Cartilage ossiculoplasty in cholesteatoma surgery: hearing results and prognostic factors.

Cartilage tympanoplasty is an established procedure for tympanic membrane and attic reconstruction. Cartilage has been used as an ossiculoplasty material for many years. The aim of this study was to evaluate hearing results of costal cartilage prostheses in ossicular chain reconstruction procedures in subjects operated on for middle ear cholesteatoma and to determine the presence of prognostic factors. Candidates for this study were patients affected by middle ear cholesteatoma whose ossicular chain was reconstructed with a chondroprosthesis. 67 cases of ossiculoplasty with total (TORP) or partial (PORP) chondroprosthesis were performed between January 2011 and December 2013. Follow-up examination included micro-otoscopy and pure tone audiometry. The guidelines of the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology Head and Neck Surgery were followed and pure-tone average (PTA) was calculated as the mean of 0.5, 1, 2 and 4 kHz thresholds. Statistical analysis was performed with ANOVA tests and regression models. Average air-bone gap (ABG) significantly improved from 39.2 dB HL (SD 9.1 dB HL) to 25.4 dB HL (SD 11 dB HL) (p < 0.001). Linear regression analysis showed that the only prognostic factor was the type of operation (p = 0.02). In fact, patients submitted to ICWT presented better post-operative ABG compared to CWDT. None of the other variables influenced the results. The present study proposes costal cartilage as material of choice when autologous ossicles are not available. The maintenance of the posterior canal wall was the only prognostic factor identified.

Pharmacological aspects and neurological speech therapy: target of dysphony, dysarthria and dysphagia.

The word dysphagy was suggested by Nicolatopoulos (1907) and derives from the ancient Greek "duz", which means "difficulty" and "katapinein", which means "to swallow". Generally, the dysphagia is defined on the basis of its origin: oral, pharynx and oesophagus, otherwise by its mechanical or neurological aetiology. The symptoms are dependent on the nature of the lesions in the affected organs. The swallow is a complex motor sequence dependent on the coordinate contraction of the muscle of mouth, of larynx and of the oesophagus. The mechanical action of the swallow helps the liquid or solid food progression from mouth to stomach thanks to cooperation of 31 muscles and 5 cranial nerves and allows swallowing about 580 times approximately. The dysphagy in neurological diseases is mainly due to the following reasons. Increase of vascular cerebral disease, increase of population age and increase of road and work traumas. The difficulties in swallowing causes heavy social problems like meager diet, social isolation and worsening of quality of life. The speech rehabilitation requires the involvement of care givers through a re-educational program that takes place in two periods: the first of relaxation, and the second of restoration of phonodeglutition praxis.

Facial nerve paralysis in temporal bone fractures: outcomes after late decompression surgery.

The aim of this paper was to address some of the unanswered questions regarding management of facial nerve paralysis in temporal bone fractures (TBF), such as the outcomes after late facial nerve decompression surgery. The study design was a retrospective review of a consecutive clinical series. Thirteen patients who underwent late decompression surgery for facial nerve paralysis due to TBF involving the perigeniculate ganglion region were analyzed. Patients were operated on 27-90 days after trauma. A transmastoid extralabyrinthine approach was used in all cases. Facial nerve-sheath slitting was performed routinely. Normal or subnormal facial nerve function (HB 1 or HB 2) was achieved in 7/9 cases (78%) evaluated at > or = 1 year after surgery. Good functional results were also obtained in two patients operated on 3 months after trauma. Bases on the outcomes observed in the present series, in patients unable to be operated on early, presenting 1 to 3 months with >95% denervation on EnoG, facial nerve decompression may have a beneficial effect.

Intratympanic therapy for Ménière's disease: effect of administration of low concentration of gentamicin.

We present results at 2 years follow-up of a group of 15 patients with Ménière's disease treated with a low concentration of intratympanic gentamicin (IG group), compared with a group of 15 patients who refused any surgical treatment (NH group). IG was administered according to a predetermined and fixed schedule consisting of 2 doses of 0.5 ml gentamicin solution, pH 7.8, injected once a week, with a drug concentration of 20 mg/ml; the total dose of gentamicin was < or = 20 mg. Additional doses of IG were administered only in patients who had recurrence of vertigo. The results were evaluated following the American Academy of Otolaryngology Head and Neck Surgery 1995 criteria for reporting Ménière's disease treatment results by means of interviews, audiologic and vestibular evaluations, and a questionnaire based on a six-point functional level scale. Seven of the 15 IG patients had recurrence of vertigo after the second injection and received a third dose of IG. Four patients had recurrence of vertigo after the third infiltration; three subjects received a fourth dose and one refused additional injection. At 2 years follow-up, 93% of the IG patients had complete (class A) or substantial (class B) control of vertigo. Only 47% of the NH patients had no vertigo or were substantially improved. Hearing deteriorated in 7% of the IG group and in 40% of the NH group. Tinnitus disappeared or improved in 20% of the IG patients and in 27% of the NH patients; 40% of the IG patients and 27% of the NH patients reported that their aural pressure was abolished. The present study demonstrates that, in patients with Ménière's disease, 0.5 ml doses of gentamicin solution, with a concentration of 20 mg/ml, injected intratympanically once a week minimize the risk of hearing loss in the treated ear, permitting complete control of vertigo in more than half of cases after 2 doses and in almost all subjects (93%) after 4 doses.

Auditory dysfunction in occupational noise exposed workers.

Occupational noise-induced hearing loss (NIHL) is well known to be an epidemiologically relevant problem. The subjects affected with NIHL show alteration of hearing thresholds as well as a worsening of the cochlear analysis functions and, usually, an impaired speech discrimination in presence of background noise. The study has evaluated the relationships between hearing threshold and equivalent exposure lever per day (Lepd), age and working seniority in a homogeneous sample of occupationally noise exposed workers. Three subgroups were also selected to study the most important cochlear functions as well as nerve and central functions. The first subgroup (Nn) contained normal hearing workers exposed to non-hazardous noise, while the second (Bn) contained workers exposed to high level continuous noise during their work day without clinical evidence of NIHL. The third subgroup (Bd) included subjects affected with the typical 4 kHz notch exposed to the same noise conditions than subgroup Bn. The results show that the hearing impaired subjects have the worst overall cochlear performance; however also the normal hearing workers exposed to hazardous noise have worse performance than subgroup Nn, relatively to high frequency thresholds, frequency resolution, TEOAEs, DPOAEs, stapedial acoustic reflex dynamic parameters. The results suggest that these measures could be used in the monitoring of the NIHL as indicators of subtle alterations of the hearing function.

[Critical ratio: effects of contralateral masking on normal and pathological ears]. / Rapporto critico: effetti del mascheramento controlaterale in orecchi normali e patologici.

In order to evaluate the central interferences on the auditory efficiency, the effect of contralateral masking noise on Critical Ratio (CR) has been studied in 14 normal ears (control group), in 12 ears with cochlear disorders and in 6 with retrocochlear lesion (acoustic neuromas); in all cases the impairment was unilateral, while the other ear was normal. CR values were calculated for 1 KHz pulsed tones (duration 500 ms, rise/fall 25 ms, duty cycle of 50%); the masking noise was a wide band (90-20,000 Hz) delivered at 40 dB SL. The results have demonstrated that in the presence of contralateral masking noise, CRs don't modify both in the normal ears and in those with retrocochlear disorder, whereas they increase, almost always, in ears with cochlear deafness. These results demonstrate that the involvement of central auditory pathways, because of contralateral noise, makes the auditory efficiency worse, only in ears with cochlear dysfunctions; this behaviour seems to confirm the peripheral origin of CR.

[Psychoacoustic tests: effects of atropine]. / Test psicoacustici: effetti dell'atropina.

The efferent pathways exert a control action on the function of the cochlear nucleus and hair cells. Acetylcholine is the neurotransmitter of the centrifugal system and its action can be blocked by atropine. In order to give a contribution to the knowledge of the function of the efferent bundle and of the cochlea efficiency we examined 10 young normal subjects before and after infusion of 1 mg of atropine i.v. a battery of three psychoacoustical tests (Remote Masking, Critical Ratio and Brief Tone Audiometry). After infusion of atropine we have shown an increase of 0.25 Hz hearing threshold, an increase of RC values and a decrease of RM values. It can be concluded that the pharmacological block of the olivo-cochlear bundle determines a stiffness of outer hair cells and basilar membrane; this finding means that the atropine can inhibit the facilitating activity of the efferent system on the cochlear performance.

[Facial nerve paralysis and mandibular fracture]. / Paralisi del nervo facciale e frattura della mandibola.

The authors describe three cases of peripheral facial nerve paralysis in patients with a mandibular fracture. In two cases, in which the onset of palsy was uncertain, the facial nerve injury was contralateral to the fractured side. Topodiagnostic tests showed neural damage at the third intrapetrosal portion and at the genicular ganglion. In one of the two patients tomography revealed a fracture line through the anterio-superior wall of the external auditory canal homolateral to the facial palsy. In the third subject palsy set in immediately after the trauma and was ipsilateral to the mandibular fracture; the facial lesion was localized at the genicular ganglion. In the first two cases, functional recovery was spontaneous (40 and 0 days after the trauma respectively). In the third subject, the nerve was decompressed surgically with a complete functional recovery two months later. The functional and clinical findings of these three cases show that a contralateral facial palsy secondary to a mandibular fracture resolves spontaneously while the traumatic displacement of the mandibular condyle may determine a temporal bone fracture sometimes followed by a lesion in the intratemporal portion of the facial nerve. An event such as the latter may delay functional recovery and thus warrant surgery such as in cases of Bell's palsy.

[Evoked oto-acoustic emissions in retrocochlear deafness]. / Otoemissioni acustiche evocate nelle sordità retrococleari.

In order to give a contribution to the genesis of the EOAEs, we have recorded the echoes in 6 subjects affected with unilateral acoustic neuroma, surgically proven (I. group); 11 subjects with sensorineural hearing loss with electrophysiological or balance signs of retrocochlear impairment (II. group) and 10 normally hearing young subjects as control group. In this study EOAEs have been recorded in response respectively to 3 ms 1000 Hz tone-burst and to 200-5000 filtered click, both sending with 2048 stimuli, at a repetition rate of 21 pps and different stimulus intensities ranging from 40 db SPL to saturation threshold in 10 db steps. The results have shown that the EOAEs were present in half of the tested patients in response to the clicks in both I. and II. group and in all the ears to the tone-burst although the 1.0 KHz audiometric threshold mean were > 65 db HL in I. group and in a third of the subjects in the II. group. The properties of EOAEs (detection and saturation threshold, dynamic range and duration) depended on the degree of hearing loss. These results suggest that acoustic tumor could determine a wallerian degeneration of the external fibers of the VIII nerve and consequently a dysfunction of the correspondent external hair cells of the cochlea, while in the II. group a contemporary or secondary involvement of the cochlear structures is possible.

[Brain-stem auditory pathways: effects of atropine]. / Le vie acustiche troncoencefaliche: effetti dell'atropina.

The efferent pathways exert a control action on the function of the cochlear nucleus and hair cells. Acetylcholine is the neurotransmitter of the centrifugal system and its action can be blocked by Atropine. In order to give a contribution to the knowledge of the function of the efferent bundle, Auditory Brainstem Responses (ABRs) and Acoustic Reflex Latencies (ARLs) have been examined in 10 young normal subjects there was also a decrease in latency greater than or equal to 100 microseconds by at least other two waves. The only statistically significant difference was relative to the latency mean value of the wave III recorded in contralateral derivation at 11 pps. The ARLs, after the infusion of atropine, showed a statistically significant increase in 7 of the 10 cases; no change was recorded in the AR amplitude. It can be concluded that the pharmacological block of the olivo-cochlear bundle determines a delay in the neural conduction of the acoustic impulses; this finding means that the atropine can inhibit the facilitating activity of the efferent system on the brainstem afferent pathways.

[Evoked acoustic oto-emissions in cochlear deafness]. / Otoemissioni acustiche evocate nelle sordità cocleari.

In order to give a contribution to the genesis of the EOAEs, we have recorded echos in 24 subjects with unilateral sudden deafness (I. group); 20 ears with Menière disease (II. group); 22 ears with progressive sensorineural hearing loss (III. group) and 10 normally hearing young subjects as control group. The results have shown that the EOAEs were present in 100% (I. group), 84.6% (II. group) and 86.3% (III. group) in response to the tone-burst; while the echos were present only in the 57.1% (I. group), 38.4% (II. group) and 45.4% (III. group) in response to the click, although the audiometric threshold mean were greater than 45 dB HL for 2-4 KHz and 1 KHz in the three experimental groups except for 2-4 KHz in the subjects with Menière disease (37.5 dB HL). The properties of EOAEs (detection and saturation threshold, dynamic range and duration) depended on the degree of hearing loss. Our results seem to corroborate the hypothesis that EOAEs could be also produced by a passive intracochlear mechanism attributable to the travelling wave of the basilar membrane provoked by the perilymph. In the normal ear this passive mechanism could be superimposed by an active mechanism, linked to the contractile activity of the outer hair cells with a consequent increase in amplitude of the EOAEs for the same stimulus intensity.

Psychoacoustical performance in children.

In order to contribute to knowledge of the elementary auditory functions in infancy, a group of normally hearing children below the age of four years was examined using advanced tests for cochlear (remote masking, brief-tone audiometry, critical ratio) and central auditory functions (masking-level difference). The results showed that both cochlear and central auditory functions were almost the same in three-year-olds as they were in adults, if not better. This behavior is similar to that recorded with electrophysiological methods and leads to the conclusion that at age three years the auditory system has completed its neurofunctional maturation and it is therefore completely efficient in its elementary psychosensorial functions.

[Evoked acoustic oto-emissions: effects of atropine]. / Otoemissioni acustiche evocate: effectti dell'atropina.

The Evoked Otoacoustic Emissions (EOE) are a sinusoidal wave complex coming from the contractile properties of the cochlea and particularly of the outer hair cells. This activity is influenced by the centrifugal pathways whose transmitter is acetylcholine. In order to study the effects of the functional block of the cochlea, ten young normal subjects were examined recording the EOE before and ten mins after the i.v. infusion of 1 mg of atropine. The statistical analysis of the results has shown a significant decrease only in EOE appearance threshold in absence of modifications of the saturation level. These data have led us to believe that atropine blocking of the centrifugal pathways causes a disfunction of the outer hair cells that accept less energy to be transduced into a neural stimulus and on the other hand more energy as EOEs.

[Effects of body posture on cochlear performance]. / Effetti della posizione del corpo sulla performance cocleare.

Experimental research has demonstrated that changes in body position influence auditory function and, specifically, supine position produces a sensorineural hearing loss at low frequencies. The hypotheses to interpret these phenomena are principally referred to an increase of hydrostatic pressure of labyrinthine fluids. In order to evaluate the effects of head position on the cochlear performance a modern test battery has been performed to study cochlear function in 11 normal subjects ranged in age from 22 to 34 years. The tests (Remote Masking:RM; Brief Tone Audiometry:BTA; Critical Ratio:RC) have been evaluated in two positions: sitting upright and supine with the head at a 20 backward angle. The results of our research have shown that in all the cases, the supine position produces a significant shift of the auditory threshold at 250 and 500 Hz, and a decrease of RM values in about all of the cases. We have estimated non statistically significant differences for the RC and BTA values, in more than half of the ears tested. On the basis of the significance given to RM, BTA, RC: we can deduce that the modifications of the auditory performance related to an increase in perilymphatic hydrostatic pressure, induced by the head position are produced by an increase in rigidity of the mechanical vibratory structures of the cochlea rather than the expression of sensorineural damage.

Subclinical changes of auditory function in the aged.

Elderly normal hearing subjects were studied using tests for cochlear functions (remote masking, brief tone audiometry, critical ratio, evoked otoacoustic emission), for neural auditory function (tone decay) and for central auditory functions (ipsilateral vs. contralateral acoustic reflex, tonal masking level difference). The findings demonstrated that ageing can cause subclinical abnormalities, almost consistently localized to the inner ear vibrating structures and only occasionally to the sensory and/or neural elements.

Remote masking, brief tone audiometry and critical ratio in sensorineural hearing losses.

Aim of this study is to evaluate in ears with different kinds of perceptive disorders the relationships between Critical Ratio (CR), Remote Masking (RM) and Brief Tone Audiometry (BTA) in order to analyse to what extent cochlear efficiency depends on functional properties of the mechanical extrasensorial structures and/or of the sensorial elements in the inner ear. Present results show that in ears with non retrocochlear sensorineural losses CR results are more often affected than RM and BTA. A reduced cochlear efficiency is related more to a failure of the mechanical properties than to dysfunctions of the cellular elements within the inner ear; presumably, micromechanisms not yet understood or unknown interfere with the efficiency of the cochlea.