Internal vascular channel architecture in human auditory ossicles.

The vascular supply of the human auditory ossicles has long been of anatomical and clinical interest. While the external blood supply has been well-described, there is only limited information available regarding the internal vascular architecture of the ossicles, and there has been little comparison of this between individuals. Based on high-resolution micro-CT scans, we made reconstructions of the internal vascular channels and cavities in 12 sets of ossicles from elderly donors. Despite considerable individual variation, a common basic pattern was identified. The presence of channels within the stapes footplate was confirmed. The long process of the incus and neck of the stapes showed signs of bony erosion in all specimens examined. More severe erosion was associated with interruption of some or all of the main internal vascular channels which normally pass down the incudal long process; internal excavation of the proximal process could interrupt vascular channels in ossicles which did not appear to be badly damaged from exterior inspection. An awareness of this possibility may be helpful for surgical procedures that compromise the mucosal blood supply. We also calculated ossicular densities, finding that the malleus tends to be denser than the incus. This is mainly due to a lower proportion of vascular channels and cavities within the malleus.

Using a Bone-Conduction Headset to Improve Speech Discrimination in Children With Otitis Media With Effusion.

The recommended management for children with otitis media with effusion (OME) is 'watchful waiting' before considering grommet surgery. During this time speech and language, listening skills, quality of life, social skills, and outcomes of education can be jeopardized. Air-conduction (AC) hearing aids are problematic due to fluctuating AC hearing loss. Bone-conduction (BC) hearing is stable, but BC hearing aids can be uncomfortable. Both types of hearing aids are costly. Given the high prevalence of OME and the transitory nature of the accompanying hearing loss, cost-effective solutions are needed. The leisure industry has developed relatively inexpensive, comfortable, high-quality BC headsets for transmission of speech or music. This study assessed whether these headsets, paired with a remote microphone, improve speech discrimination for children with OME. Nineteen children aged 3 to 6 years receiving recommended management in the United Kingdom for children with OME participated. Word-discrimination thresholds were measured in a sound-treated room in quiet and with 65 dB(A) speech-shaped noise, with and without a headset. The median threshold in quiet (N = 17) was 39 dB(A) (range: 23-59) without a headset and 23 dB(A) (range: 9-35) with a headset (Z = -3.519, p < .001). The median threshold in noise (N = 19) was 59 dB(A) (range: 50-63) without a headset and 45 dB(A) (range: 32-50) with a headset (Z = -3.825, p < .001). Thus, the use of a BC headset paired with a remote microphone significantly improved speech discrimination in quiet and in noise for children with OME.

Fentanyl and heroin contained in seized illicit drugs and overdose-related deaths in British Columbia, Canada: An observational analysis.

BACKGROUND: Due to the alarming rise in opioid-related overdose deaths, a public health emergency was declared in British Columbia (BC). In this study, we examined the relationship between illicit fentanyl and heroin found in seized drugs and illicit overdose deaths in BC. METHODS: An observational cross-sectional survey was conducted using BC data from Health Canada's Drug Analysis Service, which analyzes drug samples seized by law enforcement agencies, and non-intentional illicit overdoses from the BC Coroner's Service, from 2000 to 2016. Initial scatter plots and subsequent multivariate regression analysis were performed to describe the potential relationship between seized illicit fentanyl samples and overdose deaths and to determine if this differed from seized heroin and overdose deaths. Fentanyl samples were analyzed for other drug content. RESULTS: Fentanyl is increasingly being found combined with other opioid and non-opioid illicit drugs. Strong positive relationships were found between the number of seized fentanyl samples and total overdose deaths (R2 = 0.97) as well as between seized fentanyl and fentanyl-detected overdose deaths (R2 = 0.99). A positive association was found between the number of seized heroin samples and total overdose deaths (R2 = 0.78). CONCLUSION: This research contributes to the expanding body of evidence implicating illicit fentanyl use (often combined with heroin or other substances) in overdose deaths in BC. Policy makers and healthcare providers are urged to implement drug treatment and harm reduction strategies for people at risk of overdose associated with current trends in illicit opioid use.

Computed Tomography Estimation of Cochlear Duct Length Can Predict Full Insertion in Cochlear Implantation.

OBJECTIVE: To compare the rates of full insertion of electrodes and hearing outcomes obtained with 28-mm and 31-mm cochlear implant electrode arrays. To assess whether cochlear duct length (CDL) estimated by preoperative computed tomography (CT) predicts whether an electrode is fully inserted. STUDY DESIGN: A cohort study compared electrodes inserted and hearing outcomes after implantation with 28-mm or 31-mm arrays. CDL estimated from preoperative CT was compared in patients in whom full insertion of the 28-mm array was achieved compared with patients in whom at least one basal electrode was outside the cochlea. SETTING: Tertiary referral cochlear implantation center. PATIENTS: One hundred forty-eight patients implanted with 28-mm cochlear implant arrays (175 devices) and 74 patients implanted with 31-mm arrays (88 devices). INTERVENTION: Cochlear implantation with 28-mm or 31-mm array. MAIN OUTCOME MEASURES: Active electrodes at first programming, and at subsequent follow-ups. Bamford-Kowal-Bench sentence and auditory speech sound evaluation test results at 2 to 3 months in adult patients. CDL predicted by preoperative CT. RESULTS: There was no difference in full insertion between the 28-mm and 31-mm array cohorts (p = 0.22). Early hearing outcomes at 2 to 3 months showed no difference in mean auditory speech sound evaluation (p = 0.19) or Bamford-Kowal-Bench results (p = 0.853) between the 28-mm and 31-mm cohorts. CDL was shorter in the 22 patients with less than full insertion of the array with a mean length of 28.7 mm compared with 29.6 mm in the 42 patients in whom full insertion was achieved (p = 0.046). CONCLUSION: CT estimation of CDL predicts full insertion after cochlear implantation. Insertion depth does not affect early hearing outcome.

Pitch Discrimination: An Independent Factor in Cochlear Implant Performance Outcomes.

OBJECTIVE: To assess differences in pitch-ranking ability across a range of speech understanding performance levels and as a function of electrode position. STUDY DESIGN: An observational study of a cross-section of cochlear implantees. SETTING: Tertiary referral center for cochlear implantation. PATIENTS: A total of 22 patients were recruited. All three manufacturers' devices were included (MED-EL, Innsbruck, Austria, n = 10; Advanced Bionics, California, USA, n = 8; and Cochlear, Sydney, Australia, n = 4) and all patients were long-term users (more than 18 months). Twelve of these were poor performers (scores on BKB sentence lists <60%) and 10 were excellent performers (BKB >90%). INTERVENTION: After measurement of threshold and comfort levels, and loudness balancing across the array, all patients underwent thorough pitch-ranking assessments at 80% of comfort levels. MAIN OUTCOME MEASURE: Ability to discriminate pitch across the electrode array, measured by consistency in discrimination of adjacent pairs of electrodes, as well as an assessment of the pitch order across the array using the midpoint comparison task. RESULTS: Within the poor performing group there was wide variability in ability to pitch rank, from no errors, to a complete inability to reliably and consistently differentiate pitch change across the electrode array. Good performers were overall significantly more accurate at pitch ranking (p = 0.026). Consistent pitch ranking was found to be a significant independent predictor of BKB score, even after adjusting for age. Users of the MED-EL implant experienced significantly more pitch confusions at the apex than at more basal parts of the electrode array. CONCLUSIONS: Many cochlear implant users struggle to discriminate pitch effectively. Accurate pitch ranking appears to be an independent predictor of overall outcome. Future work will concentrate on manipulating maps based upon pitch discrimination findings in an attempt to improve speech understanding.

Pneumocoele after cochlear implantation.

OBJECTIVE AND IMPORTANCE: Scalp pneumocoele is a rare complication of cochlear implantation surgery. We present the largest case series to date; consisting of four cases over 8 years from one centre. The presentation, diagnosis, and management of each case are reviewed. Previously unreported complications of pneumocoeles are highlighted. CLINICAL PRESENTATION: Three of our four cases, consisting of two adults (aged 53 and 81 years) and one child (aged 26 months), developed scalp pneumocoeles within the first 3 months of implantation. Another child (aged 10) developed pneumocoele 7 years after surgery. The common diagnostic features include a soft, non-tender, fluctuant swelling over the receiver/stimulator package. In all cases, pneumocoeles were triggered by Valsalva's or Toynbee's manoeuvres. Complications include infection (case one) and reduction in cochlear implant (CI) function (cases three and four), secondary to displacement of the receiver/stimulator package or electrode displacement. INTERVENTION/TECHNIQUE: Diagnosis is made from clinical history and examination. Aspiration results in reduction of pneumocoeles. This is not necessary for smaller pneumocoeles as they may resolve spontaneously. Additional investigations may reveal complications of pneumocoeles, such as X-rays for implant displacement, and inflammatory marker to detect signs of infection. To prevent the recurrence of pneumocoeles, patients are advised to avoid Valsalva's or Toynbee's manoeuvres. There were no recurrences of pneumocoeles. CONCLUSION: Post-cochlear implantation pneumocoeles can be associated with harmful complications such as infection and CI dysfunction. The mechanism of pneumocoele formation is discussed, and strategies for its prevention are examined.

Contralateral recovery of cochlear function after cochlear implantation.

Significant recovery of sensorineural hearing loss in either ear after cochlear implantation (CI) is rare. We present the case of a 57-year-old lady with medically treated depression and a background of chronic suppurative otitis media (CSOM) in the non-implanted ear, who clearly fulfilled audiological criteria for CI. Two years post-implantation her CSOM in the non-implanted ear was addressed with blind sac closure of the ear. Post-operatively the hearing thresholds in this ear had improved to the extent that a bone-anchored hearing aid became a viable option. The literature is carefully reviewed to consider possible explanations of this phenomenon.

Lens Dislocation Following YAG Laser Peripheral Iridotomy.

A rare case where laser peripheral iridotomy resulted in crystalline lens dislocation into the vitreous cavity. The patient was managed with pars plana vitrectomy, fragmatome lensectomy, anterior chamber intraocular lens and surgical iridotomy with a final best corrected visual acuity of 6/9. Multiple episodes of laser peripheral iridotomy carries a risk of complete lens dislocation.

Persistent upper airway obstruction is a diagnostic feature of spondyloepimetaphyseal dysplasia with multiple dislocations (Hall type) with further evidence for dominant inheritance.

The spondyloepimetaphyseal dysplasias (SEMD) are a group of skeletal dysplasias of variable severity with a heterogeneous genetic aetiology. SEMD with multiple dislocations (Hall type) is a recently identified disorder (OMIM 603546) which is characterized by striking epiphyseal and metaphyseal changes of the long bones and joint laxity with multiple dislocations of the large joints. We report on persistent inspiratory stridor in a child with this type of SEMD in the second reported family with dominant transmission of this disorder. Microlaryngoscopy showed laryngeal stenosis due to failure of abduction of the vocal cords and a tracheostomy was required to provide a satisfactory airway. Since airway compromise has been reported previously in a small series of patients (total of five out of 13 cases so far), the evidence to date supports the association of upper airway obstruction in early childhood with the Hall type of SEMD. We therefore suggest that this is a clinically important diagnostic feature of this disorder.

Patient employment status and satisfaction following cochlear implantation.

The aim of this study was to look at the effect on employment and employee perception of career opportunities after receiving a cochlear implant. Retrospective analysis based on a patient questionnaire was conducted. Eighty patients were identified: 65 (81.3%) participated in the questionnaire. Forty-five patients (69.2%) were working prior to implant compared to 54 (83.9%) after implant. Job satisfaction rating rose from 5.56 to 6.82 following cochlear implantation. Twenty patients (30.8%) were unemployed prior to surgery while 11 (16.9%) remained unemployed post implantation. Twenty-six patients (57.7%) from the working group believed that their hearing disability had affected their career, while 18 (40%) from the same group believed that receiving the cochlear implant significantly improved their career prospects. Cochlear implantation is associated with an improved chance of being employed. It also helps with improved job satisfaction as well as improving employee perception of their career prospects.

An unusual air gun injury to the ethmoid sinus.

We report an air gun pellet in the ethmoid sinus. The entrance point was concealed in the conjunctiva of the medial canthus, sparing the eye and skin. The pellet traversed the ethmoid and was stopped by the cribriform plate. It was removed by an endoscopic approach without complications. The literature is reviewed. A high index of suspicion is required to identify penetrating foreign bodies in patients walking in with low-velocity gun injuries.

Evaluation of bilaterally implanted adult subjects with the nucleus 24 cochlear implant system.

OBJECTIVE: To evaluate the speech perception benefits of bilateral implantation for subjects who already have one implant. STUDY DESIGN: Repeated measures. PATIENTS: Thirty adult cochlear implant users who received their second implant from 1 to 7 years with a mean of 3 years after their first device. Ages ranged from 29 to 82 years with a mean of 57 years. SETTING: Tertiary referral centers across the United Kingdom. MAIN OUTCOME MEASURES: Monosyllabic consonant-nucleus-consonant words and City University of New York sentences in quiet with coincident speech and noise and with the noise spatially separated from the speech by +/-90 degrees . RESULTS: At 9 months, results showed the second ear in noise was 13.9 +/- 5.9% worse than the first ear (p < 0.001); a significant binaural advantage of 12.6 +/- 5.4% (p < 0.001) over the first ear alone for speech and noise from the front; a 21 +/- 6% (p < 0.001) binaural advantage over the first ear alone when noise was ipsilateral to the first ear; no binaural advantage when noise was contralateral to the first ear. CONCLUSIONS: There is a significant bilateral advantage of adding a second ear for this group. We were unable to predict when the second ear would be the better performing ear, and by implanting both ears, we guarantee implanting the better ear. Sequential implantation with long delays between ears has resulted in poor second ear performance for some subjects and has limited the degree of bilateral benefit that can be obtained by these users. The dual microphone does not provide equivalent benefit to bilateral implants.

Suprachoroidal hemorrhage during cataract surgery in a vitrectomized eye.

We report a case of surprachoroidal hemorrhage (SCH) that occurred during cataract surgery in a previously vitrectomized eye. The only sign of SCH was a progressive shadow obscuring the red reflex. There was no increase in intraocular pressure (IOP), shallowing of the anterior chamber, or iris prolapse. Postoperatively, the SCH gradually resolved without complications, leaving a series of subretinal pigmentary lines. Surgeons should be aware that the signs normally expected in SCH may not develop in vitrectomized eyes. Obscuration of the red reflex may be the only sign of the hemorrhage, and when this happens, it may be prudent to keep the IOP elevated and suture the incision at the end of the procedure.

Outpatient fibre-optic laryngoscopy for stridor in children and infants.

Many neonates are referred for a diagnosis with stridor. The gold standard investigation has traditionally been a rigid or direct microlaryngoscopy. This impacts on existing theatre schedules, demands a high level of skills from the paediatric anaesthetist along with the risk of exposing a neonate to a general anaesthetic. A bed in paediatric intensive care is often required and must be reserved. As laryngomalacia is the most common diagnosis and less serious than the investigations for infants with stridor themselves, clinicians have been looking to use the flexible fibre-optic laryngoscope to view the upper airway in awake neonatal patients. We present our experience in 66 neonatal patients initially managed by awake per-oral flexible fibre-optic laryngoscopy for stridor. We conclude that the technique is safe, straightforward and allows a diagnosis to be achieved in a significant number of cases. We recommend it as a first line investigation, reserving microlaryngoscopy for the group of patients in whom a diagnosis cannot be made in the outpatient clinic.

Direct referral of posterior capsular opacification by optometrists.

PURPOSE: To study referrals of posterior capsular opacification (PCO) for laser capsulotomy by optometrists and compare direct referral with that via the general practitioner (GP). METHODS: A prospective analysis of optometrist referrals with regard to diagnostic accuracy, appropriateness of referral, quality of letters and patient waiting times. RESULTS: Of 222 referrals, 156 were direct and 66 via the GP. Forty-five (20.3%) letters were of good quality, 141 (63.5%) were average and 36 (16.2%) were poor. Waiting times for direct referrals ranged from 2 to 30 weeks (mean 8.3 weeks, S.D. 4.1); that for referrals via the GP ranged from 4 to 25 weeks (mean 10.3 weeks, S.D. 3.6). Directly referred patients thus waited 2 weeks shorter than patients referred via GPs (95% confidence interval 0.7-3.1, p = 0.002). Diagnostic concurrence was 99% (211/213 patients). The rate of laser capsulotomy was 98.2% (215/219); 103 (46.4%) letters utilised a referral form (GOS18); 146 (65.8%) discussed subjective visual problems and five (2.3%) incorporated patient consent for provision of feedback to the referring optometrist. CONCLUSION: Direct optometrist referral is effective, accurate and reduces patient waiting time and GP workload. Referral letters should be typed or printed to optimise legibility. Patient consent for feedback should be obtained by the referring optometrist.