Iatrogenic facial nerve injuries during chronic otitis media surgery: a multicentre retrospective study.

OBJECTIVES: To give an insight into why, when and where iatrogenic facial nerve (FN) injuries may occur and to explain how to deal with them in an emergency setting. DESIGN AND SETTING: Multicentre retrospective study in eight tertiary referral hospitals over 17 years. PARTICIPANTS: Twenty patients with partial or total FN injury during surgery for chronic otitis media (COM) were revised. MAIN OUTCOME MEASURES: Indication and type of surgery, experience of the surgeon, intra- and postoperative findings, value of CT scanning, patient management and final FN outcome were recorded. RESULTS: In 12 cases, the nerve was completely transected, but the surgeon was unaware in 11 cases. A minority of cases occurred in academic teaching hospitals. Tympanic segment, second genu and proximal mastoid segments were the sites involved during injury. The FN was not deliberately identified in 18 patients at the time of injury, and nerve monitoring was only applied in one patient. Before revision surgery, CT scanning correctly identified the lesion site in 11 of 12 cases and depicted additional lesions such as damage to the lateral semicircular canal. A greater auricular nerve graft was interposed in 10 cases of total transection and in one partially lesioned nerve: seven of them resulted in an HB III functional outcome. In two of the transected nerves, rerouting and direct end-to-end anastomosis was applied. A simple FN decompression was used in four cases of superficially traumatised nerves. CONCLUSIONS: We suggest checklists for preoperative, intraoperative and postoperative management to prevent and treat iatrogenic FN injury during COM surgery.

Exploratory secondary analyses of a cognitive-behavioral intervention for knee osteoarthritis demonstrate reduction in biomarkers of adipocyte inflammation.

OBJECTIVE: To investigate the effects of pain coping skills training (PCST) and a lifestyle behavioral weight management (BWM) program on inflammatory markers and biomarker associations with pain and function in the OA LIFE study. METHOD: Serum samples were available from a subset (N = 169) of the overweight or obese knee OA participants in the OA LIFE study that evaluated: PCST, BWM, combined PCST + BWM, or standard care (SC). Inflammatory markers (hsCRP, IL-1ra, IL-1ß, IL-6, IL-8, TNF-α, TNFRI, TNFRII, and hyaluronic acid (HA)), and adipokines (leptin and adiponectin) were measured before and after the 24-week treatment period. Biomarkers were assessed for effects of treatment and for associations with change in weight, pain and disability (unadjusted and adjusted for age, race, sex, baseline body mass index (BMI), and baseline biomarker concentration). RESULTS: PCST + BWM was associated with significant reductions in hsCRP (P = 0.0014), IL-6 (P = 0.0075), and leptin (P = 0.0001). After adjustment, there was a significant effect of PCST + BWM on changes in leptin (b = -0.19, P = 0.01) and IL-6 (b = -0.25, P = 0.02) relative to SC. Reductions in leptin and IL-6 were significantly correlated with reductions in weight, BMI and Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain; reductions in IL-6 were correlated with improvements in WOMAC and Arthritis Impact Measurement Scales (AIMS) physical function. By mediation analyses, weight loss was responsible for 54% of the change in IL-6 and all of the change in leptin. CONCLUSIONS: OA-related inflammatory markers were reduced by a 24-week combined PCST + BWM intervention. This suggests that the inflammatory state can be successfully modified in the context of a readily instituted clinical intervention with a positive clinical outcome.

Energy recovery in individuals with knee osteoarthritis.

OBJECTIVE: Pathological gaits have been shown to limit transfer between potential (PE) and kinetic (KE) energy during walking, which can increase locomotor costs. The purpose of this study was to examine whether energy exchange would be limited in people with knee osteoarthritis (OA). METHODS: Ground reaction forces during walking were collected from 93 subjects with symptomatic knee OA (self-selected and fast speeds) and 13 healthy controls (self-selected speed) and used to calculate their center of mass (COM) movements, PE and KE relationships, and energy recovery during a stride. Correlations and linear regressions examined the impact of energy fluctuation phase and amplitude, walking velocity, body mass, self-reported pain, and radiographic severity on recovery. Paired t-tests were run to compare energy recovery between cohorts. RESULTS: Symptomatic knee OA subjects displayed lower energetic recovery during self-selected walking speeds than healthy controls (P = 0.0018). PE and KE phase relationships explained the majority (66%) of variance in recovery. Recovery had a complex relationship with velocity and its change across speeds was significantly influenced by the self-selected walking speed of each subject. Neither radiographic OA scores nor subject self-reported measures demonstrated any relationship with energy recovery. CONCLUSIONS: Knee OA reduces effective exchange of PE and KE, potentially increasing the muscular work required to control movements of the COM. Gait retraining may return subjects to more normal patterns of energy exchange and allow them to reduce fatigue.

Psychosocial interventions for managing pain in older adults: outcomes and clinical implications.

Interest in the use of psychosocial interventions to help older adults manage pain is growing. In this article, we review this approach. The first section reviews the conceptual background for psychosocial interventions with a special emphasis on the biopsychosocial model of pain. The second section highlights three psychosocial interventions used with older adults: cognitive behavioural therapy, emotional disclosure, and mind-body interventions (specifically mindfulness-based stress reduction and yoga). The final section of the paper highlights important future directions for work in this area.

Mutations in the human alpha-tectorin gene cause autosomal dominant non-syndromic hearing impairment.

The tectorial membrane is an extracellular matrix of the inner ear that contacts the stereocilia bundles of specialized sensory hair cells. Sound induces movement of these hair cells relative to the tectorial membrane, deflects the stereocilia, and leads to fluctuations in hair-cell membrane potential, transducing sound into electrical signals. Alpha-tectorin is one of the major non-collagenous components of the tectorial membrane. Recently, the gene encoding mouse alpha-tectorin (Tecta) was mapped to a region of mouse chromosome 9, which shows evolutionary conservation with human chromosome 11q (ref. 3), where linkage was found in two families, one Belgian (DFNA12; ref. 4) and the other, Austrian (DFNA8; unpublished data), with autosomal dominant non-syndromic hearing impairment. We determined the complete sequence and the intron-exon structure of the human TECTA gene. In both families, mutation analysis revealed missense mutations which replace conserved amino-acid residues within the zona pellucida domain of TECTA. These findings indicate that mutations in TECTA are responsible for hearing impairment in these families, and implicate a new type of protein in the pathogenesis of hearing impairment.

Multidisciplinary management of vestibular schwannomas: state of the art.

The preferred setting for the treatment for vestibular schwannoma these days is multidisciplinary and multimodal. A balance has to be struck between a wait-and-scan attitude and a more active approach (surgery or radiotherapy). An initial wait-and-scan attitude is a reasonable management option because many tumours do not grow during a prolonged period of observation. The different surgical approaches may or may not involve attempts to preserve hearing. Stereotactic radiotherapy as treatment of choice is often considered in the elderly patient presenting with a vestibular schwannoma smaller than 2.5 cm with documented growth. This paper will review current treatment modalities and the respective pros and cons. A decisional algorithm as currently adopted by our skull base team is presented at the end of the paper.

Prognostic significance of electrophysiological tests for facial nerve outcome in vestibular schwannoma surgery.

OBJECTIVE: To assess the prognostic significance of pre-operative electrophysiological tests for facial nerve outcome in vestibular schwannoma surgery. METHODOLOGY: Retrospective study design in a tertiary referral neurology unit. We studied a total of 123 patients with unilateral vestibular schwannoma who underwent microsurgical removal of the lesion. Nine patients were excluded because they had clinically abnormal pre-operative facial function. Pre-operative electrophysiological facial nerve function testing (EPhT) was performed. Short-term (1 month) and long-term (1 year) post-operative clinical facial nerve function were assessed. RESULTS: When pre-operative facial nerve function, evaluated by EPhT, was normal, the outcome from clinical follow-up at 1-month post-operatively was excellent in 78% (i.e. HB I-II) of patients, moderate in 11% (i.e. HB III-IV), and bad in 11% (i.e. HB V-VI). After 1 year, 86% had excellent outcomes, 13% had moderate outcomes, and 1% had bad outcomes. Of all patients with normal clinical facial nerve function, 22% had an abnormal EPhT result and 78% had a normal result. No statistically significant differences could be observed in short-term and long-term post-operative facial function between the groups. CONCLUSION: In this study, electrophysiological tests were not able to predict facial nerve outcome after vestibular schwannoma surgery. Tumour size remains the best pre-operative prognostic indicator of facial nerve function outcome, i.e. a better outcome in smaller lesions.

Diffusion-weighted magnetic resonance imaging of the temporal bone.

This paper summarizes the value of diffusion-weighted magnetic resonance imaging in the evaluation of temporal bone pathology. It highlights the use of different types of diffusion-weighted magnetic resonance imaging in the different types of cholesteatoma, prior to first stage surgery and prior to second look surgery. The value of diffusion-weighted magnetic resonance imaging in the evaluation of pathology of the apex of the petrous bone and the cerebellopontine angle is also discussed.

Benzodiazepine peptidomimetics: potent inhibitors of Ras farnesylation in animal cells.

Oncogenic Ras proteins transform animal cells to a malignant phenotype only when modified by farnesyl residues attached to cysteines near their carboxyl termini. The farnesyltransferase that catalyzes this reaction recognizes tetrapeptides of the sequence CAAX, where C is cysteine, A is an aliphatic amino acid, and X is a carboxyl-terminal methionine or serine. Replacement of the two aliphatic residues with a benzodiazepine-based mimic of a peptide turn generated potent inhibitors of farnesyltransferase [50 percent inhibitory concentration (IC50) < 1 nM]. Unlike tetrapeptides, the benzodiazepine peptidomimetics enter cells and block attachment of farnesyl to Ras, nuclear lamins, and several other proteins. At micromolar concentrations, these inhibitors restored a normal growth pattern to Ras-transformed cells. The benzodiazepine peptidomimetics may be useful in the design of treatments for tumors in which oncogenic Ras proteins contribute to abnormal growth, such as that of the colon, lung, and pancreas.

Magnetic resonance imaging of cholesteatoma: an update.

OBJECTIVE: To report on the value and limitations of new MRI techniques in pre- and post-operative MRI of cholesteatoma. The current value of magnetic resonance imaging (MRI) in diagnosing congenital, acquired, and post-operative recurrent or residual cholesteatoma is described. METHODOLOGY AND RESULTS: High resolution computed tomography (HRCT) is still considered the imaging modality of choice for detecting acquired or congenital middle ear cholesteatoma. However, MRI may provide additional information on the delineation and extension of cholesteatoma and on potential complications. Detecting post-operative residual or recurrent cholesteatoma with HRCT was shown to be inaccurate due to the technique's low sensitivity and specificity. CONCLUSIONS: Recently, improvements in MRI techniques have led to a more accurate diagnoses of cholesteatoma using delayed contrast enhanced T1-weighted imaging and diffusion-weighted imaging.

Pain catastrophizing in borderline morbidly obese and morbidly obese individuals with osteoarthritic knee pain.

OBJECTIVE: There is limited information about how morbidly obese osteoarthritis (OA) patients cope with the pain they experience. Pain catastrophizing is an important predictor of pain and adjustment in persons with persistent pain. This may be particularly relevant in the morbidly obese (body mass index [BMI] of 40 kg/m(2) or greater) OA population at risk for increased pain. The present study first examined whether borderline morbidly obese and morbidly obese OA patients report higher levels of pain catastrophizing than a sample of OA patients in the overweight and obese category (BMI between 25 kg/m(2) and 34 kg/m(2)). Next, it examined how pain catastrophizing is related to important indexes of pain and adjustment in borderline morbidly obese and morbidly obese OA patients. METHODS: Participants included 43 individuals with knee OA who were borderline morbidly obese or morbidly obese (BMI of 38 kg/m(2) or greater). Participants completed self-report measures of pain catastrophizing, pain, psychological distress, quality of life, binge eating and eating self-efficacy. RESULTS: The sample of borderline morbidly obese and morbidly obese OA patients reported significantly higher levels of pain catastrophizing (P=0.007) than a comparison sample of overweight and obese OA patients. Results suggested that patients who engaged in a high level of pain catastrophizing reported having much more intense and unpleasant pain, higher levels of binge eating, lower self-efficacy for controlling their eating and lower weight-related quality of life (P<0.05 for all). CONCLUSIONS: Pain catastrophizing is related to pain and adjustment in borderline morbidly obese and morbidly obese OA patients. Clinicians working with this population should consider assessing pain catastrophizing in the patients they treat.

Cognitive problems following hematopoietic stem cell transplant: relationships with sleep, depression and fatigue.

Cognitive problems are a significant, persistent concern for patients undergoing hematopoietic stem cell transplant (HSCT). Sleep is important for many cognitive tasks; however, the relationship between sleep and cognitive problems for HSCT patients is unknown. This study examined the relationship between sleep and cognitive problems for HSCT patients from pre to post transplant. Patients undergoing HSCT (N=138) completed questionnaires at pre-transplant and during the 12 months following transplant. Questionnaires assessed sleep and cognitive problems as well as commonly co-occurring symptoms: depressive symptoms, fatigue and pain. Post hoc analyses examined the relationship of specific sleep problems with cognitive problems. Sleep problems covaried with cognitive problems even after controlling for depressive symptoms, fatigue and pain. Depressive symptoms and fatigue were also uniquely related to cognitive problems. Post hoc analyses suggest that sleep somnolence, shortness of breath, snoring and perceptions of inadequate sleep may contribute to the association found between sleep and cognitive problems. Findings suggest that sleep problems are associated with and may contribute to cognitive problems for HSCT patients. However, sleep problems are rarely screened for or discussed during clinic visits. Assessing and treating specific sleep problems in addition to depressive symptoms and fatigue may have implications for improving cognitive problems for HSCT patients.

Single-shot, turbo spin-echo, diffusion-weighted imaging versus spin-echo-planar, diffusion-weighted imaging in the detection of acquired middle ear cholesteatoma.

Diagnosis of acquired middle ear cholesteatoma on MR imaging is mostly done on late postgadolinium T1-weighted MR images and/or echo-planar (EPI) diffusion-weighted (DWI) MR images. We describe the appearance of a case of a complicated attical middle ear cholesteatoma on single-shot (SS) turbo spin-echo (TSE) DWI compared with EPI-DWI. This case suggests a higher reliability of SS TSE-DWI in the diagnosis of acquired middle ear cholesteatoma.

In vitro characterization of four novel classes of growth hormone-releasing peptide.

Reexamination of the hexapeptide GH-releasing peptide (GHRP-6) structure/function has lead to the development of four novel classes of compound that stimulate GH release. Each class is represented as follows: a pentapeptide, G-7039; a tetrapeptide, G-7134; a pseudotripeptide, G-7502; and a rigid cyclic heptapeptide, G-7203. The EC50 values for these compounds, determined by GH dose-response curves using primary cultures of rat pituitary cells, were 0.18, 0.34, 10.6, and 0.43 nM, respectively. To demonstrate that these compounds were acting at the putative GHRP receptor, challenges were made using combinations that included GHRP-6 and GH-releasing hormone (GHRH). All four new classes further increased GH release in combination with GHRH, but not with GHRP-6. Homologous desensitization occurred after 45 min of exposure to the new compounds while the cells remained sensitive to GHRH. Somatostatin inhibited all of these compounds. Additionally, G-7039 elevated free calcium, as occurs with GHRP-6. All four classes elicited a robust GH release, a small increase in PRL, and no change in LH, FSH, ACTH, or TSH. We conclude that these novel compounds are potent and direct stimulators of pituitary GH release, with in vitro attributes that suggest mediation via a specific GHRP-like mechanism.

Otosclerosis: a genetically heterogeneous disease involving at least three different genes.

Otosclerosis is caused by abnormal bone homeostasis of the otic capsule, resulting in hearing impairment in 0.3%-0.4% of the white population. The etiology of the disease remains unclear and environmental as well as genetic factors have been implicated. We localized the first autosomal-dominant locus to chromosome 15 in 1998 (OTSC1) in an Indian family and, recently, we reported the localization of a second gene for otosclerosis to a 16 cM interval on chromosome 7q (OTSC2). In this study, we recruited and analyzed nine additional families (seven Belgian and two Dutch families with 53 affected and 20 unaffected subjects) to investigate the importance of these loci in autosomal-dominant otosclerosis. We completed linkage analysis with three microsatellite markers of chromosome 15 (D15S652, D15S1004, D15S657) and five microsatellite markers of chromosome 7 (D7S495, D7S2560, D7S684, D7S2513, D7S2426). In two families, results compatible with linkage to OTSC2 were found, but in the seven remaining families OTSC1 and OTSC2 were excluded. Heterogeneity testing provided significant evidence for genetic heterogeneity, with an estimated 25% of families linked to OTSC2. These results indicate that, besides OTSC1 and OTSC2, there must be at least one additional otosclerosis locus.

Use of antibiotic prophylaxis in ear surgery.

A prospective, double-blind, randomized, placebo-controlled study was performed to evaluate the effect of antibiotic prophylaxis in ear surgery. The present study reports on the results of 750 patients, half of whom received cefuroxime for 1 day, the other half, placebo. All postoperative infections occurring within 2 weeks after the intervention were recorded, together with several preoperative and perioperative parameters. It is concluded that exploratory tympanoplasties (including stapedotomy) and "dry perforation" tympanoplasties should be considered "clean" operations according to the American National Research Council and do not benefit from antibiotic prophylaxis. On the other hand, tympanoplasties performed on draining ears and on ears with cholesteatoma should be considered "dirty" operations for which antibiotic prophylaxis may decrease the postoperative infection rate by factor 3. All postoperative infections healed without sequels under proper treatment, except for three that resulted in graft necrosis--one in the placebo group and two in the cefuroxime group. In consequence, prophylaxis may not be mandatory in the dirty group, although the authors advocate its use for the sake of patient and surgeon comfort.

CT and MR imaging of congential abnormalities of the inner ear and internal auditory canal.

The embryology of the inner ear must be known as many of the inner ear malformations present as a result of the arrest during the various stages of embryology. These malformations are described in this "embryologic" perspective and specific names for certain malformations are no longer used. Both CT and MR can be used to look at inner ear malformations but often both techniques are complementary. However, CT is preferred when associated middle- or external ear malformations must be excluded. Magnetic resonance is preferred when subtle changes in the membranous labyrinth or abnormalities of the nerves in the internal auditory canal must be visualised. The CT and MR technique must however be adapted as more and more subtle congenital malformations can only be seen when the right technique is used. The heavily T2-weighted gradient-echo or fast spin-echo MR techniques are mandatory if malformations of the inner ear must be excluded. The purpose of this paper is to describe the techniques used to study these patients and to give an overview of the most frequent and important congenital malformations which can be found in the inner ear and internal auditory canal/cerebellopontine angle.

Box and whisker plots for graphic presentation of audiometric results of conductive hearing loss treatment.

The Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery has published guidelines for the reporting of audiometric results of middle ear interventions. It recommends the reporting of several audiometric variables by means of two summary parameters: means and standard deviation. This article advocates the use of other summary statistics, namely the median, quartiles, and extremes, because they do not require a normal distribution of the audiometric data and they are not sensitive to variations of the extreme values. On the basis of the exploratory data analysis, we propose a graphic method to present the Committee's variables in terms of their summary statistics. This "multiple box and whisker plot" offers a detailed and accurate overview of six variables in one graph.

Prognostic value of magnetic resonance imaging findings in hearing preservation surgery for vestibular schwannoma.

OBJECTIVE: The purpose of this study was to determine whether three magnetic resonance imaging (MRI) findings (tumor size, extension to the fundus, intralabyrinthine signal intensity) have a predictive value to hearing preservation in vestibular schwannoma surgery. STUDY DESIGN: A retrospective study was conducted of preoperative high-resolution MR images in a series of consecutive hearing preservation attempts for vestibular schwannomas. PATIENTS: Twenty-six consecutive records of patients with an acoustic tumor removed via a retrosigmoid transcanal approach were analyzed, and the MR images were reviewed blindly and compared with postoperative hearing. SETTING: The study took place in a tertiary referral center. Imaging Techniques: The MR sequences used in this study were unenhanced and gadolinium-enhanced T1-weighted spin-echo images and gradient echo images (3DFT-CISS). MAIN OUTCOME MEASURES: The predictive value of three MRI signs was analyzed: tumor size, lateral extension of the tumor (with and without obliteration of the fundus), and the maintenance of, or decrease in, the intralabyrinthine signal intensity on the affected side in comparison with the signal intensity on the opposite normal side as seen on 3DFT-CISS images. RESULTS: The tumor size in ears in which hearing was preserved averaged 15 mm and was 17 mm in those cases where hearing was not preserved. Hearing was preserved in 50% of ears when the tumor did not extend to the fundus but in only 33% when the fundus was obliterated by tumor. A "normal" intralabyrinthine signal on CISS images (being an isointense signal when compared with the contralateral unaffected ear) was followed by hearing preservation in 82% of ears, whereas in cases where the intralabyrinthine signal was low, hearing was preserved in only 20%. This correlation was statistically significant (p < 0.05). CONCLUSION: The intralabyrinthine signal intensity on 3DFT-CISS gradient-echo images is a valuable additional tool for determining candidacy for hearing preservation surgery. In two cases with preoperative decrease in signal intensity of the intralabyrinthine fluids, control MRI after surgery showed spontaneous recovery of normal intralabyrinthine signal intensity. The authors hypothesize that vascular compression in the internal auditory canal by the tumor is responsible for the observed intralabyrinthine signal decrease.

Contralateral suppression of transient evoked otoacoustic emissions: normative data for a clinical test set-up.

HYPOTHESIS: Contralateral suppression of transient evoked otoacoustic emissions (TEOAEs) can be used in a clinical set-up using a procedure based on a unique and robust parameter to quantify the magnitude of suppression for a subject. BACKGROUND: TEOAEs can be suppressed by delivering contralateral white noise (WN). This suppression is thought to be mediated via the efferent nerve fibers that innervate the outer hair cells. The ipsilateral TEOAE-eliciting click stimulus level and the contralateral WN level have a strong impact on the recorded level of suppression. METHODS: TEOAEs were recorded using the nonlinear stimulation mode in two conditions (with and without contralateral WN). An optimal TEOAE-eliciting click stimulus level and contralateral WN level were defined to obtain a unique and robust parameter to quantify the magnitude of suppression. RESULTS: Suppression of TEOAEs with contralateral WN can be measured in a clinical set-up using nonlinear stimulation, and the level of suppression is of the same order of magnitude as measures using the linear stimulation recording mode. The level of suppression appears to be "locked" to the interaural difference between ipsilateral TEOAE-eliciting broadband click stimulus level and the contralateral WN level. CONCLUSIONS: A procedure is proposed to record contralateral suppression in a clinical set-up, and normative data are given for a normal-hearing population (n = 60).