Hearing Outcomes with Percutaneous and Transcutaneous BAHA® Technology in Conductive and Mixed Hearing Loss.

OBJECTIVES: To evaluate outcomes of BAHA Connect® and BAHA Attract® implantations, and to examine the prognostic utility of a preimplantation Softband®-attached processor trial. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Patients who underwent Connect® (19 ears) and Attract® (25 ears) implantation between 2007 and 2017. INTERVENTION: BAHA® implantation. MAIN OUTCOME MEASURES: Unaided air conduction (AC), bone conduction (BC), and speech reception thresholds (SRTs), as well as free field (FF) aided with Softband®-attached processor and with implant-attached processor thresholds. RESULTS: Serviceable implant-attached processor PTA0.5,1,2 kHz (≤35 dB HL) was achieved in 89 and 88% of the Connect® and the Attract® ears, respectively, while at 4 kHz this was achieved in 68 and 32% of the Connect® and the Attract® ears, respectively (p  =  0.032). Significantly more Connect® ears showed alignment between FF aided with implant-attached processors thresholds and BC thresholds. The alignment between the Softband®-attached processors thresholds and implant-attached processors thresholds was similar in the two groups. Both groups exhibited similar positive improvement in the quality of life questionnaires. CONCLUSIONS: Accessibility to sound with the implant-attached processor is well predicted by the pre-implantation Softband® trial, both in the BAHA Connect® and in the BAHA Attract® ears. Hearing rehabilitation targets at 0.5, 1, and 2 kHz are met by most Connect® and Attract® ears, while at 4 kHz the outcome with Attract® is poorer. This information should be presented to the patient during consultation prior to a decision as to the type of BAHA® device to be implanted.

[MIDDLE EAR CHOLESTEATOMA].

INTRODUCTION: Cholesteatoma is the most severe middle ear disease. In most cases cholesteatoma results from under-aeration of the middle ear cleft. It is characterized by otorrhea and hearing loss, and may lead to severe complications, intra- and extra-cranial. There is no non-surgical treatment for cholesteatoma. Surgical treatment is the only option. Cholesteatoma is diagnosed by micro-otoscopy. When cholesteatoma is suspected and otoscopy is inconclusive, imaging is mandatory. The goal of treatment in cholesteatoma is to achieve a stable and safe ear. In most cases, upon diagnosis, cholesteatoma is quite extensive and mastoidectomy is needed. Choice of surgery [Canal wall up mastoidectomy with tympanoplasty (the more conservative alternative), Canal wall down (radical) mastoidectomy with meatoplasty or Canal wall down (radical) mastoidectomy with reconstruction of external ear canal, tympanoplasty and mastoid obliteration], depends on the extent of the disease, the anatomic relationship between the sensitive structures that protrude into the walls of middle ear and mastoid cavities and the bony destruction that had already been caused by the disease. Hearing rehabilitation should lead to a stable, predictable, symmetric and as close as possible to normal hearing threshold. In many cases the solution is external or implantable hearing devices. Cholesteatoma has a high recidivism rate that leads to repeated surgery. In order to diagnose and treat cholesteatoma recidivism, a structured follow-up is needed after cholesteatoma surgery, with periodical otoscopy (every 6-12 months) and MRI (every 1-2 years). When cholesteatoma recidivism is diagnosed, surgery is indicated before the disease grows and becomes infected.

Phoneme recognition in bimodal hearing.

BACKGROUND: Many unilateral cochlear implant (CI) users have residual hearing in the nonimplanted ear, allowing them to use bimodal hearing. Assessing the hearing aid (HA) contribution is important. OBJECTIVE: To examine the contribution of a contralateral HA in unilateral CI users with severe-profound hearing loss (HL) in the non-implanted ear to phonetic features perception.Participants and method: Monosyllabic word test in noise was used to assess the phonetic features perception in 29 adult bimodal users with severe-profound HL and only minimal speech recognition using HA alone in the nonimplanted ear. RESULTS: For all consonants and vowel features, participants scored better in the bimodal condition than in the CI-alone condition. Better low frequencies thresholds in the HA ear correlated with better perception of phonetic features in the bimodal condition. CONCLUSION: CI/HA users with only minimal speech recognition using HA alone in the nonimplanted ear extract low-frequency information provided by the HA ear and combine it with information coming from the implanted ear.Significance: The results of the study provide a reasoning for unilateral CI users to insist on using a contralateral HA as long as contralateral implantation is not performed, and suggest how to monitor the benefit derived from the HA.

[FOCUSING AND UPDATING INDICATIONS FOR VENTILATING TUBES INSERTION IN PEDIATRIC COCHLEAR IMPLANT CANDIDATES WHO SUFFER FROM OTITIS MEDIA].

BACKGROUND: After cochlear implantation (CI) there is concern regarding the potential risks of spread of middle ear infection along the electrode array into the cochlea and central nervous system and regarding late sequela of otitis media (OM): eardrum perforation, atelectasis and cholesteatoma. The age for implantation in children overlaps the peak age incidence of acute OM (AOM) and secretory OM (SOM) and delay of implantation reduces the potential benefit from the intervention. Therefore, control of OM by inserting ventilating tubes (VT) is widely performed in pediatric CI candidates who also suffer from otitis media. OBJECTIVES: To refine indications for VT insertion in candidates for cochlear implantation who also suffer from OM. METHODS: Of 200 children referred for CI and implanted one after another, 126 were classified as OM-prone, 98 due to AOM and 28 due to SOM. The rate of development of late sequela of middle ear disease was compared between the two subgroups of OM-proneness. RESULTS: A total of 15 children (7.5%) developed late sequela of middle ear disease; all belonged to the SOM group; 3.5% developed eardrum perforation; 3.5% atelectasis and 0.5% cholesteatoma. CONCLUSIONS: Pre-CI VT insertion in children with SOM who underwent CI did not prevent development of late sequela of middle ear disease; VT insertion with the object of preventing late sequela of middle ear disease in CI candidates who suffer from SOM only is not required; in otitis-prone children a long term oto-microscopic follow-up is needed in order to identify late sequela of middle ear disease.

Acute mastoiditis: 20 years of experience with a uniform management protocol.

OBJECTIVES: To characterize the clinical presentation of pediatric patients who, upon AM diagnosis, also had imaging-diagnosed ICCs (ID-ICCs); to define the group of AM patients at risk of developing ID-ICCs; and to update knowledge about organisms causing AM. STUDY DESIGN: Analysis of all AM patients admitted between 1997 and 2018 and treated according to an obligatory protocol including both brain imaging and sampling for bacterial culture upon clinical diagnosis of AM. RESULTS: Of 166 admitted patients (0.5-19 years old) 22 (13%) already had ID-ICCs. In patients who, on admission, had already received antibiotics for acute otitis media (AOM) and also had CRP (C-reactive protein) levels above 93.5 mg/L, the risk of ID-CC was increased by 22.5-fold (P < 0.0001). Bacterial culture results were available for all patients and were positive in 115 (69%). Organisms most commonly found in patients without prior antibiotic treatment were group A Streptococcus pyogenes (53%), Streptococcus pneumoniae (23%), and Haemophylus influenzae (11%), while with prior antibiotic treatment they were Fusobacterium necrophorum (21%), Streptococcus pyogenes (18%) and Pseudomonas aeruginosa (18%). CONCLUSIONS: Since the risk of ID-ICC in patients with the abovementioned CRP and prior antibiotic treatment was significantly higher than in the others, these high-risk patients should undergo diagnostic imaging on admission. Antibiotic treatment prior to AM development may promote growth of non-AOM pathogen.

Idiopathic Intracranial Hypertension Presenting as Auditory Neuropathy Hearing Disorder in a Child.

Otologic manifestations are known to occur in patients with idiopathic intracranial hypertension (IIH), but the occurrence of sensorineural hearing loss, especially in pediatric populations, has been addressed in only a few reports. Here, we describe a pediatric patient who presented with IIH and severe bilateral hearing loss. The patient's hearing loss was diagnosed as a form of auditory neuropathy (AN) and resolved after prompt treatment of the increased intracranial pressure. This case points to a possible association between IIH and AN and suggests that IIH may potentially be a reversible cause of AN spectrum disorder. Laryngoscope, 129:E407-E411, 2019.

Management of Pediatric Acute Mastoiditis in Israel: Nationwide Survey Among Otorhinolaryngologists and Emergency Pediatricians.

INTRODUCTION: Acute mastoiditis (AM) is a medical emergency that mandates prompt diagnosis and treatment. Nevertheless, its management often differs between otorhinolaryngologists (ORLs) and pediatricians (PEDs) working in emergency departments. We sought to characterize the similarities and differences between management protocols of these 2 disciplines. METHODS: A voluntary electronic questionnaire, including 17 items pertaining to pediatric AM management, was sent to all the 20 otorhinolaryngology and their corresponding pediatric emergency departments nationwide. Each department sent 1 filled out questionnaire. The response rate was 100%. RESULTS: Eighteen (90%) ORLs are notified when a child with suspected AM arrives. Medical history collected by both disciplines was similar-previous otologic history (100%), previous antibiotic use (100%), and pneumococcal conjugate vaccination status (60%)-whereas acute otitis media risk factors were more important to PEDs (13 [65%] PEDs, 10 [50%] ORLs). According to 85% to 90% of ORLs and PEDs, imaging was not mandatory upon admission. According to 14 (70%) PEDs and 16 (80%) ORLs, imaging was overall performed in less than 50% of patients during hospitalization. Intravenous ceftriaxone and cefuroxime were the most common first-line antibiotic treatments (8 [40%] ORLs, 10 [50%] PEDs), with a mean treatment duration of 7 to 10 days. Eighteen (90%) of the ORLs, compared with 15 (75%) PEDs, reported that myringotomy (with or without ventilating tube insertion) was performed upon diagnosis (P = 0.05). CONCLUSIONS: The management of pediatric AM is generally similar by both disciplines. The use of imaging studies is mild-moderate. We call for a national registry and encourage the publication of guidelines.

Impact of Imaging in Management of Otosclerosis.

The use of imaging in otosclerosis for diagnosis, preoperative assessment, and follow-up has the potential to give the clinician an additional tier of patient evaluation and validation of diagnosis. Before stapes surgery, imaging may help avoid unnecessary middle ear explorations in nonotosclerotic cases, prevent potential complications, and assist in appropriate patient counseling regarding management expectations. Postoperatively, following unsuccessful air-bone gap closure in stapes surgery or conductive hearing deterioration following initial successful closure of the air bone gap, imaging can be used to determine the prosthesis position in the middle ear.

Cochlear implantation outcome in straightforward cases: can we do more for adults who cannot understand speech using hearing aids alone?

BACKGROUND: Many adults with moderate-profound hearing loss whose speech recognition has deteriorated and are no longer benefitting from hearing aids (HAs) could benefit from cochlear implantation (CI). Of these, only <5% are implanted. In order to inform eligible patients about expected results and ease the route to implantation, better guidelines for candidate selection are needed. OBJECTIVES: To provide reliable guidelines by determining, in a well-characterized group of implantees, the minimal expected post-CI scores for monosyllabic (MS) word recognition. PATIENTS AND METHODS: In total, 20 adults unilateral implantees considered (prior to implantation) straightforward CI candidates were assessed ≥20 months post-CI. Their post-CI CI-aided thresholds and MS word recognition were compared to their pre-CI scores. In addition, SSQ12 scores were evaluated post-CI. RESULTS: Post-CI, thresholds were 40 dB or better in all participants, and 35 dB or better in 95% of them. 90% scored 60% or better on MS words in quiet. In speech noise all scored 15-60% and 50% scored 45-60%. Poorer unaided pre-CI thresholds yielded greater patient satisfaction. CONCLUSIONS: Adults with moderate-profound hearing loss, whose speech recognition has deteriorated, are no longer benefitting from HAs and fulfil defined criteria for straightforward CI, should be referred for formal CI candidacy evaluation.

Panel 2: Anatomy (Eustachian Tube, Middle Ear, and Mastoid-Anatomy, Physiology, Pathophysiology, and Pathogenesis).

Objective In this report, we review the recent literature (ie, past 4 years) to identify advances in our understanding of the middle ear-mastoid-eustachian tube system. We use this review to determine whether the short-term goals elaborated in the last report were achieved, and we propose updated goals to guide future otitis media research. Data Sources PubMed, Web of Science, Medline. Review Methods The panel topic was subdivided, and each contributor performed a literature search within the given time frame. The keywords searched included middle ear, eustachian tube, and mastoid for their intersection with anatomy, physiology, pathophysiology, and pathology. Preliminary reports from each panel member were consolidated and discussed when the panel met on June 11, 2015. At that meeting, the progress was evaluated and new short-term goals proposed. Conclusions Progress was made on 13 of the 20 short-term goals proposed in 2011. Significant advances were made in the characterization of middle ear gas exchange pathways, modeling eustachian tube function, and preliminary testing of treatments for eustachian tube dysfunction. Implications for Practice In the future, imaging technologies should be developed to noninvasively assess middle ear/eustachian tube structure and physiology with respect to their role in otitis media pathogenesis. The new data derived from these structure/function experiments should be integrated into computational models that can then be used to develop specific hypotheses concerning otitis media pathogenesis and persistence. Finally, rigorous studies on medical or surgical treatments for eustachian tube dysfunction should be undertaken.

Prognostic factors for facial nerve palsy in a pediatric population: A retrospective study and review.

OBJECTIVES/HYPOTHESIS: To identify and analyze factors influencing the outcome of facial nerve palsy (FNP) in a pediatric population. STUDY DESIGN: Retrospective study. METHODS: Sixty-seven pediatric patients (72 consecutive cases) diagnosed with and treated for FNP were divided into two severity subgroups. Associations between recovery in these groups and categorical variables were assessed using the Fisher exact test and for age using the t test. RESULTS: Mean age on admission was 12.0 ± 4.5 years. Neither FNP outcome (graded by severity) nor improvement rates (expressed as the percentage of patients achieving a higher FNP grade over time) were influenced by gender, affected side, presence of polyneuropathy, etiology, or recurrent or familial FNP. In cases with comparable final outcome, improvement rates of those diagnosed with severe FNP on presentation (38.9% of cases) were significantly higher than mild-to-moderate FNP. Of the 47 patients who attended a follow-up examination 2 months after discharge, 70.2% have already recovered (by at least one House-Brackmann [H-B] grade) by the time they were discharged, whereas 90.9% achieved H-B grade ≤2, and 72.3% fully recovered (H-B grade 1) 2 months postdischarge. Adding antiviral medication did not affect FNP improvement rates or outcomes. CONCLUSIONS: Rates of infectious and traumatic etiology in our patients were higher than reported for adults, but the most common etiology-as in those adults-was idiopathic. Routine extended diagnostic workup was not helpful, and antiviral medications were ineffective. The prognosis of FNP in pediatric patients is excellent, with 90% recovery by 2 months after initial presentation. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:1175-1180, 2017.

Clinical performance of a new magnetic bone conduction hearing implant system: results from a prospective, multicenter, clinical investigation.

OBJECTIVE: The aim of the investigation was to prospectively evaluate, in a multicenter setting, the clinical performance of a new magnetic bone conduction hearing implant system. METHODS: The test device was the Cochlear Baha Attract System (Cochlear Bone Anchored Solutions AB, Mölnlycke, Sweden). Instead of the skin-penetrating abutment of traditional bone conduction hearing implants, the test device uses an implantable and an external magnet to transmit sound from the sound processor (SP) through intact skin to the skull bone. Twenty-seven adult patients with a conductive or mild mixed hearing loss or single-sided sensorineural deafness were included in the clinical investigation across four investigational sites. The patients were followed for 9 months after implantation. The study evaluated efficacy in terms of hearing performance compared with unaided hearing and with hearing with the SP on a softband. Patient benefit, soft tissue status, device retention, and safety parameters were monitored continuously throughout the investigation. RESULTS: Surgery and healing was uneventful. Statistically significant improvements in audibility and speech understanding in noise and quiet were recorded for the test device compared with preoperative unaided hearing. Speech recognition was similar or better than tests performed with the same SP on a softband. Good soft tissue outcomes were reported, without major pressure-related complications. At the end of the investigation, all patients continued to use and benefit from the device. CONCLUSION: The test device provides good hearing performance in patients with a conductive hearing loss or single-sided sensorineural deafness, with good wearing comfort and minimal soft tissue complications.

[COCHLEAR IMPLANTATION IN ELDERLY INDIVIDUALS: INSIGHTS BASED ON A RETROSPECTIVE EVALUATION].

INTRODUCTION: In old age, the typical decline in temporal processing, auditory memory, speed of information processing, and ability to filter out irrelevant competing auditory input lead to deterioration in speech perception. This thereby broadens the target population for cochlear implantation among elderly individuals with severe-to-profound hearing loss. These features also raise concern regarding cochlear implant (CI) fitting and outcomes. AIM: To establish expectations from CI in older individuals. METHODS: This is a retrospective case review of 20 individuals with severe or severe-to-profound hearing loss, aged 60 or older (mean, 66.6 ± 5.25; range, 60-81 at the time of CI. Evaluation included speech-perception tests and the Glasgow Benefit Inventory (GBI) for testing quality of life. RESULTS: Between pre- and post-implantation, mean group values improved from 18.6% to 55.5%, from 37.2% to 84.5%, and from 11.2% to 60.5%, respectively, on the above speech-perception tests. No major postoperative complications were observed. The device was used consistently by all but one patient. GBI revealed improvement on all subscales. CONCLUSIONS: After implantation speech perception improved, there were no major post-CI complications, and post-implantation vertigo was less significant than expected in this age group. These results diminish concerns regarding CI in elderly individuals.

Risk factors for sensorineural hearing loss in pediatric chronic otitis media.

OBJECTIVES: To assess the clinical significance of sensorineural hearing loss (SNHL) in a group of pediatric patients suffering from unilateral chronic otitis media (COM) with or without cholesteatoma, using the contralateral healthy ear as a control, and to define risk factors for the development of SNHL in such patients. METHODS: The subjects of this retrospective study were 124 pediatric patients with unilateral COM admitted for surgery. Mean age at surgery was 13.3±3.2 years (range, 7-18) and mean duration of the disease was 88.4±45.0 months (range, 6-192 months). The preoperative pure-tone average value (PTA) for bone conduction (BC) was calculated in each ear (BC-PTA) as the average of BC thresholds at 500, 1000, 2000, and 4000Hz. Potential risk factors for SNHL that we evaluated were demographics, duration of disease, presence of cholesteatoma, and previous otologic history. RESULTS: Mean BC-PTA values in the diseased ears prior to surgery differed significantly from those in the healthy ears (12.74±8.75dB and 9.36±6.33dB, respectively; P<0.01). The degree of SNHL in the diseased ear at 2000Hz was found to be significantly correlated with the presence of cholesteatoma and with age above 10 years. CONCLUSIONS: One of the complications of COM, with or without cholesteatoma, in addition to the conductive hearing loss, is the development of clinically significant SNHL. It is therefore imperative to actively treat pediatric patients diagnosed with COM, with the aim of preventing the possible development of SNHL.

From hearing with a cochlear implant and a contralateral hearing aid (CI/HA) to hearing with two cochlear implants (CI/CI): a within-subject design comparison.

OBJECTIVE: To compare within-subject bilateral-binaural and bimodal complementary abilities between bimodal (cochlear implant and hearing aid; CI/HA) and bilateral CI hearing (CI/CI), thereby enabling better-informed counseling of experienced CI/HA users contemplating contralateral implantation. STUDY DESIGN: Comparative within-subject case review. SETTING: Outpatient hearing clinic. PATIENTS: Ten experienced adult CI/HA users with severe-to-profound hearing loss in the HA ear, who converted to CI/CI between 2 and 11 years after initial implantation. INTERVENTION: Task-specific testing of bilateral-binaural hearing (sound lateralization, binaural summation/redundancy/unmasking, head-shadow effect), bimodal complementary benefit (contribution of low-frequency information), and a self-report Speech, Spatial, and Qualities of Hearing (SSQ) questionnaire, all before and 1 year after contralateral cochlear implantation. MAIN OUTCOME MEASURES: Test result differences between CI/HA and CI/CI conditions. RESULTS: CI/CI hearing was better than CI/HA for speech lateralization and for perception of semantically unpredictable sentences in speech noise with speech at 0 degrees and noise at +90 degrees azimuth on the old CI side. CI/HA was better than CI/CI only for differences between perception of natural prosody speech and of speech with flattened fundamental frequency (F0) contour with speech and noise in front (at 0 degrees azimuth). Total scores on the SSQ questionnaire were higher in CI/CI than in CI/HA users. CONCLUSION: Counseling regarding contralateral implantation for CI/HA users with severe-to-profound hearing loss in the HA ear, though generally positive, should consider individual functional needs, and cover expectations about the expected trade-off between gaining improved understanding and speech lateralization in challenging listening conditions and losing some low-frequency cues still available with CI/HA hearing.

Fundamental frequency information for speech recognition via bimodal stimulation: cochlear implant in one ear and hearing aid in the other.

OBJECTIVE: The aim of this study was to examine the role of fundamental frequency (F0) information in improving speech perception of individuals with a cochlear implant (CI) who use a contralateral hearing aid (HA). The authors hypothesized that in bilateral-bimodal (CI/HA) users the perception of natural prosody speech would be superior to the perception of speech with monotonic flattened F0 contour, whereas in unilateral CI users the perception of both speech signals would be similar. They also hypothesized that in the CI/HA listening condition the speech perception scores would improve as a function of the magnitude of the difference between the F0 characteristics of the target speech signal and the F0 characteristics of the competitors, whereas in the CI-alone condition such a pattern would not be recognized, or at least not as clearly. DESIGN: Two tests were administered to 29 experienced CI/HA adult users who, regardless of their residual hearing or speech perception abilities, had chosen to continue using an HA in the nonimplanted ear for at least 75% of their waking hours. In the first test, the difference between the perception of speech characterized by natural prosody and speech characterized by monotonic flattened F0 contour was assessed in the presence of babble noise produced by three competing male talkers. In the second test the perception of semantically unpredictable sentences was evaluated in the presence of a competing reversed speech sentence spoken by different single talkers with different F0 characteristics. Each test was carried out under two listening conditions: CI alone and CI/HA. RESULTS: Under both listening conditions, the perception of speech characterized by natural prosody was significantly better than the perception of speech in which monotonic F0 contour was flattened. Differences between the scores for natural prosody and for monotonic flattened F0 speech contour were significantly greater, however, in the CI/HA condition than with CI alone. In the second test, the overall scores for perception of semantically unpredictable sentences in the presence of all competitors were higher in the CI/HA condition in the presence of all competitors. In both listening conditions, scores increased significantly with increasing difference between the F0 characteristics of the target speech signal and the F0 characteristics of the competitor. CONCLUSIONS: The higher scores obtained in the CI/HA condition than with CI alone in both of the task-specific tests suggested that the use of a contralateral HA provides improved low-frequency information, resulting in better performance by the CI/HA users.

Risk factors for sensorineural hearing loss in chronic otitis media.

CONCLUSIONS: Risk factors for sensorineural hearing loss (SNHL) development in patients with chronic otitis media (COM) are longer duration of disease, older age and the presence of cholesteatoma. To prevent the expected development of SNHL, it is imperative to treat COM actively. OBJECTIVES: To assess the severity of SNHL in patients with unilateral COM and to define risk factors for its development. METHODS: The study included 317 patients with unilateral COM. Mean age was 28.7 ± 16.7 years (range 7-78 years) and mean duration of disease was 12.2 ± 11.3 years (range 0.25-60 years). In all patients, air conduction (AC) and bone conduction (BC) thresholds in both ears were measured at 500, 1000, 2000 and 4000 Hz. The parameters evaluated were demographics, duration of disease, presence and location of cholesteatoma and otologic history. RESULTS: The difference in mean BC thresholds between the diseased ears and the healthy ears was statistically significant, ranging from 4.55 ± 10.89 dB to 12.55 ± 19.09 dB across the measured frequency range (p < 0.0001). Multivariate regression analysis revealed statistically significant correlations between advanced age, longer duration of disease and presence of cholesteatoma, and the BC threshold differences between the affected and healthy ears.

Functional status of hearing aids in bilateral-bimodal users.

OBJECTIVE: To assess the functional status of the hearing aid (HA) in bilateral-bimodal users, in whom HA monitoring is often neglected because fitting efforts are focused on the cochlear implant (CI). Also, to define an audiometric pattern of residual hearing that might explain why, despite nonoptimal bimodal fitting, certain cochlear implantees still opt to use a HA. STUDY DESIGN: Retrospective case review. SETTING: Ambulatory care clinic. PARTICIPANTS: Experienced bimodal (CI/HA) adult users (N = 31) who use their HA during most of their waking hours. HA settings were required to meet a selected prescriptive (NAL-NL1) electro-acoustical Verifit Speechmap target at low frequencies using the simulated real-ear mode. INTERVENTION: After initial evaluation, HAs that did not meet the Speechmap target underwent appropriate fitting and reevaluation. MAIN OUTCOME MEASURE(S): Number of patients whose HAs met the defined Speechmap criteria after refitting; residual hearing levels in patients who achieved optimal bimodal fitting and in those who did not. RESULTS: At initial evaluation, the HA in 25 (81%) of the 31 participants was malfunctioning or poorly tuned. After HA replacement or retuning, 19 participants (61%) met the Speechmap targets, and 12 (39%) did not. However, the 2 groups had similar mean levels of unaided and aided residual hearing thresholds at 250 or 500 Hz. CONCLUSION: To maximize the benefit for bilateral-bimodal users, specific guidelines must be established also for fitting of their HAs. The focus should be on achieving the maximum amplification possible at low frequencies.

Panel 2: Eustachian tube, middle ear, and mastoid--anatomy, physiology, pathophysiology, and pathogenesis.

OBJECTIVE: This report reviews the literature to identify the advances in our understanding of the middle ear (ME)-Eustachian tube (ET) system during the past 4 years and, on that basis, to determine whether the short-term goals elaborated in the last report were achieved and propose updated goals to guide future otitis media (OM) research. DATA SOURCES: Databases searched included PubMed, Web of Science (1945-present), Medline (1950 to present), Biosis Previews (1969-present), and the Zoological Record (1978 to present). The initial literature search covered the time interval from January 2007 to June 2011, with a supplementary search completed in February 2012. REVIEW METHODS: The panel topic was subdivided; each contributor performed a literature search and provided a preliminary report. Those reports were consolidated and discussed when the panel met on June 9, 2011. At that meeting, the progress was evaluated and new short-term goals proposed. CONCLUSIONS: Progress was made on 16 of the 19 short-term goals proposed in 2007. Significant advances were made in the characterization of ME gas exchange pathways, modeling ET function, and preliminary testing of treatments for ET dysfunction. IMPLICATIONS FOR PRACTICE: In the future, imaging technologies should be developed to noninvasively assess ME/ET structure and physiology with respect to their role in OM pathogenesis. The new data derived from form/function experiments should be integrated into the finite element models and used to develop specific hypotheses concerning OM pathogenesis and persistence. Finally, rigorous studies of treatments, medical or surgical, of ET dysfunction should be undertaken.