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The present study shows that AGE, DELAY, and PTA_PRE may be considered factors influencing therapeutic success in intra-tympanic steroid therapy.The aim of the study is to evaluate the relationship between the therapeutic success of intra-tympanic prednisolone therapy and age, in patients affected by idiopathic sudden sensorineural hearing loss (ISSNHL), considering the influence of factors such as delay, gender, and pure tone average (PTA) pre-therapy.This retrospective study involved 402 consecutive patients, affected by unilateral ISSNHL between January 2009 and January 2014. Patients were divided into two groups based on age: group one with 94 patients aged over 65 years and group two with all 402 patients enrolled in the study, including those over 65.PTA recorded before the beginning of the therapy (PTA_PRE) in group one was worse than for group two. In both groups the therapy was significantly effective in improving hearing thresholds, even if PTA_PRE was significant and negatively correlated with success rate. This effect disappeared within the population over 65. On average, each day of DELAY from the onset of hearing loss to the beginning of therapy cuts almost 2% of the possibility to recover. AGE was negative and significant when specified continuously for group two.

Objectives/Hypothesis The study was designed to verify if one or more electrophysiological parameters could predict a risk of nonrecovery of normal facial function and the development of synkinesis in Bell's palsy (BP) subjects. Study Design Prospective case series. Methods A total of 120 subjects ranging from 18 to 70 years with unilateral BP (International Classification of Disease-11), Grade III to VI House-Brackmann (HB) degree, were assessed and treated with standardized oral steroids and antiviral drugs within 48 hours from onset. Of these, 92 underwent electroneurography (ENoG), electromyography (EMG), and blink reflex (BR) testing at 7 to 10 and 20 days after palsy onset. Multivariate analysis and receiver operating characteristic curves were carried out to verify which combination of electrophysiological parameters may be predictive of no recovery and/or development of synkinesis. Results BR and ENoG were the best predictors of no facial function recovery, showing significant correlation coefficient with severity of facial palsy in both assessments. EMG findings did not add any prognostic significance. Worsening of facial palsy can be observed in subjects despite steroid therapy. The risk of developing synkinesis might be evaluated soon after BP on the grounds of ENoG degeneration, orbicularis oculi denervation, a younger age, and severe (V–VI) HB grade. Conclusions BR and ENoG, considered together with clinical findings, could offer a good indication in the first phases of BP for the possibility to develop palsy residua. This combination of tests is well accepted by the subjects, and is therefore suitable for multiple assessments in the early postpalsy period.Key Words: Bell's palsy, facial palsy, ENoG, blink reflex, Prognosis. Level of Evidence 4. Laryngoscope, 124:2598–2605, 2014

This individual prospective cohort study aims to report and analyze the symptoms preceding and accompanying the facial paresis in Bell’s palsy (BP). Two hundred sixty-nine patients affected by BP with a maximum delay of 48 hours from the onset were enrolled in the study. The evolution of the facial paresis expressed as House-Brackmann grade in the first 10 days and its correlation with symptoms were analyzed. At the onset, 136 patients presented postauricular pain, 114 were affected by dry eye, and 94 reported dysgeusia. Dry mouth was present in 54 patients (19.7%), facial pain, hyperlacrimation, aural fullness, and hyperacusis represented a smaller percentage of the reported symptoms. After 10 days, 39.9% of the group had a severe paresis while 10.2% reached a complete recovery. Dry mouth at the onset was correlated with severe grade of palsy and was prognostic for poor recovery in the early period. These outcomes lead to the deduction that the nervus intermedius plays an important role in the presentation of the BP and it might be responsible for most of the accompanying symptomatology of the paresis. Our findings could be of important interest to early address a BP patient to further examinations and subsequent therapy.

To analyze the presence of chronic cerebrospinal venous insufficiency parameter and vascular abnormalities, in the internal jugular veins (IJVs) and/or vertebral veins in sitting and supine posture, in patients with Meniere's disease compared to healthy general population. A prospective study on 32 patients affected by definite Meniere was performed from February 2012 to January 2013. All subjects underwent an echo-color Doppler examination of the cerebrospinal venous flow. 21 of the 32 Menieric patients showed a statistically significant reflux in the intracranial veins versus healthy (65.6 vs 25%; P < 0.001). A high prevalence of IJVs stenosis with hemodynamic changes (increased velocity or absence of flow) was observed (66.7 vs 33.3%; P < 0.05). The other parameters considered did not show statistically significant differences among the two groups. The results obtained showed a vascular pattern of cerebrospinal venous system present in patients affected by definite Meniere. This vascular impairment significantly affects the vascular areas more directly involved in the venous drainage of the inner ear. Thus venous stasis may be considered a further pathogenetic mechanism for development of Meniere's disease.

Objective:This retrospective, comparative study aimed to assess anatomical and functional results in a group of adults undergoing type I tympanoplasty for subtotal tympanic membrane perforation, using two different types of graft.Subjects and methods:The study included 106 patients affected by chronic otitis media, who underwent underlay type I tympanoplasty, 53 using an autologous chondro-perichondral tragal graft and 53 using temporalis fascia. Anatomical and functional outcomes were evaluated over time.Results:Audiometric results comparing the cartilage and fascia groups at six months and one year after surgery showed no statistically significant differences. Assessment of anatomical outcomes indicated a greater number of complications in the fascia group.Conclusion:Functional results indicate the validity of the cartilage tympanoplasty, while anatomical results indicate a slightly better outcome in terms of graft re-perforation and retraction, compared with temporalis fascia at one-year follow up. These results suggest that the cartilage technique is preferable for type I tympanoplasty.

Objectives/Hypothesis: To investigate the efficacy of an intratympanic steroid as a first-line therapy in patients affected by moderate idiopathic sudden sensorineural hearing loss (ISSNHL). Study Design: Prospective, randomized, triple-blind, placebo-controlled trial. Methods: Fifty patients presenting with moderate idiopathic sudden sensorineural hearing loss involving all frequencies from 250 Hz to 8,000 Hz (a flat audiogram) were enrolled. Patients were randomized into two groups of 25 each. The first group (intratympanic steroid) underwent a daily intratympanic administration of prednisolone for 3 consecutive days. Subjects in the second group (control) received a daily intratympanic injection of a saline solution for 3 consecutive days. Audiometric tests were performed at day 7 after the beginning of therapy (T1), and then 10 and 30 days after T1. The patients in both groups who did not show a complete recovery at T1 were treated with oral prednisone at a tapering dose. Results: In the intratympanic steroid group, 19 out of 25 patients presented at T1 complete recovery (76%), whereas in the control group the number patients who recovered completely at T1 was five out of 25 (20%). The mean pure-tone average (PTA) recorded at T1 shows a statistically significant improvement in the hearing threshold of the first group compared to the control group (P < .01). Conclusions: The mean PTA recorded after the first-line approach (T1) demonstrated a significant therapeutic action of the short-duration intratympanic steroid therapy on moderate ISSNHL, with a flat audiogram shape, compared to the natural course of the disease and the placebo effect at that time point. Laryngoscope, 2013

This study was designed to investigate the indication and advantages of contralateral implantation after postimplant meningitis (piM). Speech perception assessment, most comfortable levels and high-resolution computer tomography were used to monitor cochlear fibrosis/ossification and clinical changes in outcomes in 5 children affected by meningitis after a variable-time post-cochlear implantation. Ipsilateral ossification was found in 3 children, 1 of whom developed delayed contralateral ossification. These children were implanted on the contralateral side as they all showed deterioration of hearing performance. Results from the present paper and literature analysis suggest that, (1) piM can induce ipsilateral and contralateral ossification, (2) meningitis-induced cochlear ossification is more prone to develop in the presence of a normal cochlear structure and (3) contralateral implantation after piM has proven to be effective in restoring performance when a full electrode insertion is accomplished.

Purpose To evaluate relationship between Meniere disease (MD) and chronic cerebrospinal venous insufficiency (CCSVI) using ultrasound, magnetic resonance (MR) imaging, and venography and to evaluate the effectiveness of angioplasty of the internal jugular vein (IJV) and azygos vein (AV) in reducing symptoms of MD. Materials and Methods Patients with a confirmed diagnosis of MD unresponsive to standard treatment underwent duplex ultrasound and MR imaging to diagnose CCSVI. Healthy volunteers were also studied to evaluate CCSVI in asymptomatic subjects. Patients with CCSVI and MD underwent venography and percutaneous transluminal angioplasty (PTA) of IJV and AV. Results There were 182 patients with no clinical benefit from standard treatments evaluated. CCSVI was diagnosed in 175 (87.5%) patients with MD. Venography was performed in 69 patients to confirm the diagnosis of CCSVI. In 80% of these patients, PTA of the IJV and/or AV was effective for treating signs and symptoms of MD. In the healthy cohort, CCSVI was observed in only 12% of subjects. Conclusions These results suggest a possible etiologic relationship between CCSVI and MD that warrants further investigation.

The study suggests that Mozart therapy could be a valid alternative to the common sound therapy methods in tinnitus patients.The aim of the study was to evaluate the presence of the Mozart effect as indexed by a variation in tinnitus intensity and tolerability.Sixty-two individuals aged between 22 and 78 years, reporting tinnitus for at least 1 year, were enrolled for the study. All patients attended a 1 h cognitive behavioral counseling session and listened to Mozart's sonata k448 for 1 h per day for a month. Afterwards patients listened to Beethoven's Für Elise sonata for 1 h per day for a month. To evaluate the general stress level, the impact of tinnitus on patients' quality of life, and the intensity of tinnitus, patients were invited to participate in three tests: the Measure du Stress Psychologique (MSP) questionnaire, the Tinnitus Handicap Inventory (THI), and a 0 to 10 visual analog scale (VAS).For all the parameters investigated, MSP, THI, and intensity, there was a general significant improvement between the pre- and post-listening evaluation. A significant improvement, as regards THI and intensity, could already be appreciated after a single exposure to Mozart's sonata.

Vestibular schwannomas, also known as acoustic neuromas, are benign tumors, which originate from myelin-forming Schwann cells. They develop in the vestibular branch of the eighth cranial nerve in the internal auditory canal or cerebellopontine angle. The clinical progression of the condition involves slow and progressive growth, eventually resulting in brainstem compression. The objective of the present study was to investigate the expression level and the localization of the pro-inflammatory cytokines, transforming growth factor-β1 (TGF-β1) interleukin (IL)-1β, IL-6 and tumor necrosis factor-α (TNF-α), as well as the adhesion molecules, intracellular adhesion molecule-1 and vascular endothelial growth factor (VEGF), in order to determine whether these factors are involved in the transformation and development of human vestibular schwannoma. The present study investigated whether changes in inflammation are involved in tumor growth and if so, the mechanisms underlying this process. The results of the current study demonstrated that pro-inflammatory cytokines, including TGF-β1, IL-1β and IL-6 exhibited increased expression in human vestibular schwannoma tissue compared with normal vestibular nerve samples. TNF-α was weakly expressed in Schwann cells, confirming that a lower level of this cytokine is involved in the proliferation of Schwann cells. Neoplastic Schwann cells produce pro-inflammatory cytokines that may act in an autocrine manner, stimulating cellular proliferation. In addition, the increased expression of VEGF in vestibular schwannoma compared with that in normal vestibular nerve tissue, suggests that this factor may induce neoplastic growth via the promotion of angiogenesis. The present findings suggest that inflammation may promote angiogenesis and consequently contribute to tumor progression. In conclusion, the results of the present study indicated that VEGF and pro-inflammatory cytokines may be potential therapeutic targets in vestibular schwannoma. Further studies are necessary to confirm the involvement of these factors in the growth of neoplasms and to develop inhibitors of pro-inflammatory cytokines as a potential treatment option in the future.

Cyclo-oxygenase-2 (COX-2) enzyme would not appear to be constitutively expressed in human perilymph while it is always induced in the perilymph of patients affected by sensorineural hearing loss (SNHL). The COX-2 isoform may be involved in hearing loss and, therefore, pathological states of the inner ear should possibly be further analyzed to clarify the clinical relevance of prostaglandin and selective COX-2 antagonist therapy.Perilymph samples from a group of patients with bilateral SNHL and another with conductive hearing loss were collected to evaluate the presence of the COX-2 enzyme. The possible correlation between different causes of deafness and the expression of COX-2 in the human ear was studied.A prospective clinical study of 14 patients with severe or profound hearing loss who underwent cochlear implant surgery and 4 patients with conductive hearing loss who underwent stapes surgery was carried out. Western blot analysis of perilymph samples was performed with monoclonal anti-human COX-2 antibody.COX-2 enzyme was detected in all patients affected by SNHL and was absent in all those with conductive hearing loss due to otosclerosis.

Intratympanic administration of prednisolone at a dose of 62.5 mg/ml performed every day for 3 consecutive days is more efficacious than the therapeutic approaches described so far in the literature.The aim of the study was to evaluate the overall success rate, morbidity, and prognostic factors of a new protocol of intratympanic steroid administration as a means of primary therapy for idiopathic sensorineural hearing loss.Overall, 34 patients presenting sudden unilateral sensorineural hearing loss of at least 30 dB over three frequencies that had developed within 72 h were treated once a day for 3 consecutive days with a single intratympanic injection of prednisone diluted in saline solution.Following intratympanic therapy with prednisone, 16 patients (47%) reported complete recovery of sudden sensorineural hearing loss, with a pure tone average that returned within 25 dB; 11 patients (32.3%) showed improvement in hearing of more than 30 dB; 4 patients presented improvement in pure-tone average between 10 and 30 dB. Only three patients failed to improve following intratympanic injection.

Endoscopic cauterization of the sphenopalatine artery and anterior ethmoid artery is a first-line standard of care in managing intractable epistaxis, after the failure of previous packing. Epistaxis occurs in 12% of the population. Treatment is often based on nasal packing that could be poorly effective in the treatment of severe posterior epistaxis.To evaluate the effectiveness of the endoscopic approach for posterior epistaxis.We report the experience of endoscopic cauterization in two metropolitan hospitals in Italy: 48 patients with at least one nasal packing in the 3 weeks before hospital admission. They underwent endoscopic cauterization of the sphenopalatine artery or of the anterior ethmoid artery.The patients' mean age was 58.7 years; the mean hospital stay was 2.97 days. In 42 cases (87.5%), cauterization of the sphenopalatine artery was performed, and 6 (12.5%) were subjected to anterior ethmoid artery treatment. Epistaxis control was achieved in 93% of cases; 3 patients had a recurrent nasal bleeding, and were treated with anterior nasal packing. Minor complications occurred in 27.1%. We achieved a shorter hospital stay compared with patients who underwent anteroposterior packing.

The dimensions of the implant receiver and the material used have influenced the surgical approach leading to a reduction in complications. Ultrasonography of the haematoma is useful in the evaluation of dimensions, entity of fluid component and therapeutic options.Haematoma arising in the receiver area is considered a minor complication, nevertheless it can be complicated by infection and/or flap necrosis or fibrosis leading to difficulties in magnetic adherence of the receiver and rarely to explantation of the receiver. The objective of the study was to evaluate the clinical outcome of postoperative haematoma arising after cochlear implant surgery.This was a retrospective case series of 22 cochlear implant patients who developed post-implant haematoma over the receiver area. Haematoma extension and fluid collection were analysed via ultrasonography, implant type and predisposing factors such as trauma, coagulation disorders and type of skin incision.Patients were divided into four groups on the basis of the main predisposing factor: coagulation disorders (n=7), trauma (n=3), revision surgery (n=6) and haematoma of unknown origin (n=6). The main factors correlated to haematoma onset were coagulation disorder, type of skin incision and flap revision. In all, 21 subjects had complete recovery and the speech perception performance was not compromised over time, while 1 subject (0.3%) with an extensive haematoma due to a pharmacologically induced coagulation disorder required explantation of the device.

The image quality of 64-MDCT provided excellent definition of the fine osseous structures and individual electrode contacts. Evaluation of electrode distances revealed a more focused stimulation for the Helix contacts, with better optimization of pulse width and frequency of stimulation.A multi-slice CT scan was performed postoperatively to evaluate electrode distance from the modiolus and variability of fitting parameters (M level) for two different types of cochlear implant electrode carriers, CII and 90K implants with 1J and Helix electrode carriers.The electrode's position in different cochlear implant (CI) electrodes, Advanced Bionics 90K 1J and Helix, was assessed postoperatively in 20 adult patients by means of a 64-MDCT scanner. Axial, coronal, and oblique 0.3 mm multiplanar reconstructions (MPRs) were obtained and datasets were analyzed to assess the intracochlear position and distance from the surface of the electrodes to the bony edge of the modiolus. Patients' fitting characteristics were gathered at the time the CT was performed and correlated to intracochlear measurements.Determination of contact distances confirmed smaller average values for the Helix at the apex and medial segments. Helix electrodes were closer to the modiolus in all segments. Likewise, M level determination showed lower values for the Helix carrier, confirming a more focused stimulation and better optimization of pulse width and frequency of stimulation.

The aim of the present study is to construct a reference model with the indication for the attitude, the requirements and the resources needed in order to be able to deal with deafness in the presence of disabilities or associated problems. The study group consisted of 13 adults and 18 children affected by profound deafness, with associated problems and disabilities, who were implanted with Clarion® and Med-El® devices. Selection criteria for candidacy to cochlear implantation and counselling, hospitalization, fitting and speech therapy/rehabilitation are described. Findings were assessed evaluating: (i) use of acoustic feedback, on the ground of Erber's model; (ii) self-sufficiency: assessed by a questionnaire; and (iii) social and family relationships: qualitative judgment based on direct observation, analysis of drawings and structured interviews with family teachers and therapists. The whole group showed benefit from cochlear implantation, with particular satisfaction for post-lingual deaf-blind adults, as well as for subjects with associated psychopathologies and mental retardation. In conclusion, cochlear implants can improve life quality in profoundly deaf subjects with associated disabilities, increasing both listening and communication skills as well as self-sufficiency while family and social relationships tend to remain stable.

To determine whether an early physical rehabilitative program could improve and/or accelerate recovery from a postoperative deficit of facial nerve (FN) function.A retrospective study of the charts of patients who presented a postoperative FN deficit after surgery for acoustic neuroma (AN) was carried out. Twenty-nine patients were enrolled and divided into 2 groups: 18 who underwent early physical rehabilitation and 11 who did not undergo rehabilitation. All the AN patients underwent translabyrinthine removal and were classified preoperatively according to the House-Brackmann staging system. Physical rehabilitation was performed according to Kabat (i.e. neuromuscular facilitation). FN function was assessed postoperatively and classified according to the House-Brackmann grading system.In Grade IV and V patients, early rehabilitation allowed a faster and better recovery with respect to AN patients for whom rehabilitation was not carried out.Early physical rehabilitation has proved to be effective as a helpful tool for recovery from FN deficit and it is therefore advisable to use it soon after surgery, especially for FN deficits worse than Grade IV.

Background: Acquired cholesteatoma is a complication of chronic otitis media that is usually associated with an intense local inflammatory reaction. Cholesteatoma probably arises from epithelial migration close to an ongoing host inflammatory response attributable to a chronic bacterial infection. Chlamydia pneumoniae is an intracellular microorganism associated with several pathologic conditions originally considered noninflammatory, including asthma, atherosclerosis, and Alzheimer disease. To investigate a possible relationship between C. pneumoniae and the development of cholesteatoma, tissue was studied in three different layers by polymerase chain reaction analysis. The results were compared with those relative to other two common middle-ear pathogens, Mycoplasma pneumoniae and Haemophilus influenzae. Methods: Cholesteatoma specimens were collected from 32 patients undergoing middle ear surgery. A series of 5-m-thick specimens were obtained at three different tissue levels, internal (matrix), intermediate (perimatrix), and external (granulation tissue), and processed by polymerase chain reaction for detection of C. pneumoniae, H. influenzae, and M. pneumoniae. Fragmentation and polymerase chain reaction amplification were carried out using two substantially different techniques. Results: C. pneumoniae was detected with either polymerase chain reaction techniques in the internal layers in 16 of the 32 cholesteatomas (50%), associated with a positive finding in the intermediate layer in two cases and in the external layer in one case. Four specimens contained H. influenzae, always in the external layer, whereas none contained M. pneumoniae. Conclusions: The close relationship between cholesteatoma and C. pneumoniae demonstrated by the findings of this study could suggest a direct cause and effect link between the pathogen action and the clinical manifestations. Otherwise, a facilitated colonization by C. pneumoniae and chronic pathology of the ear could both take origin from a peculiar immunologic background of the host. Otol Neurotol 24:353–357, 2003.

To evaluate the effects of non-invasive ventilation (NIV) with facial mask or helmet on middle ear (ME). DESIGN. Prospective, randomised study.University hospital.Ten healthy subjects randomly allocated in two groups of five subjects each.NIV for 1 h, with helmet (group H) or facial mask (group M). Flow-triggered pressure support was 10 cmH(2)O, PEEP 5 cmH(2)O, FiO(2) 0.21.Impedenzometry was performed before NIV and 5 min after NIV ended; it was repeated 60 min later. In group H the acoustic compliance increased after NIV from 2.0+/-.6 ml to 2.3+/-.6 ml ( P.01), suggesting that the tympanic membrane became less stiff; 1 h later the compliance returned to basal values (2.0+/-.7 ml); in group M the compliance was unaffected (from 2.0+/-.5 ml to 2.0+/-.4 ml; 1.9+/-.4 ml 1 h later). The acoustic reflex, i.e., the contraction of the stapedial muscle in response to an auditory stimulus, involving the acoustic and facial nerves, was also evaluated during impedenzometry at 250 Hz, 500 Hz, 1,000 Hz, and 4,000 Hz; no significant change of the threshold was observed.The tympanic membrane is tighten by the tensor tympani and a reversible loosening suggests muscle fatigue in response to the application of intermittent positive pressure applied to the external ear during NIV with helmet. The loss of tensor tympani protective action could theoretically predispose the middle and inner ear to mechanical damage during NIV with helmet, suggesting the use of protective devices (ear plugs) in selective cases requiring long-term, high-pressure treatment.

In the literature, this is the first description of a delayed retroauricular cerebrospinal fluid (CSF) collection in a child after 18 months of cochlear implantation. During surgical revision, anomalous thinning of the dura and leakage of CSF was found beneath the receiver, requiring local sealing and repositioning. Exposure of the dura is a procedure usually performed during housing of the receiver to avoid excessive protrusion of the implant in subjects with insufficient bone thickness. In most cases, this has proved to be a safe procedure. However, in some cases, as in children, exposure of the dura should be undertaken with care.

The aim of the present study was to investigate the application of two new pitch perception tests in children with cochlear implants (CI) and to compare CI outcomes to normal hearing (NH) children, as well as investigating the effect of chronological age on performance. The tests were believed to be linked to the availability of Temporal Fine Structure (TFS) cues. 20 profoundly deaf children with CI (5–17 years) and 31 NH peers participated in the study. Harmonic Intonation (HI) and Disharmonic Intonation (DI) tests were used to measure low-frequency pitch perception. HI/DI outcomes were found poorer in children with CI. CI and NH groups showed a statistically significant difference (p

Objectives: To assess the therapeutic effectiveness of an intratympanic (IT) steroid protocol compared to a systemic steroid protocol. Methods: A total of 265 consecutive patients presenting unilateral idiopathic sudden sensorineural hearing loss were divided into 2 groups. One group comprised 131 patients enrolled between May 2009 and May 2010, and the other consisted of 134 patients enrolled between June 2010 and June 2011; a total of 48 patients were excluded among the 2 groups. The first group received oral prednisone for 8 days in tapering doses; the second group had IT prednisolone at a dose of 62.5 mg/ml once a day for 3 consecutive days. Audiological examinations were performed at study entry and 30 days after the beginning of therapy. Mean pure tone audiometry (PTA) of both groups and hearing outcomes following the criteria of Furuhashi et al. [Clin Otolaryngol 2002;27:458-463] and Siegel [Otolaryngol Clin North Am 1975;8:467-473] were investigated. Results: The strong efficacy of steroid therapy was evident in both groups, observing both PTA and hearing threshold improvement. The evaluation of the hearing outcomes shows a significantly better result for the short-term IT protocol; this result is ascribable to two types of audiometric curves: down- and up-sloping. Conclusion: The results show a significant efficacy of both steroid therapeutic approaches. There was no significant difference in PTA improvement between the 2 study groups; the short-term IT protocol led to better results in the evaluation of the hearing outcomes (following the criteria of Siegel and Furuhashi et al.) for up- and down-sloping audiometric curves.

The results of the present study reject the hypothesis that epithelial inclusions into the ossicles could cause cholesteatoma recurrences, but strongly suggest the performance of a safe cleaning procedure for ossicular remnants to make them usable in ossiculoplasty in patients with partially or non-encapsulated cholesteatoma.The aim of the study was to define, before any sort of cleaning procedure, if there is any epithelial inclusion inside the ossicles of patients with cholesteatoma and if the findings could be correlated with surgical aspect of cholesteatoma.The specimens used for this study comprised 19 mallei and 15 incudes, which were obtained intraoperatively from 24 patients. Each ossicle was grouped on the basis of the intraoperative aspect of the cholesteatoma as follows. Grade 1: 10 ossicles obtained from encapsulated cholestatoma, non-invasive, easily cleavable. Grade 2: 14 ossicles obtained from partially encapsulated cholesteatoma, non-invasive, not easily cleavable. Grade 3: 10 ossicles obtained from non-encapsulated cholesteatoma, invasive, not cleavable. Two stapes and one malleus were taken from patients who underwent middle ear surgery for conductive hearing loss and were used as controls. The ossicles were examined histopathologically after removal.Our results do not show any epithelial inclusion inside the ossicles independently from the macroscopic aspect or growing aggressiveness of cholesteatoma. In addition there was no infiltration of inflammatory cells in grade 1, but it was present in one incus (7.1%) of grade 2 and in five ossicles (50%) of grade 3. In ossicles of grade 3 up to four layers of epithelial cells were found on the surface of the ossicles.

Objectives To assess skills in inferences during conversations and in metaphors comprehension of unilaterally cochlear implanted children with adequate abilities at the formal language tests, comparing them with well-matched hearing peers; to verify the influence of age of implantation on overall skills. Methods The study was designed as a matched case–control study. 31 deaf children, unilateral cochlear implant users, with normal linguistic competence at formal language tests were compared with 31 normal hearing matched peers. Inferences and metaphor comprehension skills were assessed through the Implicit Meaning Comprehension, Situations and Metaphors subtests of the Italian Standardized Battery of “Pragmatic Language Skills MEDEA”. Differences between patient and control groups were tested by the Mann–Whitney U test. Correlations between age at implantation and time of implant use with each subtest were investigated by the Spearman rank correlation coefficient. Results No significant differences between the two groups were found in inferencing skills ( p = 0.24 and p = 0.011 respectively for Situations and Implicit Meaning Comprehension). Regarding figurative language, unilaterally cochlear implanted children performed significantly below their normal hearing peers in Verbal Metaphor comprehension ( p = 0.001). Performances were related to age at implantation, but not with time of implant use. Conclusions Unilaterally cochlear implanted children with normal language level showed responses similar to NH children in discourse inferences, but not in figurative language comprehension. Metaphors still remains a challenge for unilateral implant users and above all when they have not any reference, as demonstrated by the significant difference in verbal rather than figurative metaphors comprehension. Older age at implantation was related to worse performance for all items. These aspects, until now less investigated, had to receive more attention to deeply understand specific mechanisms involved and possible effects of different levels of figurative language complexity (presence or absence of contextual input, degree of transparency and syntactic frozenness). New insight is needed to orient programs in early intervention settings in considering and adequately responding to all these complex communicative need of children with hearing loss.

Objective: To propose the application of an intraoperative videomonitoring system in otologic and otoneurologic surgery. The authors also compare results obtained by using this system with findings deriving from electromyography and pneumosensorial monitoring methods. Study Design: The single-subject design study, involving six patients with middle ear or otoneurosurgery, compares reliability of different monitoring procedures, expecially in terms of advantages and drawbacks. Setting: Video system versus electrophysiologic and pneumosensorial systems. Patients: Two patients affected with chronic otitis media, two from Meniere's disease, and two from Acoustic Neuroma. Interventions: Intraoperative diagnostic and prognostic. Results: Electrophysiologic method shows more sensibility, but is affected by a moderate grade of false positive because of electric artifacts; videomonitoring system showed less sensibility, but appears reliable; pneumosensorial system gives inbetween results. Conclusions: In intraoperative monitoring techniques, reliability and feasibility are the most important factors and are achieved, in this study, by the videomonitorig system. Video recording of images have permitted further off-line analysis.

Herpes simplex virus (HSV) encephalitis is a life-threatening consequence of HSV infection of the central nervous system. Although HSV encephalitis is rare, mortality rates reach 70 per cent in the absence of therapy and only a minority of individuals return to normal function. Antiviral therapy is most effective when started early, necessitating prompt diagnosis.A case of atypical HSV encephalitis is reported. The appearance of a strong headache followed by impairment of consciousness and hypertone of arms and legs complicated the post-operative course in a 33-year-old patient who underwent surgical removal of an acoustic neuroma. Several brain magnetic resonance imaging (MRI) and computed tomography scans performed in the first week after onset of symptoms of infection did not establish a proper diagnosis. Diffusion-weighted MRI detected brain abnormalities on the fourth day after onset of symptoms, and polymerase chain reaction identification of HSV 1 DNA confirmed the diagnosis. A positive prognosis was achieved due to the decision to start specific, high-dose antiviral therapy based on clinical suspicion, before a firm diagnosis was established.

Idiopathic causes of retroauricular pain are rarely seen in clinical practice. We present a 9-year-old child who suffered from atypical retroauricular pain resistant to conventional treatment. After excluding any other cause of retroauricular pain, a nerve block was performed with a 0.3 ml lidocaine 1% injection into the trigger point. We believe that this case report is important because in the literature there are no similar cases described in children.

The aim of this study is to present a patient who developed a pneumolabyrinth following intratympanic steroid injection performed one year after stapes surgery. The patient started a medical treatment but since no improvement of his symptoms occurred, 10 days after the intratympanic injection a surgical treatment was proposed. An exploratory tympanotomy showed a displacement of the stapes prosthesis from the platinotomy, a dislocation of the incus long process, a fracture of the footplate and a depression into the vestibule. The fragment of the broken footplate was removed, a new prosthesis was located. Nausea, vertigo and nystagmus resolved immediately following surgery with a hearing threshold unchanged. In the present case report, the pathogenesis of pneumolabyrinth may be connected to an IT steroid injection proposed to the patient for the onset of sudden sensorineural hearing loss. To our knowledge, no case of a pneumolabyrinth provoked by intratympanic steroid injection has been previously described.

The results demonstrate the stability of the efficacy over time of the intratympanic prednisolone protocol and they suggest that the spontaneous recovery does not significantly influence the long-term evaluation of intratympanic therapy. A 10-day follow-up after 3 days of intratympanic prednisolone administration can be considered a sufficient period to evaluate the effectiveness of the undertaken therapy.To assess the stability of the efficacy over time of intratympanic steroid therapy for patients with idiopathic sudden sensorineural hearing loss.A total of 122 patients received an intratympanic steroid injection of prednisolone daily for 3 days. Audiograms were performed before therapy and at 10 days and 1 year after therapy. Successful recovery was defined as complete and partial recovery using Siegel's criteria and complete and marked recovery following Furuhashi's criteria.The comparison of audiometric data at study entry, at 10 days, and at 1 year after the treatment showed a statistically significant improvement of the mean pure tone audiometry. The evaluation of the hearing outcomes demonstrated a statistically significant improvement, with similar success rates when evaluated 10 days and 1 year after the treatment. Comparing the hearing outcomes at 1 year with the results at 10 days, no significant difference was detected between these two time points.

Objective: To evaluate, with a long-term follow-up, the speech perception and language development in children with cytomegalovirus (CMV)-related deafness after cochlear implantation. Study Design: A retrospective study on CMV-related profound deafness and cochlear implantation was performed from 1995 to 2010. Six children with an average follow-up of 10 years were included in this research. Medical history, imaging, cognitive delay, speech perception and production data were reviewed. Results: Two of the 6 patients developed a functional language with the use of phrases and word sequences based on morphological and syntactic rules; the others demonstrated the development of a preverbal or transitional language with the use of single words only. Conclusion: Patients with CMV-related deafness benefit from cochlear implantation; however, the expectations of the parents must be evaluated in a series of counseling efforts prior to the surgery.

The excellent tolerability of intratympanic (IT) steroid offers the possibility to use a high dose, which would appear to be more effective than intravenous (IV) steroid treatment, when both are associated with hyperbaric oxygen (HBO) therapy.The purpose of the study was to assess for the first time the efficacy of the association of IT steroid and HBO therapy in patients presenting idiopathic sudden sensorineural hearing loss (ISSNHL), comparing this protocol with another consisting of IV steroid administration and HBO therapy.A total of 48 patients presenting ISSNHL were recruited. Patients were divided into two categories: the severe ISSNHL group with a pure-tone average (PTA) between 70 and 90 dB, and the profound ISSNHL group with a PTA90 dB. The first protocol consisted of 10 days of HBO therapy together with IV methylprednisolone 1 mg/kg body weight for 7 days; the second protocol consisted of HBO therapy for 10 days, associated with an IT injection of prednisolone at a dose of 62.5 mg/ml, once a day for 3 consecutive days, performed 2 h before the HBO therapy.The overall success rate was superior in the group submitted to IT steroid and HBO therapy. Nevertheless, these clinical results were not statistically significant.

The Harmony processor was found to be reliable, comfortable and offered a substantially increased battery life compared with the previous generation processor. No significant improvement in speech understanding with HiRes was demonstrated from objective measures, but the majority of subjects showed a clear subjective preference for the combination HiRes 120/Harmony processor.To evaluate experience with the Harmony™ sound processor, together with the HiRes 120 strategy.Postlingually deafened adults implanted with a CII or HiRes 90K were included and divided into three groups: (1) experienced users using the Platinum body-worn processor; (2) experienced users who had been using other processors; (3) new users with the Harmony processor from first fitting. The latter group entered a randomized crossover protocol where half were initially fitted with HiRes and half with HiRes 120. The initial strategy was used for 3 months and the alternative for a further 3 months. Speech perception tests and questionnaires were performed.The study included 65 subjects. Implementing HiRes 120 was straightforward. The speech test group results did not show significant differences between HiRes and HiRes 120. However, the questionnaires showed significantly higher ratings for HiRes 120 in some instances. Subjects were highly satisfied with the Harmony processor.

Introduction: Serotonin seems to play a central role in tinnitus. The intensity dependence of auditory evoked potential (IDAP) is considered an index of central serotonergic activity in the auditory cortex. The higher the steepness of the N1/P2 component amplitude-stimulus function slope (N1/P2 ASF slope as calculated by IDAP), the lower the central serotonergic activity. Similarly, the N1 amplitude-stimulus function slope (N1 ASF slope) was investigated. Auditory brainstem responses (ABR) examine the auditory system functionality from the periphery and through the brainstem, where serotonergic projections have been identified. Objectives: Assessing whether tinnitus perception neurotransmitters activity inbalance could be investigated by an electrophysiological approach. Materials and Methods: Ten normoacousic tinnitus patients and 14 healthy controls were included in the study. Subjects underwent EEG (IDAP) recording, ABR recording and psychometric questionnaires administration. Results: N1/P2 ASF slope and N1ASF slope tended to have a greater steepness in patients. N1ASF slope was significantly correlated with ABR wave V and interpeak III-V latencies in patients. ABR wave V and interpeak III-V latencies were significantly longer in patients than in controls. Conclusion: N1/P2 ASF slope, N1 ASF slope and ABR components appear to be useful electrophysiologic methods to study possible functional alterations related to the serotonergic activity.

Stapedectomy is known to give good results for otosclerosis. In this study, an audiometric evaluation of patients who underwent small-opening stapedotomy has been carried out at an early stage (3 and 5 days after surgery), and 1 month after surgery. At day 5 almost 60% of the patients showed a good functional result (mean residual post-op air conduction/pre-op bone conduction gap within 5 dB). While the timing of 4 kHz recovery overlapped that of the lower frequencies, recovery for 8 kHz was evident only at day 30, and was less likely to occur than for 4 kHz.

Objectives/Hypothesis: Facial synkinesis and hyperkinesis commonly impair the outcome of facial nerve palsy. Botulinum toxin type A has shown positive results in the treatment of these symptoms. Our experience is reported in this article. Study Design: Prospective study. Methods: Forty-one patients affected by facial synkinesis and hyperkinesis due to facial palsy were treated. The etiology of the facial palsy was: 28 Bell's palsy cases, nine iatrogenic cases (seven acoustic neuroma surgeries, one tympano-jugular glomus tumor removal, and one middle ear surgery), three herpes zoster virus cases, and one case of Melkersson-Rosenthal syndrome. Botulinum toxin type A was used in the treatment. Clinical evaluation was obtained through the Sunnybrook Grading Scale and an author's modification of this method purposely designed for evaluation of hyperkinesis. Further evaluation through a self-administered synkinesis questionnaire was also performed. Results: All patients showed some improvement of synkinesis and hyperkinesis after treatment. The mean values of the data obtained, regardless of the method of evaluation, gave statistically significant results. Correlation between objective and subjective evaluation methods was also statistically positive. Conclusions: This work stresses the importance of considering synkinesis and hyperkinesis separately because they are different conditions. These two symptoms showed improvement after botulinum toxin treatment, but only hyperkinesis showed a positive correlation when objective and subjective evaluations were performed. This treatment is effective in the management of facial synkinesis and hyperkinesis due to facial palsy, thus improving quality of life. It is a safe, minimally invasive treatment that can be repeated.

Cochlear Implantation (CI) can be considered the elective choice for the treatment of severe and profound hearing loss. Its benefits are already well documented in children and in postlingually deafened adults (Bond et al., 2009; Manrique et al., 1998), whilst there is still some controversy concerning prelingually deafened adolescents and adults. Initial studies on the last two populations showed only limited improvement post-implant for closed-set speech perception tasks and for the recognition of envi-ronmental sounds, with no open-set recognition in most patients. Furthermore, the authors concluded that only a few patients with long-term prelingual deafness could be considered good candidates for CI. This can be attributed to the fact that, if implanted during this phase, prelingually deafened adolescents and adults have passed the ‘sensitive period’ for language development and the ability of the central nervous system to reorganize itself is more limited. Moreover, adolescents and adults with prelingual deafness represent a very heterogeneous group of patients, owing to age at implantation, duration of auditory deprivation, residual hearing, level of language skills, communication modes, and educational experience, all of which can affect post-implant outcomes and this makes it more difficult to decide which option to take. Finally, in adolescents further difficulties are linked to the critical period that they have to face in terms of physical, mental, emotional, and social developments and changes. During the last years, authors have widened prospects in this field via the evalua-tion of further important parameters such as quality of life, personal satisfaction, well-being, schooling, and employment. Thus, despite the limited improvement in speech perception, they were able to show positive effects resulting from cochlear implantation on the quality of life (Zwolan et al., 1996; Klop et al., 2007). However, there are still only a few papers to be found in literature on this topic. Published by Maney Publishing (c) W. S. Maney & Son Limited

(2010). Use of Sign Language in Paediatric Cochlear Implant Users: Whys and Wherefores. Cochlear Implants International: Vol. 11, Proceedings of the 9th European Symposium on Paediatric Cochlear Implantation, Warsaw, 2009, pp. 249-253.

OBJECTIVE The present study proposes an evolution of an intraoperative video-based facial nerve monitoring system for otologic and otoneurosurgical procedures in comparison with classical electromyographic (EMG) monitoring method. STUDY DESIGN Single-subject design study. SETTING Tertiary referral center, university clinic. PATIENTS Fifteen patients undergoing a translabyrinthine approach for removal of 2 cm or less acoustic neuroma. INTERVENTION Intraoperative monitoring during acoustic neuroma removal. MAIN OUTCOME MEASURES Measurement of mouth angle displacement and EMG peak amplitude at different stimulation intensities were measured and compared to evaluate the validity and reliability of the proposed new system. RESULTS The electrophysiologic method has been shown to be slightly more sensitive, although it shows limitations especially in terms of electrical artifacts during cauterization, totally masking the EMG monitoring. CONCLUSION The present version of video system can be considered as valid and reliable as EMG; its main advantages are the absence of electrical artifacts, less invasivity, and much less cost.

Conclusions: The increased spectral resolution that characterizes the HiRes 120 device contributes to improvement of performance. Discrimination and identification in noise are consistent with reports of improved perception under everyday listening situations. Objectives: This work focuses on speech perception findings after implementation of current steering in HiResolution strategy of children implanted with Clarion HiRes 90K. Subjects and methods: Comparison was made between three groups of children: standard HiRes control group, a second group switched over from HiRes to HiRes 120 and the third group switched on with HiRes 120. Children were tested before and 12 months after implementation of HiRes 120. A standard test battery was administered to obtain a speech perception development profile. The Auditory Speech Sound Evaluation (A§E) test was carried out to evaluate discrimination and identification of phonemes in quiet and in noise. Results: The HiRes and HiRes 120 switch-over groups showed quite similar results for speech perception in quiet. However, the HiRes 120 switch-over group achieved these results within a shorter time after conversion. Switch-on children showed improvement in all speech perception categories, reaching approximately 60% recognition and 30% comprehension in quiet. Results for A§E discrimination scores in quiet and noise showed a clear improvement for both HiRes 120 switch-on and switch-over groups compared with the HiRes group.

Objectives:The aim of this study was to document the occurrence of a cavernous haemangioma of the external auditory canal, and to review the literature on this pathology.Methods:We report the clinical presentation, imaging studies, surgical procedure and histological findings for a cavernous haemangioma of the external auditory canal.Results:This patient represents the fourth reported case of cavernous haemangioma affecting only the external auditory canal. A cavernous haemangioma of the external auditory canal, not affecting the tympanic membrane, was surgically removed, without post-operative complications.Conclusions:Cavernous haemangioma of the external auditory canal is a rare otological pathology. Computed tomography imaging is important in order to precisely define and localise the site and size of the lesion. Histological examination is necessary for the correct diagnosis of the pathology.

Objective:We report a case of a rare cochlear implant complication: the introduction of the electrode array into the superior semicircular canal, with intra-operative measurements of neural response reactions suggesting reasonable functioning of the implant.Case report:A two-year old patient affected by congenital, profound, sensorineural deafness underwent bilateral cochlear implantation at the ENT clinic of the ‘La Sapienza’ University of Rome. Two Clarion 90k devices were implanted, and electrophysiological and radiological checks were performed. After the introduction of the array in the right side, neural response imaging was performed, and a neural potential was found only on two apical electrodes, at a stimulation intensity of 431 clinical units. The situation differed on the left side, where neural response imaging was present at a stimulation intensity of 300 clinical units on the two electrodes tested (one apical electrode (number three), and one middle electrode (number nine)). Intra-operative radiological assessment with a transorbital plain films was performed as usual in order to assess the position of the electrodes inside the cochlea. This radiography showed the electrode array to be in the superior semicircular canal in the right ear.Conclusion:Intra-operative monitoring tests during cochlear implant surgery play different roles; measurement of impedances and neural response imaging can evaluate the integrity of implant electrodes and the status of the electrode–cochlea interface, but it must not be the sole way in which correct positioning of the array is confirmed. In our opinion, intra-operative radiological assessment is mandatory during cochlear implant surgery.

Conclusions. Increased spectral resolution via implementation of perceptual channels with HiRes120 (PSP) would seem to provide better perception of music than with standard HiRes, mainly from the point of view of music appreciation as recorded via the questionnaire. More specific tests are required for appreciation of timbre, preferably by application of protocols based on perceptual attributes using rating scales, which would not be biased by knowledge of music. Objective. The objective of this study was to verify the hypothesis whereby the implementation of perceptual channels in HiRes120 may lead to an improvement in the perception of music, owing to an increase in spectral resolution. Subjects and methods. Music perception was studied in 12 adult subjects, making a comparison between performance with HiRes90 and HiRes120 with perceptual channels. Quality of perception, loudness and rhythm were all assessed via a questionnaire. Further tests included timbre recognition trials and pitch ranking. Results. Whereas there was a significant improvement in appreciation of music as seen by the questionnaire, timbre and pitch trials seemed to be biased by various subjective factors and require further study using different criteria.

Available multichannel cochlear implants (CIs) provide effective tinnitus suppression. More sophisticated speech strategies are more effective than analogue or slow strategies. The mechanisms by which tinnitus is suppressed by CIs are unclear; however, both acoustic masking and reorganization of the right auditory association cortex induced by the CI are possible mechanisms. CI significantly reduced the tinnitus-related Handicap as assessed by the Tinnitus handicap Inventory (THI).The objective of the study was to evaluate the effects of a unilateral CI on bilaterally perceived tinnitus.Forty-one profoundly deaf patients implanted with a multichannel CI reporting bilateral tinnitus were evaluated. All patients were asked to complete a questionnaire that evaluated the presence, location and intensity of tinnitus before and after cochlear implantation.Seven patients (17%) reported the perception of a 'new tinnitus' after surgery. With the CI off tinnitus was abolished in 23 patients (56.1%) in the implanted ear and in 22 patients (53.6%) in the contralateral ear. With the CI on tinnitus was abolished in the ipsilateral ear in 27 patients (65.8%) and in the contralateral ear in 27 patients (65.8%). Statistical analysis showed a significant reduction of the total THI score and of each subscale score (p0.001).

All the classification of precancerous lesions are based on the progression of specific histopathological characteristics, which in turn considers the grade of epithelial hyperplasia and dysplasia, nevertheless the transformation of laryngeal keratosis into carcinoma occurs through progressive modifications of normal epithelium in keratosis without dysplasia, to the point of degenerating into carcinoma in situ. The treatment of laringeal precancerosis has not yet defined a gold standard: according to some authors, a simple excision biopsy may be sufficient, others, instead, perform the stripping of the involved vocal cord, while others yet perform vaporization by means of CO2 laser. The aim of this paper is to evaluate and possibly validate the treatment of mild and moderate laryngeal dysplasia (LIN1-2) by CO2 laser, with particular attention to oncological and functional results. Fifty-eight patients (44 males and 14 females, mean age 54.3 years) affected by mild and moderate dysplasia (32 LIN I and 26 LIN II) diagnosed by a bioptic exam, were treated by performing a CO2 laser cordectomy (following the European Society of Laryngology’s criteria). Before surgery to the patients was given a questionnaire to identify primary risk factors such as smoking, alcohol use and gastroesophageal reflux, were also handed a Vocal Performance Questionnaire. In all patients was performed a pH measurement over a 24-h period, a voice evaluation using a Kay digital Strobe 920. 84% of patients were smokers; the presence of reflux was reported in 11 patients (19%). The 32 LIN1 cases treated with type I cordectomy determined four recurrences (12.4%), of which two LIN1, one LIN2 and one carcinoma in situ. Of the 26 LIN2 cases examined, the 12 treated with type 1 cordectomy generated 1 recurrence alone with the presence of an invasive carcinoma (T1a) (8.3%), while no recurrences were reported in the group of 14 LIN2 cases treated with type II cordectomy. 93.1% (54/58) of cases showed a complete closing of the glottal plane over time. Considering the results in terms of disease control, and functional outcomes, our experience suggests subepithelial cordectomy (ELS I) for LIN 1 and subligament cordectomy (ELS II) for LIN 1 recurrences; therefore we suggest subligament cordectomy (ELS II) in LIN 2 cases.

Objectives/Hypothesis: The present study is a long-term follow-up of speech perception outcomes and cochlear implant use in three cases of meningitis that occurred after cochlear implantation. Study Design: Case series study. Methods: Study was performed on three children implanted with different models of Clarion® devices, two of them with positioner. Recognition and comprehension were assessed via the Italian adaptation of GASP (TAP) test, and phonetically balanced bi-syllabic words in open-set. High resolution computed tomography scan acquisition was performed to obtain axial coronal and oblique multiplanar reconstructions of the cochlea. Results: Two patients were affected by enlarged cochlear acqueduct and Mondini malformation the first carrying positioner. One patient had a normal cochlea, and the positioner could have been the main cause of bacterial spread. As a consequence of meningitis the child with normal cochlea and the other with enlarged vestibular acqueduct developed cochlear ossification, increased M-level and worsening of hearing outcomes. The child with Mondini malformation developed facial nerve stimulation. Contralateral implantation was performed in the first two patients. Conclusion: Bacterial meningitis occurring after cochlear implantation may induce cochlear ossification, facial nerve stimulation, and permanent or temporary loss of implant use. Planned follow-up with high resolution computed tomography and evaluation of M-levels could be useful prognostic tools in the management of these patients.

Objective: To identify patients developing positional vertigo after cochlear implantation. Study Design: Prospective study on a cohort of patients undergoing cochlear implantation. Setting: Academic tertiary referral center. Patients: The study included 70 consecutive patients who underwent vestibular evaluation before and after cochlear implantation. Intervention: Medical record review. Main Outcome Measure: Recorded vestibular symptoms after cochlear implantation. Patients with positional vertigo were considered case subjects, whereas those without vestibular symptoms were considered case controls. Results: Benign paroxysmal positional vertigo (BPPV) occurred in 8 patients (on the cochlear implant [CI] side in 7 patients, and in the other ear in 1). One patient had BPPV of the lateral semicircular canal on the implanted side, and 7 patients had BPPV of the posterior semicircular canal (on the same CI side in 6 patients, and on the opposite side in 1), which were detected and presented during the last examination. In 5 patients, the onset of symptoms varied from 7 to 130 days after implant activation; in 2 patients, the onset occurred before activation. Conclusion: Three different mechanisms are proposed for the occurrence of BPPV in patients with CI. The first focuses on the fall of bone dust particles into the cochlea during cochleostomy. In the second, the vibration caused by drilling the cochlea would be sufficient to dislodge otoconia into the labyrinth. The third hypothesis suggests dislodging of an otolith because of the electric stimulation. In our patients, conservative approaches have been used with a minimal invasive cochleostomy and without perilymph suction. Thus, the vibratory trauma affecting the cochlea during cochleostomy seems to play a fundamental role in the development of paroxysmal vertigo in patients with implant. Key Words: Positional vertigoVCochlear implantation. Otol Neurotol 28:764Y767, 2007.

The aim of the study was to investigate changes in middle ear dynamic characteristics caused by both otosclerosis and stapes surgery (platinotomy, prosthesis positioning, ossicular chain maneuver) and to evaluate distortion product otoacoustic emissions (DPOAEs) before and following surgery. The study included 15 patients (12 women, 3 men; mean age 51 years; range 32-69 years) with advanced otosclerosis. All the patients were evaluated with the use of pure-tone audiograms (preoperatively, 5 and 30 days after surgery), stapedial reflexes (preoperatively), and DPOAE recordings (preoperatively, at the end of surgery, and 5 and 30 days after surgery). Changes in the hearing thresholds and in the DPOAE amplitudes were compared. Preoperative tests showed conductive hearing loss, with a mean air-bone gap of 36.6 dB HL ranging from 0.25 to 1 kHz, and no stapedial reflexes were detected. DPOAEs were not measurable preoperatively, and they were detected only in 2 patients at the end of surgery, with low amplitudes in a narrow frequency range. No significant changes occurred in DPOAEs 5 days postoperatively. A month after surgery, improvement in conductive hearing loss was observed; the mean air-bone gap from 0.25 to 1 kHz was 12.9 dB HL, whereas the higher frequencies were still affected by the disease. DPOAEs increased in amplitude in 4 patients, but this was not significant. It remains unclear why DPOAEs are not detected despite a subjective hearing improvement and a sufficiently closed air-bone gap at least in middle and low frequencies. The results of our study show that DPOAEs cannot replace behavioral threshold tests; they may only be included in a battery of tests for a complete clinical follow-up for efficiency monitoring after stapes surgery.

Cochlear implantation (CI) may induce vestibular impairment soon after surgery as well as after implant activation. This impairment seems to be independent from the cause of deafness and can be considered a possible complication from the intra-operative trauma and, to minor degree, from the ongoing electric stimulation. It would also seem that vestibular damage occurs independently from the likelihood of post-operative hearing deterioration. In unilateral selected CI cases, vestibular examination can be proposed as additional pre-operative exam for selection of the ear to be implanted.This study has been planned in order to get evidence of eventual impairment of the vestibular apparatus after cochlear implantation as well as to verify whether the impairment could be related to different variables, such as cause of deafness, concomitant hearing deterioration, surgical trauma and duration of electrical stimulation.Charts from two different populations of implantees have been reviewed, 21 from a prospective, 72 from a retrospective study, respectively. All the patients were implanted with Clarion(R) devices of different generation. Vestibular testing was based on rotatory, caloric (when possible) and stabilometric measurements, which were carried out pre-operatively and at the following different times: 5 weeks after CI surgery, and 30, 60 and 90 days after CI activation. Hearing thresholds were also assessed in those patients who showed signs of vestibular impairment as well as in a group of patients without vestibular disorders (control). Patients belonging to the retrospective group were all asked to fill a questionnaire regarding their balance condition. Results. In 14.3% of the prospective study group, a grade I and II spontaneous nystagmus was evidenced pre-operatively and remained unchanged during the whole assessment period. A grade II spontaneous nystagmus was present in 3 patients (21.4%) of the same group after surgery. In the immediate post-operative period, vestibular impairment was displayed as true rotational vertigo in 21.4% and unsteadiness in 42.8% of the study group. Severe unsteadiness was present during the first 2 days after activation in 14.3% of the subjects. In 21.4% of the patients a VPPB episode occured. In the retrospective study group, 26.4% of the subjects referred pre-operative dizziness and 25 patients (34.7%) referred immediate post-operative vertigo episodes, which remained in a milder form after CI activation in 12% of them. The hearing threshold showed to deteriorate in both vestibular-impaired and control CI population without significant difference.

Electrocochleography was conducted in 185 patients with Menière's disease and 117 with sudden deafness. Electrophysiological findings from the two groups were compared in order to identify pathogenic similarities between the two conditions. Parameters investigated were the summating potential (SP)/action potential (AP) ratio, audiometric profiles and audiometric changes after medical therapy. A high SP/AP ratio was found in the patients with sudden deafness, thus supporting a possible hydropic aetiology in this group. In conclusion, electrocochleography can be considered a useful technique as it permits identification of an hydropic condition in certain cases of sudden deafness.

Sigmoid sinus thrombosis (SST) usually follows acute as well as chronic otitis media with coalescent mastoiditis. A singular case of noncoalescent mastoiditis complicated with thrombosis of deep cerebral sinuses occurring in a young child is presented. A genetic thrombophilic disorder (prothrombin G20210A allele mutation) was identified as the predisposing factor for this unusual complication. Particular emphasis is placed on the course of the disease, which showed regression only after surgical exploration and additional anticoagulant therapy. We conclude that a thorough and early assessment of coagulation factors should always be performed, especially in the population at risk, in order to rule out unusual aetiologies of these rare but still life-threatening pathological processes.