Update on consensus on diagnosis and treatment of idiopathic sudden sensorineural hearing loss. / Actualización del consenso sobre el diagnóstico y tratamiento de la sordera súbita idiopática.

INTRODUCTION: Idiopathic sudden sensorineural hearing loss (ISSNHL) is a sudden, unexplained unilateral hearing loss. OBJECTIVES: To update the Spanish Consensus on the diagnosis, treatment and follow-up of ISSNHL. MATERIAL AND METHODS: After a systematic review of the literature from 1966 to March 2018, on MESH terms «(acute or sudden) hearing loss or deafness¼, a third update was performed, including 1508 relevant papers. RESULTS: Regarding diagnosis, 11ISSNHL is clinically suspected, the following diagnostic tests are mandatory: otoscopy, acumetry, tonal audiometry, speech audiometry, and tympanometry, to discount conductive causes. After clinical diagnosis has been established, and before treatment is started, a full analysis should be performed. An MRI should then be requested, ideally performed during the first 15 days after diagnosis, to discount specific causes and to help to understand the physiopathological mechanisms in each case. Although treatment is very controversial, due to its effect on quality of life after ISSNHL and the few rare adverse effects associated with short-term steroid treatment, this consensus recommends that all patients should be treated with steroids, orally and/or intratympanically, depending on each patient. In the event of failure of systemic steroids, intratympanic rescue is also recommended. Follow-up should be at day 7, and after 12 months. CONCLUSION: By consensus, results after treatment should be reported as absolute decibels recovered in pure tonal audiometry and as improvement in speech audiometry.

Minimally invasive laser vibrometry (MIVIB) with a floating mass transducer - A new method for objective evaluation of the middle ear demonstrated on stapes fixation.

Ossicular fixation through otosclerosis, chronic otitis media and other pathologies, especially tympanosclerosis, are treated by surgery if hearing aids fail as an alternative. However, the best hearing outcome is often based on knowledge of the degree and location of the fixation. Objective methods to quantify the degree and position of the fixation are largely lacking. Laser vibrometry is a known method to detect ossicular fixation but clinical applicability remains limited. A new method, minimally invasive laser vibrometry (MIVIB), is presented to quantify ossicle mobility using laser vibrometry measurement through the ear canal after elevating the tympanic membrane, thus making the method feasible in minimally invasive explorative surgery. A floating mass transducer provides a clinically relevant transducer to drive ossicular vibration. This device was attached to the manubrium and drove vibrations at the same angle as the longitudinal axis of the stapes and was therefore used to assess ossicular chain mobility in a fresh-frozen temporal bone model with and without stapes fixation. The ratio between the umbo and incus long process was shown to be useful in assessing stapes fixation. The incus-to-umbo velocity ratio decreased by 15 dB when comparing the unfixated situation to stapes fixation up to 2.5 kHz. Such quantification of ossicular fixation using the incus-to-umbo velocity ratio would allow quick and objective analysis of ossicular chain fixations which will assist the surgeon in surgical planning and optimize hearing outcomes.

Differential Intracochlear Sound Pressure Measurements in Human Temporal Bones with an Off-the-Shelf Sensor.

The standard method to determine the output level of acoustic and mechanical stimulation to the inner ear is measurement of vibration response of the stapes in human cadaveric temporal bones (TBs) by laser Doppler vibrometry. However, this method is reliable only if the intact ossicular chain is stimulated. For other stimulation modes an alternative method is needed. The differential intracochlear sound pressure between scala vestibuli (SV) and scala tympani (ST) is assumed to correlate with excitation. Using a custom-made pressure sensor it has been successfully measured and used to determine the output level of acoustic and mechanical stimulation. To make this method generally accessible, an off-the-shelf pressure sensor (Samba Preclin 420 LP, Samba Sensors) was tested here for intracochlear sound pressure measurements. During acoustic stimulation, intracochlear sound pressures were simultaneously measurable in SV and ST between 0.1 and 8 kHz with sufficient signal-to-noise ratios with this sensor. The pressure differences were comparable to results obtained with custom-made sensors. Our results demonstrated that the pressure sensor Samba Preclin 420 LP is usable for measurements of intracochlear sound pressures in SV and ST and for the determination of differential intracochlear sound pressures.

[Subjective tympanophonia. The current concepts of therapy].

The authors overview the current concepts of the management of the patients complaining of subjective tympanophonia with special reference to the medicamental and medicamental treatment of this condition and rehabilitation. Bearing in mind a great variety of approaches to addressing this problem, only the most important, widely applied, and clinically verified methods for this purpose are considered.

A programmable acoustic stimuli and auditory evoked potential measurement system for objective tinnitus diagnosis research.

This paper presents the development of a single platform that records auditory evoked potential synchronized to specific acoustic stimuli of the gap prepulse inhibition method for objective tinnitus diagnosis research. The developed system enables to program various parameters of the generated acoustic stimuli. Moreover, only by simple filter modification, the developed system provides high flexibility to record not only short latency auditory brainstem response but also late latency auditory cortical response. The adaptive weighted averaging algorithm to minimize the time required for the experiment is also introduced. The results show that the proposed algorithm can reduce the number of the averaging repetitions to 70% compared with conventional ensemble averaging method.

[Tinnitus management in 2013]. / Les acouphènes: quelle prise en charge en 2013?

Tinnitus is a common symptom, affecting nearly 10% of the adult population. Even if most of the patients support it, it can be particularly disabling in some cases. Recent advances in neuroscience have greatly improved the understanding of its pathophysiology, resulting in development of new therapeutic strategies. The management of tinnitus requires a systematic and rational approach to avoid incomplete diagnosis procedures and unnecessary exams. The diagnostic approach will be held to identify the causal pathology. Etiological treatment, if it is possible, will be the first therapeutic step. Various symptomatic treatments, such as tinnitus retraining therapy, cognitive behavioral therapy, or neuromodulation will promote habituation to the tinnitus, to ensure that the latter won't cause discomfort anymore.

Improving tinnitus with mechanical treatment of the cervical spine and jaw.

BACKGROUND: Tinnitus affects approximately 30-50 million Americans. In approximately 0.5-1.0% of the population, tinnitus has a moderate to severe impact on their quality of life. Musculature and joint pathologies of the head and neck are frequently associated with tinnitus and have been hypothesized to play a contributing role in its etiology. However, specific physical therapy interventions to assist in improving tinnitus have not yet been reported. PURPOSE: To describe the examination and treatment intervention of a patient with subjective tinnitus. PATIENT DESCRIPTION: The patient was a 42-yr-old male experiencing intermittent bilateral tinnitus, headaches, blurred vision, and neck tightness. His occupation required long-term positioning into neck protraction. Examination found limitations in cervical extension, bilateral rotation, and side bending. Asymmetry was also noted with temporomandibular joint (TMJ) movements. Upon initial evaluation the patient demonstrated functional, physical, and emotional deficits per neck, headache, and dizziness self-report scales and a score on the Tinnitus Handicap Inventory (THI) of 62. Resisted muscle contractions of the cervical spine in flexion, extension, and rotation increased his tinnitus. INTERVENTION: Treatment focused on normalizing cervical spine mobility through repetitive movements, joint mobilization, and soft tissue massage. RESULTS: At 2.5 mo, the patient demonstrated a complete reversal of his tinnitus after 10 physical therapy sessions as noted by his score of 0 on the THI upon discharge. He also demonstrated objective improvements in his cervical motion. This case reflected treatment targeted at cervical and TMJ impairments and notable improvements to tinnitus. Future studies should further explore the direct and indirect treatment of tinnitus by physical therapists through clinical trials.

Accessing escalators: a central vestibular disorder after posterior fossa tumor removal.

About 20% of childhood tumors originate within the central nervous system. Progress in assessment and treatment of these lesions has led to improved survival rates. We describe a patient with a posterior fossa ependymoma who despite a remarkable recovery following treatment has been frustrated by difficulty in using escalators. Such symptom selectivity is explained by specific vertical visuomotor and high-frequency vestibular deficits disrupting the execution of this complex motor act.

Detection improvement for neonatal click evoked otoacoustic emissions by time-frequency filtering.

This study employed a time-frequency filtering technique to improve click evoked otoacoustic emission (CEOAE) detection at lower frequency bands, and hence to reduce the number of referral cases in neonatal OAE screening. Using this approach the detectability of CEOAEs, in terms of lower frequency SNRs and whole wave reproducibility, was significantly improved. Evaluations of screening outcomes demonstrated this method significantly reduced the overall referral rate, by 2.5 percentage points in initial CEOAE hearing screening. This approach may have potential application in OAE technology and in neonatal hearing screening programmes.

The clinical value of the multiple-frequency 80-Hz auditory steady-state response in adults with normal hearing and hearing loss.

OBJECTIVES: To determine the ability of the air-conduction multiple-frequency auditory steady-state response (ASSR) technique to diagnose normal hearing (NH) and mild and moderate degrees of sensorineural hearing loss (SNHL), to assess patients with conductive hearing loss (CHL), to evaluate flat and sloping configurations of hearing impairment, and to provide sensitivity and specificity values for various ASSR cutoff criteria. DESIGN: A comparative study between ASSR and criterion-standard behavioral thresholds. SETTING: Ear, nose, and throat department at a university hospital. PATIENTS: The study population comprised 40 adults with NH, 17 with SNHL, and 7 with CHL. MAIN OUTCOME MEASURES: The measure of interest was the difference between ASSR and behavioral thresholds at 0.5, 1.0, 2.0, and 4.0 kHz. The sensitivity, specificity, positive predictive value, negative predictive value, and efficiency were calculated for several ASSR cutoff criteria. RESULTS: The ASSR technique clearly distinguished moderate SNHL from NH, but the "mild SNHL and NH" and "mild SNHL and moderate SNHL" differentiation was particularly difficult at 0.5 and 2.0 kHz, respectively. Air-conduction ASSR thresholds accurately predicted behavioral thresholds in CHL. The ASSR system precisely reflected the flat and sloping configurations. Finally, the most appropriate ASSR cutoff point for normality seems to be the 30-dB-or-lower criterion. CONCLUSIONS: In adults, the multiple-frequency 80-Hz ASSR technique can be used to determine the degree and configuration of hearing loss. Although air-conduction ASSR thresholds accurately predicted behavioral thresholds in CHL, future research with bone-conduction ASSRs is necessary to establish the type of hearing loss. Furthermore, the applicability of these findings still needs to be confirmed for infants.

Test-retest reliability of low-level evoked distortion product otoacoustic emissions.

PURPOSE: The purpose of this study was to examine test-retest reliability of low-level evoked distortion product otoacoustic emissions (DPOAEs) as a function of L(1), L(2) level; f(2) frequency; and test condition. A predictive relationship between these variables and the presence/absence of DPOAE responses was also examined. METHOD: Sixteen normal-hearing young adults participated. DPOAEs were evoked to 12 tones with f(2) frequencies ranging from 1500 Hz to 7546 Hz at 4 L(2) levels between 45 dB SPL and 30 dB SPL. Four test conditions were employed: (a) initial test, (b) retest without probe removal, (c) retest with probe reinsertion, and (d) retest with probe reinsertion by a second tester. RESULTS: L(1), L(2) level and f(2) frequency were statistically significant (p < .0001) predictors of a DPOAE response (i.e., the presence of a DPOAE response was more likely to be observed at higher L(1), L(2) levels and lower f(2) frequencies regardless of test condition). DPOAE levels were significantly affected by L(1), L(2) level and f(2) frequency (p < .0001) but not by test condition. Intra- and intertester test-retest differences were not significantly different. CONCLUSIONS: The prevalence of missing responses coupled with large intersubject variability and intrasubject test-retest variability are a detriment to the clinical utility of DPOAEs evoked with low-level stimuli.

[Potential of acureflexotherapy for the diagnosis and treatment of occupational loss of hearing].

The present in-depth clinical and audiologic study with the use of the Nakatani reflexodiagnostic technique included 240 subjects employed in mechanical engineering, coal and ore mining industries exposed to occupational noise and vibration in excess of the maximally permissible level (MPL). Results of the study confirm the effectiveness of Nakatani's express-method for the vocational selection and designation of groups at risk of occupational neurosensory loss of hearing. The study was also designed to evaluate results of combined treatment of bilateral neurosensory deafness by reflexotherapy. It is concluded based on the results of audiometry that such treatment resulted in improved hearing of frequencies from 500 to 8000 Hz (by 10-15 dB) in more than half of the treated subjects.

Development of a clinical test of musical perception: appreciation of music in cochlear implantees (AMICI).

The purpose of this study was to develop a test to assess the ability of persons with cochlear implants (CIs) to interpret musical signals. Up to this time, the main direction in outcomes studies of cochlear implantation has been in relation to speech recognition abilities. With improvement in CI hardware and processing strategies, there has been a growing interest in musical perception as a dimension that could improve greatly users' quality of life. The Appreciation of Music in Cochlear Implantees (AMICI) test was designed to measure the following abilities: discrimination of music versus noise; identification of musical instruments (from a closed set); identification of musical styles (from a closed set); and recognition of individual musical pieces (open set). The first phase of the study was test development and recording. The second phase entailed presentation of a large set of stimuli to normal listeners. Based on phase 2 findings, an item analysis was performed to eliminate stimuli that were confusing or resulted in high error rates in normals. In phase 3, hearing-impaired participants, using cochlear Implants, were assessed using the beta version of the AMICI test.

Primary assessment of the vertiginous patient at a pre-ENT balance clinic.

INTRODUCTION: Due to problems with long waiting times for assessment of vertiginous patients (more than 24 weeks), we changed practice and instituted a pre-ENT balance clinic assessment; we then audited the results. In particular, we looked at the subgroup with benign positional paroxysmal vertigo. METHODS: One hundred and fifteen patients were seen at the pre-ENT balance clinic from October 2003 to September 2004. Those diagnosed with benign positional paroxysmal vertigo received particle repositioning therapy at the same clinic and did not subsequently need ENT assessment. RESULTS: By the end of the audit period, waiting times were reduced to three weeks, and more than one-quarter of vertiginous patients (i.e. those diagnosed with benign positional paroxysmal vertigo) did not need to be reviewed at an ENT clinic. CONCLUSION: We believe this to be the first study to present prospective data showing that patients with benign positional paroxysmal vertigo may be safely diagnosed and effectively managed at a pre-ENT balance clinic.

The vestibulo-collic reflex is abnormal in migraine.

Interictal evoked central nervous system responses are characterized in migraineurs by a deficit of habituation, at both cortical and subcortical levels. The click-evoked vestibulo-collic reflex (VCR) allows the assessment of otolith function and an oligosynaptic pathway linking receptors in the saccular macula to motoneurons of neck muscles. Three blocks of 75 averaged responses to monaural 95-dB normal hearing level 3-Hz clicks were recorded over the contracted ipsilateral sternocleidomastoid muscle in 25 migraineurs between attacks and 20 healthy subjects, without vestibular symptoms. Amplitudes, raw and corrected for baseline electromyography, were significantly smaller in migraine patients. Whereas in healthy volunteers the VCR habituated during stimulus repetition (-4.96% +/- 14.3), potentiation was found in migraineurs (4.34% +/- 15.3; P = 0.04). The combination with a reduced mean amplitude does not favour vestibular hyperexcitability as an explanation for the habituation deficit in migraine, but rather an abnormal processing of repeated stimuli in the reflex circuit.

Origin of sound-evoked EMG responses in human masseter muscles.

Sound is a natural stimulus for both cochlear and saccular receptors. At high intensities it evokes in active masseter muscles of healthy subjects two overlapping reflexes: p11/n15 and p16/n21 waves, whose origin has not yet been demonstrated. Our purpose was to test which receptor in the inner ear is responsible for these reflexes. We compared masseter EMG responses induced in normal subjects (n = 9) by loud clicks (70-100 dB normal hearing level (NHL), 0.1 ms, 3 Hz) to those evoked in subjects with a selective lesion of the cochlea (n = 5), of the vestibule (n = 1) or with mixed cochlear-vestibular failure (n = 5). In controls, 100 dB clicks induced bilaterally, in the unrectified mean EMG (unrEMG), a clear p11 wave followed by a less clear n15 wave and a subsequent n21 wave. Lowering the intensity to 70 dB clicks abolished the p11/n15 wave, while a p16 wave appeared. Rectified mean EMG (rectEMG) showed, at all intensities, an inhibitory deflection corresponding to the p16/n21 wave in the unrEMG. Compared to controls, all deaf subjects had a normal p11 wave, together with more prominent n15 wave; however, the p16/n21 waves, and their corresponding inhibition in the rectEMG, were absent. The vestibular patient had bilaterally clear p11 waves only when 100 dB clicks were delivered bilaterally or to the unaffected ear. Stimulation of the affected ear induced only p16/n21 waves. Data from mixed patients were consistent with those of deaf and vestibular patients. We conclude that click-induced masseter p11/n15 waves are vestibular dependent, while p16/n21 waves depend on cochlear integrity.

Initial audiologic assessment of infants referred from well baby, special care, and neonatal intensive care unit nurseries.

PURPOSE: The purpose of the study was to evaluate the effectiveness of a 2-hr initial audiologic assessment appointment for infants referred from area universal newborn hearing screening (UNHS) programs to a clinical audiology department in an urban hospital. METHOD: A prospective auditory brainstem response (ABR)-based protocol, including clicks, frequency-specific tone bursts, and bone-conducted stimuli, was administered by 10 audiologists to 375 infants. Depending on the ABR findings, additional test options included distortion product otoacoustic emissions (DPOAEs), high-frequency tympanometry, and/or otologic examination. RESULTS: In 88% of the 2-hr test sessions, at least 4 ABR threshold estimates were obtained (i.e., bilateral clicks and either a 500- or 1000-Hz tone burst and a 4000-Hz frequency tone burst for the better ear). The incidence of hearing loss was significantly different across nursery levels: 18% for Level I (well baby), 29% for Level II (special care), and 52% for Level III (neonatal intensive care unit). Hearing loss type was defined at the initial assessment for 35 of the 51 infants with bilateral hearing loss based on bone-conduction ABR, latency measures, DPOAEs, high-frequency tympanometry, and/or otologic examination. CONCLUSIONS: Our findings indicate that a 2-hr test appointment is appropriate for all nursery levels to diagnose severity and type of hearing loss in the majority of infants referred from UNHS. Examination by an otolaryngologist within 24-48 hr further defines the hearing loss and facilitates treatment plans.

The order of testing effect in otoacoustic emissions and its consequences for sex and ear differences in neonates.

The amplitude values of transient-evoked otoacoustic emissions, recorded from a large sample of neonates, were used to examine the asymmetry between ears tested and the differences due to the sex of the subject. Whilst the sex difference, with females having larger responses than males, has been a consistent finding in previous reports, the right/left ear difference, with the right ear giving a larger response than the left, has produced variable results that differed between laboratories. In this study, the sex difference was confirmed with females giving a 1.2 dB greater response than males. It was not affected by the age of the neonate. A significant effect of test order was found. The measured right/left difference was enhanced when the right ear was tested first but was diminished when the left ear was tested first. If the left ear is tested first then the measured right/left difference would be about 0.5 dB whereas, if the right ear is tested first, the measured right/left difference would be about 1.5 dB. When male/female comparisons were made for right and left ears separately and for the same ear tested first, the sex differences were the same for all four conditions. The sex and right/left differences have been confirmed as statistically significant effects and the order effect could explain the discrepancies and variability of the right/left differences reported in the literature.

Preoperative speech and pure-tone audiometry in four types of patients with acoustic neuroma.

PURPOSE: The goal of this study was to compare pure-tone and speech audiometry in 4 groups of patients with confirmed unilateral acoustic neuroma in which auditory brainstem responses and transient-evoked otoacoustic emissions were either both normal, abnormal, or one of the tests was abnormal. MATERIAL AND METHODS: This study was realized during a preoperative assessment of 65 patients (29 men, 36 women) from 25 to 78 years of age suffering from unilateral acoustic neuroma. The assessment, preceded by tympanometry, included recordings of auditory brainstem responses, transient-evoked otoacoustic emissions, pure-tone audiometry, speech recognition thresholds, and speech discrimination. RESULTS: Some discrepancies between objective and behavioral test results were noticed. Subjects with no otoacoustic emissions but present auditory brainstem responses did not show any significant difference in their speech scores as compared with subjects with both auditory brainstem responses and otoacoustic emissions. CONCLUSIONS: In summary, this study showed that comparable audiometric findings in acoustic neuroma patients can be found regardless of the presence of transient otoacoustic emissions (TEOAEs). TEOAEs are a good screening tool and have been used, like auditory brainstem-evoked responses, as a predictive measure before hearing preservation procedures but cannot predict the audiogram or give information about speech perception. The findings confirm that even if auditory brainstem responses are an extremely useful diagnostic tool for identifying acoustic neuroma, this test provides only giving pieces of information regarding auditory abilities. Also, the pure-tone audiogram gives useful information but has to be used in conjunction with speech audiometry to get an accurate picture of the patient's true auditory abilities.

Infant hearing screening: a comparison of two techniques.

Hearing screening programs for Australian children are known to have poor coverage in many areas. In addition, only a minority of children are screened for hearing loss before 2 years of age. However, early detection of hearing loss and early treatment are generally considered very important to successful rehabilitation outcomes. Traditional methods of screening infants have limitations with their accuracy in detecting children with hearing loss. This study compared the results obtained with a traditional questionnaire approach to screening and a newer objective technique involving otoacoustic emission measures. Poor correlation was found between pass rates for the two techniques, suggesting that the questionnaire approach is not an accurate screening method for detecting infant hearing loss. With further development, otoacoustic emission testing holds promise as an objective alternative hearing screening procedure.