[ACUTE OTITIS MEDIA BACTERIOLOGY IN CHILDREN YOUNGER THAN THREE MONTHS IN THE LAST 16 YEARS].

BACKGROUND: Only scant information is available regarding the bacteriology of acute otitis media (AOM) in neonates. OBJECTIVES: To investigate the bacteriology of AOM post the introduction of Pneumococcal Conjugate Vaccine (PCV13) in children younger than 3 months and its relation to the mode of delivery. METHODS: Retrospective bacteriological analysis of middle ear fluids taken from children younger than 60 months suffering from AOM. The effect of PCV13 and mode of delivery, caesarian section vs vaginal delivery, on AOM bacteriology was evaluated and compared between children younger than 3 months (group 1) and children aged 3-60 months (group 2). RESULTS: The prevalence of Streptococcus pneumoniae (S.pneumoniae) and Enterobacteriaceae (E.bact) was higher in group 1 compared to group 2, 47.1% vs 35.8% and 12.3% vs 4.3%, respectively (p<0.001), while that of Haemophilus influenza (H. influenzae) and Group A streptococcus (GAS) was higher in group 2 compared to group 1, 40.3% vs 30.1% and 17.5% vs 8.3% respectively (p<0.001). The mode of delivery did not affect AOM bacteriology. The introduction of PCV13 yielded in an increase in the prevalence of GAS (7% to 15%, P<0.001) in group 1. CONCLUSIONS: S. pneumoniae and E. bact are more common AOM pathogens in neonates. Also, the prevalence of GAS was increased in this age group following the introduction of PCV13. DISCUSSION: Our results are applicable towards the formulation AOM treatment guidelines in neonates. This study contributed additional information on a topic that has not been adequately researched so far - neonatal AOM.

Barotrauma-Induced Perilymph Fistula: Video Head Impulse Test and High-Resolution Temporal Bones Computed Tomography Role in Evaluation and FollowUp.

We report a case of a woman presenting with unilateral right profound hearing loss accompanied by vertigo secondary to barotrauma-induced perilymph fistula during recreational skydiving. Video head impulse test demonstrated a reduced gain in both the right horizontal and right anterior semicircular canals accompanied by frequently gathered overt corrective saccades. High-resolution computed tomography revealed an enlarged vestibular aqueduct on the affected side, a predisposing factor for the development of perilymph fistula. An exploratory tympanotomy was performed during which a perilymph leak was visualized at the round window niche. Temporal fascia patches enforced by absorbable gelatin sponges were applied to both round and oval windows. During post-surgery follow-up, the patient remained free of vestibular symptoms. An audiogram displayed mild improvement in the right ear speech reception threshold, although her hearing remained non-serviceable. The video head impulse test showed a favorable dynamic with a stepwise return to normal gain values in all semicircular canals and the disappearance of overt corrective saccades. This is the first case in which video head impulse test was employed as a valuable diagnostic tool for the evaluation and post-surgery follow-up of vestibular function in a barotrauma-induced perilymph fistula. The demonstration of an enlarged vestibular aqueduct on high-resolution computed tomography and the risk of perilymph fistula recurrence are discussed.

[THE VIDEO HEAD IMPULSE TEST (VHIT): CAN WE RELY ON THE GAIN PARAMETER ALONE?]

INTRODUCTION: While the bedside head impulse test evaluates the presence of refixation saccades (RS) as a measure of failing vestibulo-ocular reflex (VOR) the VOR gain calculated by the video head-impulse test (vHIT) is considered the primary measure for semicircular canal function while the role RS is still under evaluation. AIMS: To evaluate the benefit of various RS characteristics towards the diagnosis of the left horizontal semicircular function by vHIT. METHODS: The vHIT recordings of 40 patients with left sided horizontal VOR gains <0.8 were retrospectively evaluated for the presence of RS. The study groups included 20 patients with a final diagnosis of left horizontal semicircular canal dysfunction and 20 patients for whom vestibular dysfunction was ruled out. RESULTS: Gain values > 0.72 were found in all patients with no vestibular disease, and in 4 (20%) patients having vestibulopathy. Significantly higher average left-sided RS velocity and frequency were found among the vestibular patients. VOR gain < 0.72 was found to be highly specific for the diagnosis of vestibular dysfunction. However, for gain values in the range of 0.72-0.79 the presence of RS with frequency > 80% improved vHIT sensitivity. CONCLUSIONS: Although VOR gain<0.8 is considered to reflect dysfunction, a significant false positive rate for left-sided horizontal vHIT was found for gains in the range of 0.72-0.79. The presence of RS with frequency >80% could improve vHIT diagnostic accuracy in these patients.

[THE VIDEO HEAD IMPULSE TEST (VHIT)].

INTRODUCTION: The video head impulse test (vHIT) is a new tool in the vestibular tests' arsenal. It is based on the clinical Head Impulse Test, where the integrity of the vestibulo-ocular reflex is tested by high frequency excitation of the semi-circular canals. The vHIT system is composed of an accelerometer measuring the head movements, and a high frequency infra-red camera for eye tracking mounted on a light-weighted goggles. The main measures obtained are the vestibulo-ocular reflex gain - the ratio between the head and eye velocities, and the recording of corrective saccades taking place during the head movement (covered saccades) or following it (overt saccades).

The Vestibular Time Constant and Clinical Response to Antimotion Sickness Medication.

OBJECTIVE: The therapeutic effects of antimotion sickness medications involve suppression of several components along the vestibular system. Scopolamine-based medications have proved to be the most effective anti-seasickness agents. However, there is high variability in individual responses. The vestibular nuclei, in which the vestibular time constant is modulated, contain acetylcholine receptors which are affected by scopolamine. The hypothesis of the study was that successful seasickness prevention by scopolamine requires vestibular suppression to be reflected by the shortening of the vestibular time constant. DESIGN: Subjects were 30 naval crew members suffering from severe seasickness and were treated with oral scopolamine. The study participants were defined as responsive or non-responsive to the anti-seasickness medication according to the clinical outcome: successful response to scopolamine was defined as a reduction of seasickness severity from the highest score of 7 according to the Wiker scale to 4 or less. Scopolamine and placebo were assigned to each subject in a crossover, double-blind design. The horizontal semicircular canal time constant was evaluated by a computerized rotatory chair before, 1 and 2 hours after drug or placebo administration. RESULTS: The vestibular time constant was significantly shortened from 16.01 ± 3.43 seconds to 12.55 ± 2.40 seconds ( p < 0.001) in the scopolamine-responsive group but not in the nonresponsive group. In contrast, vestibular time constant values were 13.73 ± 4.08 and 12.89 ± 4.48 for baseline and 2 hours measurements, respectively. This change was not statistically significant. CONCLUSIONS: Reduction in the vestibular time constant after scopolamine administration can be used to predict whether motion sickness alleviation will occur. This will enable the administration of appropriate pharmaceutical treatment without the need for prior exposure to sea conditions.

Refining the Video Head Impulse Test Diagnostic Accuracy: A Case-Control Study.

INTRODUCTION: Current clinical practice considers the vestibulo-ocular reflex (VOR) gain as registered by the video head impulse test (vHIT) as the primary measure for semicircular canal function, while the role of the re-fixation saccades (RSs) is still under evaluation. The goal of the study was to appraise the added benefit of RS towards the improvement of vHIT diagnostic accuracy in cases of suspected left horizontal semicircular canal dysfunction. METHODS: The vHIT recordings of 40 patients with left-sided horizontal VOR gains <0.8 were retrospectively evaluated for the presence of RS. The study groups included 20 patients with a final diagnosis of left horizontal semicircular canal dysfunction and 20 patients for whom vestibular dysfunction was ruled out. RESULTS: Gain values >0.72 were found in all patients with no vestibular disease and in 4 (20%) patients having vestibulopathy. Significantly higher average left-sided RS velocity and frequency were found among the vestibular patients. VOR gain <0.72 was found to be highly specific for the diagnosis of vestibular dysfunction. However, for gain values in the range of 0.72-0.79, the presence of RS with frequency >80% largely improved vHIT diagnostic accuracy. CONCLUSIONS: Although VOR gain <0.8 is considered to reflect dysfunction, a significant false-positive rate for left-sided horizontal vHIT was found for gains in the range of 0.72-0.79. The presence of RS with frequency >80% could improve vHIT diagnostic ability in these patients.

Two decades of otitis media in northern Israel: Changing trends in the offending bacteria and antibiotic susceptibility.

OBJECTIVE: Bacteriology and antibiotic resistance trends changed considerably following introduction of the pneumococcal conjugate vaccines (PCV) 7 and 13, with differences between geographic regions. The objective of this study was to evaluate changes in acute otitis media (AOM) bacteriology and antibiotic susceptibility from the pre-vaccination period (2002-2008) to after the introduction of PCV13 (2010-2019) in northern Israel. METHODS: Data were collected from 3277 middle ear fluid (MEF) cultures and 4822 common AOM-generating pathogens of children aged <5 years with otitis media, taken during 2002-2019. Age of the child, bacteriology, and antibiotic resistance were compared between 2002 and 2008, the pre-vaccination period when no vaccination was available and 2010-2019 when PCV13 was introduced. RESULTS: The mean age of the children in the pre-vaccination and the vaccination periods was 18.7 ± 13.7 and 15.7 ± 12.5 months, respectively (p < 0.001); the mean age of those with group A streptococcus (GAS) positive cultures was older, p < 0.001.The prevalence of Streptococcus pneumoniae (S. pneumoniae) decreased between those periods, from 47% to 25.8%, p < 0.001, Haemophilus influenzae (H. influenza) increased from 38.4% to 47.1%, p < 0.001, GAS increased from 12.9% to 23.8%, p < 0.001, and Moraxella catarrhalis (M. cat) increased but not statistically significant from 1.7% to 3.1%. The yearly number of positive MEF cultures decreased from 395.1 to 205.6, p < 0.001. The antibiotic sensitivity rate of almost all antibiotics increased between the two study periods. CONCLUSION: The most common MEF bacteria in northern Israel today is H. influenzae. Comparing the pre-vaccination to the vaccination period, the incidence of S. pneumonia-positive cultures decreased while GAS and H. influenza cultures increased. The age of children with positive cultures increased, and the antibiotic sensitivity rate increased. Key This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Functional Integrity of the Inferior Vestibular Nerve and Posterior Canal BPPV.

The functional integrity of the inferior vestibular nerve (IVN) may be evaluated by the cervical vestibular evoked myogenic potential (cVEMP) response, which requires signal transmission via the nerve. As functional integrity of the IVN innervating the posterior semicircular canal is required to produce the typical positioning vertigo and nystagmus characterizing posterior canal benign paroxysmal positional vertigo (PCBPPV), we hypothesized that normal cVEMPs would be found in most PCBPPV patients. Twenty-four PCBPPV patients participated in a prospective cohort study. All were treated by canal repositioning maneuver and had air-conduction cVEMP and videonystagmography (VNG). Follow-up evaluations including history and otoneurological bedside examination were carried out 1, 3, 6, and 12 months after the initial treatment. At the last follow-up, the patients filled the Dizziness Handicap Inventory (DHI) questionnaire. Normal cVEMPs were recorded in 19 (79%) and were absent in 5 (21%) of the subjects. The average DHI in the patients with normal cVEMP was 16.42 ± 17.99 vs. 0.4 ± 0.89 among those with pathological cVEMP (p < 0.04, Mann-Whitney test). Thirteen (54%) patients experienced recurrent PCBPPV (rPCBPPV). The average DHI score was significantly higher among patients having recurrence (22.15 ± 18.61) when compared to those with complete cure (2.36 ± 5.98; p < 0.003, Mann-Whitney test). Ten (77%) of the subjects with rPCBPPV had normal and 3 (23%) had pathological cVEMP as compared to 9 (82%) and 2 (18%) subjects in the non-recurrent (nrPCBPPV) group (Fisher's exact test-not significant). cVEMP p13 and n23 wave latencies and amplitudes, inter-aural differences in p13-n23 peak-to-peak amplitudes, and response thresholds did not differ between the groups. No differences were found between the rPCBBPV and nrPCBBPV groups in VNG caloric lateralization and directional preponderance values. We have found that in most cases, PCBPPV symptoms and signs are associated with normal cVEMP response supporting the role of IVN functional integrity. The absent cVEMPs in the minority of patients, although having similar clinical presentation, raise the possibility that the ipsilateral saccule is affected by the same pathology causing degeneration of the utricle macula. Alternatively, lacking inhibitory stimuli from the involved ipsilateral utricle or partial degeneration of the IVN and ganglion could explain the diminished cVEMP response. Clinical Trial Registration: The study was registered in ClinicalTrials.gov Internet site (study ID-NCT01004913; https://clinicaltrials.gov/ct2/show/NCT01004913?cond=BPPV&cntry=IL&draw=2&rank=3).

Bone Mineral Density in Patients Suffering from Ménière's Disease.

INTRODUCTION: Previous studies have reported an association between reduced bone mineral density and the occurrence of benign paroxysmal positional vertigo, balance impairment, and saccular dysfunction. Furthermore, the results of recent animal studies have raised the possibility that vestibular dysfunction could affect bone remodeling and bone mass. The goal of the study was to compare bone mineral density of patients suffering from definite Ménière's disease to that of a matched control group. METHODS: We conducted a case-control cross-sectional study in a tertiary referral center. The study group included 23 patients suffering from definite Ménière's disease, and the control group was comprised of 23 patients matched in their race, gender, and age parameters in whom no vestibular pathology could be found. Dual energy X-ray absorptiometry of the femoral head was used for the assessment of bone mineral density. The T and Z scores of the femoral heads' bone mineral density were compared. RESULTS: The average T scores were -1.53 ± 1.08 in the study and -0.39 ± 0.72 (p = 0.016) in the control groups, and the Z scores were -0.4 ± 0.63 and 0.33 ± 0.31 (p = 0.018), respectively. Seventeen patients (74%) of the study group and 9 (39%) of the control group had T scores less than -1.0, indicating osteopenia/osteoporosis (p = 0.036). CONCLUSIONS: The results showed a significant association between Ménière's disease and reduced bone mineral density of the femoral head. Bone mineral density studies of the weight-bearing bones are warranted in Ménière's disease for the early diagnosis and treatment of osteopenia/osteoporosis on the one hand and possible benefit of this treatment for the evolution of Ménière's disease on the other hand.

The head impulse test as a predictor of videonystagmography caloric test lateralization according to the level of examiner experience: A prospective open-label study.

We conducted a study to compare how well the head impulse test (HIT), without and with eye-movement recordings, would predict videonystagmographic (VNG) caloric test lateralization when performed by a resident and an experienced otoneurologist. This prospective, open-label, blinded study was conducted in an ambulatory tertiary care referral center. Our study population was made up of 60 patients-29 men and 31 women, aged 20 to 82 years (mean: 56.4 ± 11.4)-with peripheral vestibulopathy who underwent HIT and VNG caloric testing. The HIT was conducted in two protocols: HIT0 and HIT1. The HIT0 was performed with passive brisk movements of the patient's head from the 0° null position to 20° sideways, and the HIT1 was performed toward the center while the null position was a 20° head rotation to the right and to the left. Each protocol was carried out without video eye-movement recordings (HIT0 and HIT1) and with such recordings (rHIT0 and rHIT1). The primary outcome measures were (1) a comparison of the HIT's sensitivity and specificity when performed by the resident and by the experienced otoneurologist and (2) the ability of video-recorded HIT to predict VNG caloric test lateralization. The sensitivity and specificity obtained by the resident were 41 and 81%, respectively, for HIT0 and 41 and 90% for HIT1. The sensitivity and specificity obtained by the experienced otoneurologist were 18 and 89% for HIT0 and 32 and 85% for HIT1. Analysis of the recorded eye-movement clips of the HIT0 and HIT1 obtained by a second experienced otoneurologist found a sensitivity and specificity of 32 and 63% for rHIT0 and 33 and 82% for rHIT1. We conclude that the HIT yields high false-negative rates in predicting significant caloric lateralization. Analysis of the eye-movement recordings was no better than normal testing alone for detecting saccades. The experience of the examining physician had no impact on test performance characteristics.

Hearing and Otoacoustic Emissions Outcome of Stapedotomy: Does the Prosthesis Diameter Matter?

OBJECTIVE: To compare the hearing and otoacoustic emissions (OAE) outcome of stapedotomy employing 0.4 and 0.6 mm diameter prostheses. MATERIALS AND METHODS: In total, 18 patients with otosclerosis participated in a prospective, double-armed, randomized cohort study. All the patients underwent small fenestra drill stapedotomy employing the Causse fluroplastic large loop piston prostheses. The patients were randomly assigned to groups of 0.4 mm (n=9) and 0.6 mm (n=9) diameter prostheses. The results of pure tone air and bone audiometries, speech audiometry, and OAE conducted 12 months post operatively were compared within and between the groups. RESULTS: The within-group analysis showed significant post-stapedotomy improvements in the average air conduction pure tone thresholds in both groups (52.9±9.6 vs. 25.6±5.2 dB HL; p<0.0001 and 54.6±10.4 vs. 22.2±8.2 dB HL; p<0.0001 for the 0.4 and 0.6 mm groups, respectively) and average air-bone gap (ABG; 37.1±8.5 vs. 8.1±3.9 dB HL; p<0.0001 and 38.3±7.5 vs. 9.9±4.5 dB HL; p<0.0001 in the 0.4 and 0.6 mm groups, respectively). No significant differences were found between the groups in these outcome measures, as well as in the rate of ABG closure within 10 dB HL and the word recognition scores. Favorable outcome in the post-stapedotomy bone conduction (BC) was found for the 0.6 mm prosthesis group, reflecting superior cancellation of the Carhart phenomenon for the 500-3000 Hz pure tone thresholds average (-1.7±3.7 vs. 3.9±6.2 dB HL for the 0.4 and 0.6 mm groups, respectively; p<0.04) and 1000, 2000, and 4000 Hz average (-2.6±4.33 vs. 3.9±7.8 dB HL for the 0.4 and 0.6 mm groups, respectively; p<0.05). Small signal-to-noise ratio (SNR) values of the transient-evoked OAE (TEOAE) and distortion product OAE (DPOAE) were found at baseline and follow-up evaluation with no consistent changes post stapedotomy. CONCLUSION: Similar post-stapedotomy hearing results were found for the 0.4 and 0.6 mm prostheses with small but statistically significant advantage in BC gain and the overclosure parameter for the 0.6 mm prosthesis. OAE testing was not found to be of clinical value in the evaluation of stapedotomy hearing outcome.

Vestibular Derangement and Motion Intolerance in VATER Association.

VATER association is a nonrandom occurrence of congenital malformations: vertebral defects, anal atresia, tracheoesophageal fistula, renal defects, and radial bone anomalies. We report the case of a 19-year-old man with a childhood diagnosis of VATER association, who presented to the motion sickness clinic with severe seasickness. We discuss the clinical and laboratory diagnosis of vestibular pathophysiology, which was confirmed by MRI of lateral semicircular canal and vestibule dysplasia. We suggest the possibility of vestibular involvement as part of the developmental field defect associated with VATER syndrome, which hitherto has rarely been reported.

Primary solitary intralabyrinthine schwannoma: A report of 7 cases and a review of the literature.

Intralabyrinthine schwannomas (ILSs) are uncommon benign tumors that originate in the Schwann cell sheath of the intralabyrinthine distal branches of the vestibulocochlear nerve. They have no initial involvement in the internal auditory canal, although that might develop later. These lesions can arise inside the cochlea, originate in the vestibule or, in rare cases, develop in the semicircular canals. From these sites, spread might take place via the anatomic connections between the perilymphatic spaces in the scala vestibuli and the anterior vestibule. Thus, ILSs centered in the cochlea might involve the vestibule, and those originating in the vestibular end organs would reach the cochlea. Presenting signs and symptoms include a progressive or sudden sensorineural hearing loss (which occurs in more than 95% of patients), as well as tinnitus and vertigo. Magnetic resonance imaging characteristics include sharp circumscription and hypointensity on thin, heavily T2-weighted 3D images and strong enhancement after gadolinium administration on T1-weighted images. We describe a series of 7 cases of primary ILS that were managed at two of our institutions. We also discuss the need for a comprehensive otoneurologic evaluation that encompasses the functional derangement and the tumor location as delineated by MRI, and we describe the treatment options.

Susac's Syndrome: A Case with Unusual Cardiac Vestibular and Imaging Manifestations.

Susac's syndrome (SS) is a disease of the microvasculature of the retina, brain, and inner ear. We describe a patient with unusual manifestations of SS with possible involvement of the brainstem, cardiac arrhythmia, and MRI findings lacking the characteristic lesions found in Susac's syndrome.

Evidence for the initiation of decompression sickness by exposure to intense underwater sound.

Mass stranding of cetaceans (whales and dolphins), in close association with the activity of naval sonar systems, has been reported on numerous occasions. Necropsy showed bubble-associated lesions similar to those described in human decompression sickness (DCS). We examined the hypothesis that exposure to underwater sound may potentiate DCS. Rats were subjected to immersion and simulated dives with and without simultaneous acoustic transmissions at pressure levels and frequencies of 204 dB/8 kHz and 183.3 dB/15 kHz. DCS severity was assessed using the rotating wheel method. Recording of somatosensory evoked potentials (SSEPs) was employed under general anesthesia as an electrophysiological measure of neurologic insult. A significantly higher rate of decompression sickness was found among animals exposed to the 204-dB/8-kHz sound field. Significantly higher pathological SSEPs scores were noted for both underwater sound protocols. Pathological SSEPs scores in animals immersed during the acoustic transmissions, but without changes in ambient pressure, were comparable to those observed in animals exposed to the dive profile. The results demonstrate induction of neurological damage by intense underwater sound during immersion, with a further deleterious effect when this was combined with decompression stress. The study outcome has potential implications for human diving safety and may provide an explanation for the mass stranding of cetaceans purportedly associated with sonar activity.

Otoacoustic emissions in the prediction of sudden sensorineural hearing loss outcome.

OBJECTIVE: To evaluate the role of otoacoustic emissions (OAEs) in the prediction of idiopathic sudden sensorineural hearing loss (ISSNHL) outcome. STUDY DESIGN: Open-label prospective study. SETTING: Tertiary referral medical center. PATIENTS: Fifteen ISSNHL patients (age: 57.6 ± 16.2 years) were prospectively followed 7 days, 14 days, and 3 months post-presentation and the commencement of treatment. INTERVENTION: Pure-tone audiometry, TEOAEs (Transient Evoked OAEs), and DPOAEs (Distortion Product OAEs) testing. MAIN OUTCOME MEASURES: The pure-tone threshold averages of the three most affected frequencies, detectability, and the signal-to-noise ratios (SNRs) values of the TEOAEs and DPOAEs were calculated. The main outcome measures were pure-tone hearing improvement, sensitivity, and specificity of the OAEs measures towards ISSNHL outcome. RESULTS: Patients having detectable TEOAEs on the first follow-up evaluation had average hearing improvement of 62 ± 41% whereas those with no response improved only by 11 ± 15% (P < 0.001). For the DPOAEs hearing improvement, results were 71 ± 37% and 10 ± 14%, respectively (P < 0.001). The sensitivity of recordable TEOAEs on the seventh day of follow-up towards the prediction of significant hearing improvement reached 71% and the specificity 100%. For the DPOAEs, the corresponding values were 83% and 100%. Univariate analysis showed significant contribution for the variance in hearing improvement by both TEOAEs and DPOAEs and their interaction (P values of 0.043, 0.005, and 0.009, respectively). CONCLUSION: The results suggest potential role of TEOAEs and DPOAEs evaluation in the early stage of treatment in the prediction of ISSNHL outcome.

Prevention of Cisplatin-Induced Hearing Loss by Intratympanic Dexamethasone: A Randomized Controlled Study.

OBJECTIVE: To examine the role of intratympanic Dexamethasone (ITD) in the prevention of Cisplatin-induced hearing loss. STUDY DESIGN: Prospective randomized controlled clinical trial. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Twenty-six patients suffering from a neoplastic disease for which the treatment protocol included Cisplatin were recruited. Prior to each Cisplatin treatment session ITD was injected to the baseline randomly assigned ear while the other ear of the same patient served as the control. Audiometry and Distortion Product Otoacoustic Emissions (DPOAEs) test results of the baseline and follow-up examinations were compared within and between the study and control ears. RESULTS: The cumulative dose of Cisplatin was greater than 400 mg for the 15 subjects who completed the study. The pure tone threshold at 8000 Hz and pure tone average threshold at 4000 to 8000 Hz significantly increased in both the study (P < .005, P < .03, respectively) and control ears (P < .01, P < .005, respectively). Significant increase in the pure tone threshold for 6000 Hz was observed in the control (P < .02) but not in the study group. Within the groups comparison also revealed significant decrease in the DPOAE average signal-to-noise ratio (SNR) for the f2 frequencies 7031 (P < .04) and 8391 Hz (P < .04) and SNR average for 4000 to 8000 Hz in the control (P < .04) but not in the study ears. CONCLUSIONS: ITD significantly attenuated hearing loss at 6000 Hz and decreased the outer hair dysfunction in the DPOAE f2 range of 4000 to 8000 Hz. ITD might have potential in the reduction of Cisplatin-induced hearing loss.