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Otologists may be reluctant to perform labyrinthectomy in unilateral Menière's disease, fearing the later development of bilateral disease and severe hearing loss in the previously normal ear. To illuminate this issue, we reviewed audiologic records for 85 patients diagnosed as having bilateral Menière's disease at the University of Washington Hospital from 1969 to 1986. The progression of hearing loss in each ear was noted, as well as interaural relationships. Nine patients experienced a significant reversal, in which the initially better ear surpassed the other ear in hearing deficit, but only one of these patients could at any time have been considered a labyrinthectomy candidate, according to hypothetically liberal audiometric criteria. [ABSTRACT FROM AUTHOR]

Forty-six patients in an emergency room (ER) setting and 159 people suspected of driving while intoxicated (DWI) had their blood alcohol concentrations estimated by the angle of onset of horizontal gaze nystagmus and confirmed by blood alcohol analysis or breath-alcohol analysis (BAA) tests. In the ER group, 25/26 (96%) of legally intoxicated patients (blood alcohol concentration greater than or equal to .10% w/v) had an estimation consistent with intoxication. There were no cases in which the blood alcohol concentration (BAC) was incorrectly estimated to be greater than .10% w/v in the absence of other drugs. In DWI suspects there was a correlation of .878 between estimated BAC and BAA results. Three subjects were incorrectly classified as intoxicated. No subjects with estimated BAC less than .10% w/v were legally intoxicated by BAA testing. Alcohol gaze nystagmus is presented as an effective tool for estimating the BAC in pure alcoholic intoxication. [ABSTRACT FROM AUTHOR]

The Hearing Conservation Amendment published by the Occupational Safety and Health Administration (OSHA) in 1983 requires hearing conservation programs to be provided for over 5 million workers whose daily noise exposures exceed 85 dBA time-weighted average. The permissible exposure level is 90 dBA, above which the use of hearing protectors is mandatory. Current policies rely heavily on periodic audiometry to detect early threshold shifts due to inadequate use of hearing protection or to individual variation in susceptibility to noise induced hearing loss (NIHL). Studies including over 1,000 noise exposed workers have shown that audiometry in the industrial setting is less reliable than clinical audiometry. Pure tone averaging markedly reduces test-retest variability and should be incorporated into rules for decision-making based on industrial audiometry. However, at least half of observed shifts are spurious. In addition, aging is an important confounding variable; in our data, about half of the population mean threshold shift seen was attributable to aging. Thus, only a minority of threshold shifts seen in industrial audiometry are due to NIHL. The large number of "false positive" shifts will inevitably eventually have the effect of a de facto lowering of the permissible exposure level to 85 dBA. Otologic referral and major administrative action should be reserved for large or repeated threshold shifts. OSHA does not specify rules for otologic referral, but the criteria recommended by the American Academy of Otolaryngology-Head and Neck Surgery are reasonable and should be supported. The necessity for otologic evaluation in the differential diagnosis of NIHL from other entities (particularly baseline audiometric abnormalities) is not universally appreciated; otolaryngologists need to educate their medical and nonmedical colleagues about this. [ABSTRACT FROM AUTHOR]

A retrospective study of 61 consecutive patients with floor of mouth carcinoma and a clinically negative neck was done to determine the value of elective treatment to the neck. Subsequent histologically proven nodal disease was analyzed according to initial treatment modality (23 surgical, 38 irradiation), stage (29--T1,27--T2,5--T3), hemi-neck at risk (midline lesions placed both hemi-necks at risk), and primary control for a minimum of 2 years (50 patients, 78 hemi-necks at risk). Neck failures were classified by T stage, extent of neck treatment (upper neck or complete) and by primary control at the time of manifest neck metastasis. Of the hemi-necks at risk with the primary controlled, 10% (17% of patients) developed nodal disease without complete neck treatment; 86% (6/7) of these patients were salvaged. The occult positive node incidence, conservatively calculated by elimination of all patients treated with elective partial or total neck irradiation, was 10% for patients with T1 and T2 lesions (7% for hemi-necks at risk). Based on the clinical course of patients with primary control, only 1 patient (2%) might have benefited from initial complete elective neck treatment. These results suggest that elective neck treatment in early (T1 and T2, N0) floor of mouth carcinoma is of doubtful value. Supraomohyoid , rather than suprahyoid dissection, is recommended if surgical treatment of the neck is undertaken. [ABSTRACT FROM AUTHOR]

Hearing conservation in industry relies heavily on monitoring audiometry to detect early noise-induced hearing loss in workers who are exposed to potentially damaging noise, with or without hearing protectors. The "real-world" reliability and validity of these measurements, as well as otoscopic observations in industry, have not been extensively investigated. In addition, there is considerable controversy over the selection of a definition of "significant threshold shift" in industrial audiometry. These and related issues were considered in a series of three studies utilizing data from an active hearing conservation program. Test-retest variability in industry is much higher than has been reported for clinical settings; this variability is reduced by pure-tone averaging. Workers referred for otologic evaluation were found to have hearing levels which were, on the average, about 5 dB better than indicated by plant audiometry, even without excluding 4% of referred workers who had unilateral deafness and showed "shadow curves" on the plant audiograms. Otoscopic data obtained by the plant audiometrists were uncorrelated with the results of otoscopy by consultant otologists. Techniques borrowed from decision theory and signal detection theory were used to evaluate possible criteria for significant threshold shift. Criteria based on pure-tone averaging were superior to those based on a certain amount of threshold shift for any frequency tested. It is proposed that a significant threshold shift be defined as a 10 dB or greater change for the worse for either the 0.5, 1, 2 kHz pure-tone average or the 3, 4, 6 kHz pure-tone average, in either ear, and that such shifts be validated by prompt retesting. Even with this criterion, a substantial number of shifts (most shifts, in some situations) will be either spurious or attributable to disorders other than noise-induced hearing loss, such as presbycusis. Otologic referral in cases of large or repeated shifts may prevent unjustified administrative actions, to the advantage of both workers and management. A practical consequence of the use of monitoring audiometry may be a de facto lowering of the permissible exposure level to 85 dBA TWA. [ABSTRACT FROM AUTHOR]

Critical assessment of head and neck cancer with respect to staging has, on occasion, been disappointingly ineffective. We have attempted to correlate the incidence of measureable uptake of cobalt 57 tagged bleomycin by primary squamous cell carcinoma and metastatic cervical lymph nodes. Forty-six cases have been evaluated with respect to histopathological confirmation of the suspected metastatic disease. We have found that this diagnostic measure increases our acumen in staging of head and neck cancer. The relevance of the Co-Bleo scans as a diagnostic aid is reported in 46 cases. Malignant tumors greater than 2 cm in size appear to demonstrate active uptake of the imaging agent. Small tumor size and excess background radioactivity contribute to the false-negatives (17%). Inflammatory conditions or benign tumors of the salivary apparatus may result in minimal uptake, thus, a false-positive result (10%). An increase in the radioactivity of the Co-Bleo may enhance the benefits of this procedure in the search for an undiagnosed primary, as well as undiagnosed local or distant metastases. [ABSTRACT FROM AUTHOR]

Objectives: Review reports of randomized clinical trials (RCTs) in tinnitus to identify well-established treatments, promising developments, and opportunities for improvement in this area of clinical research., Study Design: Literature review of RCTs (1964-1998) identified by MEDLINE and OLD MEDLINE searches and personal files., Methods: Studies were compared with the RCT criteria of Guyatt et al. for quality of design, performance, and analysis; "positive" results were critically examined for potential clinical relevance., Results: Sixty-nine RCTs evaluated tocainide and related drugs, carbamazepine, benzodiazepines, tricyclic antidepressants, 16 miscellaneous drugs, psychotherapy, electrical/magnetic stimulation, acupuncture, masking, biofeedback, hypnosis, and miscellaneous other nondrug treatments. No treatment can yet be considered well established in terms of providing replicable long-term reduction of tinnitus impact, in excess of placebo effects., Conclusions: Nonspecific support and counseling are probably helpful, as are tricyclic antidepressants in severe cases. Benzodiazepines, newer antidepressants, and electrical stimulation deserve further study. Future tinnitus therapeutic research should emphasize adequate sample size, open trials before RCTs, careful choice of outcome measures, and long-term follow-up.

Cis-platinum is an ototoxic antineoplastic drug. Evaluation of auditory thresholds in 33 children receiving cis-platinum shows that a threshold shift at 6 and 8 kHz is first measurable after a cumulative dose of 201 to 300 mg/m2. A 35- to 40-dB high-frequency threshold shift is evident after a cumulative cis-platinum dose of 301 to 400 mg/m2. Increasing cumulative doses of cis-platinum are associated with a greater degree of hearing loss. Receiver-operator characteristic curves were used to find a criterion value that effectively identified threshold shifts that were due to cis-platinum ototoxicity. A 15-dB or greater shift in the 6- and 8-kHz threshold average identifies a high true-positive (50%) and low false-positive (0%) rate of cis-platinum-induced hearing loss. Using this criterion, cis-platinum ototoxicity affected 77% of children who received cis-platinum (median cumulative dose 360 mg/m2).

Homograft stapes were used for ossicular reconstruction in 43 ears over a three-year period. The average hearing improvement was 7.9 db. These cases were divided into groups: those with an intact posterior canal wall and those with an open mastoid cavity. The latter group fared better, with an average improvement of 15 db. Fourteen of the 43 ears were subsequently re-explored. Satisfactory bony union between the homograft stapes and recipient footplate was found in eight cases, four cases showed poor bony union, and bony resorption of the homograft had occurred in two patiemise for reconstruction of the ear with a loss of the stapes arch, especially in the presence of an open mastoid cavity and thus a shallow middle ear.