To evaluate the results of vestibular evoked myogenic potential testing in patients with idiopathic sudden hearing loss, and to correlate these results with the findings of caloric testing, the clinical appearance of vertigo and the influence of age.

Eighty-six patients with unilateral idiopathic sudden hearing loss and 35 healthy controls underwent a standard protocol of neurotological evaluation. Vestibular evoked myogenic potential responses were measured and compared with caloric responses.

On the affected side, 30.2 per cent of patients showed abnormal vestibular evoked myogenic potential responses, while 52.3 per cent had abnormal caloric responses. A statistically significant relationship was found between the results of these two tests. A statistically significant relationship was also found between the type of vestibular lesion and the occurrence of vertigo. Advancing age correlated statistically with more extensive labyrinthic lesions.

A combination of vestibular evoked myogenic potential and electronystagmography testing indicated the existence of vestibular involvement in many patients with idiopathic sudden hearing loss. Both tests are necessary in order to obtain a more thorough and in-depth knowledge of the pathophysiology of idiopathic sudden hearing loss.

To demonstrate that the anatomical structure known as the processus cochleariformis, with its intimate and constant relationships to inner-ear structures, can be used as a reliable landmark during middle cranial fossa surgery, alone or in conjunction with other landmarks.

An anatomical study using cadaveric temporal bones to define six reproducible measurements that relate the processus cochleariformis to inner-ear structures, and to define 14 other measurements that relate inner-ear structures to adjacent structures within the intact bone.

Using 10 cadaver specimens, 20 reproducible measurements were defined. The first six of these defined the relation of the processus cochleariformis to inner-ear structures in the middle cranial fossa approach. The other measurements defined the exact location of the inner-ear structures and adjacent structures within the intact bone.

The vertical crest lies at a 20° angle from the processus cochleariformis to the coronal plane, and at a distance of 5 to 6 mm from the processus cochleariformis. The point at which the medial margin of the basal turn of the cochlea crosses the labyrinthine segment of the facial nerve lies at a 0° angle from the processus cochleariformis to the coronal plane, and at a distance of 6.5 to 7.5 mm from the processus cochleariformis. The superior semicircular canal lies at a 45° angle from the processus cochleariformis to the coronal plane. The other measurements obtained give important clues about the position of the cochlea, vestibulum, greater superficial petrosal nerve and labyrinthine segment of the facial nerve.

If the classical landmarks are indiscernible during middle cranial fossa surgery, then the processus cochleariformis, with its intimate and constant relationships to inner-ear structures, is a safe and constant landmark.

To evaluate differences between the functional results of framework surgery and autologous fat injection laryngoplasty, for patients with unilateral vocal fold paralysis.

Sixty-two patients underwent framework surgery, while 64 received autologous fat injection laryngoplasty. Voice function before and after both procedures was assessed using aerodynamic and acoustic analysis, with differences evaluated using paired t-test in both groups.

In both groups, all parameters improved significantly after surgery, compared with before surgery. Post-operative improvement in all parameters was significantly greater after fat injection laryngoplasty, compared with framework surgery.

Autologous fat injection laryngoplasty was thus found to be a more effective and reliable therapy for improving voice function in patients with vocal fold paralysis, compared with framework surgery.

To collect and analyse data from the published literature concerning the rare condition necrotising otitis externa, in order to formulate a prognostic scoring model based on signs and symptoms.

Retrospective data collection from published literature, and binary logistic regression analysis of the effect on outcome of identified signs and symptoms.

Six factors were identified as prognostic of a poorer outcome, including facial nerve involvement, additional cranial nerve involvement, non-cranial nerve neurological involvement, extensive granulations (or oedema) in the external auditory canal, bilateral symptoms and aspergillus species as the causative organism. A four-point scoring model based on these findings is presented.

A novel, systematic method of data analysis was utilised to construct a prognostic scoring model for necrotising otitis externa. This will better equip clinicians to treat this potentially fatal condition.

To research the protective effect of melatonin against gentamicin ototoxicity.

Guinea pigs were randomly divided into four groups. The first group received intramuscular gentamicin (120 mg/kg body weight/day) for 17 days. Over the same time period, a second group simultaneously received intramuscular gentamicin (120 mg/kg body weight/day) plus (on the other side) intramuscular melatonin (0.3 ml kg body weight/day). Two groups of controls were treated for 17 days with either intramuscular melatonin or intramuscular saline. After the 17 days, each animal underwent distortion product otoacoustic emission testing (both ears). The guinea pigs were sacrificed by decapitation just after the final injection. Their cochleae were used to produce a tissue section, surface preparation and scanning electron microscope preparation.

Distortion product otoacoustic emission testing indicated gentamicin-induced hearing loss at 3, 4, 6 and 8 kHz in gentamicin-treated animals. Animals receiving melatonin co-therapy had significantly attenuated hearing loss and their cochleae showed lower rates of outer hair cell loss (comparing the same cochlear turns), compared with gentamicin-treated animals (p < 0.01).

These findings confirm the occurrence of outer hair cell loss after gentamicin treatment, and the attenuation of such loss following simultaneous melatonin injection, using the method of morphological evaluation. These results suggest that melatonin protects against gentamicin ototoxicity by interfering with cytotoxic mechanisms.

To investigate the impact of perforation size and other variables on the success of myringoplasty, and also to determine audiological gain following successful closure of tympanic membrane perforations of various sizes.

Retrospective analysis of 130 case notes.

(1) Successful closure of tympanic membrane following myringoplasty, in relation to recorded variables (i.e. perforation size, grade of surgeon, surgical technique, graft material, previous myringoplasty and smoking history). (2) Mean, four-frequency, air conduction audiometric gain following successful myringoplasty for various, pre-operatively categorised tympanic membrane perforation sizes.

The collective myringoplasty success rate was 80.8 per cent (105/130); for successful patients, the mean air conduction audiometric gain was −6.8 dB (t = 5.29, p < 0.0001). Neither perforation size nor any other assessed variable was a statistically significant determinant factor for successful myringoplasty. Air conduction audiometric gains following successful myringoplasty were directly correlated with pre-operative perforation size (−4.0 dB for 0–20 per cent perforations, −5.0 dB for 21–40 per cent, −9.1 dB for 41–60 per cent, −10.8 dB for 61–80 per cent and −13.3 dB for 81–100 per cent).

Congenital cholesteatoma occurring behind the tympanic membrane is typically located in the anterior middle ear.

To investigate the location, clinical features and treatment of cholesteatomas located behind an intact tympanic membrane in adults.

Review of a series of 265 consecutive, new, adult cases of previously untreated cholesteatoma seen by the author over a 22-year period.

Seventeen (6 per cent) cases were located behind an intact tympanic membrane without any evidence of a retraction pocket of the attic or pars tensa. Ten (59 per cent) of these patients had undergone previous ear surgery and therefore the disease could reasonably be considered to be iatrogenic. The most common presentation was conductive deafness with no other symptoms (71 per cent). In all of the cases, the disease was located in the posterior half of the middle-ear space. The most common surgical management was simple excision of the disease via a tympanotomy. Two cases (12 per cent) developed residual disease.

The majority of the cases in this series were likely to be acquired cholesteatomas. This type of disease often presents with conductive hearing loss alone.

To report a cluster of families affected by cholesteatoma in the East Anglia region of the UK.

Otology service for the population of Norfolk and North Suffolk, East Anglia, UK.

Prospective and systematic collection of family history data for patients presenting with cholesteatoma over 10 years.

Several families were identified with affected individuals over several generations.

There is likely to be a genetic propensity for cholesteatoma in some individuals.

A reliable diagnosis of malignant carotid body tumour can only be made in the presence of metastatic disease, because the histological features of the primary tumour do not correlate with clinical behaviour.

We report two cases of malignant carotid body tumour in which regional nodal biopsy at the time of excision of the primary tumour revealed unsuspected metastatic disease.

Reoperation in the neck for recurrent metastatic carotid body tumour is difficult and potentially hazardous. The presence of occult metastatic disease is easily identified if a selective – or sentinel – nodal dissection is performed routinely in cases of carotid body tumour excision. Such an approach adds very little morbidity, effort or time to the primary surgery, and is recommended. This view has been supported by some other authors but is generally overlooked in clinical practice.

This study aimed to determine whether magnetic resonance imaging has a role in the evaluation of the sphenoid sinus and internal carotid artery. In addition, we aimed to establish reference measurements for the minimal distance between the internal carotid arteries.

The sphenoid sinuses and neighbouring internal carotid arteries of 90 patients were evaluated using sagittal T1-weighted and axial and coronal T2-weighted magnetic resonance images.

Sphenoid sinus pneumatisation was categorised as occipitosphenoidal (0 per cent), conchal (3.3 per cent), presellar (14.4 per cent) or sellar (82.2 per cent). The internal carotid artery protruded into the sphenoid sinus in 32.8 per cent, with a septum in 9.4 per cent. The incidence of sellar-type sphenoid sinus pneumatisation was higher in patients with protrusion of the internal carotid artery into the sphenoid sinus (p < 0.001). The incidence of presellar pneumatisation was higher in patients without internal carotid artery protrusion (p < 0.001). The minimal distance between the internal carotid arteries varied between 9.04 and 24.26 mm (mean, 15.94 mm).

Magnetic resonance imaging can provide useful information about the sphenoid sinus and internal carotid artery, prior to endoscopic sphenoidotomy and trans-sphenoidal hypophysectomy.

To analyse the possible impact of low and extremely low frequency electromagnetic fields on the outer hairs cells of the organ of Corti, in a guinea pig model.

Electromagnetic fields of 50, 500, 1000, 2000, 4000 and 5000 Hz frequencies and 1.5 µT intensity were generated using a transverse electromagnetic wave guide. Guinea pigs of both sexes, weighing 100–150 g, were used, with no abnormalities on general and otic examination. Total exposure times were: 360 hours for 50, 500 and 1000 Hz; 3300 hours for 2000 Hz; 4820 hours for 4000 Hz; and 6420 hours for 5000 Hz. One control animal was used in each frequency group. The parameters measured by electric response audiometer included: hearing level; waves I–IV latencies; wave I–III interpeak latency; and percentage appearance of waves I–III at 90 and 50 dB sound pressure level intensity.

Values for the above parameters did not differ significantly, comparing the control animal and the rest of each group. In addition, no significant differences were found between our findings and those of previous studies of normal guinea pigs.

Prolonged exposure to electromagnetic fields of 50 Hz to 5 KHz frequencies and 1.5 µT intensity, produced no functional or morphological alteration in the outer hair cells of the guinea pig organ of Corti.

This study aimed to compare outcomes for mastoidotympanoplasty and for tympanoplasty alone in cases of quiescent, tubotympanic, chronic, suppurative otitis media.

Single-blinded, randomised, controlled study within a tertiary referral hospital.

Sixty-eight cases were randomly allocated into two groups. In group one, 35 ears underwent type one tympanoplasty along with cortical mastoidectomy. In group two, 33 ears underwent type one tympanoplasty alone. Outcome measures were as follows: perforation closure and graft uptake, hearing improvement, disease eradication, and post-operative complications.

There were no statistically significant differences in hearing improvement, tympanic perforation closure, graft uptake or disease eradication, comparing the two groups at three and six months post-operatively.

Mastoidotympanoplasty was not found to be superior to tympanoplasty alone over a short term follow-up period. Hence, it may not be necessary to undertake routine mastoid exploration at this stage of disease.

Following a report of sudden hearing loss in a patient taking phosphodiesterase type 5 inhibitor, and a Food and Drug Administration announcement concerning this class of drugs, a study was planned to investigate if ototoxicity occurs in patients using phosphodiesterase 5 inhibitor for erectile dysfunction.

Eighteen patients with erectile dysfunction who had been using phosphodiesterase 5 inhibitor were included in the study. Audiometric tests were performed on all patients, between the frequencies 250 and 16 000 Hz, before and 1, 5 and 72 hours after drug ingestion.

Four patients showed a unilateral threshold decrease compatible with ototoxicity criteria; this change was reversible. A statistically significant difference in pre- versus post-drug hearing thresholds was observed in the right ear at 10 000 Hz (p = 0.008). There were no statistically significant hearing threshold differences at any other frequencies (p > 0.05).

Although temporary ototoxicity was noted in four patients, we could not find any permanent, deleterious effect of phosphodiesterase type 5 inhibitor on hearing thresholds.

Optical coherence tomography was used to study the stapes footplate, both in cadaveric temporal bones and during middle-ear surgery.

Optical coherence tomography was conducted on five temporal bone preparations (from two children and three adults) and in eight patients during middle-ear surgery. A specially equipped operating microscope with integrated spectral domain optical coherence tomography apparatus was used for standard middle-ear surgical procedures.

This optical coherence tomography investigation enabled in vivo visualisation and documentation of the annular ligament, the different layers of the footplate and the inner-ear structures, both in non-fixed and fixed stapes footplates. In cases of otosclerosis and tympanosclerosis, an inhomogeneous and irregularly thickened footplate was found, in contrast to the appearance of non-fixed footplates. In both fixed and non-fixed footplates, there was a lack of visualisation of the border between the footplate and the otic capsule.

Investigation of the relatively new technology of optical coherence tomography indicated that this imaging modality may assist the ear surgeon to assess the oval window niche intra-operatively.

Congenital cytomegalovirus infection is the leading identified nongenetic cause of congenital sensorineural hearing loss. Most of the infections are asymptomatic but may be detected from umbilical cord vein and/or newborn serum positivity for human cytomegalovirus immunoglobulin M, and from urine positivity (on polymerase chain reaction) for human cytomegalovirus deoxyribonucleic acid in the newborn period. Children infected by cytomegalovirus may later develop sensorineural hearing loss. In symptomatically infected infants, ganciclovir therapy administered in the neonatal period prevents hearing deterioration. However, preventative therapy of asymptomatic congenital cytomegalovirus disease with ganciclovir is controversial, as side effects such as severe neutropenia may occur during treatment.

The study population consisted of 23 asymptomatic children with congenital cytomegalovirus infection. Twelve children were treated just after diagnosis of cytomegalovirus infection in the newborn period, with ganciclovir 10 mg/kg bodyweight for 21 days. The other 11 children were observed without therapy. Over a four to 10 year follow-up period, we evaluated all the children's hearing status using pure tone audiometry.

All 23 children had normal sensorineural hearing at one year follow up. Five of the 23 children (21.7 per cent) were lost to follow up over the four to 11 year follow-up period. Of the remaining 18 children, sensorineural hearing loss occurred in two (11.1 per cent). Neither child had been treated with ganciclovir in the newborn period. An eight-year-old boy showed bilateral high frequency loss and a 10-year-old girl showed severe unilateral sensorineural hearing loss. In the ganciclovir-treated group (nine children), none showed sensorineural hearing loss. During ganciclovir therapy, moderate neutropenia occurred as a side effect in two out of 12 (16.6 per cent) treated children. Speech and general development were normal in all children.

Asymptomatic congenital cytomegalovirus infection is likely to be a leading cause of sensorineural hearing loss in young children. Intravenous ganciclovir therapy seems to offer a medical option to prevent subsequent sensorineural hearing loss. Further studies including a greater number of children are needed. Cytomegalovirus screening models are mandatory if medical therapy is to be implemented in time.

A number of authors have suggested that surgery for suspected perilymph fistula is effective in preventing deterioration of hearing and in improving hearing in some cases in the short term. We present long-term hearing outcome data from 35 children who underwent exploration for presumed perilymph fistula at The Children's Hospital, Sydney, Australia, between 1985 and 1992.

The pre-operative audiological data (mean of 500, 1000, 2000 and 4000 Hz results) were compared with the most recently available data (range two to 15 years) and the six-month post-operative data.

The short-term results showed no significant change in hearing at six months, with a subsequent, statistically significant progression of hearing loss in both operated and non-operated ears (Wilcoxon signed rank test: operated ear, p < 0.017; non-operated ear, p < 0.009).

In this case series, exploratory surgery for correction of suspected perilymph fistula did not prevent progression of long-term hearing loss.

To report cases of long-term surgical complications, implant failure and revision surgery, within a large bone-anchored hearing aid programme.

Retrospective, case–cohort study.

Tertiary referral centre.

One hundred and sixty-five adults and children who had undergone a total of 177 bone-anchored hearing aid implantations.

Diagnosis and explanation of adverse events and device failure.

Operative complications and survival analysis, surgical challenges related to revisions, and causes of failure.

Twenty-one per cent of patients (3.4 per cent of those observed) suffered from skin reactions; this rate did not increase over time. Seventeen per cent had loss of osseointegration at a median interval of 6.3 months. Loss of osseointegration was observed more frequently in patients with a 3 mm compared with a 4 mm fixture (p < 0.001). Intra-operatively, the only complication was bleeding, occurring in 3 per cent of patients. Post-operative complications included: primary bleeding (2 per cent); severe skin reactions requiring intravenous antibiotics, cautery or grafting (8 per cent); thickening or overgrowth of skin requiring excision (8 per cent); failure of osseointegration requiring a new fixture (18 per cent); and graft necrosis requiring revision (1 per cent). In two patients, it was necessary to explore the area to remove overgrowth of bone. In 16 patients (10 per cent), the bone-anchored hearing aid had to be abandoned due to failure of osseointegration (n = 4), dissatisfaction with the aid (n = 6), intolerable pain (n = 4), hair growth around the abutment (n = 1) or recurrent infections (n = 1). In 12 of these patients, the bone-anchored hearing aid was removed surgically. Overall, 57 patients (34 per cent) underwent revision surgery.

Awareness of complications is becoming increasingly important in bone-anchored hearing aid programme. A substantial workload of device maintenance should be anticipated, and patients should be appropriately counselled beforehand. Ninety per cent of our patients chose to persevere with this form of hearing rehabilitation.

To determine the causative pathogens of otomycosis, and to evaluate the in vitro activity of antifungal agents against these pathogens.

A total of 96 fungal isolate were taken from 92 patients suspected of otomycosis. The in vitro activity of fluconazole, itraconazole and voriconazole against otomycotic pathogens was tested using the E-test method.

The most common pathogen was Aspergillus fumigatus (40.6 per cent), followed by A niger (35.4 per cent), A flavus (12.5 per cent) and Candida albicans (11.5 per cent). All Aspergillus species were found to be resistant to fluconazole (minimum inhibitory concentration ≥256 µg/ml). The mean minimum inhibitory concentrations of voriconazole for A fumigatus, A niger, A flavus and C albicans were significantly lower than those of itraconazole for the same pathogens.

This study found that the most common otomycotic fungal pathogen was A fumigatus, and that voriconazole had more potent in vitro activity than itraconazole against all Aspergillus species as well as against C albicans.

To evaluate the role of vestibular assessment in the management of the dizzy patient.

A retrospective review of case notes and vestibular assessment reports of 100 consecutive patients referred for vestibular assessment.

Sixty of the 100 patients had an abnormal vestibular assessment. Eleven patients had benign paroxysmal positional vertigo as the sole diagnosis, of whom nine had not had a Dix–Hallpike manoeuvre performed before referral. Of patients referred for vestibular rehabilitation, 76 per cent had an abnormal electrophysiological assessment. After vestibular assessment, 35 patients were discharged with no further follow-up appointments in the ENT department.

All patients should have a Dix–Hallpike manoeuvre performed prior to referral for vestibular assessment. The majority of our patients undergoing vestibular rehabilitation had abnormal test results, although a significant number did not. Prior to referral, it is worth considering the implication of a ‘normal’ and ‘abnormal’ result for the management of the patient. Careful consideration should be given to the development of dedicated dizziness clinics run by practitioners with a specialist interest in balance disorders, in order to ensure appropriate requests for vestibular assessment.