Purpose: Current studies show that frequency tuning modification is a good marker for the detection of endolymphatic hydrops (EH) employing magnetic resonance imaging (MRI) in patients with Ménière's disease (MD). The purpose of the present study is to analyze the auditory and vestibular function with audiometric and vestibular-evoked myogenic potentials (VEMP) responses, respectively, in both the affected and unaffected ears of patients with unilateral MD using MRI as diagnostic support for the degree of EH. Methods: We retrospectively reviewed the medical records of 76 consecutive patients with unilateral definite MD (age 55 (28-75); 39 women, 37 men). MRI was used through intravenous gadolinium administration, audiometry, and VEMPs. Functional tests were performed up to a week after the MRI. All were followed up one year after imaging utilizing clinical, auditory, and vestibular testing to rule out bilateral involvement. Results: In the unaffected ear, the mean pure-tone average is normal even in cases with hydrops and, for a similar severity of hydrops is significantly lower than in the affected ear. Significant differences for the amplitude of the response at 0.5 kHz, at 1 kHz between the affected and unaffected ears were found to be lower in the affected ears. The relative amplitude ratio (1 Kz-0.5 kHz) was significantly lower in the affected ear and in the case of the oVEMP response depends on the degree of EH. The response in the unaffected ear was not modified by the presence or the degree of hydrops. Conclusion: In the unaffected ear, hydrops is not associated with hearing deterioration. For a similar degree of hydrops, hearing loss is significantly greater in the affected ear. The endolymphatic hydrops in the vestibule induces a frequency bias in the VEMP response only in the affected ear and not in the unaffected ear. Because of these findings we consider that hydrops does not represent an active disorder in the unaffected ear.

BackgroundThe number of intratympanic gentamicin (ITG) injections needed to achieve vertigo control in patients with intractable Meniere's disease (MD) may vary from a single dose to several instillations. Changes in different vestibular test results have been used to define an endpoint of treatment, including the decrease of the vestibulo-ocular reflex (VOR) gain elicited by the head-impulse test. ObjectiveTo assess the accuracy of the VOR gain reduction after horizontal canal stimulation, as measured with the video head-impulse test (vHIT) 1 month after the first intratympanic injection, in predicting the need for one or more instillations to control vertigo spells in the long term. MethodsThe VOR gain reduction was calculated in 47 patients submitted to (ITG) therapy 1 month after the first instillation. ResultsSingle intratympanic treatment with gentamicin has a 59.6% efficacy in vertigo control in the long term. Hearing change in the immediate period after treatment (1 month) is not significant to pre-treatment result and is similar for patients who needed multiple doses due to recurrence. Chronic disequilibrium and the need for vestibular rehabilitation were less frequent in patients with a good control of vertigo with just one single injection of gentamicin. A fair accuracy was obtained for the VOR gain reduction of the horizontal canal (area under the curve = 0.729 in the Receiver Operating Characteristic analysis) in predicting the need for one or more ITG. ConclusionsSingle intratympanic treatment with gentamicin is an effective treatment for patients with MD. That modality of treatment has very limited damaging effect in hearing. The degree of vestibular deficit induced by the treatment is significant as measured by the reduction in the gain of the VOR but not useful for prognostic purposes.

Background: Hearing loss causes a significant reduction in the quality of life of patients with Ménière's disease. Although speech recognition is also affected, it has not been extensively studied. The objective of the study was to describe speech recognition behavior during a prolonged period in patients with unilateral Ménière's disease. Methods: A prospective case-control study was performed. The case group included patients with defined unilateral Ménière's disease and the control group included patients with progressive non-fluctuating hearing loss. Patients underwent an auditory evaluation periodically. Pure-tone audiometry and speech recognition tests-speech recognition threshold and speech discrimination score-were administered. The dissociation between pure-tone audiometry and speech recognition was assessed through a linear regression analysis. During follow-up, Ménière's disease patients were subdivided into a stable and fluctuating subgroup (a change of >20% in the speech discrimination score with a change no greater than 15 dB in pure-tone audiometry). Results: The average follow-up time was 79.9 months. Fifty-seven patients were included (30 cases, 27 controls). Dissociation between puretone audiometry and speech recognition threshold began to appear in the case group after 21 months, and it was statistically significant at 108 months. Duration of the disease was the only variable studied that influenced the dissociation. The fluctuation subgroup in cluded 56.6% of the cases. Conclusion: We described 2 audiological peculiarities in Ménière's disease patients: dissociation between pure-tone audiometry and speech recognition during the evolution of the disease and the fluctuation of speech recognition regardless of the change in pure-tone audiometry. Our results highlight the importance of performing speech recognition tests during follow-up in patients with Ménière's disease.

Background: Endolymphatic hydrops (EH) is the histopathological hallmark of Ménière's disease (MD) and has been found by in vivo magnetic resonance imaging (MRI) in patients with several inner ear syndromes without definite MD criteria. The incidence and relevance of this finding is under debate. Purpose: The purpose of the study is to evaluate the prevalence and characteristics of EH and audiovestibular test results in groups of patients with fluctuating audiovestibular symptoms not fulfilling the actual criteria for definite MD and compare them with a similar group of patients with definite MD and a group of patients with recent idiopathic sudden neurosensory hearing loss (ISSNHL). Material and Methods: 170 patients were included, 83 with definite MD, 38 with fluctuating sensorineural hearing loss, 34 with recurrent vertigo, and 15 with ISSNHL. The clinical variables, audiovestibular tests, and EH were evaluated and compared. Logistic proportional hazard models were used to obtain the odds ratio for hydrops development, including a multivariable adjusted model for potential confounders. Results: No statistical differences between groups were found regarding disease duration, episodes, Tumarkin spells, migraine, vascular risk factors, or vestibular tests; only hearing loss showed differences. Regarding EH, we found significant differences between groups, with odds ratio (OR) for EH presence in definite MD group vs. all other patients of 11.43 (4.5-29.02; p < 0.001). If the ISSNHL group was used as reference, OR was 55.2 (11.9-253.9; p < 0.001) for the definite MD group, 9.9 (2.1-38.9; p = 0.003) for the recurrent vertigo group, and 5.1 (1.2-21.7; p = 0.03) for the group with fluctuating sensorineural hearing loss. Conclusion: The percentage of patients with EH varies between groups. It is minimal in the ISSNHL group and increases in groups with increasing fluctuating audiovestibular symptoms, with a rate of severe EH similar to the known rate of progression to definite MD in those groups, suggesting that presence of EH by MRI could be related to the risk of progression to definite MD. Thus, EH imaging in these patients is recommended.

Objectives The method of drug delivery directly into the cochlea with an implantable pump connected to a CI electrode array ensures long-term delivery and effective dose control, and also provides the possibility to use different drugs. The objective is to develop a model of inner ear pharmacokinetics of an implanted cochlea, with the delivery of FITC-Dextran, in the non-human primate model. Design A preclinical cochlear electrode array (CI Electrode Array HL14DD, manufactured by Cochlear Ltd.) attached to an implantable peristaltic pump filled with FITC-Dextran was implanted unilaterally in a total of 15 Macaca fascicularis (Mf). Three groups were created (5 Mf in each group), according to three different drug delivery times: 2 hours, 24 hours and 7 days. Perilymph (10 samples, 1¿L each) was sampled from the apex of the cochlea and measured immediately after extraction with a spectrofluorometer. After scarifying the specimens, x-Rays and histological analysis were performed. Results Surgery, sampling and histological analysis were performed successfully in all specimens. FITC-Dextran quantification showed different patterns, depending on the delivery group. In the 2 hours injection experiment, an increase in FITC-Dextran concentrations over the sample collection time was seen, reaching maximum concentration peaks (420-964µM) between samples 5 and 7, decreasing in successive samples, without returning to baseline...

Cerebellar ataxia with neuropathy and vestibular areflexia syndrome (CANVAS) is a recently described slowly progressive ataxia with severe imbalance due to the compromise of three of the four sensory inputs for balance, leaving only vision unaffected. Bilateral vestibulopathy is present but saccular and utricular function, measured by vestibular evoked myogenic potentials (VEMPs), has not been widely studied in these patients. Dysautonomia has been reported but is not among the diagnostic criteria. We performed a database analysis to identify patients evaluated between 2003 and 2019 with probable diagnosis of CANVAS by using key words "bilateral vestibulopathy and/or cerebellar ataxia and/or sensory polyneuropathy." Five out of 842 met all conditions. Patients underwent neurological/neurootological exam, brain MRI, visually enhanced vestibulo-ocular reflex (VVOR) exam by high-speed video-oculography using video-Head Impulse Test (vHIT), VEMPs, neurophysiological studies, and genetic tests to exclude other causes of ataxia. Dysautonomia was addressed by the standardized survey of autonomic symptoms. All patients had clinically definite CANVAS as brain MRI showed vermal cerebellar atrophy, neurophysiological studies showed a sensory neuronopathy pattern (absent sensory action potentials), VVOR was abnormal bilaterally, and genetic tests ruled out other causes of ataxia including SCA 3 and Friedreich ataxia. Patients had at least 3 dysautonomic symptoms, including xerostomia/xerophthalmia (5/5). VEMP results varied among patients, ranging from normal to completely abnormal. We found inconsistent results with VEMPs. The utilization of VEMPs in more CANVAS cases will determine its utility in this syndrome. Dysautonomia may be included in the diagnostic criteria.

Objectives: Bilateral vestibulopathy is a clinical syndrome in which laboratory testing plays a crucial diagnostic role. We aimed to establish the frequency of detection of that finding in a tertiary level hospital considering the new methods of laboratory vestibular examination nowadays in use, with respect to the conventional caloric and rotatory chair test approaches. Design: Two similar time periods (5 years) were retrospectively evaluated, and the demographic, clinical data and test results from 4,576 patients were reviewed. In the first period, the diagnosis was based on caloric and rotatory chair tests and, in the second, on the video head impulse test. Results: Of the patients included, 3.77% in the first period and 4.58% in the second met the criteria for bilateral vestibular hypofunction; there was no significant difference between both periods. Conclusions: The functional vestibular evaluation to detect bilateral deficiency makes no significant difference to the number of patients diagnosed with a bilateral vestibulopathy. New diagnostic categories probably depend not only on the availability and accessibility of complete vestibular and visual-vestibular evaluation, but also on recent advances in defining vestibular disorders. Bilateral vestibular hypofunction manifests with very different patterns. Progress in more detailed definition (clinical and laboratory) is needed, in particular when all 6 semicircular canals and both maculae are available for testing.

Objectives: The aim of this study was to determine whether the dexamethasone-eluting electrode (DEXEL) has a protective anti-inflammatory effect in a normal hearing implanted cochlea, as well as its performance and safety. Design: Ten healthy and normal hearing cynomolgus macaques (Mf) were divided into two cohorts: DEXEL group (DG) (CONCERTO CI device containing a DEXEL) and conventional CI group (CG) (unmodified CONCERTO CI device). The electrode was inserted into the scala tympani via the round window with an angle of insertion of 270 degrees. Auditory, impedance, electrically evoked compound action potential (eCAP), and recovery of function measurements were recorded monthly until sacrifice at 6 months post-implantation. A histologic analysis was also performed. Results: At 6 months, measurement of auditory brainstem responses revealed a mean threshold shift, as well as a mean impedance value, lower in the DEXEL group. The minimum eCAP for the remaining active contacts in the DEXEL group was 68% of that in the conventional CI group. Also at 6 months, the eCAP amplitude produced by a stimulating current of 800 cu (eCAP800) was almost 2.5-fold higher in the DEXEL group than in the conventional CI group (1338.86 +/- 637.87 mu V versus 545.00 +/- 137.37 mu V; p = 0.049). Tissue reactions, in particular fibrosis and ossification, were more common in the conventional CI group. Conclusions: The CI electrode array equipped with a dexamethasone-eluting component tested in ...

Purpose To compare the surgical and audiological outcomes with two perimodiolar electrode arrays (Nucleus 512-Contour Advance (R) y Nucleus 532-Slim Perimodiolar (R)) and a straight electrode array (Nucleus 422/522). Methods Patients were retrospectively selected from our cochlear implant program database. Only patients with a history of bilateral, sensorineural postlingually profound hearing loss who underwent cochlear implant surgery with either a N512, a N532 or a N422 were included. Throughout a year of follow-up, pure tone audiometry (PTA), speech perception, Impedances and T-C Thresholds levels were analyzed. Surgical data were also analyzed. Results 66 patients were included (19-CI532, 20-CI512 and 27-CI422). The most common type of cochlea access with the N532, N512 and N422 was through an extended round window, a promontorial cochleostomy and a pure round window, respectively. No significant differences were observed after 12 months in Mean PTA and Speech recognition. No significant differences were seen in the levels of hearing preservation at frequencies of 250 and 500. The average values of the impedances were significantly higher in the CI group N532 and N422 than in the N512. The mean values of the T and C levels were significantly lower in the CI groups N532 and N422 compared with the N512. Conclusions No significant differences were observed after 12 months in Mean PTA and Speech recognition; however, a faster acquisition of auditory results were observed in the group of patients treated with the CI N532. The type of electrode array influences in the type of cochleostomy.

Background: Given an increase in the aging population and its impact on healthcare systems, policy makers for provision of health and social services are aiming to keep older adults in good health for longer, in other words towards 'healthy aging'. Our study objective is to show that rehabilitation with cochlear implant treatment in the elderly with hearing impairment improves the overall health-related quality of life and general well-being that translate into healthy aging. Methods: The multicentre, prospective, repeated measures, single-subject, clinical observational study will accrue 100 elderly, first-time, unilateral CI recipients (>= 60 years) and analyze changes on specific measurement tools over ca. 20 months from preimplant to postimplant. Evaluations will consist of details collected through case history and interview questionnaires by clinicians, data logging, self-report questionnaires completed by the recipients and a series of commonly used audiometric measures and geriatric assessment tools. The primary indicator of changes in overall quality of life will be the HUI-3. Discussion: The protocol is designed to make use of measurement tools that have already been applied to the hearing-impaired population in order to compare effects of CI rehabilitation in adults immediately before their implantation, (pre-implant) and after gaining 1-1.5 years of experience (post-implant). The broad approach will lead to a greater understanding of how useful hearing impacts the quality of life in elderly individuals, and thus improves potentials for healthy aging. Outcomes will be described and analyzed in detail.

Purpose Since the beginning of cochlear implant (CI) surgery, several techniques to fixate the electrode array at the cochleostomy and stabilize it have been described; however, most techniques use autologous tissues such as fascia, muscle, fat or fibrin glue. We describe a new surgical technique aimed to stabilize the electrode array of a CI without using autologous tissues or artificial materials. Materials and methods The surgical technique described consists in creating three stabilizing channels in the temporal bone for the electrode array. The first one in a partially opened aditus, the second one in a partially preserved Koerner's septum (KS) and the last one in the sinodural angle. The procedure was performed in five human temporal bones using a straight array; a radiography was made to confirm the correct placement of the electrode array and afterwards all temporal bones were shaken using a Titramax 1000 platform. The correct placement of the array post-shaking was then confirmed using the microscope and another radiography. Results No migration of the electrodes outside the cochlea was observed. The CI cable remained in the same position at the aditus and the KS in all the temporal bones. In three cases (60%), the electrode array moved away from the groove carved in the sinodural angle. Conclusions The new surgical technique described stabilizes the electrode array using the temporal bone's normal anatomy, preserving the middle ear spaces, facilitating the ulterior explantation and reimplantation if necessary, and may reduce cost and surgery time.

Objectives It has been suggested that in Ménière¿s disease (MD) a dissociated result in the caloric test (abnormal result) and video head-impulse test (normal result) probably indicates that hydrops affects the membranous labyrinth in the horizontal semicircular canal (HSC). The hypothesis in this study is that based on endolymphatic hydrops¿ cochleocentric progression, hydrops should also be more severe in the vestibule of these patients than in those for whom both tests are normal. Methods 22 consecutive patients with unilateral definite MD were included and classified as NN if both tests were normal or AN if the caloric test was abnormal. MRI evaluation of endolymphatic hydrops was carried out with a T2-FLAIR sequence performed 4 h after intravenous gadolinium administration. The laterality and degree of vestibular endolymphatic hydrops and the presence or absence of cochlear endolymphatic hydrops were recorded. Demographic data, audiometric and vestibular evoked myogenic potentials were collected, and video head-impulse and caloric tests were performed. Results Patients in both groups (NN and AN) were similar in terms of demographic data and hearing loss. The interaural asymmetry ratio was significantly higher for ocular and cervical VEMP in patients in the AN group. There was a significantly higher degree of hydrops in the vestibule of the affected ear of AN patients (¿2; p = 0.028). Conclusion Significant canal paresis in the caloric test is associated with more sev

OBJECTIVES: Bimodal stimulation for asymmetric hearing loss is an emerging treatment with proven audiometric outcomes. Our objectives are to assess the changes of the hearing impairment and the quality of life of patients treated with this type of stimulation, when compared to a unilateral Cochlear Implant (CI) stimulated condition. MATERIALS and METHODS: 31 patients with asymmetric hearing loss (Group 1) were recruited for the study. They were divided into three groups, based on their hearing loss in the ear treated with the hearing aid: Group 1A (Pure Tone Audiometry (PTA) between 41 and 70 decibels (dB)); Group 1B, (PTA between 71 and 80 dB) and Group 1C (PTA between 81 and 90 dB). 30 patients had profound, bilateral hearing loss. Then, users of a unilateral cochlear implant were recruited for the control group. Their hearing impairment and quality of life were analyzed with questionnaires Abbreviated Profile of Hearing Aid Benefit (APHAB), Speech, Spatial and Qualities of Hearing Scale (SSQ) and the Health Utilities Index (HUI). They were followed up for at least 2 years. RESULTS: The group with the asymmetric hearing loss obtains a statistically significant clinical improvement in the APHAB under category "with hearing aid" compared to "without hearing aid". The group with the asymmetric hearing loss benefits more across basically all variables compared with the control group in the SSQ. Group 1A obtains the best outcome of the sample in the HUI. CONCLUSION: Bimodal stimulation and better hearing in the ear treated with the hearing aid reduce hearing impairment and improve the quality of life.

Introduction: Publishing in scientific journals is an indicator of hospital quality and has become a standard of excellence for medical doctors and institutions. The aim of the study is to identify the scientific publications performed by Otolaryngology Departments in Spain within the period 2011-2015 and to compare them to a previous period between 1998-2002. Material and methods: Original papers published by Otolaryngology Departments in Spain in PubMed within 2011-2015 were retrieved. They were classified according to the type of journal published (international or Acta ORL Espanola) and the following subspecialty areas: Otology, Audiology and Neuro-Otology, Head and Neck Surgery (including Oncology), Rhinology and Paediatric ENT. Hospitals were ranked according to: number of original papers, accumulated impact factor and total number of publications. Results: Between 2011 and 2015, 49342 publications were included in PubMed, 1.44% from Otolaryngology Departments in Spain. Between 1998 and 2002, 3.80% publications were from Spanish ENT departments. Of the 712 papers published within the period 2011-2015, 389 were published in Acta ORL Espanola and 323 in international journals. From the latter, 20.7% belong to the Otology area, 19.2% to Audiology-Neuro-otology, 30.6% to Head and Neck Surgery, 15.2% to Rhinology and 3.4% to Paediatric ENT. Five tertiary centres published at least 10 original papers in the same period. Conclusions: Spanish otolaryngology's contribution to international journals has decreased in the last 12 years. A few institutions are responsible for the majority of publications and they have notably increased the cumulative impact factor. (C) 2018 Sociedad Espanola de Otorrinolaringologia y Cirugia de Cabeza y Cuello. Published by Elsevier Espana, S.L.U. All rights reserved.

OBJECTIVES: To determine the feasibility of progressive insertion (two sequential surgeries: partial to full insertion) of an electrode array and to compare functional outcomes. MATERIAL AND METHODS: 8 normal-hearing animals (Macaca fascicularis (MF)) were included. A 14 contact electrode array, which is suitably sized for the MF cochlea was partially inserted (PI) in 16 ears. After 3 months of follow-up revision surgery the electrode was advanced to a full insertion (FI) in 8 ears. Radiological examination and auditory testing was performed monthly for 6 months. In order to compare the values a two way repeated measures ANOVA was used. A p-value below 0.05 was considered as statistically significant. IBM SPSS Statistics V20 was used. RESULTS: Surgical procedure was completed in all cases with no complications. Mean auditory threshold shift (ABR click tones) after 6 months follow-up is 19 dB and 27 dB for PI and FI group. For frequencies 4, 6, 8, 12, and 16 kHz in the FI group, tone burst auditory thresholds increased after the revision surgery showing no recovery thereafter. Mean threshold shift at 6 months of follow- up is 19.8 dB ranging from 2 to 36dB for PI group and 33.14dB ranging from 8 to 48dB for FI group. Statistical analysis yields no significant differences between groups. CONCLUSION: It is feasible to perform a partial insertion of an electrode array and progress on a second surgical time to a full insertion (up to 270º). Hearing preservation is feasible for both procedures. Note that a minimal threshold deterioration is depicted among full insertion group, especially among high frequencies, with no statistical differences.

Different types of otic capsule dehiscence restricted to the cochlea have been described. Here we describe the case of a patient with a cochlear-internal auditory canal dehiscence associated with a cochlear-facial dehiscence not reported before. A 53-year-old patient with severe to profound sensor ineural hearing loss due to bilateral Meniere's disease under went a cochlear implant surgery on the right ear. Preoperative brain magnetic resonance imaging findings were reported to be normal; dur ing surgery, a cerebrospinal fluid gusher occur red at the time of round window opening. Postoperative computed tomography imaging showed a bony dehiscence at two levels of the otic capsule.

OBJECTIVES: To measure the auditory (pure tone audiometry and word recognition scores) and vestibular (video head impulse test and vestibular myogenic potentials) outcomes in patients diagnosed with Meniere¿s disease (MD) who underwent cochlear implantation. MATERIAL AND METHODS: This prospective study included 23 cochlear implant users with MD and 29 patients diagnosed with far-advanced oto - sclerosis (the control group). RESULTS: The preoperative mean pure tone average thresholds were 99 and 122.5 dB for the Meniere¿s and control groups, respectively. Word recog- nition scores after cochlear implant yielded a median of 80% and 72% for the Meniere¿s and control groups, respectively. Semicircular canal gain was not observed to vary post implantation (mean variation for lateral, posterior, and anterior plane was 0, 0.03, and 0, respectively). The mean ocular and cervical myogenic potentials asymmetry varied as 9.65% and 18.39%, respectively. CONCLUSIONS: The auditory performance improved in patients with MD similar to the general cochlear implant population. No major dysfunction of otolithic or semicircular canal function was demonstrated after the implantation surgery

OBJECTIVES:: The objectives of this study were to evaluate the effect of reimplanting a cochlear implant electrode in animal normal-hearing cochlea to propose measures that may prevent cochlear injury and, given its close phylogenetic proximity to humans, to evaluate the macaque as a model for electroacoustic stimulation. DESIGN:: Simultaneous, bilateral surgical procedures in a group of 5 normal-hearing specimens (Macaca fascicularis) took place in a total of 10 ears. Periodic bilateral auditory testing (distortion product otoacoustic emissions and auditory brainstem evoked responses [ABR]) took place during a 6-month follow-up period. Subsequently, unilateral explantation and reimplantation was performed. Auditory follow-up continued up to 12 months, after which animals were sacrificed and both temporal bones extracted for histological analysis. RESULTS:: Implantation and reimplantation surgeries were performed without complications in 9 of 10 cases. Full insertion depth was achieved at reimplantation in four of five ears. Auditory evaluation: Statistically significant differences between implanted and reimplanted were observed for the frequencies 2000 and 11,000 Hz, the remaining frequencies showed no differences for distortion product otoacoustic emission. Before the procedure, average thresholds with click-stimuli ABR of the five animals were 40 dB SPL (implanted group) and 40 dB SPL (reimplanted group). One week after first implantation, average thresholds were 55 dB SPL and 60 dB, respectively. After 12 months of follow-up, the average thresholds were 72.5 dB SPL (implanted group) and 65 dB SPL (reimplanted group). Hearing loss appeared during the first weeks after the first implantation and no deterioration was observed thereafter. Differences for ABR under click stimulus were not significant between the two ear groups. Similar results were observed with tone-burst ABR. A 15 dB shift was observed for the implanted group preoperatively versus 1-week post surgery and an additional 17.5 dB shift was seen after 12-month follow-up. For the reimplanted group, a 20 dB shift was observed within the first week post reimplantation surgery and an additional 5 dB after 6 months follow-up. Statistical analysis revealed significant differences between the implanted and reimplanted ear groups for frequencies 4000 Hz (p = 0.034), 12000 Hz (p = 0.031), and 16,000 Hz (p = 0.031). The histological analysis revealed that the electrode insertion was minimally traumatic for the cochlea, mainly indicating rupture of the basilar membrane in the transition area between the basal turn and the first cochlear turn only in Mf1 left ear. CONCLUSIONS:: With application of minimally traumatic surgical techniques, it is possible to maintain high rates of hearing preservation after implantation and even after reimplantation. Partial impairment of auditory thresholds may occur during the first weeks after surgery, which remains stable. Considering the tonotopic distribution of the cochlea, we found a correlation between the histological lesions sites and the auditory findings, suggesting that a rupture of the basilar membrane may impact hearing levels. The macaque was observed to be a functionally and anatomically an excellent animal model for cochlear implantation

Cluster analysis defines clinical subgroups in MD, and it extends the phenotype beyond audiovestibular symptoms. This classification will help to improve the phenotyping in MD and facilitate the selection of patients for randomised clinical trials

Introducción El objetivo de este trabajo es conocer el impacto que el implante coclear (IC) tiene en la vida laboral de las personas implantadas, a través de una primera versión de un cuestionario elaborado en el programa de implantes cocleares de la Clínica Universidad de Navarra. Se pretende demostrar que el IC está teniendo un impacto significativo en la vida laboral de estos pacientes. Material y métodos Se estudia una población de 60 pacientes de 48 años de edad media, con hipoacusia neurosensorial profunda bilateral tratada con un IC, a la que se le presenta un cuestionario elaborado para evaluar su calidad de vida laboral con carácter retrospectivo. Resultados El 94,23% de los pacientes que completaron el cuestionario están actualmente satisfechos con su trabajo. El 93,05% se sienten más motivados para ir a trabajar tras su IC. Un 79,31% se consideran más competentes tras la cirugía y activación del dispositivo. Un 67,23% de los pacientes han mejorado sus relaciones interpersonales en el ámbito de trabajo tras la implantación coclear. Conclusiones El IC proporciona una ayuda positiva en la esfera profesional al igual que en las destrezas sociales al beneficiar la capacidad de comunicación de los pacientes implantados. El desarrollo de herramientas para evaluar el grado de satisfacción laboral de los pacientes tratados con un IC es de gran interés.

Bimodal stimulation provides better results than any monaural hearing mode, regardless of whether it involves the use of a hearing aid alone or a cochlear implant alone.

The objective of this study was to review cochlear reimplantation outcomes in the tertiary hospital and analyze whether facts such as type of failure, surgical findings, or etiology of deafness have an influence. A retrospective study including 38 patients who underwent cochlear implant revision surgery in a tertiary center is performed. Auditory outcomes (pure tone audiometry, % disyllabic words) along with etiology of deafness, type of complication, issues with insertion, and cochlear findings are included. Complication rate is 2.7 %. Technical failure rate is 57.9 % (50 % hard failure and 50 % soft failure), and medical failure (device infection or extrusion, migration, wound, or flap complication) is seen in 42.1 % of the cases. Management of cochlear implant complications and revision surgery is increasing due to a growing number of implantees. Cases that require explantation and reimplantation of the cochlear implant are safe procedures, where the depth of insertion and speech perception results are equal or higher in most cases. Nevertheless, there must be an increasing effort on using minimally traumatic electrode arrays and surgical techniques to improve currently obtained results.

Se entiende por telemedicina la prestación de servicios de medicina a distancia. En áreas rurales o remotas donde no llegan muchos de los servicios médicos especializados requeridos por la comunidad, la telemedicina puede ser una alternativa viable y fiable para facilitar el acceso a dichos servicios. En el caso de la tele-audiología, se ha mostrado que los resultados obtenidos mediante pruebas remotas son equivalentes a los de las mismas pruebas presenciales. Aunque todavía se ha investigado poco en este campo, es un área de gran importancia debido a los problemas en el desarrollo y la calidad de vida que implica la pérdida de audición y a que la mayor parte de la población mundial no tiene fácil acceso a los servicios de salud auditiva. Se revisan las potenciales aplicaciones de la telemedicina, sus ventajas y sus inconvenientes.

The study aim was to determine the benefit of cochlear implantation and hearing aids in older adults diagnosed with hearing loss and to evaluate the index of depression, anxiety and quality of life after such treatments. A retrospective cohort comprised 117 patients older than 65 years and diagnosed with moderate to profound hearing loss who were included and classified into 2 groups (treated vs. non-treated). A battery of tests including auditory (pure-tone average, disyllabic words in quiet at 65 dB SPL) and findings from a series of questions relevant to quality of life were compared between both groups. Auditory outcomes for disyllabic words were 58.21% for the cochlear implant-treated group and 82.8% for the hearing aid-treated group. There was a positive effect on anxiety, depression, health status and quality of life in the cochlear implant group versus the profound hearing loss control group. We conclude that older adults with moderate to profound hearing loss gain benefit from hearing aids or cochlear implants not only in terms of improved hearing function, but also in terms of positive effects on anxiety, depression, health status and quality of life.

The aim of this paper is to present for the first time the functional evaluation of each of the vestibular receptors in the six semicircular canals in a patient diagnosed with Meniere's disease during an acute attack. A 54-year-old lady was diagnosed with left Meniere's disease who during her regular clinic review suffers an acute attack of vertigo, with fullness and an increase of tinnitus in her left ear. Spontaneous nystagmus and the results in the video head-impulse test (vHIT) are shown before, during, and after the attack. Nystagmus was initially left beating and a few minutes later an upbeat component was added. No skew deviation was observed. A decrease in the gain of the vestibuloocular reflex (VOR) and the presence of overt saccades were observed when the stimuli were in the plane of the left superior semicircular canal. At the end of the crisis nystagmus decreased and vestibuloocular reflex returned to almost normal. A review of the different possibilities to explain these findings points to a hypothetical utricular damage.

This article presents an analysis of the impact of functional neuroimaging studies (positron emission tomography, PET) in asymmetric hearing loss based on the clinical expertise obtained from a group of 21 patients. In these patients, PET studies are performed at rest and after auditory stimulation in order to measure the increase in brain activity in the ipsi- and contralateral cortex, providing supporting evidence to recommend a specific treatment and the side to implant. In conclusion, PET is a useful tool for selected cases in which information on the metabolic status of the auditory pathway can drive the decision regarding the treatment of the most appropriate ear. However, in view of our small sample, further research is needed to confirm our results in this topic

Cochlear implants are indicated in severe to profound hearing loss with no benefit with hearing aids. Since the beginning of cochlear implants 30 years ago, auditory outcomes have been improving due to changes introduced in differ-ent areas: electrode design, strategy, surgical technique... Given good results within this period of time, cochlear implant indication has varied too. The aim of this paper is to show an update on indication criteria for cochlear implantation in Navarre, for application in daily practice. The indications are established by consensus amongst the hospitals of the region.

CONCLUSION: Patients with cochlear implants should be treated no differently than non-implanted patients with similar symptomatology. OBJECTIVES: To describe the spectrum of symptomatology, treatment, and long-term follow-up of patients with cochlear implant and vestibular complaints. METHODS: This retrospective study included 25 patients with late onset vestibular complaints (more than 1 month post-implantation). Each patient underwent an extensive interrogatory and physical exam with ancillary test to complete a diagnosis. Treatment was given according to this and all patients followed a vestibular rehabilitation program. RESULTS: The total population was 72% male and 28% female, median age was 58 years; minimal follow-up was 9 months (mean = 51, median = 34). Cochleostomy was performed in eight cases and round window insertion was performed in 19 (two patients were removed from each group in the analysis due to their bilateral implantation under a different approach). The mean time from implant to vestibular symptoms was 53 months, median = 32; a Kaplan Meier graphic showed the round window approach has faster onset of symptoms with statistical significance (p = 0.020). The most common complaint was instability in all patients and after both surgical approaches. No difference in symptoms was found with a Kruskall Wallis test except for vertigo spells (more common in the round window approach). In 12 patients the symptomatology was attributed to the implanted side. In the long-term follow-up a relatively high number of patients (20/25) recovered with standard treatment, suggesting the presence of the implant is not associated with poor recovery prognosis.

OBJECTIVE: Assess angular vestibular-ocular reflex (VOR) changes after treatment with intratympanic gentamicin (ITG) for Ménière's disease (MD) and impact on short-term follow-up. DESIGN: Prospective study. METHODS: Patients submitted to ITG for unilateral MD. The gain VOR and the presence of compensatory saccades elicited by rapid head impulses were measured using the video head impulse test (vHIT). RESULTS: The study included 31 subjects (mean age: 59 years). Functional Level Scale (FLS) distributions were 35,5% (FLS3); 32,2% (FLS4); and 32,2% (FLS5). Mean follow-up was 21¿±¿7 months. Multiple injections were needed in nine patients. VOR gain in the treated ear was significantly reduced in all subjects and for all the semicircular canals (paired samples t test; P¿<¿0,05). Gain averages after treatment were 0,61 (superior); 0,69 (horizontal); and 0,47 (posterior). A horizontal canal VOR gain superior to 0,80 after treatment was associated with the need for a second gentamicin injection (Chi-square; P¿=¿0,003). Gain asymmetry between the symptomatic and asymptomatic ear (GASM) was increased after treatment. The rate of vestibular function reduction was 47,9%; 26,0%; and 35,8% for the superior, horizontal, and posterior canals, respectively. According to the receiving operator characteristic curve, the amount of change in GASM must be greater than 7 in order to predict the avoidance of a second procedure (area under the curve [AUC] horizontal canal¿=¿0,861) and the amount of vestibular function reduction in the pathologic ear in patients with a controlled disease must be greater than 17,8% (AUC horizontal canal¿=¿0,843). CONCLUSIONS: When evaluated with the vHIT, intratympanic gentamicin changes in VOR seem to foresee short-term control of vertigo attacks. LEVEL OF EVIDENCE: 4. Laryngoscope, 125:1915-1920, 2015.

Conclusion: The low clinical efficacy of the treatment for patients included in this work correlates with no noticeable effect on the vestibular function. Objective: To assess follow-up in patients with idiopathic and secondary Ménières disease after treatment with intra-tympanic dexamethasone and correlate clinical findings with changes in the vestibular-ocular reflex elicited after stimulation of each of the six semicircular canals. Methods: This is a single center retrospective review of patients presenting the clinical symptomatology of Meniérès disease treated with intra-tympanic dexamethasone. An audiometric evaluation was performed in each patient before and after treatment. The study cohort was divided into two groups: those evaluated after a short period of time and after a long period of time. Results: The study included 30 patients, mean age = 61 years. Differences in mean pure-tone average before and after treatment were non-significant for both treated (0.61 dB, p = 0.723) and untreated (0.59 dB, p = 0.609) ears. Vestibular-ocular reflex gain averages in the treated ear after treatment were 0.73 (superior semicircular canal), 0.86 (horizontal semicircular canal), and 0.69 (posterior semicircular canal). The gain did not vary significantly in the Superior (p = 0.194), the Horizontal (p = 0.646), or the Posterior Semicircular Canal (p = 0.820). Similar were obtained for the untreated ear.

Primary objective of this study was to find a statistical link between the most worldwide comorbidities affecting the elderly population (hypertension, diabetes, osteoarthrosis, osteoporosis and depression) and recurrent episodes of BPPV. Secondary objective was defining possible "groups of risk" for people suffering recurrent positional vertigo related to the presence of a well documented comorbidity. METHODS: This was an observational, cross-sectional, multicenter, spontaneous, non-pharmacological study. The data of 1092 patients suffering BPPV evaluated in 11 different Departments of Otolaryngology, Otoneurology and Neurology, referring Centers for positional vertigo evaluation, were retrospectively collected. RESULTS: Regarding evaluated comorbidities (hypertension, diabetes, osteoarthrosis, osteoporosis and depression), data analysis showed the presence of at least one comorbid disorder in 216 subjects (19.8%) and 2 or more in 408 subjects (37.4%). Moreover there was a statistical significant difference between the number of comorbidities and the number of recurrences, otherwise said as comorbidity disorders increased the number of relapses increased too. CONCLUSION: The presence of a systemic disease may worsen the status of the posterior labyrinth causing a more frequent otolith detachment. This condition increases the risk for patients suffering BPPV to have recurrent episodes, even if correctly managed by repositioning maneuvers. The combination of two or more of aforementioned comorbidities further increases the risk of relapsing BPPV, worsened by the presence of osteoporosis. On the basis of this results it was possible to define "groups of risk" useful for predicting BPPV recurrence in patients with one or more comorbidity.

OBJECTIVE: To describe the surgical technique under local or general anesthesia of 5 cases that have undergone this procedure and the audiologic results obtained with this new device. PATIENTS: Four patients with mixed hearing loss and 1 patient with single-sided deafness. INTERVENTION: Therapeutic. MAIN OUTCOME MEASURES: The surgery was planned beforehand with a 3D reconstruction of a CT scan. The procedure was documented and timed in every case. Air and bone conductive pure tone audiometry and disyllabic words discrimination were tested after and before the procedure. Results were statistically analyzed. RESULTS: All patients tolerated well the procedure. Four patients were intervened under local anesthesia and 1 under general anesthesia because of an associated procedure. All patients showed statistically significant difference between the presurgery and postsurgery audiologic tests. CONCLUSION: Implantation of the Bonebridge with local or general anesthesia is a safe and feasible procedure, with audiometric results that can come close with the ones provided by BAHD users.

Hypothesis: Evaluate, based on morphologic and histologic parameters, the atraumaticity of 2 electrode arrays implanted in 10 human temporal bones. Background: Atraumatic surgery and electrode arrays are current topics in otologic surgery. The preservation of cochlear anatomy and its functions is a priority and morphologic evaluation of the surgical trauma is essential to continue improving in this field. Methods: Ten preserved human temporal bones (TB) without anatomic alterations were used in this study. They were divided into 2 groups of 5, and atraumatic surgery was performed to insert HiFocus 1J (group A) and HiFocus Helix (group B) electrode arrays. Anatomic comparisons were performed using computed tomography and histologic analysis. Results: Group A: the mean length for the cochlear longitudinal axis was 10.30 mm, and the cochlear transversal axis was 7.2 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 19.2 mm and 325.5°, respectively. Lateral location of the electrode array was achieved in all specimens. No significant correlation was observed between these dimensions and depth of insertion. Group B: the mean length for the cochlear longitudinal axis was 9.52 mm, and cochlear transversal axis was 6.38 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 17.5 mm and 352°, respectively. Modiolar location of the electrode array was achieved in all specimens. A positive correlation was established between the linear and angular insertion depths (p = 0.044). Conclusion: In summary, it is safe to state that neither electrode array shows significant insertion trauma.

HYPOTHESIS: Evaluate, based on morphologic and histologic parameters, the atraumaticity of 2 electrode arrays implanted in 10 human temporal bones. BACKGROUND: Atraumatic surgery and electrode arrays are current topics in otologic surgery. The preservation of cochlear anatomy and its functions is a priority and morphologic evaluation of the surgical trauma is essential to continue improving in this field. METHODS: Ten preserved human temporal bones (TB) without anatomic alterations were used in this study. They were divided into 2 groups of 5, and atraumatic surgery was performed to insert HiFocus 1J (group A) and HiFocus Helix (group B) electrode arrays. Anatomic comparisons were performed using computed tomography and histologic analysis. RESULTS: Group A: the mean length for the cochlear longitudinal axis was 10.30 mm, and the cochlear transversal axis was 7.2 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 19.2 mm and 325.5°, respectively. Lateral location of the electrode array was achieved in all specimens. No significant correlation was observed between these dimensions and depth of insertion. Group B: the mean length for the cochlear longitudinal axis was 9.52 mm, and cochlear transversal axis was 6.38 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 17.5 mm and 352°, respectively. Modiolar location of the electrode array was achieved in all specimens. A positive correlation was established between the linear and angular insertion depths (p = 0.044). CONCLUSION: In summary, it is safe to state that neither electrode array shows significant insertion trauma.

Abstract Conclusion: The distribution of abnormal results is not uniform between different canals in each patient; the most frequent gain reduction is obtained for the posterior canal. Gain reduction reflects the disease duration and amount of hearing loss. OBJECTIVE: To test the hypothesis that the vestibulo-ocular reflex (VOR) evoked after stimulation of each semicircular canal behaves in a different manner in patients with unilateral definite Ménière's disease. METHODS: We studied the VOR evoked by rapid head-impulses in the plane of the 6 semicircular canals in 36 patients. It was evaluated with a video system that analyzes the head and eye velocity and the gain was the objective measure. RESULTS: In 12 (33.3%) patients the examination of both ears was normal for all the semicircular canals, in 12 patients the results from the affected ear were abnormal in at least 1 of the semicircular canals, in 11 (30.5%) patients the results were abnormal in at least 1 of the semicircular canals in both the affected and unaffected ears, and in 1 (2.9%) patient the results were abnormal only in the unaffected ear. The most frequent abnormal result was obtained from the posterior canal of the affected ear and from the coupled superior canal of the unaffected ear. The distribution of abnormal findings was dependent on the disease duration and hearing loss.

Much attention has been focused on hearing preservation in the implanted ear. Thus, investigations into electrode array design, surgical technique and pharmacological management have been undertaken. Minimizing damage in the inner ear not only enhances the possibility for hearing preservation and better performance in complex listening scenarios but also conserves inner ear structures for future treatments.

The mean gain of VOR was within normal limits for the six semicircular canals and there were no significant differences between the same canals on each side of patients with BPPV in whom canalolithiasis was located in the SSC. However, gain asymmetry was different for each pair of canals.

Introducción La aticoexposición-antroexclusión (AE-AE) simple o ampliada, es una técnica a la demanda para el tratamiento del colesteatoma. Las tasas de recurrencia/recidiva descritas con diferentes técnicas quirúrgicas son variables. El objetivo de este estudio es describir la técnica quirúrgica, sus indicaciones y analizar los resultados a largo plazo. Material y métodos Se incluyen 42 pacientes intervenidos de AE-AE en un centro terciario con un seguimiento de 6 meses-7 años. Esta técnica expone completamente el ático fresando la pared superior del conducto auditivo externo y excluye el antro y mastoides cerrando el additus con injertos de cartílago. Se indica en pacientes con colesteatoma localizado en la caja timpánica sin sobrepasar el additus o en caso de hacerlo estar encapsulado sin erosionar la cápsula laberíntica. El seguimiento es clínico y radiológico (TC de peñascos y RM con secuencias de difusión desde 2009). Resultados El 4,8% de los casos presentó una recidiva, los cuales fueron rescatados en un segundo tiempo quirúrgico. En el seguimiento la tasa de otorrea (2/42), otitis serosa (2/42) u otras complicaciones fue baja, no contraindicando las actividades acuáticas. La AE-AE no modificó el tipo de reconstrucción osicular respecto a otras técnicas. Conclusiones La AE-AE es una técnica abierta. Pretende eliminar totalmente la lesión y reducir la recidiva de colesteatoma, facilitando una normalización en los baños y una disminución de revisiones posquirúrgicas. La RM en secuencias de difusión es una técnica fiable en el despistaje y seguimiento, especialmente para el control de los espacios mastoideos tras la AE-AE.

The purpose of this study is to determine if surgical approach to the inner ear is feasible without generating a hearing loss in an animal model. Five Macaca fascicularis were used as experimental animals and followed up for 27 months. Mastoidectomy, posterior tympanotomy and promontorial cochleostomy were performed on four specimens and one specimen was kept as control animal. Before and after drilling and exposing the endosteal layer and the membranous labyrinth, otoacustic emissions (dPOAE) and auditory brainstem responses (ABR) were used to test hearing. In vivo experimental studies prove it is reliable to expose the membranous labyrinth without causing hearing loss. dPOAE were present after 3, 6, 12, 24 and 26 months of follow-up. Regarding the ABR results from the four M. fascicularis in which a cochleostomy has been carried out, auditory thresholds are within the 20-30 dB interval at 27 months of follow-up. Experimental studies support clinical experiences indicating it is feasible to surgically approach the membranous labyrinth of the cochlea without damaging its hearing function.

Introduction: The assessment of the vestibulo-ocular reflex (VOR) is one of the main steps in clinically evaluating patients with dizziness. It can be performed at the bedside with common head-impulse test in which eye position is analysed at the end of the head-thrust. It is an important test due to its high specificity but low sensitivity. Material and Methods: We studied 179 patients with different types of balance- affecting disorders. The results were analysed in contingency tables. The clinical test was classified as normal or abnormal according to the absence or existence, respectively, of fixation saccades once the head-thrust was ended. The video head-impulse test (vHIT) was classified according to vestibulo-ocular reflex (VOR) gain and presence of fixation saccades. The speed of the slow phase of spontaneous nystagmus was also quantified, as well as the caloric test results. Results: There were significant differences (Chi-square test, P=0.00) for the findings in the clinical evaluation and with the vHIT: 32.1% of the tests performed yielded different findings in both tests. In the vHIT, the differences were due to the finding of normal gain with saccades; in these patients, the mean canal paresis was significantly abnormal: 39% ± 10%. Conclusions: The distribution of findings for the VOR bedside examination and for that with the help of a video system are significantly different; as such, the video head-impulse examination is not simply an added VOR detection and registration system. The difference relies mainly on a vHIT response characterised as of normal gain but with fixation saccades. These have been considered as the cause for the low sensitivity of the bedside VOR examination and sometimes regarded as normal responses; we have demonstrated that these findings are abnormal according to the findings of higher canal paresis in the caloric test.

Introduction: The assessment of the vestibulo-ocular reflex (VOR) is one of the main steps in clinically evaluating patients with dizziness. It can be performed at the bedside with common head-impulse test in which eye position is analysed at the end of the head-thrust. It is an important test due to its high specificity but low sensitivity. Material and methods: We studied 179 patients with different types of balance- affecting disorders. The results were analysed in contingency tables. The clinical test was classified as normal or abnormal according to the absence or existence, respectively, of fixation saccades once the head-thrust was ended. The video head-impulse test (vHIT) was classified according to vestibulo-ocular reflex (VOR) gain and presence of fixation saccades. The speed of the slow phase of spontaneous nystagmus was also quantified, as well as the caloric test results. Results: There were significant differences (Chi-square test, P=0.00) for the findings in the clinical evaluation and with the vHIT: 32.1% of the tests performed yielded different findings in both tests. In the vHIT, the differences were due to the finding of normal gain with saccades; in these patients, the mean canal paresis was significantly abnormal: 39% ± 10%. Conclusions: The distribution of findings for the VOR bedside examination and for that with the help of a video system are significantly different; as such, the video head-impulse examination is not simply an added VOR detection and registration system. The difference relies mainly on a vHIT response characterised as of normal gain but with fixation saccades. These have been considered as the cause for the low sensitivity of the bedside VOR examination and sometimes regarded as normal responses; we have demonstrated that these findings are abnormal according to the findings of higher canal paresis in the caloric test.

El temblor ortostático (TO) es una enfermedad neurológica de origen desconocido caracterizada por un temblor de 10-20Hz en las piernas en bipedestación. Se manifiesta por mareo e inestabilidad, que típicamente mejoran al apoyarse o sentarse y la ingesta de pequeñas cantidades de alcohol lo reduce de manera significativa. Se muestran 4 casos clínicos atendidos en nuestra consulta cuyo diagnóstico sugiere ser el de TO. Consideramos que ante un paciente con inestabilidad, es preciso plantearse como diagnóstico diferencial un TO. La historia clínica nos orienta hacia esta entidad y en caso de sospecha, el diagnóstico definitivo viene dado por el registro de la electromiografía en las extremidades inferiores en condición de reposo sentado y en ortostatismo donde se registra un temblor de 10-20Hz. El tratamiento es médico y, se emplea el clonazepam como primera opción terapéutica.