Contribution of Vestibular-Evoked Myogenic Potential (VEMP) testing in the assessment and the differential diagnosis of otosclerosis.

BACKGROUND: The aim of this prospective clinical study was to evaluate the clinical importance of Vestibular-Evoked Myogenic Potentials (VEMPs) in the assessment and differential diagnosis of otosclerosis and otologic diseases characterized by "pseudo-conductive" components. We also investigated the clinical appearance of balance disorders in patients with otosclerosis by correlating VEMP results with the findings of caloric testing and pure tone audiometry(PTA). MATERIAL AND METHODS: Air-conducted(AC) 4-PTA, bone-conducted(BC) 4-PTA, air-bone Gap(ABG), AC, BC tone burst evoked VEMP, and calorics were measured preoperatively in 126 otosclerotic ears. RESULTS: The response rate of the AC-VEMPs and BC-VEMPs was 29.36% and 44.03%, respectively. Statistical differences were found between the means of ABG, AC 4-PTA, and BC 4-PTA in the otosclerotic ears in relation to AC-VEMP elicitability. About one-third of patients presented with disequilibrium. A statistically significant interaction was found between calorics and dizziness in relation to PTA thresholds. No relationship was found between calorics and dizziness with VEMPs responses. CONCLUSIONS: AC and BC VEMPs can be elicited in ears with otosclerosis. AC-VEMP is more vulnerable to conductive hearing loss. Evaluation of AC-VEMP thresholds can be added in the diagnostic work-up of otosclerosis in case of doubt, enhancing differential diagnosis in patients with air-bone gaps. Otosclerosis is not a cause of canal paresis or vertigo.

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.

Cochlear dysfunction in patients with acute hypothyroidism.

The effect of acute hypothyroidism on the cochlear function was studied prospectively, in a group of 52 patients with thyroid carcinoma who underwent total thyroidectomy. All patients were examined before surgery and 6-8 weeks postoperatively. During this period there was no replacement with levothyroxine and the magnitude of thyroxin depletion was monitored by serum thyroid-stimulating hormone levels. Pure-tone audiometry, tympanometry and transiently evoked otoacoustic emissions were performed. A group of healthy volunteers of similar age and sex were used as controls. Tympanograms were normal, either on initial or on repeat testing. Audiometry showed elevation of all postoperative hearing thresholds, whereas the thresholds varied significantly across frequency. Transiently evoked otoacoustic emission testing showed response signal-to-noise ratios lower in the postoperative session (hypothyroid state) than in the preoperative session on all measured frequencies. Emission levels varied significantly across frequency, with maximum response observed at 2 kHz. Comparison of significant pure-tone and otoacoustic emission shifts for individual ears showed more ears affected in otoacoustic emission testing, indicating subclinical involvement. Comparing hearing thresholds and otoacoustic emission levels between patients and controls showed significant differences on postoperative testing. It may be thus concluded that acute hypothyroidism causes elevation of hearing thresholds in humans and to a greater degree subclinical damage of the cochlear function.

Universal newborn hearing screening, a revolutionary diagnosis of deafness: real benefits and limitations.

The finding that early detection of permanent congenital childhood hearing loss produces worthwhile benefit in terms of improved speech and language provides the rationale for the universal screening of newborns. The aim of the present study is to collect the current evidence with regard to the efficacy, the results and outcomes of universal hearing screening programs. An extensive search of the literature was performed in Medline and other available database sources. Study selection was based on the evaluation of the protocols used and the assessment of their efficacy in the early diagnosis of congenital hearing impairment. The initial referral rate and the rate of false positives were also evaluated. A total of 676,043 screened children have been identified in 20 studies. The average initial referral rate in these studies was 3.89%. The initial referral rate varied from 0.6 to 16.7%. The lost-to-follow-up rates varied from 3.7 to 65%. Although universal hearing screening is now widely adopted, there are still some serious drawbacks and limitations. False positives rates remain considerably high when newborns are screened with TEOAE's. The combination of TEOAE's and a-ABR provides a significantly reduced referral rate. Close cooperation between audiological centres and maternity units and a dedicated secretariat team are of paramount importance with regard to the reliability and efficacy of universal hearing screening.

Rhinology resources on the internet: an update.

AIM: There has been a significant increase in the number of clinically useful biomedical resources available through the Internet over the last few years. The aim of this article is to present an updated list of all the worldwide web sites of rhinology. METHODS: All rhinologic links, which appear on the web site of the journal "Rhinology" were accessed and updated. Non-responding links were discarded and a new extensive survey of all rhinologic sites on the Internet was performed using on-line available search engines. All sites were accessed more than once at different times and their uniform resource locator (URL) address was recorded. RESULTS: The URL addresses of all rhinologic sites on the Internet appear in categories. Main categories include endoscopy and operative techniques, allergy, olfaction, rhinology clinics and research centers, organizations and societies, scientific journals, discussion groups, news and medical conferences, collective otolaryngology resources, and miscellaneous other sites of interest to rhinologists. CONCLUSIONS: This paper summarizes several types of resources available to rhinologists on the Internet. A complete universal list was composed, in which links to almost all interesting rhinologic links were included.

Etiology of vertigo in children.

OBJECTIVE: To detect the most common causes of vertigo in children. METHODS: Fifty-four children (20 boys and 34 girls) aged 3-16 years, who presented with vertigo attacks during a 3-year period, were studied. A detailed medical history for vestibular symptoms and migraine was obtained from our patients or their parents. All patients underwent otolaryngologic, ophthalmologic and neurologic clinical evaluation. A detailed laboratory examination, including serologic tests for viral infections, was also obtained. Additionally, a complete audiological and neurotologic evaluation was performed. Computed tomography (CT) scans and magnetic resonance imaging (MRI) were obtained in selected cases. RESULTS: Viral infections, benign paroxysmal vertigo of childhood and migraine were the most common causes of vertigo accounting for approximately 65% of our patients. Otitis media, head trauma, benign paroxysmal positional vertigo, Meniere's disease and brain tumor were less common causes of vertigo. CONCLUSIONS: A peripheral type of vertigo was found in most cases. Diagnostic approach in vertigo in children should include a detailed history and clinical examination in conjunction with a test battery of audiological and neurotologic tests. When a central cause of vertigo is suspected an MRI or CT scan should be ordered.

Functional tension nose as a cause of nasal airway obstruction.

OBJECTIVE: The purpose of this prospective study was to evaluate the influence of functional tension nose in nasal obstruction and to discuss its frequency and management. METHODS: Over the years 2000-2006, 153 patients underwent revision operation for nasal obstruction in our rhinoplastic center. Twenty-two of them (14.37%) suffered from functional tension nose. All 22 patients refused rhinoplasty during primary septoplasty. Sixteen of them had a kyphotic nose and the rest six cases suffered from hanging columella (drooped nose). Eighteen of them underwent primary rhinoplasty in combination with caudal diminution under general anesthesia. The other four patients refused rhinoplasty, and under local anesthesia their tip was deprojected and reprojected. RESULTS: Marked improvement in nasal airflow was noted at the most recent follow-up evaluation in 20 patients out of 22 (90.91%). The mean length of follow-up was 8 months (ranging from 4 to 12 months). All follow-up results were based on office examination and pre- and post-operative computer-assisted rhinomanometry evaluation. In only two cases results were not efficient enough. CONCLUSION: Our study strongly suggests that tension nose is a usual misdiagnosed cause of nasal obstruction. This problem is concealed under a "kyphotic", "big", or "pinocchio" nose. Usually the functional defect is spontaneously corrected during conventional rhinoplasty. However, tip should be deprojected and reprojected in cases where the patient refuses cosmetic intervention and surgeon tries to resolve his functional problem.

Making universal newborn hearing screening a success.

OBJECTIVE: Following a long period of pilot study, Iaso maternity hospital established a universal newborn hearing screening program based on transiently evoked otoacoustic emissions (TEOAEs). The aim of this study is to present the improvement of outcome measures of this program, comparing the results of two groups of newborns screened successively. METHODS: We analyzed data from two groups of full-term newborns screened at our setting. The first group included all newborns born and screened during the initial 3 years of application of the program and the second group included all newborns born and screened during the next 2 years. TEOAEs were performed during the first days after birth. All newborns who failed the initial test underwent repeat testing with TEOAEs before hospital discharge. Newborns with absence of otoacoustic emissions were referred to follow-up test after 1 month. Results were compared between the two groups. RESULTS: The first group included 22,195 newborns-examined during 3 years and the second group included 25,032 newborns-examined during 2 years, due to reduction of the rate of newborns who missed screening. Refer rate was 3.1% for the first group and 2.1% for the second group. "Missed to follow-up" rate was reduced from 72.2% in the first group to 58.2% in the second group. CONCLUSIONS: The rate of newborns who did not undergo screening and the rate of "missed to follow-up" newborns were reduced in time, due to various modifications of the protocol. Universal newborn hearing screening may be, thus, a feasible and cost effective method of identifying congenital hearing loss.

The effect of the number of averaged responses on the measurement of transiently evoked otoacoustic emissions in newborns.

OBJECTIVE: The aim of this study was to examine the effect of the number of averaged responses on the measurement of transiently evoked otoacoustic emissions (TEOAEs). METHODS: The study was performed on the background of a universal newborn hearing screening program implemented in Iaso Maternity Hospital. Two groups of full-term newborns with normal otoacoustic emissions were studied. The first group included 58 newborns (115) ears, in which 260 low-noise samples, provided by the default setting of the equipment used (ILO88), were presented. The second group included 58 newborns (113) ears, in which 20-50 averaged responses were presented, until the "pass" criteria would be met. Statistical comparison between the following parameters recorded during TEOAE measurement was performed: Overall response, signal-to-noise ratios, reproducibility (whole and partial), stimulus intensity, stimulus stability, input noise, noise rejection level and duration of testing. RESULTS: Statistically significant differences were found in most of these parameters, except for overall response, stimulus intensity and noise rejection level. CONCLUSIONS: Although a smaller number of clicks is usually sufficient to obtain a "pass" in newborn hearing screening programs, the quality of recording of TEOAEs is significantly improved by increasing the number of averaged low-noise responses.

Correlation of transiently evoked to distortion-product otoacoustic emission measures in healthy children.

OBJECTIVE: Transiently evoked (TEOAEs) and distortion-product otoacoustic emissions at the 2f1-f2 frequency (DPOAEs) are being used as a clinical tool for diagnosis of peripheral auditory pathology. Because both tests are fast and non-invasive, they may be an excellent method for hearing screening in infants and children. The purpose of this study was to compare the TEOAE and DPOAE measures obtained in a group of healthy children. METHODS: Sixty-six school-aged children with normal hearing were included in the study. Subjects with recent otologic disease or abnormal tympanograms were excluded. TEOAEs and DPOAEs were performed using a DP Echoport ILO 292 Otodynamics analyzer connected to a portable personal computer. Correlation between TEOAE amplitudes and DPOAE levels was estimated. RESULTS: Correlation between TEOAE amplitudes and DPOAE levels was highly significant across all measured frequencies. Correlation was more significant at the middle frequencies than at the low and high frequencies. CONCLUSIONS: Although frequency specific information may be obtained by both tests, most reliable results were obtained at the middle frequencies. TEOAE values were more prominent at low frequencies, whereas DPOAEs were more effective at high frequencies. Both methods are reliable, objective, fast and useful tests of the cochlear status and should be included in the standard audiological diagnostic work-up of children.

Success rate of newborn and follow-up screening of hearing using otoacoustic emissions.

OBJECTIVE: During the last 6 years, and after a long period of pilot study, a universal newborn hearing screening program based on otoacoustic emissions is implemented in Iaso Maternity Hospital. Our purpose is to present the success rate of otoacoustic emission testing on discharge from the hospital and 1 month later. METHODS: All full-term newborns who were screened during a period of 2 years and failed testing after one or more sessions of transiently evoked otoacoustic emissions, on discharge from the hospital, were included in the study. These newborns were retested approximately 1 month after discharge. RESULTS: Twenty-five thousand and thirty-two newborns were examined in total. We found 534 (2.1%) 'refer' cases. Only 223 of them (41.8%) returned to retest in follow-up after 1 month. From the rescreening, 59 (2.3 per thousand) newborns failed in the test again and were referred for diagnostic audiological evaluation. CONCLUSIONS: The rate of referrals was small, but efforts should be made to decrease it further. The final number of 'failures' found, approaches the expected rate of definitely diagnosed deafness reported from other settings. The main problem we have still to confront is the high missed to-follow-up rate.

Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo is the most common peripheral vestibular disorder. It can be defined as transient vertigo induced by a rapid head position change, associated with a characteristic paroxysmal positional nystagmus. Canalolithiasis of the posterior semicircular canal is considered the most convincing theory of its pathogenesis and the development of appropriate therapeutic maneuvers resulted in its effective treatment. However, involvement of the horizontal or the anterior canal has been found in a significant rate and the recognition and treatment of these variants completed the clinical picture of the disease. This paper describes the advances in understanding how this disease is generated and discusses the current therapeutic modalities.

Electronystagmographic findings in benign paroxysmal positional vertigo.

The aim of this study was to investigate the electronystagmographic findings in patients with benign paroxysmal positional vertigo. A retrospective review of the records of 168 patients with this disease during the past 3 years was performed. Epidemiological data and results from the audiological and neuro-otologic workup, including electronystagmography, were recorded. One hundred fifty-one patients had involvement of the posterior canal, 14 of the horizontal canal, and 3 of the anterior canal. Seventy-two patients (42.8%) had abnormal findings on the caloric tests. Thirty-seven of them (22%) had canal paresis and 23 (13.7%) had directional preponderance, whereas in 12 patients (7.1%) both unilateral weakness and directional preponderance were found. Finally, 21 patients (12.5%) had spontaneous nystagmus. It may be thus concluded that electronystagmographic abnormalities are quite common in patients with benign paroxysmal positional vertigo. Their presence may be explained according to several mechanisms, which are further discussed herein.

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.

Rhinology resources on the internet: a critical review.

During recent years, the Internet has gradually evolved into a worldwide network, allowing access to vast amounts of information and providing various services. The benefits of medical professionals of using it are growing rapidly, as even more scientific, technical and biomedical resources become available on line. The Internet has always provided useful resources to rhinologists, with the number of relevant sites increasing daily, at a rapid pace. In this article, a review of the information included in several selected rhinology web sites is presented, in order to provide guidance and context for the vast amount of information which is available on the Internet, and to promote the use of the medium to rhinologists who do not have extensive experience in computers or telecommunications.

Rhinology resources on the Internet.

During recent years medical information through Internet is increasingly available to both patients and professionals and ever more biomedical resources become available on line to assist in clinical medicine, education and research. The purpose of this article is to present a detailed list of all the worldwide web sites of rhinology that are accessible through the Internet.

Subjective benign paroxysmal positional vertigo.

OBJECTIVE: To study the demographic, clinical, pathogenetic, and nystagmographic features and treatment outcomes of subjective benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Prospective clinical trial. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Sixty-three patients were studied (mean [SD] age 55.4 [9.4] years), 27 men and 36 women, who presented with a positive history for BPPV and Dix-Hallpike or supine roll tests positive for vertigo but negative for nystagmus. A comprehensive history was obtained, followed by clinical examination of the ears, nose, and throat and a complete audiologic and neurotologic examination, including videonystagmography. All patients were treated with the appropriate canalith repositioning procedure, depending on the type of provoking positioning test. A group of 204 patients with typical BPPV were used for comparison. RESULTS: Forty-five patients with subjective BPPV were successfully treated. Eighteen patients, in most of whom vertigo of other causes was identified, did not respond to treatment. Comparison between patients with subjective and typical BPPV showed similar epidemiological and clinical features. Treatment failed in 13.5% of patients with subjective disease, after excluding patients with different causes of positional vertigo, as compared with 7.8% of patients with typical BPPV (odds ratio = 1.8; 95% confidence interval, 0.7-4.7; P = .32). CONCLUSION: Subjective BPPV is quite common, accounting for more than one-fourth of patients with typical BPPV and sharing common features with it, with the exception of nystagmus. No statistical difference in treatment outcomes between patients with subjective and typical BPPV was found, but study of a larger sample is needed.

Aesthetic reconstruction of a crooked nose via extracorporeal septoplasty.

BACKGROUND: The aim of this study was to evaluate the effectiveness, indications, and contraindications of the extracorporeal approach in treating a severely deviated nose. METHODS: Sixty-four patients operated on for aesthetic correction of a severely deviated nose were studied. Forty-six of them were first operations and 18 were revision cases. The surgical procedure of choice was the closed technique. Septal cartilage was prepared and then dislocated, followed by external alignment and reimplantation. Hump reduction with lateral osteotomies and, occasionally, medial dislocation of nasal bones was carried out. RESULTS: Cosmetic results were satisfactory in all first operation cases. In 11 of the 18 revision cases, septal preparation was impossible; in 2, septal sagging was observed; and in 1, perforation was noted. CONCLUSIONS: Extracorporeal septoplasty is an effective, safe, and reliable technique, especially for twisted noses undergoing surgery for the first time. However, it is strongly contraindicated in a revised deviated nose.