Transcutaneous auricular vagus nerve stimulation induces stabilizing modifications in large-scale functional brain networks: towards understanding the effects of taVNS in subjects with epilepsy.

Transcutaneous auricular vagus nerve stimulation (taVNS) is a novel non-invasive brain stimulation technique considered as a potential supplementary treatment option for subjects with refractory epilepsy. Its exact mechanism of action is not yet fully understood. We developed an examination schedule to probe for immediate taVNS-induced modifications of large-scale epileptic brain networks and accompanying changes of cognition and behaviour. In this prospective trial, we applied short-term (1 h) taVNS to 14 subjects with epilepsy during a continuous 3-h EEG recording which was embedded in two standardized neuropsychological assessments. From these EEG, we derived evolving epileptic brain networks and tracked important topological, robustness, and stability properties of networks over time. In the majority of investigated subjects, taVNS induced measurable and persisting modifications in network properties that point to a more resilient epileptic brain network without negatively impacting cognition, behaviour, or mood. The stimulation was well tolerated and the usability of the device was rated good. Short-term taVNS has a topology-modifying, robustness- and stability-enhancing immediate effect on large-scale epileptic brain networks. It has no detrimental effects on cognition and behaviour. Translation into clinical practice requires further studies to detail knowledge about the exact mechanisms by which taVNS prevents or inhibits seizures.

Relapsing polychondritis: an unusual cause of sore throat, painful ear swelling and bilateral costal margin pain.

A 54-year-old Chinese woman presented with a 3-month history of sore throat and dry cough, which was treated as chronic pharyngitis with minimal improvement. One month ago, she presented with painful right ear swelling without signs or symptoms of otitis media or otitis externa. She was treated with antibiotics and antiviral drugs without any improvement. Two weeks prior to her presentation to hospital, she developed bilateral costal margin pain with raised C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), mild chronic pharyngitis and painful right ear swelling. All other investigations including bloods and imaging were non-specific. Her painful right auricle swelling prompted the diagnosis of relapsing polychondritis (RP), which was supported by clinical improvement with high-dose corticosteroids. RP is a clinical diagnosis with non-specific inflammation of affected cartilage. It is a diagnosis of exclusion and early diagnosis can be made by the most common presenting feature of auricular chondritis.

Multiple cranial nerve injury in Ramsay Hunt Syndrome: a case report.

Herpes zoster oticus (Ramsay Hunt Syndrome) is characterized by facial nerve paralysis, ear pain and auricular skin rash. It occurs as a result of reactivation oflatent varicella zoster virus infection in the geniculate ganglion of the facial nerve. Major clinical symptoms include 7th nerve paralysis or cranial nerve paralysis and vesicles along the nerve with cocomitant ear pain. Other cranial nerve involvement although uncommon, can be found in some cases. In this study, a 74-year-old female patient had ipsilateral 8th, 9th and 10th cranial nerves injury. Cranial nerve paralysis accompanied with injury has been repor ted in R amsay Hunt Syndrome.

Contribution of spectral pinna cues for sound localization in children with congenital unilateral conductive hearing loss after hearing rehabilitation.

Congenital unilateral conductive hearing loss (UCHL) jeopardizes directional hearing and speech perception in noisy conditions. Potentially, children with congenital UCHL can benefit from fitting a hearing device, such as a bone-conduction device (BCD). However, the literature reports limited benefit from fitting a BCD, and often, surprisingly, relatively good sound localization in the unaided condition is reported. In this study, we hypothesized that the limited benefit with a BCD is related to (i) insufficient access to binaural cues and (ii) relying on monaural spectral pinna cues for sound localization in the horizontal plane. Directional hearing was tested in seventeen children with congenital UCHL (age 6-19) using a percutaneous BCD. Additionally, a mold was placed in the pinna of the normal-hearing ear to diminish direction-dependent spectral pinna cues. Relatively good localization in azimuth was found in the unaided hearing condition in the majority of the children. Sound localization improved when listening with a BCD, and no correlation between age of implantation and aided localization performance was found. When the mold was inserted, the unaided and aided localization abilities of most children deteriorated. Interestingly, in the children with poor localization performance in the unaided condition, sound localization improved significantly with the BCD, and was hardly affected by molding the pinna of the normal-hearing ear. These observations indicate that the majority of these children rely on spectral pinna cues to localize sounds, independent of listening with or without their device. In conclusion, an important reason for the limited benefit of BCD fitting in children with congenital UCHL might be ascribed to an effective coping strategy (use of spectral pinna cues) that still plays a dominant role after BCD fitting.

Relationship of the lobular branch of the great auricular nerve to the tympanoparotid fascia: Spatial anatomy for salvage during face and neck lift.

To enable selection of a safer suspension site to use in face and neck lifting procedures, the spatial relationship between the tympanoparotid fascia and the great auricular nerve should be clarified. In this study, we aimed to elucidate the position of the tympanoparotid fascia and the pathway of the lobular branch of the great auricular nerve traversing the tympanoparotid fascia. Twenty hemifaces from non-preserved bequeathed Korean cadavers (5 males, 7 females; mean age, 77.0 years) were dissected to determine the great auricular nerve distribution close to the tympanoparotid fascia of clinical significance for face and neck lift procedures. We observed the tympanoparotid fascia in all specimens (20 hemifaces). The tympanoparotid fascia was located anteriorly between the tragus and intertragic notch. Regarding the spatial relationship between the tympanoparotid fascia and the great auricular nerve, we found the sensory nerve entering the tympanoparotid fascia in all specimens (100%), and the depth from the skin was approximately 4.5 mm; in 65% of the specimens, the lobular branch was found to run close to the tympanoparotid fascia before going into the earlobe. Provided with relatively safer surface mapping to access the tympanoparotid fascia free of the lobular branch of the great auricular nerve, surgeons may better protect the lobular branch by anchoring the SMAS-platysma flap and thread to the deeper superior and anterior portions of the expected tympanoparotid fascia.

[IgG4-associated diseases mainly with auricular symptoms: a case report and literature review].

Summary To analyze the clinical features of IgG4-related diseases mainly with otologic manifestations and investigate diagnosis and treatment of IgG4-related diseases. We report the clinical course and diagnosis and treatment process of a case of IgG4-related disease misdiagnosed as chronic suppurative otitis media. After looking through relevant literatures, we review 22 cases of IgG4-related diseases mainly with otologic manifestations, and summarize their epidemiological characteristics, clinical manifestations, histopathologic features, radiologic features, and diagnostic and therapeutic criteria. IgG4-related diseases mainly with otologic manifestations are usually clinically characterized by atypical symptoms such as otalgia, tinnitus, aural fullness, otorrhea and progressive or fluctuating hearing loss, together with nausea, vomiting, and dizziness. The three central histopathologic features are dense lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. The exact diagnosis of IgG4-related diseases requires a combination of clinical manifestations, serology, histopathology and radiologic results. Glucocorticoids are currently the first-line approach for IgG4-related diseases. Otologic manifestations involved in IgG4-related diseases are poorly specific, which is likely to result in more misdiagnosis and treatment delay. Current golden standard for diagnosing IgG4-related diseases is the identification of characteristic histopathology. In addition, immunohistochemistry can help clinicians diagnose IgG4-related diseases as early as possible. Otologists should strengthen their understanding of otologic manifestations of IgG4-related diseases. Early diagnosis and treatments are the key factors in prognosis.

Speech polar plots for different directionality settings of SONNET cochlear implant processor.

Objectives: The newest CI processor from MED-EL company, the SONNET, has two new directional microphone settings. Besides the Omnidirectional microphone mode, it has the possibility to switch to Natural or Adaptive directionality. Both new modes favour perception of sound coming from a front-facing direction compared to sounds from sources at alternate azimuths. Natural directionality mimics the pinna effect of the normal external ear. Design: We undertook to verify the effect of these options in vivo by means of clinical audiological tests. Speech reception thresholds were successively measured for a variety of speech presentation azimuths while keeping the noise azimuths constant. Complete 'Speech Reception Threshold (SRT)-Polar-Plots' were obtained from these data for the Omnidirectional and Natural directionality modes of the SONNET. In addition, one 'SRT-point' was also measured in the 'Adaptive' mode for speech coming from 45° azimuth. Study sample: A group of 13 adult CI recipients participated. Only one of these subjects had previous experience with the SONNET processor. Results: Complete 'SRT-Polar-Plots' could be measured in Natural and Omnidirectional modes in CI recipients within an acceptable timeframe. The pinna-following directionality for Natural mode could be confirmed. Median SRT in noise for speech coming from the 45° azimuth speaker was -5.6 dB SNR for Omnidirectional, -9.1 dB SNR for Natural and -12.8 dB SNR for Adaptive microphone. Natural and Adaptive significantly improved performance compared to Omnidirectional mode at this optimal azimuth of 45° with a median improvement in SRT of 3.5 and 7.2 dB respectively. Conclusions: A novel audiological method, 'SRT-Polar-Plot', was developed and described. Significant directionality benefits for Natural and Adaptive mode were confirmed in vivo using this technique.

Periotic sensory dysfunction via postauricular approach after otitis media surgery.

OBJECTIVES/HYPOTHESIS: To assess the somatosensory dysfunction of the auricle and periotic skin in patients undergoing otitis media surgery. STUDY DESIGN: Retrospective study. METHODS: Symptoms of periotic somatosensory function after surgery were investigated in 100 patients (42 males, 58 females, mean age 41.39 years) who underwent otitis media surgery. Questionnaires on periotic somatosensory disturbance were answered after surgery at least over 1 year postoperatively. RESULTS: Of 100 tympanoplasties, all patients were completed within a postauricular approach. The highest incidence rates of periotic sensory disturbance were found in the postauricular region (75%), followed by the auricular region (20.83%); lower rates were found in the preauricular region (2.08%) and the earlobe (2.08%). Periotic somatosensory dysfunction occurred in 48 patients (48%). The most prevalent somatosensory abnormality was tactile hypoaesthesia/numbness, evident in 28% of the patients; more remarkable, inferior postauricular region. Periotic pain was reported by 21% of the cases, mostly located in the upper auricle. Compared to the recovery time of tactile hypoaesthesia (7.36 months), patients' periotic somatosensory pain improved significantly within 4.07 months, which has obvious statistical significance (P < 0.01). CONCLUSION: The likelihood of periotic cutaneous sensory dysfunction should be emphasized to patients undergoing otitis media surgery via postauricular approaches, which occurred in nearly half of patients; the majority recovered within 1 year. Furthermore, the postauricular region is the most vulnerable location to sensory disturbance, followed by the auricular region. Functionally, periotic somatosensory pain was more easily resilient, relative to tactile hypoaesthesia/numbness. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:454-458, 2019.

Tissue engineering the human auricle by auricular chondrocyte-mesenchymal stem cell co-implantation.

Children suffering from microtia have few options for auricular reconstruction. Tissue engineering approaches attempt to replicate the complex anatomy and structure of the ear with autologous cartilage but have been limited by access to clinically accessible cell sources. Here we present a full-scale, patient-based human ear generated by implantation of human auricular chondrocytes and human mesenchymal stem cells in a 1:1 ratio. Additional disc construct surrogates were generated with 1:0, 1:1, and 0:1 combinations of auricular chondrocytes and mesenchymal stem cells. After 3 months in vivo, monocellular auricular chondrocyte discs and 1:1 disc and ear constructs displayed bundled collagen fibers in a perichondrial layer, rich proteoglycan deposition, and elastin fiber network formation similar to native human auricular cartilage, with the protein composition and mechanical stiffness of native tissue. Full ear constructs with a 1:1 cell combination maintained gross ear structure and developed a cartilaginous appearance following implantation. These studies demonstrate the successful engineering of a patient-specific human auricle using exclusively human cell sources without extensive in vitro tissue culture prior to implantation, a critical step towards the clinical application of tissue engineering for auricular reconstruction.

¿Cuál sería su diagnóstico? / What would your diagnosis be?

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Pseudoquiste auricular / Pseudocyst of the auricle

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Novel Presentation of Fibroepithelioma of Pinkus on the Ear of a Patient Treated on a Panamanian Humanitarian Mission.

Fibroepithelioma of Pinkus (FEP) is traditionally classified as an unusual variant of basal cell carcinoma. It has non-specific clinical findings yet distinct histologic features. The diagnosis can be challenging for clinicians because it often mimics benign entities such as intradermal nevi. FEP typically occurs on the trunk, but many body sites can be involved including the head, neck, and genitalia. According to a PubMed search of articles indexed in MEDLINE using "Fibroepithelioma of Pinkus" and "ear" or "auricle," there are no reports of FEP specifically occurring on the ear. We describe the first case of FEP on the ear of a heavily sun-damaged male treated while on a military humanitarian mission to Panama. This case helps support the classification of FEP as a basal cell carcinoma variant and raises awareness for this entity as it may be encountered both on military humanitarian missions and in military clinics.

A Rare Case of Endochondral Pseudocyst of the Auricle.

Endochondral pseudocyst of the auricle is a very rare, benign, non-inflammatory cystic lesion. It most commonly develops in the scaphoid or triangular fossa of the ear. In this case report, we present a 46-year-old man with a painless lesion on the scaphoid fossa of the right ear. We removed the hypertrophic perichondrium forming the anterior wall of the pseudocyst, curetted the ear cartilage, and dressed it with compression. No complications, such as infection, seroma, or hematoma, occurred during the postoperative period. A good cosmetic result was ultimately obtained. The patient experienced no recurrence within a 14-month follow-up period. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Audiologic changes after pinna augmentation.

No studies to date have objectively assessed whether pinna morphology affects sound intensity detected within the external auditory canal (EAC). Commonly performed procedures on the EAC are carried out for acquired and congenital pathology, together with correction of ear deformities. Our aim was to use an experimental model to identify whether a relationship exists between pinna shape and its subsequent effect on the hearing subject. An anatomically accurate and life-size model made of rubber composite was used for this study. Serial sections (small wedge, defect open; small wedge, defect closed; large wedge, defect open; large wedge, defect closed [equivalent to a protruding ear]; and pinnectomy) were undertaken, and the sound intensity changes assessed at the junction between the EAC and middle ear (tympanic membrane position) using an AURICAL Plus (Otometrics; Taastrup, Denmark) sound processor. A statistically significant loss was demonstrated for wedge-excised models, which was greatest at 180° azimuth. This loss was significantly reduced when the wedge defects were closed. A statistically significant improvement was demonstrated in the protruding ("bat") ear model compared with the normal ear at 0° azimuth. In this model, gain in sound intensity is adversely affected by pinna wedge resection. Because this change may be increased in those with protruding ears, this factor is important to consider for all cosmetic and noncosmetic operations to the pinna, and it supports the notion that the pinna is not a simple funnel.

[Effect of electroacupuncture stimulation of auricular concha region at different time-points on behavior changes in depression rats].

UNLABELLED: OBJECTIVE To observe the effect of electroacupuncture (EA) stimulation of auricular concha region (ACR) on behavior changes of depression rats. METHODS: A total of 80 male Wistar rats were randomized into depression model (model, n = 6), EA-ACR (n = 12), preventive EA-ACR (Pre-EA-ACR, n = 11) and EA-ear-tip (n = 12) groups. Depression model was established by chronic unpredictable mild stress for 21 days and isolated breeding. Open-field test and sucrose solution intake preference test were conducted to assess changes of the rats' behavior activities before modeling and on day 22, 36 and 50 after starting model. For rats of the pre-EA-ACR group, EA (2 Hz, 1 mA) was applied to the bilateral auricular concha area for 20 min, once daily for 14 days, beginning from the 8th day on after starting model preparation till the end of the modeling, and for rats of the EA-ACR and EA-ear-tip groups, EA was given to the bilateral ACR and ear-tips respectively, beginning after modeling, once daily for 14 days. RESULTS: In comparison with pre-modeling, the percentages of sucrose solution consumption in rats of the model group decreased gradually from day 22 to 50 (P > 0.05). Compared with the model group,the percentage of sucrose solution consumption in the EA-ACR group was increased significantly on day 50 (P < 0.05), suggesting an inhibitory effect of EA on the reduction of sucrose intake preference at this time-point. No significant differences were found between the pre-EA-ACR and the model groups and between the EA-ear-tip and model groups as well as between the EA-ACR and model groups at most time-points (P > 0.05). Open-field test showed that in comparison with pre-modeling in the same one group, the total scores, crossing and rearing scores on day 22 were decreased considerably in the model and EA-ear-tip groups (P < 0.05, P < 0.01), rather than in the pre-EA-ACR and EA-ARC groups (P > 0.05), suggesting a suppressing effect of pre-EA-ACR and EA-ACR on depression behavior. Compared to day 22 in the same one group, the total scores, crossing and rearing scores on day 36 and 50 in the pre-EA-ACR and EA-ear-tip groups were decreased significantly (P < 0.05, P < 0.01). CONCLUSION: EA of auricular concha region can restrain the development of depression behavioral status in depression rats, which is superior to that of EA of ear-tip.