A Fully Automated Analytic System for Measuring Endolymphatic Hydrops Ratios in Patients With Ménière Disease via Magnetic Resonance Imaging: Deep Learning Model Development Study.

BACKGROUND: Recently, the analysis of endolymphatic hydropses (EHs) via inner ear magnetic resonance imaging (MRI) for patients with Ménière disease has been attempted in various studies. In addition, artificial intelligence has rapidly been incorporated into the medical field. In our previous studies, an automated algorithm for EH analysis was developed by using a convolutional neural network. However, several limitations existed, and further studies were conducted to compensate for these limitations. OBJECTIVE: The aim of this study is to develop a fully automated analytic system for measuring EH ratios that enhances EH analysis accuracy and clinical usability when studying Ménière disease via MRI. METHODS: We proposed the 3into3Inception and 3intoUNet networks. Their network architectures were based on those of the Inception-v3 and U-Net networks, respectively. The developed networks were trained for inner ear segmentation by using the magnetic resonance images of 124 people and were embedded in a new, automated EH analysis system-inner-ear hydrops estimation via artificial intelligence (INHEARIT)-version 2 (INHEARIT-v2). After fivefold cross-validation, an additional test was performed by using 60 new, unseen magnetic resonance images to evaluate the performance of our system. The INHEARIT-v2 system has a new function that automatically selects representative images from a full MRI stack. RESULTS: The average segmentation performance of the fivefold cross-validation was measured via the intersection of union method, resulting in performance values of 0.743 (SD 0.030) for the 3into3Inception network and 0.811 (SD 0.032) for the 3intoUNet network. The representative magnetic resonance slices (ie, from a data set of unseen magnetic resonance images) that were automatically selected by the INHEARIT-v2 system only differed from a maximum of 2 expert-selected slices. After comparing the ratios calculated by experienced physicians and those calculated by the INHEARIT-v2 system, we found that the average intraclass correlation coefficient for all cases was 0.941; the average intraclass correlation coefficient of the vestibules was 0.968, and that of the cochleae was 0.914. The time required for the fully automated system to accurately analyze EH ratios based on a patient's MRI stack was approximately 3.5 seconds. CONCLUSIONS: In this study, a fully automated full-stack magnetic resonance analysis system for measuring EH ratios was developed (named INHEARIT-v2), and the results showed that there was a high correlation between the expert-calculated EH ratio values and those calculated by the INHEARIT-v2 system. The system is an upgraded version of the INHEARIT system; it has higher segmentation performance and automatically selects representative images from an MRI stack. The new model can help clinicians by providing objective analysis results and reducing the workload for interpreting magnetic resonance images.

Sound Localization and Speech Perception in Noise of Pediatric Cochlear Implant Recipients: Bimodal Fitting Versus Bilateral Cochlear Implants.

OBJECTIVES: The aim of this study was to compare binaural performance of auditory localization task and speech perception in babble measure between children who use a cochlear implant (CI) in one ear and a hearing aid (HA) in the other (bimodal fitting) and those who use bilateral CIs. DESIGN: Thirteen children (mean age ± SD = 10 ± 2.9 years) with bilateral CIs and 19 children with bimodal fitting were recruited to participate. Sound localization was assessed using a 13-loudspeaker array in a quiet sound-treated booth. Speakers were placed in an arc from -90° azimuth to +90° azimuth (15° interval) in horizontal plane. To assess the accuracy of sound location identification, we calculated the absolute error in degrees between the target speaker and the response speaker during each trial. The mean absolute error was computed by dividing the sum of absolute errors by the total number of trials. We also calculated the hemifield identification score to reflect the accuracy of right/left discrimination. Speech-in-babble perception was also measured in the sound field using target speech presented from the front speaker. Eight-talker babble was presented in the following four different listening conditions: from the front speaker (0°), from one of the two side speakers (+90° or -90°), from both side speakers (±90°). Speech, spatial, and quality questionnaire was administered. RESULTS: When the two groups of children were directly compared with each other, there was no significant difference in localization accuracy ability or hemifield identification score under binaural condition. Performance in speech perception test was also similar to each other under most babble conditions. However, when the babble was from the first device side (CI side for children with bimodal stimulation or first CI side for children with bilateral CIs), speech understanding in babble by bilateral CI users was significantly better than that by bimodal listeners. Speech, spatial, and quality scores were comparable with each other between the two groups. CONCLUSIONS: Overall, the binaural performance was similar to each other between children who are fit with two CIs (CI + CI) and those who use bimodal stimulation (HA + CI) in most conditions. However, the bilateral CI group showed better speech perception than the bimodal CI group when babble was from the first device side (first CI side for bilateral CI users or CI side for bimodal listeners). Therefore, if bimodal performance is significantly below the mean bilateral CI performance on speech perception in babble, these results suggest that a child should be considered to transit from bimodal stimulation to bilateral CIs.

Objective and Subjective Improvement of Hearing in Noise After Surgical Correction of Unilateral Congenital Aural Atresia in Pediatric Patients: A Prospective Study Using the Hearing in Noise Test, the Sound-Spatial-Quality Questionnaire, and the Glasgow Benefit Inventory.

OBJECTIVES: The aim of this study was to assess the objective and subjective long-term binaural benefits of surgical correction in children with unilateral congenital aural atresia, using an open-set sentence test in noise and subjective questionnaires. DESIGN: A prospective study was performed between August 2010 and February 2013. This study included pediatric patients who had unilateral conductive hearing loss (normal bone conduction hearing) on the atretic side but normal air conduction hearing on the normal side and were scheduled to undergo a primary canaloplasty. Pure-tone audiometry, the hearing in noise test (HINT), and questionnaires (Sound-Spatial-Qualities of Hearing Scale; Glasgow Benefit Inventory [GBI]) were administered preoperatively and at 6 and 12 months postoperatively. RESULTS: Among 34 consecutive patients who initially met enrollment criteria, 26 subjects (23 boys and 3 girls) aged 10 to 16 years (mean 12.3 years) completed this study. Canaloplasty and hearing restoration procedures were performed uneventfully in all patients. The mean air conduction thresholds were significantly improved from 63.9 to 35.0 dB (6 months) and 39.4 dB (12 months) after surgery (p < 0.001). In HINT, speech understanding in noise that was presented toward the newly opened atretic ear significantly improved at 1 year postoperatively (p = 0.014). In noise toward the normal ear, speech understanding significantly improved after surgery, from -0.1 dB preoperatively to -2.0 dB at 6 months (p = 0.002) and -1.8 dB at 12 months (p = 0.005) (p for quadratic trend = 0.036). The composite score improved from -2.6 dB preoperatively to -3.4 dB at 6 months and -3.6 dB at 12 months (p = 0.045; p for linear trend = 0.005). The Sound-Spatial-Qualities of Hearing Scale scores in all domains significantly improved 1 year after surgery (p < 0.034). The mean GBI scores in each domain ranged from 14.2 to 49.4. Total GBI score was correlated with better signal to noise ratio in noise toward the atretic ear as measured by HINT at postoperative 1 year (Spearman ρ = 0.482, p = 0.013). CONCLUSIONS: Teenaged patients with unilateral congenital aural atresia showed satisfactory hearing improvement after canaloplasty with hearing restoration surgery. In a serial long-term follow-up, speech understanding in noise measured by HINT improved over time. One year after surgery, teenaged children acquired binaural hearing (binaural squelch), as measured by the HINT with noise presented to the newly opened atretic ear. Subjective questionnaires also showed improvements in binaural hearing function and quality of life.

Effect of a Bluetooth-implemented hearing aid on speech recognition performance: subjective and objective measurement.

OBJECTIVES: The object was to evaluate speech perception improvement through Bluetooth-implemented hearing aids in hearing-impaired adults. METHODS: Thirty subjects with bilateral symmetric moderate sensorineural hearing loss participated in this study. A Bluetooth-implemented hearing aid was fitted unilaterally in all study subjects. Objective speech recognition score and subjective satisfaction were measured with a Bluetooth-implemented hearing aid to replace the acoustic connection from either a cellular phone or a loudspeaker system. In each system, participants were assigned to 4 conditions: wireless speech signal transmission into hearing aid (wireless mode) in quiet or noisy environment and conventional speech signal transmission using external microphone of hearing aid (conventional mode) in quiet or noisy environment. Also, participants completed questionnaires to investigate subjective satisfaction. RESULTS: Both cellular phone and loudspeaker system situation, participants showed improvements in sentence and word recognition scores with wireless mode compared to conventional mode in both quiet and noise conditions (P < .001). Participants also reported subjective improvements, including better sound quality, less noise interference, and better accuracy naturalness, when using the wireless mode (P < .001). CONCLUSIONS: Bluetooth-implemented hearing aids helped to improve subjective and objective speech recognition performances in quiet and noisy environments during the use of electronic audio devices.

Clinical characteristics of persistent postural-perceptual dizziness and its visual subtype in Korean patients: A multicenter cross-sectional study.

OBJECTIVES: Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder for which the Bárány Society has established diagnostic criteria. This nationwide multicenter study aims to investigate the clinical features of individuals with definite PPPD and clinical variant PPPD who do not fully meet the diagnostic criteria, with a particular focus on visual exaggeration. METHODS: Between September 2020 and September 2021, a total of 76 individuals with definite PPPD and 109 individuals with clinical variant PPPD who did not meet all three exacerbating factors outlined in Criterion B were recruited from 18 medical centers in South Korea. The study gathered information on demographic factors, clinical manifestations, balance scales, and personality assessments. RESULTS: Comparative analysis between groups with definite PPPD and clinical variant with visual exacerbation revealed no significant differences in sociodemographic characteristics, clinical course, dizziness impact, and specific precipitants. Only disease duration was significantly longer in definite PPPD compared with variant with visual exacerbation. However, the variant without visual exacerbation displayed significantly reduced rates of panic disorder, diminished space-motion discomfort, lesser impact of dizziness, and decreased prevalence of depression when compared with the definitive PPPD. CONCLUSION: This is the first comprehensive nationwide study examining clinical features of both definite PPPD patients and its clinical variants, considering visual exacerbating factors. Differences in dizziness and personality traits emerged between definite PPPD and its potential variant without visual issues. Our results highlight the possibility of a distinct clinical variant of PPPD influenced by visual dependency.

Findings of Intravenous Gadolinium Inner Ear Magnetic Resonance Imaging in Patients With Acute Low-Tone Sensorineural Hearing Loss.

OBJECTIVES: Acute low-tone sensorineural hearing loss (ALHL) is thought to have a different etiology from that of idiopathic sudden sensorineural hearing loss. We hypothesized that endolymphatic hydrops (EH) in the inner ear organ contributes to ALHL, even in patients without vertigo. This study investigated the presence of EH in ALHL and compared the clinical characteristics of patients with or without EH. METHODS: We retrospectively reviewed 38 patients diagnosed with ALHL without vertigo from January 2017 to March 2022. EH was measured in all patients using inner ear magnetic resonance imaging (MRI). In addition, we selected patients who showed only mid- or high-frequency hearing loss and had available MRI data as a control group and compared the ALHL and control groups. RESULTS: After treatment, the pure-tone average at low frequencies significantly improved compared to the initial hearing (P<0.001). Hearing recovery was observed in 63.1% of patients; however, the recovery rate did not differ based on the treatment method. During the follow-up period, six patients (15.8%) progressed to Meniere's disease, and 18 (47.4%) experienced recurrence. In the ALHL group, the cochlear hydrops ratio on the affected side (0.34±0.09) was significantly higher than on the contralateral side (0.29±0.12) (P=0.005), and most patients showed hydrops in the apex area of the cochlea. Compared with the control group (0.25±0.15), the ALHL group showed a significantly higher cochlear hydrops ratio (P=0.043). The correlation analysis showed a tendency for hearing thresholds at low frequencies to increase as the hydrops ratio increased, albeit without statistical significance. CONCLUSION: The cochlear hydrops ratio, especially in the apex area on the affected side, was significantly higher in patients with ALHL, suggesting that EH in the cochlea contributes to the pathogenesis of ALHL.

Round-window delivery of lithium chloride regenerates cochlear synapses damaged by noise-induced excitotoxic trauma via inhibition of the NMDA receptor in the rat.

Noise exposure can destroy the synaptic connections between hair cells and auditory nerve fibers without damaging the hair cells, and this synaptic loss could contribute to difficult hearing in noisy environments. In this study, we investigated whether delivering lithium chloride to the round-window can regenerate synaptic loss of cochlea after acoustic overexposure. Our rat animal model of noise-induced cochlear synaptopathy caused about 50% loss of synapses in the cochlear basal region without damaging hair cells. We locally delivered a single treatment of poloxamer 407 (vehicle) containing lithium chloride (either 1 mM or 2 mM) to the round-window niche 24 hours after noise exposure. Controls included animals exposed to noise who received only the vehicle. Auditory brainstem responses were measured 3 days, 1 week, and 2 weeks post-exposure treatment, and cochleas were harvested 1 week and 2 weeks post-exposure treatment for histological analysis. As documented by confocal microscopy of immunostained ribbon synapses, local delivery of 2 mM lithium chloride produced synaptic regeneration coupled with corresponding functional recovery, as seen in the suprathreshold amplitude of auditory brainstem response wave 1. Western blot analyses revealed that 2 mM lithium chloride suppressed N-methyl-D-aspartate (NMDA) receptor expression 7 days after noise-exposure. Thus, round-window delivery of lithium chloride using poloxamer 407 reduces cochlear synaptic loss after acoustic overexposure by inhibiting NMDA receptor activity in rat model.

Treatment Efficacy of Various Maneuvers for Lateral Canal Benign Paroxysmal Positional Vertigo With Apogeotropic Nystagmus: A Randomized Controlled Trial.

OBJECTIVES: The aim of this study was to determine the most effective treatment approach by comparing the impacts of various otolith reduction techniques in patients with apogeotropic lateral semicircular canal benign paroxysmal positional vertigo (LC-BPPV). METHODS: We performed a multicenter randomized prospective study from January to December 2015, involving 72 consecutive patients with apogeotropic LC-BPPV. The patients were divided into three treatment groups: therapeutic head-shaking (group A), the Gufoni-Appiani maneuver (group B), and the cupulolith repositioning maneuver (CuRM; group C). Each group underwent evaluation and treatment up to the fourth week. Treatment success was defined as the disappearance of positional vertigo and nystagmus. RESULTS: This study included 72 patients (49 male and 23 female), with a mean (±standard deviation) age of 55.4±13.5 years. The mean duration of vertigo experienced prior to treatment was 3.9±4.4 days. The mean latency and duration of nystagmus were 2.7±3.0 seconds and 47.9±15.8 seconds, respectively. The overall treatment frequency was 2.0±0.9. The number of treatments differed significantly among the three groups (P<0.05). After 4 weeks, the success rates for groups A, B, and C were 90.5%, 92.3%, and 100%, respectively. No significant difference was observed in the success rate across treatment. METHODS: and periods (P>0.05). However, CuRM was the only method with a 100% treatment success rate. CONCLUSION: While no clear difference was observed among the three treatments for LC-BPPV, CuRM was found to be superior to the other approaches in the long term.

Auditory characteristics and therapeutic effects of enzyme replacement in mouse model of the mucopolysaccharidosis (MPS) II.

Mucopolysaccharidosis (MPS) II is an X-linked metabolic disorder caused by dysfunction of iduronate-2-sulfatase (I2S). This abnormality causes the progressive accumulation of incompletely degraded glycosaminoglycans (GAGs) in the lysosomes. The auditory characteristics of MPS II in mouse models have not been reported. In this study, we evaluated the auditory characteristics of the MPS II in IDS knock-out (IDS-KO) mice. In addition, the effect of enzyme replacement therapy (ERT) on hearing was studied. The IDS-KO mice had normal histology of the cochlea and retained good hearing at 7 weeks of age. However, at 17 weeks of age, the hearing thresholds of the IDS-KO mice were elevated and exudates were found in the middle ear. The hearing thresholds of the enzyme-treated IDS-KO (IDS-ERT) mice were similar to the wild-type (WT) mice at 17 weeks. Moreover, the microstructure of the inner ear was similar to the IDS-KO by transmission electron microscopy. The histology findings indicated that the microstructure of the inner ear was similar in comparisons between IDS-KO and IDS-ERT mice, even after 10 weeks of treatment. However, the hearing deficits in the MPS II mouse model can be prevented if ERT is started before the onset of hearing impairment.

The clinical significance of preoperative brain magnetic resonance imaging in pediatric cochlear implant recipients.

Although central nervous system abnormalities are incidentally detected in preoperative brain magnetic resonance imaging (MRI) studies in pediatric cochlear implant (CI) candidates, the clinical significance of the abnormalities remains unclear. We aimed to assess post-implantation auditory and speech performance in patients with brain lesions seen on MRI. Pediatric CI recipients (n = 177) who underwent preoperative MRI scans of the brain between January 2002 and June 2009 were included in this study. Patients with brain lesions on MRI were reviewed and categorized into the following groups: brain parenchymal lesions (focal vs. diffuse), ventriculomegaly, and extra-axial lesion. The main communication mode as well as progress in auditory perception and speech production were evaluated preoperatively and at 3, 6, 12, and 24 months postoperatively. Performance in patients with brain lesions was compared with the age- and sex-matched control group. Various brain lesions were found in 27 out of 177 patients. Children with brain lesions who received CIs showed gradual progress in auditory and speech outcomes for 2 years, though performance was reduced compared with the control group. In addition, there was a significant difference in the main communication mode between the two groups at 2 years following cochlear implantation. This difference was especially significant in patients with diffuse brain parenchymal lesions after further stratification of the brain lesion group. Preoperative brain MRI may have a role in improving the prediction of adverse outcomes in pediatric CI recipients. In particular, children with diffuse brain parenchymal lesions should be counseled regarding the poor prognosis preoperatively, and followed up with special attention.

The influence of various factors on the performance of repetition tests in adults with cochlear implants.

A variety of internal and external factors influence speech perception performance following cochlear implantation (CI) in adult deaf patients. The aim of this study was to evaluate the speech perception performance during repetition testing according to various factors and to identify the predictive factors associated with postoperative speech perception. The performances on speech perception under audio-only conditions were examined over time in 61 adult patients with CI. Mono- and bi-syllable and sentence repetition testing, using both the Korean version of the Central Institute for the Deaf (K-CID) and the K-Western Aphasia Battery test (K-WAB), were performed preoperatively and at 3, 6 and 12 months postoperatively. To elucidate the effect that the etiology of deafness has on postoperative outcome, patients were divided into the following four groups: Prelingual hearing loss (HL) (n = 9), Meningitis (n = 6), Progressive HL (n = 31) and Sudden HL groups (n = 15). Moreover, the duration of HL and deafness was defined as follows: (1) "age of deafness onset: AoD", (2) "number of years between the onset of profound deafness and CI: DoD" and (3) "percentage of the patient's life with moderate-to-profound hearing loss before CI: PoL". DoD and PoL were significantly different between the four groups. Although AoD appeared to be associated with performance on the sentence repetition test before standardizing for education level and age (P = 0.015), there was no association after adjusting for these factors (P = 0.719). Only PoL showed a good correlation with performance on repetition testing after CI after adjusting for AoD and DoD. However, DoD was associated with speech perception performance on the sentence repetition test only. In addition, speech perception performance results in the Progressive and Sudden HL groups were improved over the Prelingual HL and Meningitis groups. The Meningitis group showed the poorest speech perception performance among postlingually deaf adults. Consideration of age, education level, etiology and overall time with hearing loss may be necessary for predicting speech perception outcomes in CI recipients.

Results of Active Middle Ear Implantation in Patients With Mixed Hearing Loss After Middle Ear Surgery: A Prospective Multicenter Study (the ROMEO Study).

OBJECTIVES: This study was conducted to evaluate the user satisfaction, efficacy, and safety of round window (RW) vibroplasty using the Vibrant Soundbridge (VSB) in patients with persistent mixed hearing loss after mastoidectomy. METHODS: The study included 27 patients (mean age, 58.7 years; age range, 28-76 years; 11 men and 16 women) with mixed hearing loss after mastoidectomy from 15 tertiary referral centers in Korea. The VSB was implanted at the RW. The Korean translation of the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire and the Korean version of the International Outcome Inventory for Hearing Aids (K-IOI-HA) questionnaire were used to evaluate user satisfaction as the primary outcome. The secondary outcome measures were audiological test results and complication rates. RESULTS: The mean scores for ease of communication (61.3% to 29.7% to 30.2%), reverberation (62.1% to 43.1% to 37.4%), and background noise (63.3% to 37.7% to 34.3%) subscales of the APHAB questionnaire significantly decreased after VSB surgery. The mean K-IOI-HA scores at 3 and 6 months after surgery were significantly higher than the mean preoperative score (18.6 to 27.2 to 28.1). The postoperative VSB-aided thresholds were significantly lower than the preoperative unaided and hearing aid (HA)-aided thresholds. There was no significant difference between preoperative unaided, preoperative HA-aided, and postoperative VSB-aided maximum phonetically balanced word-recognition scores. None of the 27 patients experienced a change in postoperative bone conduction pure tone average. One patient developed temporary facial palsy and two developed surgical wound infections. CONCLUSION: RW vibroplasty resulted in improved satisfaction and audiological test results in patients with mixed hearing loss after mastoidectomy, and the complication rate was tolerable.

Significance of Pseudo-Conductive Hearing Loss and Positional Nystagmus for Perilymphatic Fistula: Are They Related to Third-Window Effects?

OBJECTIVES: Patients' clinical presentation is critical for identifying suspected perilymphatic fistula (PLF). The involvement of third-window lesions in the pathomechanism of PLF has been hypothesized. This study investigated the clinical features of PLF and the relationship of the third-window effect with PLF. METHODS: Sixty patients underwent surgical exploration for suspected PLF and the oval and round windows were reinforced. Clinical features including demographics, pure-tone audiometry (PTA), and videonystagmography were evaluated preoperatively and 1 month postoperatively. Surgical outcomes were analyzed according to the improvement of hearing and vestibular symptoms and signs. The conductive components of PTA (air-bone gap [ABG]) were measured, and the relationship between ABG closure after surgery and hearing improvement was analyzed. In addition, postoperative subjective dizziness was assessed by clinical interviews. Changes in positional nystagmus were analyzed according to ABG closure and hearing improvement. RESULTS: ABG at lower frequencies (LFABG; 250 Hz, 500 Hz, 1,000 Hz) was present in 27 patients (45%). Postoperatively, PTA significantly improved after surgical repair. Among the patients with preoperative LFABG (n=27), 15 (55.5%) showed postoperative ABG closure and significant improvement in PTA at all frequencies compared with the patients without ABG closure (P=0.012). Subjective dizziness improved in 57 patients (93.3%). Positional nystagmus was found in 45 of 49 patients. Multiple canal involvement was more common than single canal involvement (67% vs. 33%). The horizontal semicircular canal was most commonly involved, followed by the posterior and anterior canals. Postoperatively, positional nystagmus disappeared, or the number of involved canals decreased in 22 of 34 patients (64.7%). CONCLUSION: Pseudo-conductive hearing loss at lower frequencies and positional nystagmus originating from multiple semicircular canals were common findings in PLF. Surgical reinforcement of the oval and round windows improved the hearing threshold accompanied by closure of ABG. A third-window lesion might explain these clinical features of PLF.

Clinical predictors of cybersickness in virtual reality (VR) among highly stressed people.

The use of virtual reality (VR) in the treatment of psychiatric disorders is increasing, and cybersickness has emerged as an important obstacle to overcome. However, the clinical factors affecting cybersickness are still not well understood. In this study, we investigated clinical predictors and adaptation effect of cybersickness during VR application in highly stressed people. Eighty-three healthy adult participants with high stress level were recruited. At baseline, we conducted psychiatric, ophthalmologic, and otologic evaluations and extracted physiological parameters. We divided the participants into two groups according to the order of exposure to VR videos with different degrees of shaking and repetitively administered the Simulator Sickness Questionnaire (SSQ) and the Fast Motion sickness Scale (FMS). There was no significant difference in changes in the SSQ or the FMS between groups. The 40-59 years age group showed a greater increase in FMS compared to the 19-39 years age group. Smoking was negatively associated with cybersickness, and a high Positive Affect and Negative Affect Schedule score was positively associated with cybersickness. In conclusion, changing the intensity of shaking in VR did not affect cybersickness. While smoking was a protective factor, more expression of affect was a risk factor for cybersickness.

Factors Contributing to the Severity and Laterality of Pisa Syndrome in Parkinson's Disease.

Objective: Pisa syndrome (PS) is a disabling postural deformity in Parkinson's disease (PD). We aimed to elucidate clinical factors determining the severity and laterality of PS in PD. Methods: In 54 PD patients with PS, we measured the clinical factors that are previously known to contribute to the occurrence of PS as follows: asymmetry of motor symptoms for the evaluation of asymmetric basal ganglia dysfunction, the degree and direction of subjective visual vertical (SVV) tilt for the misperception of body verticality, the canal paresis for unilateral peripheral vestibulopathy, and the tonic electromyographic (EMG) hyperactivity of paraspinal muscles for dystonia. Multivariable linear and logistic regression analyses were conducted to identify the clinical factors associated with the degree of truncal tilt, for the quantification of the severity of PS, and PS tilting to the less affected side, respectively. Results: The multivariable linear regression analyses revealed that the larger degree of SVV tilt (ß = 0.29, SE = 0.10, p = 0.005), right-sided SVV tilt (ß = 2.32, SE = 0.82, p = 0.007), and higher Hoehn and Yahr (HY) stage (ß = 4.01, SE = 1.29, p = 0.003) significantly increased the severity of PS. In the multivariable logistic regression analyses, greater asymmetry of motor symptoms [odds ratio (OR) = 2.01, 95% CI = 1.34-3.49] was significantly associated with PS tilting to the less affected side, while right-sided SVV tilt (OR = 0.02, 95% CI = 0.001-0.21), unilateral canal paresis (OR = 0.06, 95% CI = 0.003-0.79), and higher HY stage (OR = 0.04, 95% CI = 0.002-0.46) were associated with PS tilting to the more affected side. Conclusion: Misperception of verticality, asymmetric basal ganglia dysfunction, unilateral peripheral vestibulopathy, and motor disability are the clinical factors associated with the severity and laterality of PS in patients with PD.

Validation of inner ear MRI in patients with Ménière's disease by comparing endolymphatic hydrops from histopathologic specimens.

Intravenous gadolinium-enhanced inner-ear magnetic resonance imaging (IV-Gd inner-ear MRI) has been used to visualize endolymphatic hydrops (EH) in clinical diagnosis of Ménière's disease (MD). However, lack of histological validation has led to several concerns regarding how best to interpret the resulting images. Here, we compared hydropic changes in temporal bone specimens with the results of IV-Gd inner-ear MRI in patients with MD. Histopathologic images of temporal bones from 37 patients with MD and 10 healthy controls were collected from the National Temporal Bone Bank of the Massachusetts Eye and Ear Infirmary in the United States. The EH ratios in the vestibule and cochlea were calculated from temporal bones using the methods used for IV-Gd inner-ear MRI, and the degree to which the saccular and utricular hydrops contributed to vestibular hydrops was measured. The presence of hydropic change in each semicircular canal was assessed using temporal bone images and compared with IV-Gd inner-ear MRI scans of 74 patients with MD. Based on human temporal bone imagery, the EH ratios in the cochlea and the vestibule on the affected side were 0.314 and 0.757, respectively. In the healthy control group, the ratio was 0.064 for the cochlea and 0.289 for the vestibule; these values were significantly different from those for the affected side of MD patients. The values for the affected ear were similar to the ratios from the IV-Gd inner-ear MRI scans in MD patients. In the vestibule, saccular hydrops were more common than utricular hydrops. The average EH ratios in the saccule and utricle were 0.513 and 0.242, respectively. No significant hydropic change from each of three semicircular canals was evident in temporal bone histopathology. However, herniation of otolithic organs (saccule or utricle) into the lateral semicircular canal was found in 44.4% of the patients, with saccular herniation (24.8%) more common than utricular herniation (16.7%). Although IV-Gd inner-ear MRI might not reflect fully the results of actual histopathology due to the limited resolution of MRI and image-processing techniques, the measured EH ratios from temporal bone specimens and IV-Gd inner-ear MRI scans were similar. Hydropic change in the three semicircular canals was not significant at either the ampullated or nonampullated end. Canal invasion of vestibular hydrops seen on MRI also appeared in temporal bone histopathology, and saccular invasion was dominant.

Effect of Virtual Reality on Stress Reduction and Change of Physiological Parameters Including Heart Rate Variability in People With High Stress: An Open Randomized Crossover Trial.

Introduction: Although, attempts to apply virtual reality (VR) in mental healthcare are rapidly increasing, it is still unclear whether VR relaxation can reduce stress more than conventional biofeedback. Methods: Participants consisted of 83 healthy adult volunteers with high stress, which was defined as a score of 20 or more on the Perceived Stress Scale-10 (PSS-10). This study used an open, randomized, crossover design with baseline, stress, and relaxation phases. During the stress phase, participants experienced an intentionally generated shaking VR and serial-7 subtraction. For the relaxation phase, participants underwent a randomly assigned relaxation session on day 1 among VR relaxation and biofeedack, and the other type of relaxation session was applied on day 2. We compared the State-Trait Anxiety Inventory-X1 (STAI-X1), STAI-X2, the Numeric Rating Scale (NRS), and physiological parameters including heart rate variability (HRV) indexes in the stress and relaxation phases. Results: A total of 74 participants were included in the analyses. The median age of participants was 39 years, STAI-X1 was 47.27 (SD = 9.92), and NRS was 55.51 (SD = 24.48) at baseline. VR and biofeedback significantly decreased STAI-X1 and NRS from the stress phase to the relaxation phase, while the difference of effect between VR and biofeedback was not significant. However, there was a significant difference in electromyography, LF/HF ratio, LF total, and NN50 between VR relaxation and biofeedback. Conclusion: VR relaxation was effective in reducing subjectively reported stress in individuals with high stress.

Signal intensity change of the labyrinth in patients with surgically confirmed or radiologically diagnosed vestibular schwannoma on isotropic 3D fluid-attenuated inversion recovery MR imaging at 3 T.

OBJECTIVE: The purpose of this study was to evaluate the signal intensity (SI) change of the labyrinth in patients with vestibular schwannoma on isotropic 3D fluid-attenuated inversion recovery (FLAIR) imaging at 3 T. METHODS: Thirty-four patients with surgically confirmed or radiologically diagnosed vestibular schwannoma were included in this study. Retrospectively, we visually and quantitatively compared the SIs of the cochlea and vestibule on the affected side with those on the unaffected side. We also investigated whether there was correlation between the SI ratios (SIRs) of the labyrinth and the audiometric findings. RESULTS: On 3D FLAIR images, the SI of the cochlea and vestibule on the affected side was significantly increased in 97% (33/34) and 91% (31/34), respectively. While the SI of the cochlea was diffusely increased, that of the vestibule was only partially increased. Quantitative study also revealed statistically significantly higher SIRs of the cochlea (0.99 +/- 0.29) and vestibule (0.73 +/- 0.31) on the affected side, compared with the cochlea (0.47 +/- 0.20) and vestibule (0.19 +/- 0.10) on the unaffected side. There was no significant correlation of the SIRs of the labyrinth with the degree of hearing loss. CONCLUSION: In patients with vestibular schwannoma, isotropic 3D FLAIR imaging is a useful method for the evaluation of the SI changes of the labyrinth.

Evaluating Reasons for Revision Surgery and Device Failure Rates in Patients Who Underwent Cochlear Implantation Surgery.

Importance: Understanding the reasons for cochlear implant (CI) revision surgery and device failure rates is important for clinicians when counseling patients who are considering CI. Objectives: To analyze the revision surgery rate, reasons for revision surgery, and device failure and survival rates of different device models in recipients of CIs. Design, Setting, and Participants: In this cohort study, cochlear implants at Samsung Medical Center, a tertiary referral center, were retrospectively reviewed. Patients who underwent CI surgery from October 2001 to March 2019 were included. In the device survival analysis, the first revision surgery was considered the primary event, and the end point of observation was June 1, 2019. Interventions: Therapeutic and rehabilitative CI surgery. Main Outcomes and Measures: The revision surgery rate, reasons for revision surgery, and the failure and survival rates of different device models were analyzed. The Kaplan-Meier method and the log-rank test were used to present both the device survival and cumulative survival curves with rates. Results: In this study, 43 of 925 patients with CIs (4.6%) underwent a revision surgery. Device failure was the most common reason (28 of 43 patients [65%]). Flap-associated problems and migration of the inner device were the next most important reasons (4 of 43 [9.3%] each). Overall, the 10-year cumulative survival rate of CI surgery was 94.4%, and the device survival rate was 96.0%. Thirteen different CI devices from 4 different manufacturers were implanted, and no meaningful differences in device failure were found among CI manufacturers or devices (hazard ratios for cumulative survival: Cochlear, 1.67 [95% CI, 0.72-3.88]; Advanced Bionics, 1.67 [95% CI, 0.61-4.53]; Med-El, reference; hazard ratios for device survival: Cochlear, 1.65 [95% CI, 0.55-4.99]; Advanced Bionics, 1.93 [95% CI, 0.56-6.74]; Med-El, reference). Several recalls were issued by manufacturers during the study period, and after excluding the recalled devices, the device survival rates for 5, 10, and 15 years were 98.2%, 97.7%, and 94.9%, respectively. Conclusions and Relevance: Generally, implanted devices remain safe and stable for a long time, and no significant differences in survival rates were found between device types or manufacturers. Device failure was the main reason for CI revision, followed by flap-associated problems and migration of the inner device.