Management of Migraine-Associated Vestibulocochlear Disorders.

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

Meniere's disease is a manifestation of migraine.

PURPOSE OF REVIEW: To discuss the theory that Meniere's disease (MD) is a variation of otologic migraine rather than an isolated inner ear condition. RECENT FINDINGS: In contrast to the approximately 12% of the general population suffering from migraine headaches, 51-60% of patients with MD experience migraine headaches. While pathognomonic for MD, endolymphatic hydrops has also been identified in patients with vestibular migraine. Treatment with the integrative neurosensory rehabilitation approach (diet and lifestyle changes, magnesium and riboflavin supplementation, and when needed, prophylactic medication) to treat the underlying migraine process has been highly effective in patients with MD. SUMMARY: MD can be understood as a manifestation of migraine such that patients with MD can be effectively treated with migraine therapies.

Migrainous Vertigo, Tinnitus, and Ear Symptoms and Alternatives.

Migraine headaches frequently coexist with vestibular symptoms such as vertigo, motion sickness, and gait instability. Migraine-related vasospasm can also damage the inner ear, which results in symptoms such as sudden sensorineural hearing loss and resultant tinnitus. The pathophysiology of these symptoms is not yet fully understood, and despite their prevalence, there is no universally approved management. This review summarizes the data on complementary and integrative medicine in treating patients with migrainous ear disorders.

Selective Facial Muscle Activation with Acute and Chronic Multichannel Cuff Electrode Implantation in a Feline Model.

OBJECTIVES: Facial paralysis is a debilitating condition with substantial functional and psychological consequences. This feline-model study evaluates whether facial muscles can be selectively activated in acute and chronic implantation of 16-channel multichannel cuff electrodes (MCE). METHODS: Two cats underwent acute terminal MCE implantation experiments, 2 underwent chronic MCE implantation in uninjured facial nerves (FN) and tested for 6 months, and 2 underwent chronic MCE implantation experiments after FN transection injury and tested for 3 months. The MCE were wrapped around the main trunk of the skeletonized FN, and data collection consisted of EMG thresholds, amplitudes, and selectivity of muscle activation. RESULTS: In acute experimentation, activation of specific channels (ie, channels 1-3 and 6-8) resulted in selective activation of orbicularis oculi, whereas activation of other channels (ie, channels 4, 5, or 8) led to selective activation of levator auris longus with higher EMG amplitudes. MCE implantation yielded stable and selective facial muscle activation EMG thresholds and amplitudes up to a 5-month period. Modest selective muscle activation was furthermore obtained after a complete transection-reapproximating nerve injury after a 3-month recovery period and implantation reoperation. Chronic implantation of MCE did not lead to fibrosis on histology. Field steering was achieved to activate distinct facial muscles by sending simultaneous subthreshold currents to multiple channels, thus theoretically protecting against nerve damage from chronic electrical stimulation. CONCLUSION: Our proof-of-concept results show the ability of an MCE, supplemented with field steering, to provide a degree of selective facial muscle stimulation in a feline model, even following nerve regeneration after FN injury. LEVEL OF EVIDENCE: N/A.

Adapting Personal Therapies Using a Mobile Application for Tinnitus Rehabilitation: A Preliminary Study.

OBJECTIVES: To develop a smartphone application providing sound therapy and cognitive behavioral therapy (CBT) for treating tinnitus and performing a proof-of-concept pilot study evaluating its potential efficacy. METHODS: An interactive smartphone application available on iOS and Android platforms was developed, which provided an 8-week tinnitus-specific CBT and personalized and frequency-matched sound therapy. Included patients presented to our tertiary clinic between 2017 and 2018, while those waitlisted were regarded as controls. Three surveys were administrated: Tinnitus Handicap Inventory (THI), Generalized Anxiety Disorder 7-item (GAD-7), and Perceived Stress Scale (PSS). RESULTS: A total of 30 patients enrolled in this study consisting of 20 treatment and 10 control patients and mean age was 55.4 ± 11.6 years. Treatment and control patients had similar age, sex, and pre-enrolment GAD and PSS (all P > .05). Baseline THI scores were also similar between treatment and control cohorts (50.1 ± 21.9 vs 62.0 ± 20.7; P = .15). After 8 weeks, though changes in GAD and PSS scores were similar (P > .05), the treatment group reported a significantly greater improvement in THI scores (17.7 ± 15.8 vs 5.3 ± 10.5, P = .04). CONCLUSIONS: This pilot study demonstrated potentially promising efficacy of a smartphone-based CBT and sound therapy platform for treating tinnitus and encourages future randomized controlled trials on this treatment modality.

Interfacing with the nervous system: a review of current bioelectric technologies.

The aim of this study is to discuss the state of the art with regard to established or promising bioelectric therapies meant to alter or control neurologic function. We present recent reports on bioelectric technologies that interface with the nervous system at three potential sites-(1) the end organ, (2) the peripheral nervous system, and (3) the central nervous system-while exploring practical and clinical considerations. A literature search was executed on PubMed, IEEE, and Web of Science databases. A review of the current literature was conducted to examine functional and histomorphological effects of neuroprosthetic interfaces with a focus on end-organ, peripheral, and central nervous system interfaces. Innovations in bioelectric technologies are providing increasing selectivity in stimulating distinct nerve fiber populations in order to activate discrete muscles. Significant advances in electrode array design focus on increasing selectivity, stability, and functionality of implantable neuroprosthetics. The application of neuroprosthetics to paretic nerves or even directly stimulating or recording from the central nervous system holds great potential in advancing the field of nerve and tissue bioelectric engineering and contributing to clinical care. Although current physiotherapeutic and surgical treatments seek to restore function, structure, or comfort, they bear significant limitations in enabling cosmetic or functional recovery. Instead, the introduction of bioelectric technology may play a role in the restoration of function in patients with neurologic deficits.

Selective recurrent laryngeal nerve stimulation using a penetrating electrode array in the feline model.

OBJECTIVES/HYPOTHESIS: Laryngeal muscles (LMs) are controlled by the recurrent laryngeal nerve (RLN), injury of which can result in vocal fold (VF) paralysis (VFP). We aimed to introduce a bioelectric approach to selective stimulation of LMs and graded muscle contraction responses. STUDY DESIGN: Acute experiments in cats. METHODS: The study included six anesthetized cats. In four cats, a multichannel penetrating microelectrode array (MEA) was placed into an uninjured RLN. For RLN injury experiments, one cat received a standardized hemostat-crush injury, and one cat received a transection-reapproximation injury 4 months prior to testing. In each experiment, three LMs (thyroarytenoid, posterior cricoarytenoid, and cricothyroid muscles) were monitored with an electromyographic (EMG) nerve integrity monitoring system. Electrical current pulses were delivered to each stimulating channel individually. Elicited EMG voltage outputs were recorded for each muscle. Direct videolaryngoscopy was performed for visualization of VF movement. RESULTS: Stimulation through individual channels led to selective activation of restricted nerve populations, resulting in selective contraction of individual LMs. Increasing current levels resulted in rising EMG voltage responses. Typically, activation of individual muscles was successfully achieved via single placement of the MEA by selection of appropriate stimulation channels. VF abduction was predominantly observed on videolaryngoscopy. Nerve histology confirmed injury in cases of RLN crush and transection experiments. CONCLUSIONS: We demonstrated the ability of a penetrating MEA to selectively stimulate restricted fiber populations within the feline RLN and selectively elicit contractions of discrete LMs in both acute and injury-model experiments, suggesting a potential role for intraneural MEA implantation in VFP management. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1606-1614, 2018.

Customized Versus Noncustomized Sound Therapy for Treatment of Tinnitus: A Randomized Crossover Clinical Trial.

OBJECTIVES: To determine the effectiveness of a customized sound therapy and compare its effectiveness to that of masking with broadband noise. METHODS: Subjects were randomized to receive either customized sound therapy or broadband noise for 2 hours per day for 3 months and then switched to the other treatment after a washout period. The outcome variables were tinnitus loudness (scored 0-10), Tinnitus Handicap Inventory (THI), Beck Anxiety Inventory (BAI), minimum masking levels (MML), and residual inhibition (RI). RESULTS: Eighteen subjects completed the study. Mean age was 53 ± 11 years, and mean tinnitus duration was 118 ± 99 months. With customized sound therapy, mean loudness decreased from 6.4 ± 2.0 to 4.9 ± 1.9 ( P = .001), mean THI decreased from 42.8 ± 21.6 to 31.5 ± 20.3 ( P < .001), mean BAI decreased from 10.6 ± 10.9 to 8.3 ± 9.9 ( P = .01), and MML decreased from 22.3 ± 11.6 dB SL to 17.2 ± 10.6 dB SL ( P = .005). After 3 months of broadband noise therapy, only BAI and, to a lesser degree, MML decreased ( P = .003 and .04, respectively). CONCLUSIONS: Customized sound therapy can decrease the loudness and THI scores of tinnitus patients, and the results may be superior to broadband noise.

Selective Stimulation of Facial Muscles Following Chronic Intraneural Electrode Array Implantation and Facial Nerve Injury in the Feline Model.

BACKGROUND: Our group has previously shown that activation of specific facial nerve (FN) fiber populations and selective activation of facial musculature can be achieved through acute intraneural multichannel microelectrode array (MEA) implantation in the feline model. HYPOTHESIS: Selective stimulation of facial muscles will be maintained in the setting of 1) chronic and 2) acute MEA implantation after FN injury and subsequent recovery. METHODS: This study included seven cats. In three cats with normal facial function, 4-channel penetrating MEAs were implanted chronically in the FN and tested biweekly for 6 months. Electrical current pulses were delivered to each channel individually, and elicited electromyographic (EMG) voltage outputs were recorded for each of several facial muscles. For FN injury experiments, two cats received a standardized hemostat-crush injury, and two cats received a transection-reapproximation injury to the FN main trunk. These four underwent acute implantation of MEA and EMG recording in terminal experiments 4 months postinjury. RESULTS: Stimulation through individual channels selectively activated restricted nerve populations, resulting in activation of individual muscles in cats with chronic MEA implantation and after nerve injury. Increasing stimulation current levels resulted in increasing EMG voltage responses in all patients. Nerve histology showed only minor neural tissue reaction to the implant. CONCLUSION: We have established in the animal model the ability of a chronically implanted MEA to selectively stimulate restricted FN fiber populations and elicit activations in specific facial muscles. Likewise, after FN injury, selective stimulation of restricted FN fiber populations and subsequent activation of discrete facial muscles can be achieved after acute MEA implantation.

Customized web-based sound therapy for tinnitus.

INTRODUCTION: Traditional masking efforts have presented broadband noises, most typically white noise. Targeted (customized) sound therapies have been introduced to overcome the limitations of traditional maskers. OBJECTIVES: To evaluate the efficacy of a web-based delivery of customized sound therapy in reducing tinnitus loudness and increasing the residual inhibition. MATERIALS AND METHODS: Thirty-two subjects matched their tinnitus frequency using a web-based protocol. A customized Harmonic Sound Therapy file was produced by the web-based software and downloaded by the patient onto an MP3 player. The subjects listened to the sound file for one hour. RESULTS: Tinnitus loudness mean was 6.0 ± 2.3 standard deviation (SD) which decreased to 3.3 ± 1.9 SD after one hour of sound therapy. Some reduction in loudness was seen in 81%, while 72% experienced a reduction of 25% or more. Tinnitus annoyance decreased from an average of 6.1 ± 2.6 SD to 3.1 ± 2.0 SD. Median duration of residual inhibition was 32.5 minutes, with an average of 75 minutes ± 132 SD. CONCLUSION: Customized sound therapy can be delivered via the internet. Harmonic Sound Therapy is effective in reducing the loudness and annoyance of tinnitus.

Ipsilateral masking between acoustic and electric stimulations.

Residual acoustic hearing can be preserved in the same ear following cochlear implantation with minimally traumatic surgical techniques and short-electrode arrays. The combined electric-acoustic stimulation significantly improves cochlear implant performance, particularly speech recognition in noise. The present study measures simultaneous masking by electric pulses on acoustic pure tones, or vice versa, to investigate electric-acoustic interactions and their underlying psychophysical mechanisms. Six subjects, with acoustic hearing preserved at low frequencies in their implanted ear, participated in the study. One subject had a fully inserted 24 mm Nucleus Freedom array and five subjects had Iowa/Nucleus hybrid implants that were only 10 mm in length. Electric masking data of the long-electrode subject showed that stimulation from the most apical electrodes produced threshold elevations over 10 dB for 500, 625, and 750 Hz probe tones, but no elevation for 125 and 250 Hz tones. On the contrary, electric stimulation did not produce any electric masking in the short-electrode subjects. In the acoustic masking experiment, 125-750 Hz pure tones were used to acoustically mask electric stimulation. The acoustic masking results showed that, independent of pure tone frequency, both long- and short-electrode subjects showed threshold elevations at apical and basal electrodes. The present results can be interpreted in terms of underlying physiological mechanisms related to either place-dependent peripheral masking or place-independent central masking.

Treatment of culture-negative skull base osteomyelitis.

OBJECTIVE: To evaluate the efficacy of a therapeutic regimen in the treatment of patients with culture-negative skull base osteomyelitis. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral hospital. PATIENTS: Eight patients with diabetes mellitus presented with otalgia and were found to have positive technetium and gallium scans of the temporal bone. These patients, however, all had negative cultures of their external auditory canals. All patients had been treated with ototopic drops and two patients had undergone a 2-week course of oral quinolones. INTERVENTIONS: All patients were treated with a 6-week course of intravenous ceftazidime or aztreonam for penicillin-allergic patients, oral ciprofloxacin at a higher dose than normal, and topical aminoglycoside steroid drops. MAIN OUTCOME MEASURES: Resolution of the temporal bone gallium scan abnormality, recurrence rate, and time to discharge from the hospital. RESULTS: The patients were discharged from the hospital within 4 days from admission. All patients showed resolution of the temporal bone abnormality on the gallium scan at the 6-week time point. The median follow-up period was 6 months, and none of the patients had a recurrence of the infection. CONCLUSION: The above-described treatment regimen will result in a high cure rate and a short hospitalization period.

Transcanal cochlear implantation under monitored anesthesia care.

OBJECTIVE: Given the associated risk of general anesthesia in elderly patients with cardiovascular disease, the authors set out to determine the feasibility of transcanal cochlear implantation under local anesthesia with monitored anesthesia care. METHODS: A 70-year-old man with a history of coronary artery bypass grafting, diabetes mellitus, and an American Society of Anesthesiologists Class III cardiac status underwent cochlear implantation under local with monitored anesthesia care. RESULT: With the described technique and regimen of intravenous remifentanil and dexmedetomidine, the patient tolerated the 60-minute procedure without tachycardia, hyper- or hypotension, or cardiac ischemia. CONCLUSION: Cochlear implantation using the pericanal electrode technique performed under local anesthesia with monitored anesthesia care is possible in patients at risk for undergoing general anesthesia for cochlear implantation.