Mastoid condition and clinical course of cholesteatoma.

This study was carried out to establish which type of cholesteatoma is controllable by conservative treatment from the viewpoint of mastoid ventilation. We examined the area of the air cell system and airspace (aeration) in the mastoid cavity by computed tomography and eustachian tube (ET) function by inflation-deflation test in 20 ears (20 patients) with severe attic retraction for over 12 months (retraction pocket group), 16 ears (16 patients) with cholesteatoma which could be controlled only by conservative treatment for over 12 months (nonsurgical group) and 43 ears (43 patients) which required surgery within a year in spite of similar conservative treatment (surgical group). The size of the mastoid air cell system in the retraction pocket group, nonsurgical group and surgical group was 2.9 +/- 1.3, 1.9 +/- 0.7 and 1.5 +/- 0.9 cm(2) on average, respectively, with no significant difference between both cholesteatoma groups (nonsurgical and surgical group). While aeration was observed in the mastoid in 17 of 20 ears (85.%) in the retraction pocket group and in 12 of 16 ears (75.0%) in the nonsurgical group, aeration was present only in 9 of 43 ears (26.5%) in the surgical group, being significantly less in the surgical group than in the nonsurgical group and the retraction pocket group. In all ears in the retraction pocket and nonsurgical groups, and 19 of 30 ears in the surgical group, ET function was poor, there being no significant difference among the three groups. The present clinical observations suggest that progressiveness of cholesteatoma could be related to the ventilatory conditions in the mastoid rather than ET function, and that conservative treatment may be effective when ears with cholesteatoma have aeration in the mastoid.

Functional differentiation of the auditory association area in prelingually deaf subjects.

BACKGROUND: it is believed that the number of neurons of the human cortex increases rapidly in the first postnatal year, and then decreases gradually towards adult level as their functions are revised up to 11 years of age ('synaptic revision'). It is also confirmed that regional cerebral blood flow (rCBF) at rest represents the density of the neurons and decreases in accordance with the synaptic revision in process. If synaptic revision does not occur, rCBF remains at high level. Thus, we can evaluate whether functional differentiation has occurred in the human cortex by measuring rCBF at resting state. OBJECTIVE: to examine functional differentiation of the auditory association area (A2) in prelingually deaf subjects. METHODS: six postlingually and six prelingually deaf subjects who had undergone cochlear implant (CI) were involved in the current study. All prelingually deaf subjects underwent CI over 8 years old. The rCBF in A2 was examined during resting and listening to speech sounds using positron emission tomography (PET) and H2(15)O intravenous injection. Twelve normal subjects' rCBFs were also measured as control. Furthermore, three prelingually deaf subjects underwent follow up PET studies in which cortical activities in A2 for listening and lipreading were examined. RESULTS: in the examination of rCBF at rest, rCBFs of prelingually deaf subjects in A2 showed significantly higher than those of either the postlingually deaf subjects or normal subjects. During listening, rCBFs in A2 increased in postlingually deaf subjects and normal subjects, while there was no significant rCBF increase in the prelingually deaf. High rCBF level in A2 at rest observed in prelingually deaf subjects implied a lack of synaptic revision, and it was suggested that the functional differentiation for auditory processing was little in the A2 of prelingually deaf subjects. In the follow up study for three prelingually deaf subjects, activation of A2 was observed during lipreading but not during listening in two cases, who had developed the skill of lipreading while speech recognition was not improved by CI. In contrast, the other case had not used any visual clues in daily communication prior to CI, and the hearing acuity was well improved by CI. This case demonstrated an activity in A2 during listening, while lipreading induced no activation. CONCLUSION: it is suggested that functional differentiation of A2 should differ according to which of visual and auditory clue is chiefly used during critical periods for speech acquisition. The findings are thought to be important for us to schedule the education and treatment for prelingually deaf children.

Organic change of effusion in the mastoid in otitis media with effusion and its relation to attic retraction.

To try to solve the pathogenesis of severe attic retraction viewed from mastoid condition, we examined the residual soft tissue density (RSTD) in the mastoid by computed tomography (CT) in 85 patients (107 ears) with otitis media with effusion (OME) 3 months after tympanostomy tube insertion or later. The incidence of RSTD in the mastoid was significantly higher in OME of adults (52.6%) than in children (24.1%). Ears with severe attic retraction had RSTD significantly more frequently (80%) than those with no or mild attic retraction, and many of the mastoids with severe attic retraction were occupied totally by RSTD. The area of the mastoid (mastoid pneumatization) was significantly smaller, and CT density of the mastoid (sclerotic tendency) was significantly higher in ears with RSTD than in those without. RSTD after tympanostomy tube insertion in the mastoid indicating organic change of effusion was considered one of the important factors relating to the pathogenesis of severe attic retraction.

Verbal self-monitoring in deaf subjects using cochlear implants.

Cortical activation during vocalization was studied in an attempt to elucidate verbal self-monitoring mechanisms in cochlear implant users. Six post-lingually deafened subjects using cochlear implants were included in this study. Significant activation was observed in the bilateral temporal cortices during reading sentences aloud, which was not found in normal subjects in our previous study. The activation patterns in the temporal cortex were similar for reading aloud and for listening to the examiner's speech, and the activation foci in the middle temporal gyri for the two tasks were almost identical. Cochlear implant users may monitor their own speech during speech production, and their verbal self-monitoring mechanisms are thought to depend on similar mechanisms that are used to monitor externally generated speech.

Cochlear implant in patients with residual hearing.

OBJECTIVE: The postoperative speech perception abilities of severely hearing-impaired patients with multi-channel cochlear implant were compared with preoperative speech perception performance with conventional hearing aids. METHODS: Cochlear implantation was performed in six severely to profoundly hearing-impaired patients. They had unaided pure-tone thresholds of 70-100-dB HL and aided thresholds of 35-90-dB HL in the better ear, but were not able to perceive speech sounds well with hearing aids. RESULTS: Postoperatively, all the patients had significantly improved speech perception performance, exceeded the average skills of profoundly deaf cochlear implant users, and were able to communicate without writing. CONCLUSION: These results imply that cochlear implant may be indicated for severely to profoundly deaf subjects, if they receive little or no benefit from conventional hearing aids.

[Three-dimensional reconstruction of functional brain images].

We consider PET (positron emission tomography) measurement with SPM (Statistical Parametric Mapping) analysis to be one of the most useful methods to identify activated areas of the brain involved in language processing. SPM is an effective analytical method that detects markedly activated areas over the whole brain. However, with the conventional presentations of these functional brain images, such as horizontal slices, three directional projection, or brain surface coloring, makes understanding and interpreting the positional relationships among various brain areas difficult. Therefore, we developed three-dimensionally reconstructed images from these functional brain images to improve the interpretation. The subjects were 12 normal volunteers. The following three types of images were constructed: 1) routine images by SPM, 2) three-dimensional static images, and 3) three-dimensional dynamic images, after PET images were analyzed by SPM during daily dialog listening. The creation of images of both the three-dimensional static and dynamic types employed the volume rendering method by VTK (The Visualization Toolkit). Since the functional brain images did not include original brain images, we synthesized SPM and MRI brain images by self-made C++ programs. The three-dimensional dynamic images were made by sequencing static images with available software. Images of both the three-dimensional static and dynamic types were processed by a personal computer system. Our newly created images showed clearer positional relationships among activated brain areas compared to the conventional method. To date, functional brain images have been employed in fields such as neurology or neurosurgery, however, these images may be useful even in the field of otorhinolaryngology, to assess hearing and speech. Exact three-dimensional images based on functional brain images are important for exact and intuitive interpretation, and may lead to new developments in brain science. Currently, the surface model is the most common method of three-dimensional display. However, the volume rendering method may be more effective for imaging regions such as the brain.

A new vestibulo-ocular reflex recording system designed for routine vestibular clinical use.

A new vestibulo-ocular reflex (VOR) recording system was developed, which consists of an infrared eye camera, a small velocity sensor and a frequency modulator. Using this system, the head velocity signal was frequency modulated and simultaneously recorded as a sound signal on the audio track of a Hi8 video recorder with eye images. This device enabled recording of the VOR response in routine vestibular clinical practice. The reliability and effectiveness of this system were estimated by recording and analysing the VOR response against manually controlled rotation in normal subjects (n = 22) and in patients with unilateral severe vestibular hypofunction (n = 11). VOR gain on clockwise rotation viewed from the top was defined as R gain, and counterclockwise rotation as L gain. Directional preponderance (DP%) was also calculated. VOR gain towards the diseased side was significantly lower than that towards the intact side, and also significantly lower than that of normal subjects. DP% of unilateral vestibular hypofunction cases was significantly larger than that of normal subjects. These findings indicate that this VOR recording system reliably detects severe unilateral vestibular hypofunction.

Correlation between rCBF and speech perception in cochlear implant users.

OBJECTIVE: Although cochlear implants (CIs) have provided the opportunity for bilaterally deaf individuals to recover their hearing abilities, the speech perception performances of the CI users varies considerably. To elucidate the cortical mechanisms of processing speech signals coded by CIs, we evaluated the correlation between the brain activity during speech activation and speech perception in CI users by PET. METHODS: Fourteen postlingually deaf CI users were examined. CI used in the patients was a 22-channel system and its speech-coding strategy was the Nucleus spectral peak (SPEAK) strategy. To evaluate the speech perception performances, we examined vowel perception, consonant perception and speech tracking performances in the Japanese language. Regional cerebral blood flow (rCBF) was measured during no sound stimulation and speech sound stimulation. PET data of the silent condition was subtracted from that of speech stimulation to determine changes in rCBF. In the search for changes in rCBF in the areas for auditory processing, three regions of interest (ROI) were selected; primary auditory area, auditory association area and Broca's area. The correlation between the rCBF changes in the ROIs and the speech perception performances was analyzed using Pearson's correlation coefficient. RESULTS: The patient's speech perception performances ranged widely. Although there were no significant correlations between the speech perception and the rCBF increases in the primary auditory area and Broca's area, there were positive correlations in the auditory association area. In the left auditory association area, the correlation coefficient of the vowel perception performance was 0.546 (P <0.05) and that of the speech-tracking test was 0.657 (P < 0.05). Regarding the consonant perception performance, the correlation coefficient was 0.743 (P < 0.01). There was a positive correlation only between the consonant perception performance and the rCBF increase (R = 0.576, P < 0.05) in the right auditory association area. These correlations are stronger in the left hemisphere than in the right hemisphere. CONCLUSIONS: It is suggested that the improvement of the auditory processing of speech in CI users with SPEAK strategy is accompanied by the recruitment of more neurons in the auditory association areas. The adult auditory cortices may still have plasticity or

Factors affecting recovery of mastoid aeration after ear surgery.

Fifty-six patients after tympanomastoid surgery were examined to determine recovery of mastoid aeration and various pre- and intraoperative factors such as eustachian tube (ET) function, how the mastoid mucosa had been treated during surgery and whether or not a large silastic sheet had been placed in the middle ear or a ventilation tube used. Mastoid aeration recovery was confirmed by computed tomography in 27 of the 57 cases (47%) within 12 months of surgery. Among the factors examined, preservation of the epitympanic mucosa was found to be most important in mastoid aeration recovery. Use of a large silastic sheet to cover the area from the bony ET and tympanic cavity to epitympanum, aditus ad antrum or antrum was found to be of some help in recovery mastoid aeration after complete resection of the mucosa and mastoid air cells. Preoperative ET function, anterior tympanotomy and use of a ventilation tube did not influence recovery.

The diagnostic and prognostic value of eardrum mobility in otitis media with effusion.

Diagnostic and prognostic values of eardrum mobility were determined by pneumatic otoscopy in 37 patients (56 ears) having otitis media with effusion (OME). Eardrum mobility was impaired or lost in less than half of the ears (46.4%), while a tympanogram detected 77.8% of OME. In 27 of the 37 patients (42 of the 56 ears), aeration of the middle ear space was examined by CT and demonstrated that the presence or absence of aeration was significantly correlated with the presence or absence of eardrum mobility. In another 38 children (62 ears with OME), effect of antibiotics was correlated with eardrum mobility before treatment, and the improvement rate was found to be significantly higher in ears with positive mobility of eardrum (34.3%) than in ears without eardrum mobility (10.0%). These results indicate that eardrum mobility is a good prognostic indicator of OME rather than its diagnostic indicator alone.

Soft-wall reconstruction of posterior canal wall for surgery of noninflamed ears: a preliminary report.

OBJECTIVE: To test whether the posterior external auditory canal (EAC) wall reconstructed only by soft tissues retracts after surgery in the noninflamed ear. STUDY DESIGN: The condition of the posterior EAC wall was observed for more than 1 year after surgery in 20 noninflamed ears in which only the posterior EAC wall skin was preserved or in which the wall was reconstructed only by soft tissue during surgery. PATIENTS: Eighteen patients (20 ears) underwent ear surgery for conditions other than otitis media, including ossiculoplasty in 12 ears, cochlear implant in 3, resection of congenital cholesteatoma in 4, and resection of glomus tympanicum tumor in 1. RESULTS: Retraction of the soft posterior EAC wall was observed in only 1 of the 20 ears. In this ear, the posterior EAC wall showed only a slight retraction without any serious problems. Computed tomography revealed that mastoid aeration recovered in all 20 ears. CONCLUSIONS: In noninflamed ears, surgeons can remove the bony posterior EAC wall if necessary, and may not need to reinforce or reconstruct the wall with hard tissue. This enables surgeons to spare time and energy and obtain the same advantages as in the intact-canal-wall technique or canal wall reconstruction by a hard material.

Electrocochleographic documentation of temporal findings of speech perception in normal and hearing-impaired individuals.

Compound action potentials (CAPs) evoked by the short Japanese syllables /a/ and /ka/ were recorded by extratympanic electrocochleography in 17 subjects with normal hearing (17 ears) and 34 patients with sensorineural hearing losses (35 ears) to investigate the temporal aspects of speech coding for perception. In normal ears, three characteristics were found common to the temporal patterns of all CAPs: (1) a prominent CAP at the beginning of both stimuli; (2) periodic CAPs with the same interval as the pitch period through the vowel part of both stimuli; (3) absence of a prominent CAP at the onset of voice. These characteristics may help to produce consonant recognition. Among the subjects with sensorineural hearing loss, some ears showed the following two characteristics different from those with normal hearing: (1) a significantly lower CAP at the onset of both stimuli than in those with normal hearing; (2) decay of CAPs during the voiced part. These findings may result in abnormal loudness perception in sensorineural hearing loss as produced by loudness recruitment and pathological adaptation. Such different temporal patterns of CAPs may have an adverse influence on the speech discrimination of patients with sensorineural hearing impairments.

Vestibulo-ocular reflex in patients with Meniere's disease between attacks.

In Meniere's disease, spontaneous nystagmus beating toward the affected ear (ipsilateral nystagmus) is frequently observed especially during vertiginous periods. VOR against horizontal rotation was recorded in 19 patients with Meniere's disease exhibiting ispilateral beating nystagmus, and the dynamic aspect of vestibular function during vertiginous periods was examined by determining VOR gain and directional preponderance (DP). The patients sat on a rotation chair and were passively rotated at about 0.3-0.6 Hz. The maximal head velocity ranged from 80 to 120 deg/s and the duration of rotation from 20 to 30 s. In most patients exhibiting ipsilateral nystagmus, VOR gain toward the affected side was higher than that toward the intact side, indicating that the peripheral vestibular system on the affected side could still respond to head movements and that its dynamic function was increased. This asymmetry disappeared along with disappearance of ipsilateral nystagmus. During the period with contralateral nystagmus, VOR gain toward the affected side became lower than that toward the intact side. These findings indicate that alterations in the dynamic property of the peripheral vestibular system may correlate with the directional change of spontaneous nystagmus. However, the degree of VOR DP (VOR DP%) did not correlate with the slow phase velocity of spontaneous nystagmus, indicating that observation of spontaneous nystagmus alone cannot determine with precision the degree of imbalance in the dynamic aspect of vestibular function.