cochlear implantation on cognition in profoundly deaf elderly patients is not known. OBJECTIVE: To analyze the relationship between cognitive function and hearing restoration with a cochlear implant in elderly patients. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal study performed in 10 tertiary referral centers between September 1, 2006, and June 30, 2009. The participants included 94 patients aged 65 to 85 years with profound, postlingual hearing loss who were evaluated before, 6 months after, and 12 months after cochlear implantation. INTERVENTIONS: Cochlear implantation and aural rehabilitation program. MAIN OUTCOMES AND MEASURES: Speech perception was measured using disyllabic word recognition tests in quiet and in noise settings. Cognitive function was assessed using a battery of 6 tests evaluating attention, memory, orientation, executive function, mental flexibility, and fluency (Mini-Mental State Examination, 5-word test, clock-drawing test, verbal fluency test, d2 test of attention, and Trail Making test parts A and B). Quality of life and depression were evaluated using the Nijmegen Cochlear Implant Questionnaire and the Geriatric Depression Scale-4. RESULTS: Cochlear implantation led to improvements in speech perception in quiet and in noise (at 6 months: in quiet, 42% score increase [95% CI, 35%-49%; P < .001]; in noise, at signal to noise ratio [SNR] +15 dB, 44% [95% CI, 36%-52%, P < .001], at SNR +10 dB, 37% [95% CI 30%-44%; P < .001], and at SNR +5 dB, 27% [95% CI, 20%-33%; P < .001]), quality of life, and Geriatric Depression Scale-4 scores (76% of patients gave responses indicating no depression at 12 months after implantation vs 59% before implantation; P = .02). Before cochlear implantation, 44% of the patients (40 of 91) had abnormal scores on 2 or 3 of 6 cognition tests. One year after implant, 81% of the subgroup (30 of 37) showed improved global cognitive function (no or 1 abnormal test score). Improved mean scores in all cognitive domains were observed as early as 6 months after cochlear implantation. Cognitive performance remained stable in the remaining 19% of the participants (7 of 37). Among patients with the best cognitive performance before implantation (ie, no or 1 abnormal cognitive test score), 24% (12 of 50) displayed a slight decline in cognitive performance. Multivariate analysis to examine the association between cognitive abilities before implantation and the variability in cochlear implant outcomes demonstrated a significant effect only between long-term memory and speech perception in noise at 12 months (SNR +15 dB, P = .01; SNR +10 dB, P < .001; and SNR +5 dB, P = .02). CONCLUSIONS AND RELEVANCE: Rehabilitation of hearing communication through cochlear implantation in elderly patients results in improvements in speech perception and cognitive abilities and positively influences their social activity and quality of life. Further research is needed to assess the long-term effect of cochlear implantation on cognitive decline.

Vestibular schwannoma surgery outcomes: our multidisciplinary experience in 400 cases over 17 years.

OBJECTIVES/HYPOTHESIS: The aim of the study was to evaluate the incidence of short- and intermediate-term postoperative complications after vestibular schwannoma surgery. STUDY DESIGN: Retrospective review in a tertiary referral center. METHODS: In 400 patients who underwent surgical removal of vestibular schwannoma from 1984 to 2000,symptoms, preoperative evaluation, surgery, and postoperative complications were analyzed using standardized grading systems. RESULTS: One hundred ninety-four men and 206 women had an operation. Mean age was 53.9 years (age range, 11-78 y). Tumor size according to Koos stage was stage 1 in 39 cases, stage 2 in 122 cases, stage 3 in 87 cases, and stage 4 in 152 cases. Preoperatively, 7.5% of patients had facial nerve dysfunction. Surgical approaches were translabyrinthine in 229 patients, widened retrolabyrinthine in 128 cases, suboccipital in 42 cases, and transotic in 1 case. Mortality was 0.5%. Facial nerve was transected in 15 cases (3.7%) and immediately repaired in 5 cases. A delayed hypoglossal-to-facial nerve anastomosis was performed in 12 cases. At 1 year, House-Brackmann grade in 70.7% of patients was 1 to 2; in 24.3%, 3 to 4; and in 5%, 5 to 6. Poor facial nerve outcome was correlated with tumor size, preoperative irradiation, and nerve dysfunction and was not correlated with the approach used. Most patients had postoperative dizziness, and 30% still had vestibular disturbances after 1 year. Nine patients (2.2%) had a cerebrospinal fluid rhinorrhea, and 24 had a cerebrospinal fluid wound leak (6%). Twenty-two patients (5.5%) had postoperative meningitis. Two patients had a cerebellopontine angle hemorrhage, and three a brainstem infarct. CONCLUSION: Transpetrosal approaches (translabyrinthine, widened retrolabyrinthine) are safe for vestibular schwannoma removal, and rates of postoperative complications and sequelae are decreasing.

Congenital middle ear cholesteatomas in children: our experience in 34 cases.

OBJECTIVES: To evaluate clinical data, extensions, residual disease rate, and functional results in cases of congenital cholesteatoma in pediatric patients compared with cases of acquired forms. STUDY DESIGN AND SETTING: In a retrospective study conducted at a single tertiary care center over a decade, 34 congenital cholesteatomas (mean patient age, 6.6 years) isolated from a series of 215 cholesteatomas in children were treated surgically and followed up for an average of 83 months. Surgical treatment consisted of the closed technique (CT), open technique tympanoplasty in CT [TOT], radical mastoidectomy (RM), or Rambo's technique. The main outcome measures were surgical findings, residual lesion rate, and hearing assessment. RESULTS: The first surgical procedure was CT in 85.3%, TOT in 8.8%, RM in 2.9%, and Rambo's technique in 2.9% of patients. Two, 3, and 4 operations were necessary in 76.5%, 11.4%, and 11.4% of children, respectively. Residual lesions were observed in 34.6% of those multi-operated patients (7 CT and 2 TOT), 24.1% in those treated with CT, and 29.2% in those treated with CT with a planned second look. Mean postoperative pure tone average and air-bone gap were 26 and 21 dB, respectively. A speech reception threshold of less than 30 dB HL was achieved in 66% of patients. A total of 26 ossiculoplasties had to be performed (8 partial and 18 total); the mean postoperative air-bone gap was lower after the former (15 dB) than after the latter (22 dB). A high-frequency pure-tone hearing loss of more than 10 dB was uncommon (5.8%). Unsurprisingly, the residual lesion rate seems to be higher for congenital than for acquired cholesteatomas, but hearing results are significantly better. CONCLUSION: In most cases, staged CT appears to be the best technique to treat these lesions, which often develop in a well-pneumatized mastoid.

Prognostic value of the blink reflex in acoustic neuroma surgery.

OBJECTIVE: The study goal was to demonstrate that blink reflex analysis can predict postoperative facial nerve outcome in cerebellopontine angle tumor surgery. STUDY DESIGN, SETTING, AND PATIENTS: In an open and prospective study conducted at a single tertiary care center over 3 years, 91 subjects with a vestibular schwannoma filling the internal auditory meatus were enrolled and operated on via a translabyrinthine approach. The difference in latency of the early response (DeltaR1) of the blink reflex between the pathologic side and the healthy side was calculated in every patient during a complete electrophysiologic examination of the facial nerve performed on the day before surgery. MIN OUTCOME MEASURES: DeltaR1 was compared with the other preoperative data (tumor volume, facial function), with the perioperative observations (difficulties with the dissection of the facial nerve), and especially with the postoperative status after 1 year. The statistical study was conducted using polynomial regression. RESULTS: Patients with a negative or zero DeltaR1 have normal facial function at 1 year. For those with a positive DeltaR1 the outcome is not favorable unless the tumor is small. For patients presenting with an immediate complete facial paralysis, the value of DeltaR1 is also indicative of facial function outcome. CONCLUSION: Statistical analysis shows that the blink reflex, through DeltaR1, has an excellent prognostic value in anticipating the difficulties with facial nerve dissection and postoperative facial function after 1 year.

Surgery of cerebellopontine angle epidermoid cysts: role of the widened retrolabyrinthine approach combined with endoscopy.

OBJECTIVES: To evaluate the use of the retrolabyrinthine approach (RLA) combined with endoscopy with particular reference to preservation of cranial nerve function and completeness of excision in surgery of epidermoid cysts. METHODS: A retrospective study was performed on a series of 8 consecutive patients of whom 7 have undergone surgery. Main outcome measures Measures include audiological and neurological status preoperatively and postoperatively, size of the lesion, the surgical approach, completeness of excision, and operative morbidity. RESULTS: The tumors were all large, ranging from 2 x 3 cm to 6 x 6 cm. Presenting symptoms were headache (75%), dysequilibrium (62%), trigeminal nerve palsy (38%), abducens nerve palsy (25%), and, rarely, auditory symptoms. Seven patients underwent surgery, 5 by the RLA, 1 by a translabyrinthine approach (TLA), and 1 by a transcochlear approach. Complete excision was achieved in 5 of the 7 patients. A transtentorial approach was combined in 2 cases (1 RLA, 1 TLA). Endoscopy was used in 3 cases. It allowed a complete tumor excision. One case of keratinous meningitis was observed. Trigeminal nerve function returned to normal in all patients. Postoperative facial nerve function was grade I in 5 cases and grade III in 2 cases. Hearing was preserved in 3 cases as class A, 1 case as class B. In the 2 cases presenting with abducens nerve palsy preoperative symptoms were initially aggravated before returning to normal function by 1 year postoperatively. The RLA with endoscopy allowed less invasive surgery and preservation of hearing in 4 of the 5 cases where it was attempted. Tumor control appeared better than with the suboccipital approach. Mortality and postoperative morbidity also appear reduced. CONCLUSION: RLA combined with endoscopy should be considered as the standard approach for excision of epidermoid cysts. Extension of this approach into a TLA or transcochlear approach will depend on preoperative difficulties and preoperative hearing.