Differences in the suppression of distortion product otoacoustic emissions by contralateral white noise between patients with acute or chronic tinnitus.

OBJECTIVE: The mechanisms underlying the shift from acute tinnitus to chronic remain obscure. An association between tinnitus and medial olivocochlear bundle (MOCB) reflex dysfunction has been hypothesised by several studies. The differences between participants with acute and chronic tinnitus have not yet been investigated. DESIGN: Participants were examined with distortion product otoacoustic emissions (DPOAEs) suppression elicited by contralateral white noise. They were compared in terms of frequency regions with non-recordable DPOAEs, suppression amplitudes and the presence of DPOAE enhancement. STUDY SAMPLE: Eighteen participants with acute tinnitus, 40 age-matched adults with chronic tinnitus and 17 controls were included. All participants (aged 34.7 ± 9.6years; mean ± Standard deviation) had normal hearing. Tinnitus was bilateral in 22 participants and unilateral in 36. RESULTS: Ears with chronic tinnitus presented significantly lower DPOAE suppression amplitudes than ears with acute tinnitus (p < 0.0001). Both acute and chronic tinnitus ears present a high prevalence of enhancement, significantly different from controls (p < 0.0001, p = 0.0002, respectively). Non-recordable DPOAEs were significantly more frequent in the chronic than in the acute tinnitus and control groups (p < 0.0001). CONCLUSIONS: The differences between study groups indicate that when tinnitus becomes chronic, DPOAEs suppression presents changes that might reveal corresponding steps in tinnitus pathophysiology. Treatment implications are discussed.

The profile of otoacoustic emissions and multifrequency tympanometry in otosclerotic patients undergoing two types of stapes surgery: small fenestra and microtraumatic stapedotomy.

BACKGROUND: Otoacoustic emissions (OAEs) are influenced in otosclerosis. The aim of the current study was to investigate the profile of transient evoked (TEOAEs) and distortion product otoacoustic emissions (DPOAEs) in association with multifrequency tympanometry measures in otosclerotic patients undergoing 2 types of stapes surgery: small fenestra and microtraumatic stapedotomy. MATERIAL AND METHODS: A retrospective analysis of prospectively collected data was conducted evaluating 51 otosclerotic patients and 50 normal hearing subjects. Small fenestra and microtraumatic stapedotomy were performed in 27 and 24 patients, respectively. Pure tone audiometry (PTA) was always measured. Detection of TEOAEs and DPOAEs at 5 frequency steps (1, 1.4, 2, 2.8, and 4 kHz) preoperatively and at 2 and 5 months postoperatively, stratified by the type of surgery, represented the main goal of the study. Resonant frequency derived by multifrequency tympanometry was also evaluated. RESULTS: All patients demonstrated improvement in hearing level postoperatively, with significant closure of air-bone gap on PTA. Resonant frequency values returned to normal after microtraumatic stapedotomy but were exceedingly decreased following the small fenestra technique. The detection of both TEOAEs and DPOAEs was improved, but when the detection was stratified by the tested frequencies, significant increase in the number of patients with detectable OAEs was observed, mainly during testing at 1 and 1.4 kHz. CONCLUSIONS: Otosclerotic patients exhibited improvement in the detection of OAEs, particularly at low frequencies, after both procedures. Resonant frequency was normalized following the microtraumatic stapedotomy, whereas it is over-decreased after the small fenestra technique.

A longitudinal study of changes in distortion-product otoacoustic emissions and pure-tone thresholds in an industrial setting.

In a longitudinal study of 76 noise-exposed industrial workers, 34 (68 ears) of them were available for final evaluation after 9 years of observation. Distortion-product otoacoustic emissions (DP) at 65/55 dB SPL and pure-tone audiometry were used to detect noise-induced inner ear changes. Repeated measures analyses of variance were made on the subjects and in a control group, whereas significant threshold shifts (STS) and significant emission shifts (SES) were calculated. Both hearing thresholds and DP showed a high-frequency deterioration, but there was absence of statistical correlation between elevation of hearing thresholds and decrease of DP. There was no clear pattern between individual changes in audiometric thresholds and DP, and all combinations were present: ears with only STS, ears with only SES, ears with both STS and SES and ears with absence of STS and SES. Audiometric changes were maximal at 4 and 6 kHz and DP changes at 2 and 3 kHz. Since significant individual emission changes do not necessarily follow the same pattern as the group-averaged results, the use of DP for monitoring of individual subjects is not advised. However, its use in conjunction with audiometry in hearing conservation programs is highly recommended.

Nonsurgical management of silent sinus syndrome with hyaluronic acid gel.

A 44-year-old woman was referred with 3 mm of left enophthalmos and a deep superior sulcus. She was diagnosed 6 months earlier with silent sinus syndrome and had undergone a left middle-meatal antrostomy with improvement of her hypoglobus but not of her enophthalmos and superior sulcus deformity. Two milliliters of Restylane SubQ (Q-Med AB, Uppsala, Sweden) was injected as a single bolus in the intraconal and extraconal posterior orbit via a standard transcutaneous inferotemporal approach using a primed green 21-gauge needle. Immediate reduction of enophthalmos by approximately 2 mm and superior sulcus improvement were noted. This remained stable at 6 months. The symptoms and signs of silent sinus syndrome can be effectively corrected with this minimally invasive nonsurgical option. To our knowledge, the use of hyaluronic acid gel for the treatment of enophthalmos in silent sinus syndrome has not been previously reported.

Surgical versus percutaneous tracheostomy: an evidence-based approach.

The choice between surgical (ST) and percutaneous tracheostomy (PT) is not often based on evidence. The aim is to evaluate the quality of evidence in published articles comparing the two methods. A MEDLINE search was done. From 298 articles found, 37 fulfilled the inclusion criteria and 35 were further analyzed. No study was based on type I evidence, 13 (37%) represented type II, in 1 (3%) a clear-cut definition between type II or III was not possible and 21 (60%) represented type III or IV evidence. Taking into account the complication rate of the 13 type II evidence studies, 7 are in favor of PT and 3 in favor of ST. The majority of studies comparing PT with ST are of type III or IV level of evidence. Even if only type II studies are analyzed, outcomes are controversial. Any claims by clinicians in favor of a particular treatment are still debatable.

Are GJB2 mutations an aggravating factor in the phenotypic expression of mitochondrial non-syndromic deafness?

Hearing impairment is a frequent condition, and genes have an important role in its etiology. The majority of hearing loss occurs in non-syndromic form, with deafness being the only clinically recognizable feature. More than 60 nuclear genes or loci have been shown to be involved in non-syndromic hearing loss, but mutations in mitochondrial DNA also cause hearing impairment. Mitochondrial DNA mutations usually lead to progressive hearing loss with an age of onset varying from childhood to early adulthood. It is interesting to note that there is a great variability among phenotypes between individuals harboring the same mitochondrial mutation, even within the same family, and the phenotype may range from profound deafness to completely normal hearing. In the past years, the debate on mitochondrial mutations has been about the penetrance, the tissue specificity and the mechanisms of modifier genes that can modulate the severity of the phenotypic expression of the deafness-associated mitochondrial DNA mutations. Here we summarize evidence regarding modifying genes, and we discuss the effect of the coexistence of mitochondrial and GJB2 mutations in families reported to date.

Effect of perioperative immuno-enhanced enteral nutrition on inflammatory response, nutritional status, and outcomes in head and neck cancer patients undergoing major surgery.

Administration of immuno-enhanced nutritional support may decrease postoperative morbidity, mortality, and infectious complications in cancer patients. The aim of this study was to verify that perioperative enteral diet, enriched with the nutrients arginine, ribonucleic acid (RNA), and ω-3 fatty acids improves outcomes of head and neck cancer patients undergoing major surgery. Forty patients with squamous cell carcinoma of the head and neck were studied. Group 1 received no preoperative nutritional support, whereas Group 2 received an oral formula with nutrients arginine, RNA, and ω-3 fatty acids. After surgery, Group 1 received a standard enteral formula, whereas Group 2 received an enriched enteral formula. Albumin (g/dl), prealbumin, fibrinogen, CRP, Il-6, and TNFa were measured 5 days before and 8 days after surgery. No statistically significant difference was observed for all the evaluated markers between postoperative and preoperative levels for both groups. The rate of complications was significantly reduced in the total number of patients receiving immunonutrition and in the particular subgroup of well-nourished patients receiving an immuno-enhanced diet. Perioperative enteral immuno-enhanced feeding in head and neck cancer patients undergoing major surgery may influence the postoperative outcomes by reducing the frequency rate of infections and wound complications.

The A1555G mitochondrial DNA mutation in Greek patients with non-syndromic, sensorineural hearing loss.

Mitochondrial DNA mutations are undoubtedly a factor that contributes to sensorineural, non-syndromic deafness. One specific mutation, the A1555G, is associated with both aminoglycoside-induced and non-syndromic hearing impairment. The mutation is considered to be the most common of all mitochondrial DNA deafness-causing mutations but its frequency varies between different populations. Here we report on the first large screening of the A1555G mitochondrial DNA mutation in the Greek population. The aim of this study was to determine the frequency of the A1555G mutation in Greek sensorineural, non-syndromic deafness patients, with childhood onset. We screened 478 unrelated Greek patients with hearing loss of any degree and found two individuals harboring the A1555G mutation (0.42%). Both cases had been subjected to aminoglycosides. They were prelingual, familial and homoplasmic for the A1555G mutation. One of the cases was also found heterozygous for the frequent GJB2 35delG mutation, while the other case was negative. The A1555G mutation seems to be less common than in other European populations.

Resection of giant ethmoid osteoma with orbital and skull base extension followed by duraplasty.

BACKGROUND: Osteomas of ethmoid sinus are rare, especially when they involve anterior skull base and orbit, and lead to ophthalmologic and neurological symptoms. CASE PRESENTATION: The present case describes a giant ethmoid osteoma. Patient symptoms and signs were exophthalmos and proptosis of the left eye, with progressive visual acuity impairment and visual fields defects. CT/MRI scanning demonstrated a huge osseous lesion of the left ethmoid sinus (6.5 cm x 5 cm x 2.2 cm), extending laterally in to the orbit and cranially up to the anterior skull base. Bilateral extensive polyposis was also found. Endoscopic and external techniques were combined to remove the lesion. Bilateral endoscopic polypectomy, anterior and posterior ethmoidectomy and middle meatus antrostomy were performed. Finally, the remaining part of the tumor was reached and dissected from the surrounding tissue via a minimally invasive Lynch incision around the left middle canthus. During surgery, CSF rhinorrhea was observed and leakage was grafted with fascia lata and coated with bio-glu. Postoperatively, symptoms disappeared. Eighteen months after surgery, the patient is still free of symptoms. CONCLUSION: Before management of ethmoid osteomas with intraorbital and skull base extension, a thorough neurological, ophthalmological and imaging evaluation is required, in order to define the bounders of the tumor, carefully survey the severity of symptoms and signs, and precisely plan the optimal treatment. The endoscopic procedure can constitute an important part of surgery undertaken for giant ethmoidal osteomas. In addition, surgeons always have to take into account a possible CSF leak and they have to be prepared to resolve it.

Juvenile nasopharyngeal angiofibroma stages I and II: a comparative study of surgical approaches.

OBJECTIVE: The aim of this study was to compare different surgical options used for removal of stages I and II juvenile nasopharyngeal angiofibromas (JNAs). Treatment morbidity was evaluated through blood loss, surgery duration, postoperative hospitalization and outcome. Moreover, an effort was made to explore the role and limits of endoscopic surgery. MATERIALS AND METHODS: 20 male patients (mean age 14.9 years) were treated for JNA using three different surgical approaches in the Department of Otolaryngology of the University of Athens between May 1998 and January 2007. 9 patients were managed using endoscopic approach, while 5 were treated through midfacial degloving. A transpalatal approach was performed in remaining 6 patients. Preoperative angiography with embolization was performed in all 9 patients who underwent endoscopic removal and in 3 patients treated by midfacial degloving technique. RESULTS: Findings demonstrated that endoscopic approach, assisted by preoperative embolization, lead to less intraoperative blood loss, shorter duration of surgical procedure, shorter length of hospital stay and no complications, compared with the conventional techniques. CONCLUSIONS: Our data suggest that with proper patient selection, endoscopic resection of stages I and II JNA, when it is performed after embolization of the feeding vessels, is remarkably bloodless and precise and may be preferable to traditional open approaches.

Acoustic stapedial reflex in normal adults: biological behavior and determination of threshold levels.

OBJECTIVE: To record acoustic reflex thresholds for admittance (Y) and its components, susceptance (B) and conductance (G) in healthy subjects and to establish normative data. STUDY DESIGN: Acoustic reflex threshold was determined in 100 healthy persons, divided into 5 age groups of 20 persons each (20-29, 30-39, 40-49, 50-59 and 60-69 years old). Detection was performed for Y, B, and G at 226-, 678- and 1,000-Hz probe tones, using 500-, 1,000-, 2,000- and 4,000-Hz stimuli. RESULTS: Statistically significant differences in acoustic reflex thresholds were revealed between different components, stimuli and tones. The lowest threshold level was recorded for Y at 226 Hz using stimulus 1,000 Hz. Four percent missing values were observed at 226 Hz. Subjects belonging to different age groups had different reflex thresholds. CONCLUSION: Inclusion of acoustic reflex detection for B and G offers more detailed information about the middle ear status compared with Y alone, and appears to be sensitive in detecting subtle diseases.

Association between squamous cell carcinoma of the head and neck and serum folate and homocysteine.

UNLABELLED: The aim of this study was to evaluate the serum levels of folate and homocysteine in patients with squamous cell carcinoma of the head and neck (SCCHN) and to correlate them with the clinical stage. An attempt was made to associate the results with the effects of smoking. MATERIALS AND METHODS: Serum levels of folate and homocysteine were measured in 150 patients with histologically-proven SCCHN before any treatment and in 150 healthy volunteers (77 smokers and 73 nonsmokers). RESULTS: The study indicated a positive correlation between hyperhomocysteinemia and hypofolatemia and the presence of SCCHN. Folate deficiency and high levels of homocysteine were noted in a large number of healthy smokers. CONCLUSION: If metabolic disorders of the methionine cycle are confirmed as risk factors for SCCHN, folate as a dietary supplement might play a role in chemoprevention and the posttreatment care of SCCHN patients.

Clinical effectiveness of tumor markers in squamous cell carcinoma of the larynx.

BACKGROUND: The aim of this study was to examine and compare the value of the serum tumor markers CYFRA 21-1, TPA-M, SCCA and CEA in squamous cell carcinoma (SCC) of the larynx. Moreover, their possible clinical applications were studied. MATERIALS AND METHODS: The serum levels of CYFRA 21-1, TPA-M, SCCA and CEA were measured in 79 patients with histologically-proven squamous cell carcinoma (SCC) of the larynx before and after treatment and in 77 healthy volunteers. The association of the results with the clinicopathological characteristics was investigated. RESULTS: The study showed that none of the markers revealed a significant sensitivity; TPA-M indicated a positive correlation with the grade of differentiation. CEA indicated a positive correlation only with distant metastasis. CONCLUSION: Among the four markers, only TPA-M may play a role in monitoring the success of therapy and follow-up in patients with SCC of the larynx.

Inverted papilloma of the sphenoid sinus: presentation of three cases.

INTRODUCTION: Inverted papilloma deriving originally from the sphenoid sinus is extremely rare. Three such cases are presented aiming to show the particularities and diagnostic clues of this clinical entity. CASE REPORTS: All three patients were male, and presented mainly with nasal symptoms. In all three cases imaging shows the sphenoid sinus was completely occupied by the tumor. Additionally the ethmoids and nasal cavities have been invaded in contiguity to the site of the initial appearance of the tumor. In particular one of the cases was of even more interest as a malignant transformation of the inverted papilloma of the sphenoid sinus was histologically observed. Endoscopic sinus surgery was the therapeutic approach chosen for all three cases, with very good results. Follow up 30 months after the operation has not revealed any signs of recurrence of the disease. CONCLUSION: Inverted papilloma of the sphenoid sinuses--and even more malignant transformation--although quite rare, may present occasionally. The ENT surgeon should be aware of this condition. Preoperative imaging with CT scan and MRI and the experience of the surgeon will dictate the appropriate surgical approach.

Corneal topography with upper eyelid platinum chain implantation using the pretarsal fixation technique.

PURPOSE: To determine the effect of upper eyelid platinum chain implantation, with the pretarsal fixation technique, on corneal astigmatism. METHODS: This is a prospective, cohort study. Fifteen eyes of 15 patients underwent upper eyelid platinum chain implantation, with the pretarsal fixation technique, for facial nerve palsy. Information recorded included patient demographics, etiology for facial palsy, weight of the implant, time from onset of paresis to upper eyelid platinum chain implantation, associated surgical procedures, and preoperative and postoperative corneal topography measurements. RESULTS: Of the 15 patients studied, 10 were male and five were female. The mean age was 55.9 ± 13.8 years (range, 33-87 years). The most common etiology for facial palsy was acoustic neuroma. The weight of the implant ranged from 0.6 to 1.6gr (median 1.2gr). The time from onset of paresis to upper eyelid platinum chain implantation varied from 1 week to 3 months (median 1 month). Four patients had an associated procedure to correct the effect of paralytic ectropion. There was no statistically significant difference in with the rule astigmatism before and after platinum chain implantation. CONCLUSIONS: Upper eyelid platinum chain implantation, with the pretarsal fixation technique, does not appear to cause significant change in corneal astigmatism. This is contrary to data for pretarsal gold weight implantation, which does induce significant with the rule astigmatism.

Occurrence of semicircular canal involvement in benign paroxysmal positional vertigo.

OBJECTIVES: To study the occurrence of each variant of benign paroxysmal positional vertigo (BPVV) and to present some specific clinical features and the results of their treatment by appropriate repositioning maneuvers. STUDY DESIGN: A retrospective review of the records of patients with BPPV. SETTING: Neurotology clinic of the ear, nose, and throat department of a general hospital. PATIENTS: One hundred twenty-two patients were included in the study, 54 male and 68 female, mean ages 61.8 and 59.6 years, respectively, ranging in age from 25 years to 86 years and with symptoms lasting for an average of 124 days. The diagnosis of each type of BPPV was based on the history of the patients and on the positive results of the appropriate provoking maneuver. METHODS: From all the patients, a comprehensive history was obtained, followed by clinical examination of the ears, nose, and throat and a complete audiologic and neurotologic examination, including electronystagmography. All patients were treated with an appropriate repositioning maneuver, depending on the type of BPPV. RESULTS: Of 122 patients, 110 had posterior canal involvement, 10 had horizontal canal involvement, and only 2 had the anterior canal variant. The canalith repositioning procedure was immediately successful in 106 patients and in 8 more patients proved successful after its repetition in a second session, resulting in a total success rate of 93.4%. CONCLUSIONS: All the BPPV variants shared the same clinical and demographic characteristics and responded equally well to treatment. However, differential diagnosis was necessary to apply the appropriate canalith repositioning procedure. Although data from clinical and histologic studies do not fully account for the observed relative occurrence of each variant of BPPV, a satisfactory explanation may be provided by the anatomic location of each semicircular canal and additionally by self-treatment of most cases of the horizontal and the anterior canal variety.

Partial laryngectomy after irradiation failure.

INTRODUCTION: Radiation therapy is often the first method of treating patients with early cancer of the glottis. There is a substantial failure rate among these patients. Total laryngectomy has usually been the means of treating patients with failure after radiation. In recent decades, partial laryngectomy has been used for salvage in such patients. This article will discuss the use of partial laryngectomy for radiation failure both from the oncologic result as well as the morbidity. PATIENTS AND METHODS: Between 1984 and 1995, 27 patients with early-stage laryngeal carcinoma underwent salvage partial laryngectomy after irradiation failure. Vertical laryngectomy was performed in 18 patients (13 with T1 N0 and 5 with T2 N0) and horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1 with T2 N0, and 5 with T2 N1). The mean follow-up was 4.1 years. RESULTS: Local control was obtained in 77.7% of patients with glottic lesions (T1: 84.6%; T2: 60%, P = NS) and in 55.5% of patients with supraglottic lesions (T1: 66.6%; T2: 50%; P = NS). There was no regional recurrence in the vertical laryngectomy group, whereas the regional control rate in the horizontal-supraglottic laryngectomy group was 77.7%. Distant control was achieved in 94.4% of patients with glottic disease and in 77.7% of patients with supraglottic disease. The overall survival rate for glottic lesions was 88.8% (T1: 92.3%; T2: 80%; P = NS) versus 66.6% for supraglottic lesions (T1: 100%; T2: 50%; P = NS). CONCLUSION AND SIGNIFICANCE: Vertical laryngectomy was not associated with an increased complication rate. Morbidity in the horizontal-supraglottic laryngectomy group was higher, but a satisfactory functional outcome was obtained in all cases. Therefore, in early laryngeal cancer (glottic T1-T2, supraglottic T1) partial laryngectomy can be performed with good expectation of cure and satisfactory laryngeal function. In T2 supraglottic lesions, the oncologic results are less satisfactory; further research is required for developing more efficient complimentary or alternative treatments modalities.

Audiological assessment in Ramsay Hunt syndrome.

Ramsay Hunt syndrome is known to cause symptoms and signs of vestibulocochlear dysfunction, including sensorineural hearing loss. The present study investigates the audiological features of a group of 15 patients with this syndrome. A complete otolaryngological, neurologic, and audiological workup was performed in every patient, including auditory brain stem response measurements and recording of transiently evoked otoacoustic emissions. In most patients, some degree of hearing loss was evident, and abnormal latencies and interpeak latencies of the auditory brain stem response, or even absence of the waves, were observed. Transiently evoked otoacoustic emissions were present in only 6 cases, and caloric tests showed unilateral weakness in the majority of the patients. In all of the performed tests, abnormalities were present only on the affected side. The audiological data suggested cochlear or retrocochlear involvement or involvement at more than one site along the auditory pathway.

Internet resources available to otolaryngologists.

During recent years, the Internet has evolved into the largest computer network in the world, allowing access to vast amounts of information and services. Medical information is increasingly available to both patients and professionals, and ever more biomedical resources are becoming available on-line to assist in research, clinical medicine, and education. The Internet has always provided useful resources to otolaryngologists, implemented at various academic departments and national organizations or by specialists or specific medical web sites offering technical, scientific, and biomedical information. The purpose of this article is to provide as complete a list as possible of the World Wide Web sites accessible through the Internet that are of interest to otolaryngologists. It summarizes different types of resources available, including educational material, audiology sites, outcomes research, discussion lists, research laboratories, publications, medical libraries, news and medical conferences, organizations, academic departments, otolaryngological and medical resources, medical and surgical equipment and suppliers, and miscellaneous other sites of interest to otolaryngologists. This review is intended to present the wealth of the accessible information on the Internet and to promote the use of the network to otolaryngologists who do not have extensive experience in computers or telecommunications.