Volumetry improves the assessment of the vestibular aqueduct size in inner ear malformation.

OBJECTIVES: Enlarged vestibular aqueduct (EVA) is a common finding associated with inner ear malformations (IEM). However, uniform radiologic definitions for EVA are missing and various 2D-measurement methods to define EVA have been reported. This study evaluates VA volume in different types of IEM and compares 3D-reconstructed VA volume to 2D-measurements. METHODS: A total of 98 high-resolution CT (HRCT) data sets from temporal bones were analyzed (56 with IEM; [cochlear hypoplasia (CH; n = 18), incomplete partition type I (IPI; n = 12) and type II (IPII; n = 11) and EVA (n = 15)]; 42 controls). VA diameter was measured in axial images. VA volume was analyzed by software-based, semi-automatic segmentation and 3D-reconstruction. Differences in VA volume between the groups and associations between VA volume and VA diameter were assessed. Inter-rater-reliability (IRR) was assessed using the intra-class-correlation-coefficient (ICC). RESULTS: Larger VA volumes were found in IEM compared to controls. Significant differences in VA volume between patients with EVA and controls (p < 0.001) as well as between IPII and controls (p < 0.001) were found. VA diameter at the midpoint (VA midpoint) and at the operculum (VA operculum) correlated to VA volume in IPI (VA midpoint: r = 0.78, VA operculum: r = 0.91), in CH (VA midpoint: r = 0.59, VA operculum: r = 0.61), in EVA (VA midpoint: r = 0.55, VA operculum: r = 0.66) and in controls (VA midpoint: r = 0.36, VA operculum: r = 0.42). The highest IRR was found for VA volume (ICC = 0.90). CONCLUSIONS: The VA diameter may be an insufficient estimate of VA volume, since (1) measurement of VA diameter does not reliably correlate with VA volume and (2) VA diameter shows a lower IRR than VA volume. 3D-reconstruction and VA volumetry may add information in diagnosing EVA in cases with or without additional IEM.

Assessment of cochlear implant candidacy in patients with cochlear nerve deficiency using the P1 CAEP biomarker.

OBJECTIVE: The goal of this report was to ascertain the efficacy of the P1 cortical auditory evoked potential (CAEP) biomarker as an objective tool to assist in the evaluation of cochlear implant (CI) candidacy in children with a radiological diagnosis of cochlear nerve deficiency (CND). METHODS: Retrospective case study review of audiological and radiological findings was performed in four pediatric patients identified with CND and severe-to-profound sensorineural hearing loss. Cortical auditory evoked potential testing was conducted, and the presence and latency of the P1 component were analyzed. RESULTS: Three out of four children demonstrated robust P1 CAEP responses, indicating activation of the central auditory pathways by auditory stimulation, despite the diagnosis of CND. These children were considered good candidates for cochlear implantation. DISCUSSION: Although cochlear implantation in children is a fairly routine procedure, cases exist for which implant candidacy is questionable. Among these cases are children with CND. In these children, cochlear implantation may be contraindicated due to the likelihood that the implant electrodes may not stimulate the VIII nerve adequately. Magnetic resonance imaging (MRI) is considered the gold standard in the assessment of CND, but this measure is not always sufficient to determine CI candidacy in cases of CND. The addition of the P1 CAEP measurement to the usual electrophysiological, audiometric, and radiological test battery may prove to be useful in determining CI options for children with CND.

Parent versus child assessment of quality of life in children using cochlear implants.

OBJECTIVE: Children with hearing loss who use cochlear implants have lower quality of life (QoL) in social situations and lower self-esteem than hearing peers. The child's QoL has been assessed primarily by asking the parent rather than asking the child. This poses a problem because parents have difficulty judging less observable aspects like self-esteem and socio-emotional functioning, the domains most affected by hearing loss. METHODS: This case-control study evaluated QoL in 50 preschoolers using a cochlear implant and their parents with the Kiddy KINDL(®), an established QoL measure. Children's responses were compared to a hearing control group and correlated with demographic variables. We used a questionnaire for parents and a face-to-face interview with children. T-tests were used to compare (a) paired parent-child ratings and (b) children with cochlear implants versus normal hearing. Pearson rank correlations were used to compare QoL with demographic variables. RESULTS: Children using cochlear implants rated overall QoL significantly more positively than their parents (M(Difference)=4.22, p=.03). Child rating of QoL did not differ significantly by auditory status (cochlear implant (82.8) vs. hearing (80.8), p=.42). Overall QoL correlated inversely with cochlear implant experience and chronologic age, but did not correlate with implantation age. CONCLUSIONS: Preschool children using cochlear implants can assess adequately their own QoL, but parents afford valuable complementary perspective on the child's socio-emotional and physical well-being. Preschool children using cochlear implants rate overall QoL measures similar to hearing peers. A constellation of QoL measures should be collected to yield a better understanding of general QoL as well as specific domains centered on hearing loss.

An assessment of the onset and duration of action of olopatadine nasal spray.

OBJECTIVE: Seasonal allergic rhinitis (SAR) is a highly prevalent disease. This study was conducted to evaluate the onset and duration of action of three concentrations of olopatadine nasal spray. METHODS: This was a randomized, double-blind, single-dose, placebo-controlled study, conducted in an environmental exposure chamber in patients with SAR. A total of 320 patients were exposed to ragweed allergen in the chamber and randomized to olopatadine nasal spray 0.2%, 0.4%, 0.6%, or placebo nasal spray. Symptoms (sneezing, runny, itchy, and stuffy nose) were self-assessed during a 12-hour study period. RESULTS: All concentrations of olopatadine nasal spray provided clinically meaningful reductions in total nasal symptom scores at 30 minutes compared to the placebo. Olopatadine nasal spray 0.6% was significantly more effective (P < 0.05) than placebo nasal spray at all time-points starting at 90 minutes post-dose and continuing over 12 hours. CONCLUSIONS: Olopatadine nasal spray 0.6% demonstrated a fast onset of action and maintained an effect for at least 12 hours after dosing.

An economic evaluation of two ototopical treatments for acute otitis media in tympanostomy tube patients.

OBJECTIVE: The goal of this research was to determine the cost-effectiveness of ciprofloxacin 0.3%/dexamethasone 0.1% (CD) otic suspension versus ofloxacin 0.3% otic solution (OFX) for treatment of acute otitis media in tympanostomy tube patients. METHODS: A decision-analytic model was used to emulate the ototopical treatment of acute otitis media in patients with tympanostomy tubes. The economic outcome was the cost per otorrhea-free day (OFD) achieved per episode of care. Three tiers of antimicrobial therapy were modeled, with each successive tier representing the retreatment of clinical failures from the preceding tier. First-tier therapy compared CD and OFX using outcome measures obtained from a randomized clinical trial (n = 599). Second-tier therapy modeled the use of amoxicillin/clavulanate (ACA) using outcome measures obtained from a physician survey and medical literature. Third-tier therapy was modeled as pathogen-specific and curative. It could follow one of three pathways: 1) intramuscular ceftriaxone; 2) oral fluconazole; or 3) hospitalization for intravenous antibiotics. Third-tier outcomes were based on a physician survey. Cost data were obtained from standard references and presented from a payer perspective. RESULTS: The expected therapeutic costs were 249.40 dollars for the CD pathway and 265.44 dollars for the OFX pathway. The estimated number of OFDs per episode of care was 25.88 for the CD pathway and 23.86 for the OFX pathway. The cost-effectiveness ratios for CD and OFX therapies were 9.64 dollars and 11.13 dollars per OFD, respectively. CONCLUSION: CD is both more effective and less costly than OFX for the treatment of acute otitis media in patients with tympanostomy tubes.

Advantages of magnetic resonance imaging over computed tomography in preoperative evaluation of pediatric cochlear implant candidates.

OBJECTIVES: To compare magnetic resonance imaging (MRI) to high-resolution computed tomography (HRCT) in the preoperative evaluation of pediatric cochlear implant candidates. METHODS: The charts of pediatric cochlear implant candidates evaluated between July 1, 2000 and November 30, 2003 with an MRI scan of the inner ear were included in the study. Fifty-six patients were included. Associated HRCT scans were examined. Abnormalities of the cochlea, cochlear nerve, endolymphatic sac, endolymphatic duct, vestibule, and modiolus were noted. A pediatric neuroradiologist gave an opinion as to whether patients with anomalies seen with MRI but without associated HRCT would have been identified by HRCT. RESULTS: Of the 112 temporal bones imaged with MRI, the following abnormalities were encountered: 32% (36/112) had abnormalities of the cochlear turns, 30% (34/112) had abnormal signal in the modiolus, 23% (26/112) had abnormal vestibulae, 16% (18/112) had abnormal endolymphatic ducts, 15% (17/112) had abnormal endolymphatic sacs, 12% (13/112) had abnormalities of the cochlear nerves, 29% (17/56) had abnormalities of the brain. HRCT cannot directly evaluate the cochlear nerve. Available HRCT findings were combined with radiologic opinion and compared with MRI findings. The percentages of abnormalities identifiable by HRCT when compared with those seen with MRI are cochlea 42% (15/36), modiolus 35% (12/34), vestibulae 88% (23/26), endolymphatic duct 100% (18/18), and endolymphatic sac 6% (1/17). CONCLUSION: MRI is more sensitive and specific in diagnosing soft tissue abnormalities in the inner ear than HRCT in cochlear implant candidates (Fig. 4). Moreover, the abnormalities detected with MRI are more likely to influence the implantation process (e.g., asymmetric nerve aplasia, cochlear obstruction). (Figure is included in full-text article).

Acquired external auditory canal stenosis: assessment and management.

PURPOSE OF REVIEW: Although uncommon, acquired external auditory canal stenosis is an entity that is encountered by many otolaryngologists. This paper reviews the causes, pathogenesis, assessment, and management options for external auditory canal stenosis. RECENT FINDINGS: Initially, acquired external auditory canal stenosis was described as resulting from a number of different causes. Since then, histology and imaging studies of this disease have shown that a common cascade of inflammatory changes resulting from these different causes is the primary pathogenesis leading to medial canal fibrosis. Once there is complete obstruction of the external auditory canal, surgery is the primary treatment. Understanding the strong role of inflammation in the pathogenesis of external auditory canal stenosis may lead to new preventative medical therapies. SUMMARY: Although acquired external auditory canal was described several years ago, its underlying pathophysiology is now better understood. From this knowledge, improved medical as well as surgical approaches can be developed.

A cost threshold analysis of ciprofloxacin-dexamethasone versus ofloxacin for acute otitis media in pediatric patients with tympanostomy tubes.

OBJECTIVE: The aim of this study was to determine the cost-effectiveness hreshold of a ciprofloxacin 0.3% and dexamethasone 0.1% (CD) otic suspension relative to olfloxacin otic solution (OFX) for the treatment of acute otitis media in pediatric patients with tympanostomy tubes (AOMT). METHODS: This study used a decision-analytic model to simulate the costs and consequences of the ototopical treatment of AOMT. The AOMT model consisted of 3 tiers of antimicrobial therapy. Each successive tier represented the repeat treatment of clinical failures from the preceding tier. Patients were modeled for treatment until cured or until third-tier therapy was complete, at which time patients were considered cured. First-tier therapy modeled a comparison of CD and OFX using efficacy rates taken from a randomized clinical trial with a population of 599 patients. Second-tier therapy modeled the use of amoxicillin and clavulanic acid using an efficacy rate taken from the medical literature. Third-tier therapy was modeled as being pathogen specific and could follow 1 of 3 possible clinical pathways: (1) PO fluconazole, (2) IM ceftriaxone, or (3) IV antibiotics administered in a hospital setting. Third-tier therapeutic pathway probabilities were based on the microbiologic spectrum of the treatment failures from the clinical trial. Cost information (in year-2003 US dollars) was taken from accepted cost reference sources and presented from the perspective of a third-party payer. The economic outcome of interest was the cost-effectiveness threshold of CD relative to OFX. RESULTS: Given the model parameters, CD had a cost-effectiveness threshold value of 4.5 times the wholesale acquisition cost of OFX. Based on actual cost, first-tier CD therapy was more cost-effective than OFX up to a threshold price of US 152.64 dollars. CONCLUSION: In this decision-analytic model, CD was more cost-effective than OFX for AOMT therapy in pediatric patients up to a threshold price of 4.5 times the price of OFX.