Complication from hearing aid mold material: a case report and review of legal matters.

Ear mold impression middle ear foreign bodies are a rare complication of hearing aid fitting. Only a small number of cases have been reported; however, the actual incidence is unknown and likely much higher than expected. We present the case of a 77-year-old man with a history of preexisting tympanic membrane perforations who presented with an ear mold impression middle ear foreign body that required surgical removal. We explore the state and federal laws that guide the interaction between patients, hearing aid sellers and otolaryngologists. We highlight steps that can be taken to reduce the incidence of this complication.

Eye movements reset visual perception.

Human vision uses saccadic eye movements to rapidly shift the sensitive foveal portion of our retina to objects of interest. For vision to function properly amidst these ballistic eye movements, a mechanism is needed to extract discrete percepts on each fixation from the continuous stream of neural activity that spans fixations. The speed of visual parsing is crucial because human behaviors ranging from reading to driving to sports rely on rapid visual analysis. We find that a brain signal associated with moving the eyes appears to play a role in resetting visual analysis on each fixation, a process that may aid in parsing the neural signal. We quantified the degree to which the perception of tilt is influenced by the tilt of a stimulus on a preceding fixation. Two key conditions were compared, one in which a saccade moved the eyes from one stimulus to the next and a second simulated saccade condition in which the stimuli moved in the same manner but the subjects did not move their eyes. We find that there is a brief period of time at the start of each fixation during which the tilt of the previous stimulus influences perception (in a direction opposite to the tilt aftereffect)--perception is not instantaneously reset when a fixation starts. Importantly, the results show that this perceptual bias is much greater, with nearly identical visual input, when saccades are simulated. This finding suggests that, in real-saccade conditions, some signal related to the eye movement may be involved in the reset phenomenon. While proprioceptive information from the extraocular muscles is conceivably a factor, the fast speed of the effect we observe suggests that a more likely mechanism is a corollary discharge signal associated with eye movement.

Clinical and genomic signatures of SARS-CoV-2 Delta breakthrough infections in New York.

BACKGROUND: In 2021, Delta became the predominant SARS-CoV-2 variant worldwide. While vaccines have effectively prevented COVID-19 hospitalization and death, vaccine breakthrough infections increasingly occurred. The precise role of clinical and genomic determinants in Delta infections is not known, and whether they contributed to increased rates of breakthrough infections compared to unvaccinated controls. METHODS: We studied SARS-CoV-2 variant distribution, dynamics, and adaptive selection over time in relation to vaccine status, phylogenetic relatedness of viruses, full genome mutation profiles, and associated clinical and demographic parameters. FINDINGS: We show a steep and near-complete replacement of circulating variants with Delta between May and August 2021 in metropolitan New York. We observed an increase of the Delta sublineage AY.25 (14% in vaccinated, 7% in unvaccinated), its spike mutation S112L, and AY.44 (8% in vaccinated, 2% in unvaccinated) with its nsp12 mutation F192V in breakthroughs. Delta infections were associated with younger age and lower hospitalization rates than Alpha. Delta breakthrough infections increased significantly with time since vaccination, and, after adjusting for confounders, they rose at similar rates as in unvaccinated individuals. INTERPRETATION: We observed a modest adaptation of Delta genomes in breakthrough infections in New York, suggesting an improved genomic framework to support Delta's epidemic growth in times of waning vaccine protection despite limited impact on vaccine escape. FUNDING: The study was supported by NYU institutional funds. The NYULH Genome Technology Center is partially supported by the Cancer Center Support Grant P30CA016087 at the Laura and Isaac Perlmutter Cancer Center.

Rethinking Surge Preparedness After COVID-19: Effective Patient Load Balancing Within Health Systems and Beyond.

Within weeks of New York State's first confirmed case of COVID-19, New York City became the epicenter of the nation's COVID-19 pandemic. With more than 80,000 COVID-19 hospitalizations during the first wave alone, hospitals in downstate New York were forced to adapt existing procedures to manage the surge and care for patients facing a novel disease. Given the unprecedented surge, effective patient load balancing-moving patients from a hospital with diminishing capacity to another hospital within the same health system with relatively greater capacity-became chief among the capabilities required of New York health systems. The Greater New York Hospital Association invited members of downstate New York's 6 largest health systems to talk about how each of their systems evolved their patient load balancing procedures throughout the pandemic. Informed by their insights, experiences, lessons learned, and collaboration, we collectively present a set of consensus recommendations and best practices for patient load balancing at the facility and health system level, which may inform regional approaches to patient load balancing.

The first new otologic disorder in a century: superior canal dehiscence syndrome.

Superior canal dehiscence syndrome is a recently described vestibular and hearing condition caused by an absence of bone over the arc of the superior semicircular canal. Patients with the condition present with a variety of perplexing symptoms including conductive hearing loss, hyperacusis, vertigo, autophony, and eye movement in response to sound. This article presents the case of a patient with the condition, discusses how it is distinct from other vestibular and hearing disorders, and describes how patients with this disorder can be diagnosed and treated.

Clinical and genomic signatures of rising SARS-CoV-2 Delta breakthrough infections in New York.

In 2021, Delta has become the predominant SARS-CoV-2 variant worldwide. While vaccines effectively prevent COVID-19 hospitalization and death, vaccine breakthrough infections increasingly occur. The precise role of clinical and genomic determinants in Delta infections is not known, and whether they contribute to increased rates of breakthrough infections compared to unvaccinated controls. Here, we show a steep and near complete replacement of circulating variants with Delta between May and August 2021 in metropolitan New York. We observed an increase of the Delta sublineage AY.25, its spike mutation S112L, and nsp12 mutation F192V in breakthroughs. Delta infections were associated with younger age and lower hospitalization rates than Alpha. Delta breakthroughs increased significantly with time since vaccination, and, after adjusting for confounders, they rose at similar rates as in unvaccinated individuals. Our data indicate a limited impact of vaccine escape in favor of Delta's increased epidemic growth in times of waning vaccine protection.

Hazardous noise exposure from noisy toys may increase after purchase and removal from packaging: A call for advocacy.

OBJECTIVE: Previous studies identified hazardous noise levels from packaged toys. Sound levels may increase when packaging is removed and therefore, complicate the ability to accurately assess noise levels before purchase. The goal of this study was to evaluate how packaging affects the decibel (dB) level of toys by: 1) Assessing dB level of toys with and without packaging. 2) Evaluating the percentage of packaged and unpackaged toys that exceed a safety limit of 85 dB. METHODS: Thirty-five toys were selected from the 2009-2011 Sight and Hearing Association (SHA) based on availability for purchase. Toys' speakers were categorized as Exposed, Partially Exposed, or Covered, based on its packaging. The dB level of each toy was tested at 0 cm and 25 cm from the speaker using a handheld digital sound meter in a standard audiometric booth. T tests and ANOVA were performed to assess mean change in sound level before and after packaging removal. RESULTS: Significant dB increases were noted after packaging was removed (mean change 11.9 dB at 0 cm; and 2.5 dB at 25 cm, p < 0.001). Sixty-four percentage of Covered toys (n = 14) had dB greater than 85 dB when packaged and this increased to 100% when unpackaged. CONCLUSION: Many manufactured toys have hazardous sound levels. Caregivers and healthcare providers should be aware that toys tested in the store may actually be louder when brought home and removed from their packaging. Limits on and disclosure of dB level of toys should be considered nationally.

Bevacizumab for Hearing Preservation in Neurofibromatosis Type 2: Emphasis on Patient-Reported Outcomes and Toxicities.

OBJECTIVE: Bevacizumab for hearing preservation in patients with neurofibromatosis type 2 (NF2) is an emerging practice. We set out to characterize the effectiveness and toxicity of bevacizumab in our patient group. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Seventeen consecutive patients with NF2 received bevacizumab treatment for vestibular schwannomas, including 2 patients treated to maintain cochlear implant performance. Volumetric analysis of serial magnetic resonance imaging scans was used to evaluate radiographic response, and hearing response was evaluated with serial audiograms. Patient-reported outcomes were also assessed, including subjective hearing improvement, changes in tinnitus, vertigo, headaches, ear pain, and improvement in ability to communicate via telephone. RESULTS: A positive radiographic response occurred in 8 of 17 (47%) patients and the median tumor volume change was a tumor decrease of 19%. A positive hearing response was recorded in 5 of 9 (56%) patients. Two patients had a word recognition score improvement over 40%. There was an approximately 40% improvement in patient-reported outcomes. Primary toxicities included hypertension, proteinuria, dysgeusia, and amenorrhea. CONCLUSION: Bevacizumab treatment was followed by hearing improvement in 56% of patients, while decreased tumor volume was noted in 47%. These outcomes agree favorably with prior reported series. There were significant improvements in patient-reported outcomes that have not been described previously.

Rebounding V1 activity and a new visual aftereffect.

A serendipitous observation led to this study of V1 activity rebounds, which occur well after stimulus offset, and their relationship to visual aftereffects. We found that when a stimulus bar and background were simultaneously turned off, there was strong delayed rebounding activity (distinct from any off response). The neural rebound started 350-500 ms after stimulus offset, and its magnitude and duration were correlated with the prior visual response of the cell. In human psychophysical experiments, we found a delayed aftereffect that may be a perceptual correlate of the activity rebound. Both the rebound activity and the perceptual aftereffect disappeared if the stimulus bar and background were not extinguished together. The magnitude of the rebound varied with the spatial scale of the background even though background size had little effect on the visual response. It thus appeared that rebound magnitude was determined by a relatively large integration area. The aftereffect was not seen when the bar and background offsets were presented to different eyes, suggesting an early neural (monocular) basis for the aftereffect. Overall, we find a strong correlation between rebound activity and the perceived aftereffect. In addition to providing a possible explanation and neural correlate of a visual aftereffect, rebounding activity may provide new insight into the dynamics of early visual processing.

Utilization of Nerve Integrity Monitor for Promontory Stimulation Testing Prior to Cochlear Implant.

OBJECTIVE: To demonstrate the feasibility of a nerve integrity monitor as a tool for promontory stimulation testing in patients with profound sensorineural hearing loss considering cochlear implantation. PATIENTS: Adult patients considered for cochlear implantation with no auditory response on audiometric testing INTERVENTION:: Promontory stimulation testing using the nerve integrity monitor. MAIN OUTCOME MEASURE: By using a facial nerve stimulator and the nerve integrity monitor, transtympanic promontory stimulation testing was performed to assess auditory nerve function and determine candidacy for cochlear implantation. Patients indicated if they heard the stimulus. RESULTS: Of the four patients completing the promontory stimulation tests, three patients heard the stimulus and one patient did not hear the stimulus. Of the three patients with a positive stimulation test, two patients have a history of progressive profound sensorineural hearing loss and one patient had a history of severe blunt temporal bone trauma. Two of these patients proceeded with cochlear implantation. The patient who had a negative promontory stimulation test has a history of neurofibromatosis type 2. CONCLUSION: The nerve integrity monitor is a convenient tool that can be used in the clinic setting to perform promontory stimulation tests and aid in determining cochlear implant candidates, specifically in those patients who require verification of auditory nerve function. This tool is a feasible and reasonable method for promontory stimulation testing.

Randomized Controlled Pilot Study of Video Self-assessment for Resident Mastoidectomy Training.

A prospective randomized controlled pilot study was performed to determine if video self-assessment improves competency in mastoidectomy and to assess interrater agreement between expert and resident evaluations of recorded mastoidectomy. Sixteen otolaryngology residents were recorded while performing cadaveric mastoidectomy and randomized into video self-assessment and control groups. All residents performed a second recorded mastoidectomy. Performance was evaluated by blinded experts with a validated assessment scale. Video self-assessment did not lead to greater skill improvement between the first and second mastoidectomy. Interrater agreement was fair to substantial between the expert evaluators and between resident self-evaluations by recall and video review. Agreement between experts and residents was only slight to fair; residents consistently rated their performance higher than experts (P < .05). In conclusion, 1 session of video self-review did not lead to improved competence in mastoidectomy over standard practice. While experts agree on assessments, residents may overestimate their competency in performing cadaveric mastoidectomy.

Cochlear stem cells/progenitors and degenerative hearing disorders.

Hearing loss (deafness) affects approximately 250 million people globally. The major cause of deafness is loss of hair cells and spiral ganglion neurons due to aging, antibiotic use, noise exposure, and genetic defects. At the present time, there is no effective method for restoration of hearing biologically. Cochlear stem cells/progenitors (CSCs), quiescent in the organ of Corti, are excellent candidates for restoration of cell types in the organ of Corti biologically. However, little is known about the biology of CSCs and developmental cues for CSCs to differentiate into hair cells and neurons at the present time. In this article, we briefly reviewed the isolation of CSCs from the postnatal organ of Corti in mice and their capability to differentiate into hair cells and neurons in vitro under the guidance of a group of growth factors: sonic hedgehog (SHH), epidermal growth factor (EGF), retinoic acid (RA), and brain-derived neurotrophic factor (BDNF), herein termed SERB. The identification of CSCs and their differentiation signals is potentially of clinical importance.

Infectious complications in pediatric cochlear implants.

OBJECTIVES: Infectious complications may cause significant delay in cochlear implant device initiation and programming and be a source of additional morbidity. We reviewed our experience with infectious complications in the pediatric age group to determine specific sources that may not be seen in adults. STUDY DESIGN: A retrospective analysis from a single implant center. METHODS: Cases of pediatric cochlear implants were reviewed for data on infectious complications. Complications were identified as "major" or "minor," "early" or "delayed." Information was gathered regarding any comorbid, chronic health condition. Data related to the causative organism(s) were collected. RESULTS: Two hundred sixty-eight cases of pediatric implants were reviewed. Twenty-two cases were identified (an infection rate of 8.2%), all classified as "major." The majority, 12, were classified as "delayed" complications. Twenty-one cases required explantation with 14 successfully reimplanted. Five cases (in 4 patients) or 23% were associated with a specific chronic pediatric condition including two children with tracheostomies. Among implanted children who had chronic health conditions, 42% developed implant-related infections. Among otherwise healthy implanted children, only 6.6% developed implant-related infections. Resistant bacterial infections were not identified. CONCLUSIONS: Health conditions in the pediatric age group were associated with 23% of our complications, a risk factor not previously identified in the literature. These children, demonstrating seven times the infection rate of healthy children, should be carefully observed postoperatively. Overall, cochlear implantation in children continues to be associated with a low risk of infectious complications.

Predictors for resident success in otolaryngology.

BACKGROUND: This study aimed to determine predictors for otolaryngology resident success using data available at the time candidates are interviewed (eg, medical school attended, letters of recommendation, test scores) and data that emerge during residency. STUDY DESIGN: We performed a retrospective cohort study of 36 residents who entered our program between 1983 and 1993. RESULTS: Seventy percent of Alpha Omega Alpha (AOA) members and 13% of nonmembers were in the highest tertile based on faculty ranking (p<0.01), and candidates with an exceptional trait were more likely than those without an exceptional trait to rank in the highest tertile (57% versus 10%, p<0.01). AOA membership was also related to current academic appointment (p=0.02). Significant correlations included United States Medical Licensing Examination (USMLE) I score, year 2 in-training score (0.48, p=0.03), and years 3 and 4 in-training score and faculty ranking (minus 0.39, minus 0.50, respectively, p50% of the interviewers (p<0.05 for both). CONCLUSIONS: In our program designed to train academic otolaryngologists, postresident success was strongly predicted by having an exceptional trait and AOA membership. Success during residency was predicted by interviewer's impression of the candidate and a USMLE I score>570. Knowledge of these factors at the time of the resident interview could increase the likelihood of selecting the most appropriate candidates for academic otolaryngology. Resident success is a complex outcome, and other unmeasured and unexamined characteristics can provide additional insight into choosing successful residents.

Incidence of spontaneous hearing threshold shifts during modern concert performances.

OBJECTIVES: Concerts have long periods of intense sound with short break intervals. Hearing concerns are well known to performers; concertgoers largely ignore them. Preperformance and postperformance audiograms were compared to assess hearing threshold shifts with and without earplugs. METHODS: A prospective, randomized study in which 29 volunteers attended 3 concerts, encompassing 3 music genres. Audiograms, seating location, sound intensity, and earplug-use data were collected. Data were analyzed to determine frequency test-retest variability. RESULTS: Sound levels averaged 99.8 dBA, and the maximum was 125.6 dBA. Sixty-four percent (9/14) of participants without earplugs showed significant threshold shifts compared with 27% (4/15) of those using earplugs. No significant differences existed between music genres or seating location. CONCLUSIONS: This study showed a high incidence of threshold shifts in unprotected concertgoers. Sound levels exceeded all Occupational Safety and Health Act rules despite standardized sound systems. A significant reduction in threshold shifts was seen with the use of earplugs. EBM RATING: A-1b.

Peripheral facial nerve regeneration using collagen conduit entubulation in a cat model.

OBJECTIVES: Facial nerve (FN) injuries are functionally, psychologically, and financially debilitating. Facial nerve autograft repairs produce significant donor nerve morbidity and functional results that rarely exceed House-Brackmann (HB) grade III over VI. In this study we sought to enhance FN regeneration via collagen conduit entubulation. METHODS: Five control cats underwent right ("cut-side") FN transection and immediate microsurgical anastomosis repair. Five experimental cats underwent identical repairs plus collagen conduit entubulation of each anastomosis. RESULTS: Postoperative behavioral observations revealed gradual FN functional recovery in all cats, who attained adapted HB grades of II to III over VI after 6 weeks. Electromyographic latencies and amplitudes from the bilateral orbicularis oculi and orbicularis oris muscles indicated restoration of FN continuity in all 10 cats. In comparison with FN repairs without conduits, repairs with conduits significantly enhanced recovery of amplitude in cut-side orbicularis oculi muscles (p = .037) and latency in cut-side orbicularis oris muscles (p = .048). In comparison with intact left ("uncut-side") FN latencies and amplitudes, more statistically significant differences in cut-side FN function were observed in repairs without conduits than in repairs with conduits. Conduits therefore facilitated a more complete return of electrophysiological function. Histologic analyses confirmed FN continuity and revealed more organized FN regenerative architecture in conduit-implanted repairs. CONCLUSIONS: The overall results support enhanced FN regeneration with collagen conduit entubulation.

Quantitative Proteomics of Vestibular Schwannoma Cerebrospinal Fluid: A Pilot Study.

This pilot study aimed to identify candidate proteins for future study that are differentially expressed in vestibular schwannoma (VS) cerebrospinal fluid (CSF) and to compare such proteins with those previously identified in perilymph and specimen secretions. CSF was collected intraoperatively prior to removal of untreated sporadic VS (3 translabyrinthine, 3 middle cranial fossa approaches) and compared with reference CSF samples. After proteolytic digestion and iTRAQ labeling, tandem mass spectrometry with ProteinPilot was used to identify candidate proteins. Of the 237 proteins detected, 13 were dysregulated in ≥3 of the 6 VS patients versus controls, and 13 were dysregulated (12 up, 1 down) in samples from patients with class D versus class B hearing. Four perilymph proteins of interest were dysregulated in ≥1 VS CSF samples. Thus, 26 candidate VS CSF biomarkers were identified that should be considered in future VS biomarker and tumor pathophysiology investigations.

Cochlear implantation in severe traumatic brain-injury and paranoid schizophrenia: two case studies.

In view of the demanding instruction and training requirements associated with cochlear implantation;,patients with cognitive impairments have typically been considered to be poor candidates for this procedure. This presumption persists in part because experience and research in this area are limited. We describe our experience with implanting cochlear devices in 2 patients who had significant psychological impairments; 1 patient had experienced a severe brain injury, and the other had paranoid schizophrenia. Nevertheless, both patients were able to follow the implant training program, and they experienced different degrees of improvement in their hearing. We discuss our preoperative evaluations of these patients and the key factors that led to our decision to proceed with surgery.

Identification of gene expression profiles in rat ears with cDNA microarrays.

The physiological processes of hearing implicate thousands of molecules acting in harmony; however, their identities are only partially understood. We used cDNA microarrays containing 1,176 genes to identify >150 genes expressed in rat middle and inner ear tissue. Expressed genes covered several gene families and biological pathways, many of which have previously not been described. Transcription factor genes that were expressed included inhibitors of DNA binding protein (Id). These were localized to the spiral ganglion, organ of Corti and stria vascularis, and they are possibly involved in neurogenesis and angiogenesis. Transcriptional factors that were highly expressed included Gax (homeobox) and I-kappaB, which inhibit cellular proliferation. Their presence suggests that inhibitory programs for cell proliferation are enforced in the ear. Ion channel genes that were expressed included voltage-dependent L-type calcium channels (LTCC) and proton-gated cation channels (PGCC). Genes involved in neurotransmitter production and release included glutamic acid decarboxylase (GAD1). Genes involved in postsynaptic inhibition included neuropeptide Y5 receptors (NPY5) and GAD1. Due to the existence of receptors and/or enzymes involved in their biochemical synthesis, neurotransmitters associated with these might include serotonin, glutamide, acetylcholine, gamma-aminobutyric acid (GABA), neurotensin, and dopamine.

High-resolution magnetic resonance imaging of human cochlea.

OBJECTIVES: High-resolution MRI (MRI) of human inner ear structures provides several advantages over other imaging modalities. High-resolution visualization of inner ear ultrastructure in a noninvasive manner may provide important information about inner ear disease that is not obtainable in other ways. The study was performed to demonstrate the capabilities of MRI at high resolution on the human cochlea, vestibular structures, and facial nerve. Comparative analyses of MRI anatomy with that seen on histological dissection were made. The aim of the study was to define the anatomy of human cadaveric cochlea using a 9.4-Tesla magnetic resonance scanner, currently the most powerful magnetic resonance magnet available. STUDY DESIGN: Experimental pilot study of cadaveric human cochleae. METHODS: Serial scanning using a 9.4-Tesla magnetic resonance imager on normal preserved and fresh cadaveric inner ears was performed in different planes. RESULTS: The images revealed detailed anatomy of the modiolus, utricle, saccule, semicircular canals, and facial nerve. Specifically, identifiable structures within the cochlea included the osseous spiral lamina, Reissner's membrane, membranous spiral lamina, spiral ligament, and others. CONCLUSIONS: Data established through the acquisition of images from cadaver cochlea, facial nerve, and vestibular complex provide a foundation for developing steps for testing temporal bones and, eventually, patients with Meniere's disease and other inner ear disease. The present ongoing project will provide information on baseline images of the inner ear using high-resolution MRI.