David R. Friedland

Objectives/Hypothesis: To systematically review the existing literature on outcomes and management of facial paralysis resulting from intratemporal blunt trauma.Study Design: Systematic review of the literature.Methods: Thirty‐five articles met our inclusion criteria. Outcome variables analyzed included severity of paralysis, time of onset of paralysis, surgical or nonsurgical management, steroid use, and final facial nerve function.Results: All studies were classified as level 4 evidence as defined by the Oxford Centre for Evidence‐Based Medicine. There was marked variation in the quality of the studies with inconsistent outcome measures, diagnostic testing, and follow‐up, thus ruling out a formal meta‐analysis. In an exploratory pooling of data, 612 cases had sufficient follow‐up and facial movement grading for some evaluation of trends. In 189 patients who were followed observationally, 66% achieved an outcome equivalent to House‐Brackmann (HB) I, 25% achieving HB II‐V, and two patients an HB VI score. Among 83 patients treated with steroids, 67% achieved HB I, 30% HB II‐V, and no patients with HB VI. In 340 patients treated surgically, 23% achieved HB I postoperatively, 58% were graded as HB II‐V, and 9% with HB grade VI postoperatively. No patient presenting with partial paralysis had an HB VI outcome.Conclusions: The role of surgery versus nonsurgical interventions for this clinical entity remains inconclusive. Level 4 evidence studies predominate and are further hindered by poor description of outcome measures and incomplete data reporting. Exploratory pooling of data without formal meta‐analysis suggests the need to compare any intervention to the natural course of healing, which overall appears to be favorable. Laryngoscope, 2010

Cochlear implantation has become an accepted treatment for adults with advanced presbycusis or the continued progression of early-onset sensorineural hearing loss. Older adults (ie, those ≥ 65 years) make up greater than 12% of the current US population, and this number is expected to double in the next 20 years.¹ As such, the number of older cochlear implant candidates is expected to increase, as well as their mean age at presentation. Issues associated with cochlear implantation in elderly patients include surgical safety, quality-of-life and cost-utility concerns, and postimplantation performance.

Objectives: The goal of this study was to identify novel regulatory mechanisms controlling the growth and proliferation of cholesteatoma. Specifically, the potential role of microRNAs, regulators of protein translation, was studied in cholesteatoma. Study Design: This study represents a molecular biologic investigation characterizing and comparing microRNA and protein expression in cholesteatoma and normal postauricular skin. Methods: Cholesteatoma and normal skin were taken from patients at the time of surgery. Tissue was processed for RNA and protein extraction. Real-time reverse-transcriptase-polymerase chain reaction was used to assess levels of human microRNAs, reverse-transcriptase-polymerase chain reaction was used to confirm the presence of upstream regulators, and Western blot analyses were used to assess levels of downstream target proteins. Results: Among the microRNAs investigated, human microRNA-21 (hsa-miR-21) showed a 4.4-fold higher expression in cholesteatoma as compared with normal skin (p = 0.0011). The downstream targets of hsa-miR-21, PTEN and programmed cell death 4, were found to be greatly reduced in 3 of 4 cholesteatoma samples. Proposed upstream regulators of hsa-miR-21 expression (CD14, interleukin 6R, gp130, and signal transducer and activator of transcription 3) were present in all cholesteatoma tissues. Conclusion: MicroRNAs represent powerful regulators of protein translation, and their dysregulation has been implicated in many neoplastic diseases. This study specifically identified up-regulation of hsa-miR-21 concurrent with down-regulation of potent tumor suppressor proteins PTEN and programmed cell death 4. These proteins control aspects of apoptosis, proliferation, invasion, and migration. The results of this study were used to develop a model for cholesteatoma proliferation through microRNA dysregulation. This model can serve as a template for further study into potential RNA-based therapies for the treatment of cholesteatoma.

Recent advances in cochlear implant technology have focused renewed attention on the preservation of residual hearing. The focus on preservation of residual hearing is driven by the concept of electroacoustic stimulation. This option depends on the insertion of a short cochlear implant electrode into the basal region of the cochlea while preserving native function in the apical region. The desire to preserve residual hearing has led to the development of the soft-surgery cochlear implantation technique. Here, the authors evaluate its various components. Avoiding entry of blood into the cochlea and the use of hyaluronate seem to be reasonably supported, whereas the use of topical steroids is unlikely to be beneficial. The site of entry into the cochlea, the use of contoured or straight devices, and the depth of insertion are also evaluated. The authors highlight the importance of systematic recording of outcomes and surgical events.

Objectives/Hypothesis: This study hypothesizes that low‐frequency hearing loss is associated with underlying cardiovascular disease. The objective of this study was to use a mathematical model of hearing thresholds to predict cardiovascular status.Study Design: Logistic regression analyses of audiometric and cardiovascular data obtained through retrospective chart review. Application of a derived mathematical formula to a distinct prospectively enrolled cohort.Methods: Cardiovascular status was determined for a cohort of 1,168 patients seen in the audiology division. Associations between audiogram pattern and cardiovascular variables were tested with the Mantel‐Haenszel statistic controlling for age and gender. Logistic regression models were developed incorporating cardiovascular risk factors and audiogram pattern. The models were applied to a separate cohort of 90 subjects recruited from cardiology and geriatric medicine clinics in whom audiograms were performed.Results: A significant association was found between low‐frequency hearing loss and cardiovascular disease and risk factors. When controlling for age, hypertension, diabetes, smoking, and hyperlipidemia, low‐frequency presbycusis was significantly associated with intracranial vascular pathology such as stroke and transient ischemic attacks. Significant associations were also seen with peripheral vascular disease, coronary artery disease, and a history of myocardial infarction. A mathematical formula using audiometric pattern and medical history to predict the probability of cardiovascular diseases and events was developed and tested.Conclusions: Audiogram pattern correlates strongly with cerebrovascular and peripheral arterial disease and may represent a screening test for those at risk. Patients with low‐frequency hearing loss should be regarded as at risk for cardiovascular events, and appropriate referrals should be considered. Laryngoscope, 119:473–486, 2009

OBJECTIVE: To assess and compare the current management of sudden sensorineural hearing loss (SSHL) between primary care physicians and general otolaryngologists.STUDY DESIGN: Written survey of physician practice patterns.METHODS: A multiple choice and Likert scale survey was mailed to 1306 otolaryngologists and primary care physicians in the upper midwest with respect to management of SSHL.RESULTS: A significant number of general practitioners treat SSHL independent of an otolaryngologist. General practitioners are significantly less impressed than otolaryngologists that steroids are an effective treatment (P < 0.0001). Over 98 percent of otolaryngologists use oral steroids as compared with 73 percent of general practitioners treating on their own. The vast majority of otolaryngologists start therapy with at least 60 mg of prednisone whereas lower doses and medrol dosepaks are more commonly used by general practitioners. Otolaryngologists are more likely to treat with steroids beyond one week of onset of hearing loss whereas general practitioners overwhelmingly will only treat within the first week. Approximately 50 percent of otolaryngologists add antiviral medications in contrast to 16 percent of generalists.CONCLUSION: The approach to SSHL differs between otolaryngologists and general practitioners. The lack of strong evidence‐based guidelines for the treatment of SSHL may underlie the variability in management by first line providers.

To investigate the feasibility and safety of an implantable epidural cortical stimulator for the treatment of severe tinnitus. Prospective, controlled, single-blinded study of cortical stimulation for 4 weeks, and then an open-label stimulation period. Tertiary care referral center. Adults (n = 8) with constant tinnitus of at least 1 year with a tinnitus reaction questionnaire score greater than 33. Tinnitus was predominantly unilateral with a frequency less than 8,000 Hz. Surgical implantation of an investigational epidural electrode over the posterior superior temporal gyrus using functional magnetic resonance imaging targeting. A 2-week stimulation period alternated with a 2-week sham period in random order to which subjects were blinded. This was followed by continuous stimulation with parameter adjustments to maximize tinnitus suppression. Subjective rating of tinnitus severity, loudness, and device efficacy. Objective measures of hearing thresholds, tinnitus frequency, loudness, and minimum masking levels. Outcome measures using the Tinnitus Handicap Questionnaire, Tinnitus Reaction Questionnaire, and Beck Depression Inventory. There were no effects of stimulation during the 4-week blinded period. With continuous chronic stimulation, 2 patients had persistent reduction of pure-tone tinnitus, and 6 patients had short periods of total tinnitus suppression.Significant improvements in the Beck Depression Inventory and tinnitus questionnaires were found, although objective measures of tinnitus loudness remained fairly stable. No surgical or stimulation-related complications were noted. Chronic electrical stimulation of the secondary auditory cortex seems safe and warrants further investigation as a potential therapeutic intervention for the suppression of tinnitus.