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Background: It is essential that nonbenign forms of hearing impairment are recognized and addressed before audiological management is entertained. Purpose: To present an illustrative case and focused literature review of early red flag indicators for retrocochlear impairment, as might be discerned from a patient's history or physical examination. Results: The presenting history and clinical course of a female patient with fatal adenocarcinoma presenting as a suspected retrocochlear mass is reviewed over the last four months of her life. Clinical signs, symptoms and test results pointing to the diagnosis of 'acoustic neuroma' and then 'metastatic neoplasm' are reviewed along with selected supporting reference literature. The ambiguous clinical pictures at various points in her history are analyzed, with an effort to point out how early audiological decisions may significantly impact patient's overall health. Conclusions: Clear communication with primary care physicians, vigilance when audiological results are ambiguous for active disease, and pre-established referral relationships with practitioners in the neurologic and otologic disciplines are stressed as important requirements for audiologists who serve as entry points into hearing healthcare. [ABSTRACT FROM AUTHOR]

The vestibular evoked myogenic potential (VEMP) is a promising test of the descending vestibulocollic system. Our aim was to determine whether the VEMP can be applied to an older patient population and can detect lesions in descending vestibulospinal pathways. We also compared VEMP clinical performance with that of the standard caloric test. VEMP test performance was retrospectively analyzed in relation to clinical diagnosis and other vestibular test performance in 62 patients (age, 30-85 years) referred for vestibular testing to Mayo Clinic, Jacksonville, Florida. The VEMP was evoked using a 250 Hz tone burst. Results suggest age-related changes in VEMP amplitude and latency in this patient population. VEMP tests were sensitive to lesions not detected by electronystagmography. VEMP and caloric sensitivity and specificity were essentially equal (d' = 1). Combining both tests improved sensitivity. However, VEMP false-positive rates hampered specificity. VEMP testing may be refined to improve false-positive rates and clinical utility. [ABSTRACT FROM AUTHOR]

Background: Takotsubo cardiomyopathy, also known as left ventricular apical ballooning syndrome, ampulla cardiomyopathy, or transient left ventricular dysfunction is characterized by chest pain, electrocardiographic changes, transient left ventricular apical aneurysm, and normal coronary arteries. Takotsubo is a round-bottomed, narrow-necked Japanese octopus trap and lends its name to takotsubo cardiomyopathy because of its resemblance to echocardiographic and ventricular angiographic images of the left ventricle in this condition. This appearance takes its source from peculiar, transient regional systolic dysfunction involving the left ventricular apex and mid-ventricle with hyperkinesis of the basal left ventricular segments. Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo caused by peripheral vestibular dysfunction. The symptoms of BPPV are attributed to intralabyrinthine particles, presumed displaced otoconia. Thus, the treatment recommended for BPPV is head repositioning maneuvers. Purpose: To present the first takotsubo cardiomyopathy case in the English literature related to BPPV undergoing canalith repositioning procedure. Conclusion: This report will provide additional information for physicians encountering acute-onset chest pain and vertigo. It will also expand the spectrum of clinical correlates of the increasingly well recognized but poorly understood syndrome, takotsubo cardiomyopathy. [ABSTRACT FROM AUTHOR]

Almost since the inception of the modern-day electroacoustic audiometer a century ago the results of pure-tone audiometry have been characterized by an audiogram. For almost as many years, clinicians and researchers have sought ways to distill the volume and complexity of information on the audiogram. Commonly used approaches have made use of pure-tone averages (PTAs) for various frequency ranges with the PTA for 500, 1000, 2000 and 4000 Hz (PTA4) being the most widely used for the categorization of hearing loss severity. Here, a three-digit triad is proposed as a single-number summary of not only the severity, but also the configuration and bilateral symmetry of the hearing loss. Each digit in the triad ranges from 0 to 9, increasing as the level of the pure-tone hearing threshold level (HTL) increases from a range of optimal hearing (< 10 dB Hearing Level; HL) to complete hearing loss (≥ 90 dB HL). Each digit also represents a different frequency region of the audiogram proceeding from left to right as: (Low, L) PTA for 500, 1000, and 2000 Hz; (Center, C) PTA for 3000, 4000 and 6000 Hz; and (High, H) HTL at 8000 Hz. This LCH Triad audiogram-classification system is evaluated using a large United States (U.S.) national dataset (N = 8,795) from adults 20 to 80 + years of age and two large clinical datasets totaling 8,254 adults covering a similar age range. Its ability to capture variations in hearing function was found to be superior to that of the widely used PTA4., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: An unexpectedly low word recognition (WR) score may be taken as evidence of increased risk for retrocochlear tumor. We sought to develop evidence for or against using a standardized WR (sWR) score in detecting retrocochlear tumors. The sWR is a z score expressing the difference between an observed WR score and a Speech Intelligibility Index-based predicted WR score. We retrospectively compared the sensitivity and specificity of pure-tone asymmetry-based logistic regression models that incorporated either the sWR or the raw WR scores in detecting tumor cases. Two pure-tone asymmetry calculations were used: the 4-frequency pure-tone asymmetry (AAO) calculation of the American Academy of Otolaryngology-Head and Neck Surgery and a 6-frequency pure-tone asymmetry (6-FPTA) calculation previously optimized to detect retrocochlear tumors. We hypothesized that a regression model incorporating the 6-FPTA calculation and the sWR would more accurately detect retrocochlear tumors., Design: Retrospective data from all patients seen in the audiology clinic at Mayo Clinic in Florida in 2016 were reviewed. Cases with retrocochlear tumors were compared with a reference group with noise- or age-related hearing loss or idiopathic sensorineural hearing loss. Two pure-tone-based logistic regression models were created (6-FPTA and AAO). Into these base models, WR variables (WR, sWR, WR asymmetry [WRΔ], and sWR asymmetry [sWRΔ]) were added. Tumor detection performance for each regression model was compared twice: first, using all qualifying cases (61 tumor cases; 2332 reference group cases), and second, using a data set filtered to exclude hearing asymmetries greater than would be expected from noise-related or age-related hearing loss (25 tumor cases; 2208 reference group cases). The area under the curve and the DeLong test for significant receiver operating curve differences were used as outcome measures., Results: The 6-FPTA model significantly outperformed the AAO model-with or without the addition of WR or WRΔ variables. Including sWR into the AAO base regression model significantly improved disease detection performance. Including sWR into the 6-FPTA model significantly improved disease detection performance when large hearing asymmetries were excluded. In the data set that included large pure-tone asymmetries, area under the curve values for the 6-FPTA + sWR and AAO + sWR models were not significantly better than the base 6-FPTA model., Conclusions: The results favor the superiority of the sWR computational method in identifying reduced WR scores in retrocochlear cases. The utility would be greatest where undetected tumor cases are embedded in a population heavily representing age- or noise-related hearing loss. The results also demonstrate the superiority of the 6-FPTA model in identifying tumor cases. The 2 computational methods may be combined (ie, the 6-FPTA + sWR model) into an automated tool for detecting retrocochlear disease in audiology and community otolaryngology clinics. The 4-frequency AAO-based regression model was the weakest detection method considered. Including raw WR scores into the model did not improve performance, whereas including sWR into the model did improve tumor detection performance. This further supports the contribution of the sWR computational method for recognizing low WR scores in retrocochlear disease cases., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Cartilage cap resurfacing is a method to seal a superior semicircular canal dehiscence. The purpose of this study was to evaluate the detection of new bone formation after surgical placement of a cartilage cap over a dehiscent semicircular canal., Methods: In this retrospective review, two neuroradiologists blinded to each other's interpretation reviewed the temporal bones of 20 patients, five of which had a pre-operative computed tomography (CT) exam which was interpreted as unilateral superior semicircular canal dehiscence and with new bone formation following repair on follow-up CT. There were also 15 control subjects. Each neuroradiologist was blinded to history, including post-operative changes, and asked to determine if there was a dehiscence or no dehiscence., Results: Out of the 15 controls, there was 100% inter-observer agreement. On the five post-operative patients, there was agreement in 4/5 that there was no dehiscence post-operatively and 1/5 agreement of dehiscence post-operatively, but ectopic bone adjacent to the dehiscence., Conclusion: Our results indicate that new bone formation can be seen at the site of cartilage cap placement over the dehiscence and be interpreted as bony closure of the dehiscence.

This article introduces the Consumer Ear Disease Risk Assessment (CEDRA) tool. CEDRA is a brief questionnaire designed to screen for targeted ear diseases. It offers an opportunity for consumers to self-screen for disease before seeking a hearing device and may be used by clinicians to help their patients decide the appropriate path to follow in hearing healthcare. Here we provide highlights of previously published validation in the context of a more thorough description of CEDRA's development and implementation. CEDRA's sensitivity and specificity, using a cut-off score of 4 or higher, was 90% and 72%, respectively, relative to neurotologist diagnoses in the initial training sample used to create the scoring algorithm (n = 246). On a smaller independent test sample (n = 61), CEDRA's sensitivity and specificity were 76% and 80%, respectively. CEDRA has readability levels similar to many other patient-oriented questionnaires in hearing healthcare, and informal reports from pilot CEDRA-providers indicate that the majority of patients can complete it in less than 10 min. As the hearing healthcare landscape changes and provider intercession is no longer mandated, CEDRA provides a measure of safety without creating a barrier to access.

Objectives: The International Classification of Functioning, Disability, and Health (ICF) Core Sets for Hearing Loss (CSHL) consists of short lists of categories from the entire ICF classification that are thought to be the most relevant for describing the functioning of persons with hearing loss. A comprehensive intake that covers all factors included in the ICF CSHL holds the promise of developing a tailored treatment plan that fully complements the patient's needs. The Comprehensive CSHL contains 117 categories and serves as a guide for multiprofessional, comprehensive assessment. The Brief CSHL includes 27 of the 117 categories and represents the minimal spectrum of functioning of persons with HL for single-discipline encounters or clinical trials. The authors first sought to benchmark the extent to which Audiologist (AUD) and Otorhinolaryngologist (ORL) discipline-specific intake documentation, as well as Mayo Clinic's multidisciplinary intake documentation, captures ICF CSHL categories., Design: A retrospective study design including 168 patient records from the Department of Otorhinolaryngology/Audiology of Mayo Clinic in Jacksonville, Florida. Anonymized intake documentation forms and reports were selected from patient records filed between January 2016 and May 2017. Data were extracted from the intake documentation forms and reports and linked to ICF categories using pre-established linking rules. "Overlap," defined as the percentage of ICF CSHL categories represented in the intake documentation, was calculated across document types. In addition, extra non-ICF CSHL categories (ICF categories that are not part of the CSHL) and extra constructs (constructs that are not part of the ICF classification) found in the patient records were described., Results: The total overlap of multidisciplinary intake documentation with ICF CSHL categories was 100% for the Brief CSHL and 50% for the Comprehensive CSHL. Brief CSHL overlap for discipline-specific documentation fell short at 70% for both AUD and ORL. Important extra non-ICF CSHL categories were identified and included "sleep function" and "motor-related functions and activities," which mostly were reported in relation to tinnitus and vestibular disorders., Conclusion: The multidisciplinary intake documentation of Mayo Clinic showed 100% overlap with the Brief CSHL, while important areas of nonoverlap were identified in AUD- and ORL-specific reports. The ICF CSHL provides a framework for describing each hearing-impaired individual's unique capabilities and needs in ways currently not documented by audiological and otological evaluations, potentially setting the stage for more effective individualized patient care. Efforts to further validate the ICF CSHL may require the involvement of multidisciplinary institutions with commonly shared electronic health records to adequately capture the breath of the ICF CSHL.

Objectives: The purpose of this study was to evaluate the specificity and sensitivity of two red flag protocols in detecting ear diseases associated with changes in hearing., Design: The presence of red-flag symptoms was determined in a chart review of 307 adult patients from the Mayo Clinic Florida Departments of Otorhinolaryngology and Audiology. Participants formed a convenience sample recruited for a separate study. Neurotologist diagnosis was the criterion for comparisons., Results: Of the 251 patient files retained for analysis, 191 had one or more targeted diseases and 60 had age- or noise-related hearing loss. Food and Drug Administration red flags sensitivity was 91% (confidence interval [CI], 86 to 95%) and specificity was 72% (CI, 59 to 83%). American Academy of Otolaryngology-Head and Neck Surgery red flags sensitivity was 98% (CI, 95 to 99%) and specificity was 20% (CI, 11 to 32%)., Conclusions: Stakeholders must determine which diseases are meaningful contraindications for hearing aid use and whether these red-flag protocols have acceptable levels of sensitivity and specificity. As direct-to-consumer models of hearing devices increase, a disease detection method that does not require provider intercession would be useful.

Importance: The already large population of individuals with age- or noise-related hearing loss in the United States is increasing, yet hearing aids remain largely inaccessible. The recent decision by the US Food and Drug Administration to not enforce the medical examination prior to hearing aid fitting highlights the need to reengineer consumer protections when increasing accessibility. A self-administered tool to estimate ear disease risk would provide disease surveillance without posing an unreasonable barrier to hearing aid procurement., Objective: To develop and validate a consumer questionnaire for the self-assessment of risk for ear diseases associated with hearing loss., Design, Setting, and Participants: The questionnaire was developed using established methods including expert opinion to validate and create questions, and cognitive interviews to ensure that questions were clear to respondents. Exploratory structural equation modeling, logistic regression, and receiver operating characteristic curve analysis were used to determine sensitivity and specificity with blinded neurotologist opinion as the criterion for evaluation. Patients 40 to 80 years old with ear or hearing complaints necessitating a neurotologic examination and a control group of participants with a diagnosis of age- or noise-related hearing loss participated at the Departments of Otorhinolaryngology and Audiology of Mayo Clinic Florida., Main Outcomes and Measures: Sensitivity and specificity of the prototype questionnaire to identify individuals with targeted diseases., Results: Of 307 participants (mean [SD] age, 62.9 [9.8] years; 148 [48%] female), 75% (n = 231) were enrolled with targeted disease(s) identified on neurotologic assessment and 25% (n = 76) with age- or noise-related hearing loss. Participants were randomly divided into a training sample (80% [n = 246; 185 with disease, 61 controls]) and a test sample (20% [n = 61; 46 with disease, 15 controls]). Using a simple scoring method, a sensitivity of 94% (95% CI, 89%-97%) and specificity of 61% (95% CI, 47%-73%) were established in the training sample. Applying this cutoff to the test sample resulted in 85% (95% CI, 71%-93%) sensitivity and 47% (95% CI, 22%-73%) specificity., Conclusions and Relevance: This is the first self-assessment tool designed to assess an individual's risk for ear disease. Our preliminary results demonstrate a high sensitivity to disease detection. A further validated and refined version of this questionnaire may serve as an efficacious tool for improving access to hearing health care while minimizing the risk for missed ear diseases.

Purpose: The purpose of this research note is to identify and prioritize diseases important for detection in adult hearing health care delivery systems., Method: Through literature review and expert consultation, the authors identified 195 diseases likely to occur in adults complaining of hearing loss. Five neurotologists rated the importance of disease on 3 dimensions related to the necessity of detection prior to adult hearing aid fitting., Results: Ratings of adverse health consequences, diagnostic difficulty, and presence of nonotologic symptoms associated with these diseases resulted in the identification of 104 diseases potentially important for detection prior to adult hearing aid fitting., Conclusions: Current and evolving health care delivery systems, including direct-to-consumer sales, involve inconsistent means of disease detection vigilance prior to device fitting. The first steps in determining the safety of these different delivery methods are to identify and prioritize which diseases present the greatest risk for poor health outcomes and, thus, should be detected in hearing health care delivery systems. Here the authors have developed a novel multidimensional rating system to rank disease importance. The rankings can be used to evaluate the effectiveness of alternative detection methods and to inform public health policy. The authors are currently using this information to validate a consumer questionnaire designed to accurately identify when pre- fitting medical evaluations should be required for hearing aid patients.

Purpose: Ocular vestibular evoked myogenic potentials (oVEMPs) are used to describe utricular/superior vestibular nerve function; however, optimal recording parameters have not been fully established. This study investigated the effect of repetition rate on air-conducted oVEMPs., Method: Ten healthy adults were evaluated using 500-Hz tone bursts (4-ms duration, Blackman gating, 122 dB pSPL). Four repetition rates were used (1.6, 4.8, 8.3, and 26.6 Hz) and resulting oVEMP response presence, amplitude, amplitude asymmetry, and n1/p1 latency were assessed., Results: Response presence was significantly reduced for 26.6 Hz using monaural stimulation and for 8.3 Hz and 26.6 Hz for binaural stimulation. For monaural stimulation using 1.6, 4.8, and 8.3 Hz, no significant differences were noted for amplitude or latency. Responses obtained using binaural stimulation demonstrated a significant effect of rate on amplitude, with 8.3 Hz producing significantly reduced amplitude. Binaural amplitudes were significantly larger than monaural contralateral responses but with reduced response presence. No significant differences were noted for latency or amplitude asymmetry., Conclusion: Using repetition rates of approximately 5 Hz or less may produce more consistent oVEMP response presence with minimal effects on amplitude for monaural or binaural recordings.

Vestibular function laboratories utilize a multitude of diagnostic instruments to evaluate a dizzy patient. Caloric irrigators, oculomotor stimuli, and rotational chairs produce a stimulus whose accuracy is required for the patient response to be accurate. Careful attention to everything from cleanliness of equipment to threshold adjustments determine on a daily basis if patient data are going to be correct and useful. Instrumentation specifications that change with time such as speed and temperature must periodically be checked using calibrated instruments.

Objective: Literature investigating otolith reflexes in patients with vestibular migraine (VM) is variable and primarily describes the descending saccular pathway. This research aimed to study ocular vestibular evoked myogenic potential (oVEMP) and cervical vestibular evoked myogenic potential (cVEMP) prevalence and response characteristics in patients with suspected VM and in control patients. The purpose is to assess vulnerabilities within the ascending utricular and descending saccular pathways in the VM population., Study Design: Retrospective study, Setting: Tertiary academic referral center, Patients: 39 adults with VM, 29 control patients, Main Outcome Measure(s): Air conducted oVEMPs and cVEMPs measured with 500 Hz tone burst stimuli, Results: Age of headache onset was most often in childhood or adolescence, with dizziness onset occurring later. The rate of bilaterally absent oVEMPs was significantly higher (28%, p < 0.01) in the VM group compared with the control group (0%). oVEMP amplitude asymmetry ratios were significantly higher for the definite VM (p < 0.01) and probable VM (p = 0.023) groups than the control group. Eleven patients also had history of concussion; they were significantly more likely to demonstrate bilaterally absent oVEMPs (p < 0.01) in comparison to the control patients. When VM patients with a history of concussion were omitted from analysis, differences in oVEMP amplitude asymmetry (p < 0.01) and bilateral oVEMP absence remained significant (p = 0.015). There were no differences in the rate of bilateral cVEMP presence or response parameters between VM and control groups., Conclusion: VEMP presentation differs for some patients diagnosed with VM. The higher rates of abnormal oVEMPs may suggest greater vulnerability within the ascending utricular-ocular pathway in patients with VM.

Background: The cervical vestibular evoked myogenic potential (cVEMP) is a reflexive change in sternocleidomastoid (SCM) muscle contraction activity thought to be mediated by a saccular vestibulo-collic reflex. CVEMP amplitude varies with the state of the afferent (vestibular) limb of the vestibulo-collic reflex pathway, as well as with the level of SCM muscle contraction. It follows that in order for cVEMP amplitude to reflect the status of the afferent portion of the reflex pathway, muscle contraction level must be controlled. Historically, this has been accomplished by volitionally controlling muscle contraction level either with the aid of a biofeedback method, or by an a posteriori method that normalizes cVEMP amplitude by the level of muscle contraction. A posteriori normalization methods make the implicit assumption that mathematical normalization precisely removes the influence of the efferent limb of the vestibulo-collic pathway. With the cVEMP, however, we are violating basic assumptions of signal averaging: specifically, the background noise and the response are not independent. The influence of this signal-averaging violation on our ability to normalize cVEMP amplitude using a posteriori methods is not well understood., Purpose: The aims of this investigation were to describe the effect of muscle contraction, as measured by a prestimulus electromyogenic estimate, on cVEMP amplitude and interaural amplitude asymmetry ratio, and to evaluate the benefit of using a commonly advocated a posteriori normalization method on cVEMP amplitude and asymmetry ratio variability., Research Design: Prospective, repeated-measures design using a convenience sample., Study Sample: Ten healthy adult participants between 25 and 61 yr of age., Intervention: cVEMP responses to 500 Hz tone bursts (120 dB pSPL) for three conditions describing maximum, moderate, and minimal muscle contraction., Data Collection and Analysis: Mean (standard deviation) cVEMP amplitude and asymmetry ratios were calculated for each muscle-contraction condition. Repeated measures analysis of variance and t-tests compared the variability in cVEMP amplitude between sides and conditions. Linear regression analyses compared asymmetry ratios. Polynomial regression analyses described the corrected and uncorrected cVEMP amplitude growth functions., Results: While cVEMP amplitude increased with increased muscle contraction, the relationship was not linear or even proportionate. In the majority of cases, once muscle contraction reached a certain "threshold" level, cVEMP amplitude increased rapidly and then saturated. Normalizing cVEMP amplitudes did not remove the relationship between cVEMP amplitude and muscle contraction level. As muscle contraction increased, the normalized amplitude increased, and then decreased, corresponding with the observed amplitude saturation. Abnormal asymmetry ratios (based on values reported in the literature) were noted for four instances of uncorrected amplitude asymmetry at less than maximum muscle contraction levels. Amplitude normalization did not substantially change the number of observed asymmetry ratios., Conclusions: Because cVEMP amplitude did not typically grow proportionally with muscle contraction level, amplitude normalization did not lead to stable cVEMP amplitudes or asymmetry ratios across varying muscle contraction levels. Until we better understand the relationships between muscle contraction level, surface electromyography (EMG) estimates of muscle contraction level, and cVEMP amplitude, the application of normalization methods to correct cVEMP amplitude appears unjustified., (American Academy of Audiology.)

Background: Asymmetric hearing loss (AHL) can be an early sign of vestibular schwannoma (VS). However, recognizing VS-induced AHL is challenging. There is no universally accepted definition of a "medically significant pure-tone hearing asymmetry," in part because AHL is a common feature of medically benign forms of hearing loss (e.g., age- or firearm-related hearing loss). In most cases, the determination that an observed AHL does not come from a benign cause involves subjective clinical judgment., Purpose: Our purpose was threefold: (1) to quantify hearing asymmetry distributions in a large group of patients with medically benign forms of hearing loss, stratifying for age, sex, and noise exposure history; (2) to assess how previously proposed hearing asymmetry calculations segregate tumor from nontumor cases; and (3) to present the results of a logistic regression method for defining hearing asymmetry that incorporates age, sex, and noise information., Research Design: Retrospective chart review., Study Sample: Five thousand six hundred and sixty-one patients with idiopathic, age- or noise exposure-related hearing loss and 85 untreated VS patients., Data Collection and Analysis: Audiometric, patient history, and clinical impression data were collected from 22,785 consecutive patient visits to the audiology section at Mayo Clinic in Florida from 2006 to 2009 to screen for eligibility. Those eligible were then stratified by VS presence, age, sex, and self-reported noise exposure history. Pure-tone asymmetry distributions were analyzed. Audiometric data from VS diagnoses were used to create four additional audiograms per patient to model the hypothetical development of AHL prior to the actual hearing test. The ability of 11 previously defined hearing asymmetry calculations to distinguish between VS and non-VS cases was described. A logistic regression model was developed that integrated age, sex, and noise exposure history with pure-tone asymmetry data. Regression model performance was then compared to existing asymmetry calculation methods., Results: The 11 existing pure-tone asymmetry calculations varied in tumor detection performance. Age, sex, and noise exposure history helped to predict benign forms of hearing asymmetry. The logistic regression model outperformed existing asymmetry calculations and better accounted for normal age-, sex-, and noise exposure-related asymmetry variability., Conclusions: Our logistic regression asymmetry method improves the clinician's ability to estimate risk of VS, in part by integrating categorical patient history and numeric test data. This form of modeling can enhance clinical decision making in audiology and otology., (American Academy of Audiology.)

Introduction: Despite improvement in the computational capabilities of visual displays in flight simulators, intersensory visual-vestibular conflict remains the leading cause of simulator sickness (SS). By using galvanic vestibular stimulation (GVS), the vestibular system can be synchronized with a moving visual field in order to lessen the mismatch of sensory inputs thought to result in SS., Methods: A multisite electrode array was used to deliver combinations of GVS in 21 normal subjects. Optimal electrode combinations were identified and used to establish GVS dose-response predictions for the perception of roll, pitch, and yaw. Based on these data, an algorithm was then implemented in flight simulator hardware in order to synchronize visual and GVS-induced vestibular sensations (oculo-vestibular-recoupled or OVR simulation). Subjects were then randomly exposed to flight simulation either with or without OVR simulation. A self-report SS checklist was administered to all subjects after each session. An overall SS score was calculated for each category of symptoms for both groups., Results: The analysis of GVS stimulation data yielded six unique combinations of electrode positions inducing motion perceptions in the three rotational axes. This provided the algorithm used for OVR simulation. The overall SS scores for gastrointestinal, central, and peripheral categories were 17%, 22.4%, and 20% for the Control group and 6.3%, 20%, and 8% for the OVR group, respectively., Conclusions: When virtual head signals produced by GVS are synchronized to the speed and direction of a moving visual field, manifestations of induced SS in a cockpit flight simulator are significantly reduced.

Galvanic stimulation has long been used as a nonmechanical means of activating the vestibular apparatus through direct action on the vestibular nerve endings. This stimulation has been reported to be safe, but no studies have examined the potential changes in the corresponding cochlear receptors. The aim of the present study was to evaluate the effect of galvanic vestibular stimulation (GVS) on distortion product otoacoustic emissions (DPOAEs). Fourteen subjects underwent DPOAEs during several conditions of GVS. The DPOAEs ranged from ∼ 1 kHz to ∼ 8 kHz at 65/55 dB for f1/f2 and with an f2/f1 ratio of 1.2. The subjects were evaluated at 10 stimulation conditions that ranged from -2.0 mA to +2.0 mA for each frequency. Statistical analysis showed no significant differences in DPOAE amplitudes for all conditions with and without GVS. Results also showed no significant differences between DPOAE amplitudes before and after GVS. Multivariate analysis found subject variability in DPOAE amplitude, which was not thought to be GVS related. Results indicated that GVS produced neither temporary nor permanent changes in DPOAEs.

The right to confidentiality is a central tenet of the doctor-patient relationship. In the United Kingdom this right to confidentiality is recognised in published GMC guidance. In USA the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) strengthened the legal requirement to protect patient information in all forms and failure to do so now constitutes a federal offence. The aims of this study are to assess the acoustic privacy of an otolaryngology outpatient consultation room. Acoustic privacy was measured using the articulation index (AI) and Bamford-Kowal-Bench (BKB) speech discrimination tests. BKB speech tests were calibrated to normal conversational volume (50 dB SPL). Both AI and BKB were calculated in four positions around the ENT clinic: within the consultation room, outside the consulting room door, in the nearest waiting area chair and in the farthest waiting area chair. Tests were undertaken with the clinic room door closed and open to assess the effect on privacy. With the clinic room door closed, mean BKB scores in nearest and farthest waiting area chairs were 51 and 41% respectively. AI scores in the waiting area chairs were 0.03 and 0.02. With the clinic room door open, privacy was lost in both AI and BKB testing, with almost 100% of word discernable at normal talking levels. The results of this study highlight the poor level of speech privacy within a standard ENT outpatient department. AI is a poor predictor or privacy.

We describe a rarely encountered case of coexisting bilateral multicanal benign paroxysmal positional vertigo (BPPV) and vestibular schwannoma in a 56-year-old woman. The patient had presented with a 10-year history of dizziness and imbalance, and her vestibular findings were perplexing. We decided on a working diagnosis of BPPV and began treatment. After several months of canalith repositioning maneuvers had failed to resolve her symptoms, we obtained magnetic resonance imaging, which revealed the presence of the vestibular schwannoma. This case serves as a reminder of the importance of differentiating between central and peripheral vestibular disorders, as well as central and anterior canal BPPV-induced down-beating nystagmus in order to establish the correct diagnosis and initiate appropriate treatment.

Background: Allowing Medicare beneficiaries to self-refer to audiologists for evaluation of hearing loss has been advocated as a cost-effective service delivery model. Resistance to audiology direct access is based, in part, on the concern that audiologists might miss significant otologic conditions., Purpose: To evaluate the relative safety of audiology direct access by comparing the treatment plans of audiologists and otolaryngologists in a large group of Medicare-eligible patients seeking hearing evaluation., Research Design: Retrospective chart review study comparing assessment and treatment plans developed by audiologists and otolaryngologists., Study Sample: 1550 records comprising all Medicare eligible patients referred to the Audiology Section of the Mayo Clinic Florida in 2007 with a primary complaint of hearing impairment., Data Collection and Analysis: Assessment and treatment plans were compiled from the electronic medical record and placed in a secured database. Records of patients seen jointly by audiology and otolaryngology practitioners (Group 1: 352 cases) were reviewed by four blinded reviewers, two otolaryngologists and two audiologists, who judged whether the audiologist treatment plan, if followed, would have missed conditions identified and addressed in the otolaryngologist's treatment plan. Records of patients seen by audiology but not otolaryngology (Group 2: 1198 cases) were evaluated by a neurotologist who judged whether the patient should have seen an otolaryngologist based on the audiologist's documentation and test results. Additionally, the audiologist and reviewing neurotologist judgments about hearing asymmetry were compared to two mathematical measures of hearing asymmetry (Charing Cross and AAO-HNS [American Academy of Otolaryngology-Head and Neck Surgery] calculations)., Results: In the analysis of Group 1 records, the jury of four judges found no audiology discrepant treatment plans in over 95% of cases. In no case where a judge identified a discrepancy in treatment plans did the audiologist plan risk missing conditions associated with significant mortality or morbidity that were subsequently identified by the otolaryngologist. In the analysis of Group 2 records, the neurotologist judged that audiology services alone were all that was required in 78% of cases. An additional 9% of cases were referred for subsequent medical evaluation. The majority of remaining patients had hearing asymmetries. Some were evaluated by otolaryngology for hearing asymmetry in the past with no interval changes, and others were consistent with noise exposure history. In 0.33% of cases, unexplained hearing asymmetry was potentially missed by the audiologist. Audiologists and the neurotologist demonstrated comparable accuracy in identifying Charing Cross and AAO-HNS pure-tone asymmetries., Conclusions: Of study patients evaluated for hearing problems in the one-year period of this study, the majority (95%) ultimately required audiological services, and in most of these cases, audiological services were the only hearing health-care services that were needed. Audiologist treatment plans did not differ substantially from otolaryngologist plans for the same condition; there was no convincing evidence that audiologists missed significant symptoms of otologic disease; and there was strong evidence that audiologists referred to otolaryngology when appropriate. These findings are consistent with the premise that audiology direct access would not pose a safety risk to Medicare beneficiaries complaining of hearing impairment., (American Academy of Audiology.)

Individual psychological responses to heights vary on a continuum from acrophobia to height intolerance, height tolerance, and height enjoyment. This paper reviews the English literature and summarizes the physiologic and psychological factors that generate different responses to heights while standing still in a static or motionless environment. Perceptual cues to height arise from vision. Normal postural sway of 2 cm for peripheral objects within 3 m increases as eye-object distance increases. Postural sway >10 cm can result in a fall. A minimum of 20 minutes of peripheral retinal arc is required to detect motion. Trigonometry dictates that a 20-minute peripheral retinal arch can no longer be achieved in a standing position at an eye-object distance of >20 m. At this distance, visual cues conflict with somatosensory and vestibular inputs, resulting in variable degrees of imbalance. Co-occurring deficits in the visual, vestibular, and somatosensory systems can significantly increase height imbalance. An individual's psychological makeup, influenced by learned and genetic factors, can influence reactions to height imbalance. Enhancing peripheral vision and vestibular, proprioceptive, and haptic functions may improve height imbalance. Psychotherapy may improve the troubling subjective sensations to heights.

Down-beating positional nystagmus is typically associated with central nervous system disease. Anterior canal benign paroxysmal positional vertigo (AC-BPPV) can mimic down-beating positional nystagmus of central origin, particularly when it is bilateral. Factors that increase the probability of bilateral AC-BPPV include a history of bilateral multicanal BPPV, transient down-beating and torsional nystagmus that follows the plane of the provoked canal, and the absence of co-occurring neurologic signs and symptoms of central nervous system dysfunction. With neurologic clearance for canalith repositioning, exploration for AC-BPPV and canalith repositioning trials may alleviate symptoms even when the nystagmus does not appear to fatigue. In the case presented, the use of a side-lying maneuver with the nose down to provoke AC-BPPV symptoms and the use of a reversed Epley to clear AC-BPPV symptoms are highlighted. This approach is helpful when the diagnosis is unclear and neck hyperextension is to be avoided.

An acutely vertiginous 47-year-old woman presented to the emergency department with simultaneous acute left neurolabyrinthitis and left posterior canal benign paroxysmal positional vertigo (BPPV). Gaze nystagmus from the neurolabyrinthitis hampered diagnosis of the BPPV. However, once the BPPV was identified and treated, the patient's subjective vertigo improved rapidly. Concomitant BPPV should not be overlooked when a diagnosis of acute neurolabyrinthitis is made in the emergency department.

A number of commercial distortion product otoacoustic emission (DPOAE) systems are available. Each system uses a slightly different signal processing approach. As a result, calculations commonly used to quantify the quality of collected DPOAE data (such as noise level and signal to noise ratio) differ across systems. In this report, the theory underlying DPOAE noise estimation is reviewed and a probabilistic approach to establishing local DPOAE norms is presented. Using this approach, a DPOAE detection criterion of 15 dB estimated signal-to-noise ratio was found to yield a false negative hearing screen outcome rate of .00053 and a false positive outcome rate identical to an established transient evoked otoacoustic emission (TEOAE) based protocol. Reasons why detection criteria may vary across distortion product systems and literature reports are presented.

There is controversy over whether the wave I to V interpeak latency (I-V IPL) of the auditory brain-stem response can be manipulated by cochlear processing. In this study, a forward masking paradigm was used to test the predictions of two contrasting models of I-V IPL generation. The paradigm was designed to determine if the I-V IPL can be affected by masking selected portions of the cochlear response region. The results from ten normal hearing subjects suggest that: (1) waves I and V can be masked semi-independent of each other, and (2) the I-V IPL can be shortened or prolonged by masking the basal or apical portion of the cochlear response region respectively. These findings support the hypothesis that, at least in normal hearing subjects, wave V is biased to reflect more apical cochlear events than wave I. Additionally, they offer tentative support for anecdotal reports of shortened I-V IPLs in the presence of high-frequency hearing loss.