Allergy and health-related quality of life.

OBJECTIVE: We asked patients with allergies to complete the SF-36 Health Survey, a health-related quality-of-life (QOL) measure, to determine the impact of allergy on QOL. STUDY DESIGN AND SETTING: In total, 377 adults-140 men (37%) and 237 women (63%)-seen in a tertiary care private neurotologic practice allergy clinic completed the questionnaire before beginning immunotherapy and dietary management. One hundred patients completed both initial and 1-year follow-up questionnaires. The SF-36 measures 8 health concepts ranging from physical to mental health, and scale scores range from 0 to 100. RESULTS: Initial mean scores ranged from a high of 79.1 for the physical functioning scale to a low of 47.2 for the vitality scale, lower (poorer) on all scales than norms for the general US population. Significant improvement occurred from initial to follow-up on all scales. The largest improvements were in role functioning-physical, role functioning-emotional, and social functioning. CONCLUSION: Findings suggest that allergy symptoms can affect QOL and that treatment with specific immunotherapy and/or dietary management may lead to measurable improvements. SIGNIFICANCE: The significant impact of allergy must be recognized, and treatment should be offered. The SF-36 can be used to evaluate treatment outcome.

Prevalence of allergy in Meniere's disease.

OBJECTIVES: The goal of this study was to determine the prevalence of allergy in a population of patients with Meniere's disease. METHODS: A survey was mailed to all patients with Meniere's disease seen at our institution from 1994 to July 1998 (n = 1490). As a control group, 172 patients with otologic problems other than Meniere's disease completed the same survey. RESULTS: Of 734 respondents with Meniere's disease, 59.2% reported possible airborne allergy, 40.3% had or suspected food allergies, and 37% had had confirmatory skin or in vitro tests for allergy. These prevalence rates were significantly higher than those found in the control group, of which 42.7% reported having or suspecting airborne allergies and 25% had or suspected food allergies (differences all significant at P< or =0.005). CONCLUSION: The prevalence of allergy appears to be much higher in patients with Meniere's disease than in the general population or the population of patients visiting an otologic clinic for other symptoms.

Acoustic tumor growth: implications for treatment choices.

BACKGROUND: Knowledge of acoustic neuroma (AN) growth is essential for treatment planning. METHODS: A retrospective analysis of 119 patients with AN (mean age, 65 years; range, 37-84 years) followed with interval magnetic resonance imagings (MRIs) was performed. Change in maximum tumor dimension as a function of follow-up period was analyzed. RESULTS: Overall, maximum tumor dimension increased >2 mm in only 30% of patients. Of those that grew, the mean growth rate was 3.8 mm/year (maximum, 25 mm/year). Age, gender, and laterality did not predict growth. Most tumors that grew (86.1 %) were <20 mm at presentation. However, tumors >20 mm were statistically more likely to grow (71%, p =0.028). CONCLUSIONS: Most ANs followed with periodic MRIs do not grow. Available clinical information usually cannot predict growth. Serial MRIs are advocated for all patients treated with observation.

Intraoperative corticosteroids in acoustic tumor surgery.

BACKGROUND: Corticosteroids are frequently used for the prevention and treatment of neural edema. Although perioperative steroid therapy has been used in patients undergoing acoustic neuroma removal, the efficacy of such therapy has not been previously documented. METHODS: A retrospective review of 169 patients who underwent acoustic neuroma surgery with (n = 75) or without (n = 94) a single dose of intraoperative corticosteroids was performed. Tumor size ranged from 0.4 cm to 6 cm (mean, 2.1; SD, 1.0) The translabyrinthine approach was used in 85% of the patients, and the middle cranial fossa approach was used in 13%. Data were analyzed for differences in postoperative facial function and complication rates. RESULTS: After controlling for differences in tumor size, no significant effects of steroid therapy were found for any of the outcome variables. CONCLUSIONS: This retrospective study showed no apparent benefit from intraoperative steroid use in acoustic neuroma surgery. A prospective, randomized, placebo-controlled trial should be performed to confirm these findings.

Allergy for the otologist. External canal to inner ear.

Allergy may affect the outer, the middle, or the inner ear. Although the otologic manifestations of allergy are not by themselves diagnostic, the history, including family history and associated symptoms in other target organs, will often help lead to the correct diagnosis and institution of therapy. Patients with significant and chronic symptoms, including those with labyrinthine symptoms of allergy, will respond well to specific immunotherapy and/or dietary elimination.

Plasmapheresis in autoimmune inner ear disease: long-term follow-up.

OBJECTIVE: This study aimed to evaluate the outcome of long-term hearing benefits of plasmapheresis (PMP) in presumed autoimmune inner ear disease (AIED). STUDY DESIGN: The study was a case series, with retrospective chart review, written questionnaire, telephone interview, and follow-up examination. SETTING: It was performed in a private practice otology and neurotology referral center. PATIENTS: Sixteen patients (5 males, 11 females) whose symptoms were compatible with the diagnosis of AIED, who underwent PMP, and who had 2-year or later objective follow-up. Age ranged from 8-62 years, with a mean of 40.9 years. Follow-up ranged from 2-12 years, with a mean of 6.7 years. INTERVENTION: Plasmapheresis at one or more times during the active phase of disease. MAIN OUTCOME MEASURE: Stability of hearing, defined according to the American Academy of Otolaryngology-Head and Neck Surgery recommended criteria for reporting hearing results in Meniere's disease, was used as the main outcome measure. RESULTS: Eight (50%) of 16 patients had improved or stable hearing in 1 or both ears. Eleven (39.3%) of 28 ears with measurable hearing pre-PMP were improved or stable. Only 25% of patients required continued use of immunosuppressive drugs. CONCLUSION: Plasmapheresis may be beneficial as an adjunctive therapy for maintaining hearing in some patients with AIED. Cost and reimbursement factors are major obstacles in the use of this therapy. The overall success rate and individual patient results warrant further study of PMP in the treatment of AIED.

Allergic eustachian tube dysfunction: diagnosis and treatment.

OBJECTIVE: The objective of this study was to describe the characteristics and response to specific allergy therapy of patients with clinically significant eustachian tube dysfunction secondary to allergy. STUDY DESIGN: This was a retrospective case review conducted in the setting of a private otologic practice (tertiary referral). PATIENTS: The study population was composed of 151 patients presenting with eustachian tube dysfunction who had evidence of allergy and had undergone allergy testing and treatment. The 105 females and 50 males ranged in age from 2.8 to 84 years (mean 41.8 +/- 17.3). INTERVENTIONS: Interventions used included diagnostic allergy testing (inhalants and food) and treatment with immunotherapy and diet. MAIN OUTCOME MEASURES: The main outcome measures were descriptive characteristics and ratings of fullness, allergy symptoms, and well-being rated as "improved," "no change," or "worse." RESULTS: All patients had reactivity to inhalants, and 92.3% were positive to one or more foods. Nearly half of the patients (49.4%) had undergone at least one advanced test beyond an audiogram as part of their diagnostic evaluation before referral to a tertiary center for treatment. Forty percent had undergone radiological assessment. Nearly all had used one or more other treatments without success before allergy therapy. The majority were rated as improved on all three symptoms (fullness 70.9%; allergy symptoms 82.8%; and well-being 80.2%). Adherence to the recommended elimination diet was significantly related to outcome. CONCLUSIONS: Eustachian tube dysfunction may be due to underlying inhalant and/or food allergies. Even patients with refractory cases of patulous eustachian tube and eustachian tube obstruction who have not responded to traditional medical and surgical management may do well on specific allergy therapy.

Reporting operative hearing results in stapes surgery: does choice of outcome measure make a difference?

PURPOSE: Findings of a prior study indicated that neither choice of pre- versus postoperative bone-conduction scores nor choice of frequencies to include in averaging makes a substantial difference in reported outcomes of chronic ear surgery. METHODS: In this study, audiologic data from 240 stapes surgery patients at three different institutions were used to generate a variety of outcome measures. RESULTS: Use of preoperative rather than postoperative bone-conduction values in computing postoperative air-bone gap resulted in an approximately 5-dB smaller mean gap and a 2% higher success rate. Frequencies included in averaging made little difference in mean computed air-bone gap, although success rate (gap < or = 10 dB) was lower by 6% when 4 kHz was used in a four-frequency average rather than 3 kHz. Results for air conduction were similar to those for air-bone gap regarding choice of frequencies to include in averaging. When we used air-conduction pure-tone average (PTA) as the outcome measure, those with normal preoperative sensorineural hearing had a > 20% higher success rate than the general population of patients with stapes surgery. CONCLUSIONS: The greatest differences in success rate were based on definition of and criteria for success. Success rate was higher when based on air-bone gap than when based on air-conduction PTA. As in the prior chronic ear study, differences in outcome were more drastically affected by criteria for "success" than by frequencies included. Unlike similar data from chronic ear surgery, however, success rate differed depending on choice of air-bone gap or air-conduction PTA as the definition for success. Further, air and bone scores from the same test interval must be used accurately to reflect air-bone gap in stapes surgery.

Reporting operative hearing results in stapes surgery: does choice of outcome measure make a difference?

In a prior study, findings indicated that when reporting results of chronic ear surgery, neither choice of pre-versus postoperative bone-conduction scores nor choice of frequencies to include a averaging makes a substantial difference in reported outcome. In this study, audiologic data from 240 stapes-surgery patients at three different institutions were used to generate a variety of outcome measures. Use of preoperative rather than postoperative bone-conduction values in computing postoperative air-bone gap resulted in an approximately 5-dB smaller mean gap and a 2% higher success rate. Frequencies included in averaging made little difference in mean computed air-bone gap, although success rate (gap < 10 dB) was lower by 6% when 4 kHz was used in a four-frequency average rather than 3 kHz. Results for air conduction were similar to those for air-bone gap regarding choice of frequencies to include in averaging. When using air-conduction pure-tone average (PTA) as the outcome measure, those with normal preoperative sensorineural hearing had a > 20% higher success rate than the general population of stapes-surgery patients. The greatest differences in success rate were based on definition of and criteria for success. Success rate was higher when based on air-bone gap than when based on air-conduction PTA. As in the prior chronic ear study, differences in outcome were more drastically affected by criteria for "success" than by frequencies included. Unlike similar data from chronic ear surgery, however, success rate differed depending on choice of air-bone gap or air-conduction PTA as the definition for success. Further, air and bone scores from the same test interval must be used to accurately reflect air-bone gap in stapes surgery.

Foot and ear disease--the dermatophytid reaction in otology.

Chronic otitis external (COE) is occasionally refractory to treatment and may persist for years. In such cases, a dermatophytid (id) reaction from a fungal infection in a remote location should be suspected. Immunotherapy with dermatophyte (Trichophyton, Oidiomycetes, and Epidermophyton [T.O.E.]) extracts and dust mite, based on serial endpoint titration skin test results, as well as a yeast elimination diet, is the treatment of choice. Fourteen cases of id reaction are described. The primary fungal source was not always obvious, but immunotherapy and diet led to complete resolution of the COE in 8 cases (21.4%). Some case reports illustrate presentation, treatment, and outcome.

Reporting operative hearing results: does choice of outcome measure make a difference?

Choice of outcome measure in reporting hearing results following otologic surgery, including the frequencies used and use of pre- or postoperative bone thresholds, varies from author to author. In this study, data from 550 ossicular reconstruction and pediatric tympanoplasty surgery patients were used to generate a variety of outcome measures, including pure-tone thresholds for frequencies from 0.5 kHz to 8 kHz and different frequency combination pure-tone averages (PTAs) and air-bone gaps. There were no significant differences between mean pre- and postoperative bone conduction thresholds for any of the frequencies from 0.5 to 4 kHz nor for a PTA of 1, 2, and 4 kHz. Mean postoperative air-bone gap differed by no more than 2 dB across six different frequency combination PTAs. If "success" is defined as a postoperative air-bone gap of less than 20 dB, the largest difference in success rate across the six frequency combinations was 5%. There was also little difference in mean postoperative air conduction PTAs for any of the combinations that include frequencies through 4 kHz. Choice of a more conservative or more liberal definition of success was more important than whether air-bone gap or air conduction PTA was used. The authors recommend that a standard reporting procedure be adopted that ensures presentation of the results in a format such that more direct comparisons can be made within the published literature.

High-resolution computed tomography in evaluation of cochlear patency in implant candidates: a comparison with surgical findings.

High-resolution computed tomography (HRCT) is important in the evaluation of cochlear implant candidates. This study examines the accuracy of radiological assessment of cochlear patency in relation to findings at the time of surgery. Older and newer HRCT methods and attending and senior radiologist interpretations are compared in a large series of cochlear implant patients. Subjects were 50 adults (22 to 74 years) and 31 children (2.4 to 11.7 years) who received either a 3M/House or a Nucleus 22-channel cochlear implant. Attending radiologist reports were obtained by chart review and the scans were re-reviewed for this study by a senior radiologist. Accuracy in detecting cochlear ossification ranged from 86.4 per cent for attending radiologists, with all HRCT scans, to 94.7 per cent for the senior radiologist with newer HRCT scans. False positives were rare, but false negatives did occur. Overall, best results were obtained with newer HRCT scans and a senior radiologist. Knowledge of the presence and extent of cochlear ossification is important to the implant surgeon and for patient counselling. Technical guidelines and a check list for interpretation of results are presented.

Facial nerve function following middle fossa and translabyrinthine acoustic tumor surgery: a comparison.

Postoperative facial function was compared for middle cranial fossa and translabyrinthine removal of acoustic tumors. Included were 164 primary acoustic tumor surgeries performed between 1988 and 1991 in patients with normal preoperative facial function; postoperative House-Brackmann facial function grade available immediately postoperatively, at time of discharge and at 1 year or more postoperatively; and a tumor 1.5 cm or smaller. There were 116 translabyrinthine surgeries and 48 middle fossa surgeries. There was no significant difference in facial function results between the two surgical approaches at any of the three postoperative time intervals. Immediate postoperative facial function grade I or II was present in 90 percent of patients who underwent the middle cranial fossa approach, and in 90 percent of those with translabyrinthine surgery. By long-term follow-up, grade I or II function was recorded after 96 percent of middle fossa, and 91 percent of translabyrinthine surgeries. Results were similar when evaluating subgroups of those with tumors measuring 1.0 or smaller and 1.1-1.5 cm. There was also no difference in facial function result between superior and inferior vestibular nerve tumors with either approach. The authors conclude that, in an experienced center, long-term postoperative facial function outcome is not a basis for selecting surgical approach for tumors measuring 1.5 cm or less.

Clinical behavior of acoustic tumors. A flow cytometric analysis.

OBJECTIVE: Recently, nonsurgical treatment of acoustic tumors has been advocated as an alternative to surgical resection. Because of the relatively short follow-up in reported series of radiation-treated acoustic tumors, the lack of growth of some tumors may merely reflect the variable biologic growth potential of these tumors and not the result of treatment. DNA flow cytometry has been used to predict biologic activity in other solid tumors. It is applied in this study to assess the variability of growth potential in a typical acoustic tumor population and to determine whether relationships exist between flow cytometric data and clinical characteristics of acoustic tumors. DESIGN: DNA flow cytometry techniques were used to evaluate formalin-fixed, paraffin-embedded tissue previously obtained from patients who were surgically treated for acoustic neuromas. Relationships between flow cytometry data and historical data were also statistically evaluated. SETTING: Tissue samples were from patients of a large private otologic practice. PATIENTS: Subjects were a convenience sample of 49 patients (26 female and 23 male) with a mean age of 59 years who had undergone surgical removal of an acoustic neuroma. None of the patients had other stigmata of neurofibromatosis or tumor recurrence. All tissue specimens were pathologically confirmed acoustic neurons, with a range in tumor size from 1 to 6 cm. MAIN OUTCOME MEASURES: The measures included DNA ploidy and S-phase fraction. Historical data included age, sex, size of tumor, presenting symptom, and symptom duration. RESULTS: All 49 tumors showed a diploid distribution, with S-phase values ranging from 1.07% to 20.74% (mean +/- SD, 6.30 +/- 4.24). The ploidy and S-phase data compare favorably with previously published data in which fresh tissue was used. There were no statistically significant relationships between S-phase value and historical data. CONCLUSIONS: The wide range of S-phase values is consistent with a large variation in tumor growth potential and suggests caution in interpreting the results of radiation treatment of acoustic tumors when follow-up relatively short.

Acoustic tumors: effect of surgical removal on tinnitus.

Tinnitus is common in patients with acoustic tumors and may be the initial symptom leading to diagnosis. We might anticipate that tumor removal would alleviate preoperative tinnitus. However, few have studied this systematically. Further, the effect of tumor removal in those with no preoperative tinnitus has rarely been examined. In this study, a questionnaire was sent retrospectively to patients who had undergone surgical removal of an acoustic tumor, addressing the characteristics of tinnitus, and asking whether surgery had directly affected tinnitus. A total of 134 questionnaires were returned. Those who indicated preoperative tinnitus tended to show small but statistically significant improvements in the perceived severity of the tinnitus after surgery, although the symptom rarely resolved entirely. Those with no preoperative tinnitus have an approximately 50 percent chance of developing it following surgery.

Investigator differences in the cochlear implantation of children.

Eight investigational sites are involved in clinical trials of the 3M/House cochlear implant for children. Statistical analyses have been performed to examine differences between investigators in patient populations selected for implantation and in the results achieved. Important characteristics of the subjects from different investigational sites were compared for House, Maddox, and all "others" combined. There were no differences between investigators in sex, age at surgery, or duration of deafness of the children enrolled in the study. For age at onset, House and Others had higher proportions of postlingually deaf subjects than Maddox (16% for House and 18% for Others, compared with less than 2% for Maddox). However, all investigators had some subjects in every category: postlingual, prelingual, and congenital. Auditory discrimination and speech production scores for subjects from the three groups were compared using analysis of variance techniques. A few interaction effects between time interval and investigator indicated that not all investigator groups performed similarly over time for all measures. However, postimplant scores were always significantly higher than preimplant scores for all investigators. Differences that did occur appeared to be attributable to differences in subject characteristics.

3M/house cochlear implant in children.

Data on 265 children with the 3M/House single-channel cochlear implant have been collected and analyzed for presentation to FDA. Significant improvements from preimplant to postimplant in auditory detection, auditory discrimination/identification, and speech production have been demonstrated. Some children also demonstrate the ability to recognize words and sentences without the aid of speechreading.