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O – Otology: Neurootology

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 DOI 10.1007/s00405-007-0341-x

O: Otology and Neurootology

INSTRUCTIONAL COURSES OIC 1 The suprameatal approach (SMA) the alternative technique for safe cochlear implant surgery Jona Kronenberg, Wolf-Dieter Baumgartner* ENT Department Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel; *ENT Department Medical University Vienna, Austria, Wa¨hringer Gu¨rtel 18–20, A-1097 Wien In 1999 we developed an alternative technique for cochlear implantation in the Sheba Medical Center—the suprameatal approach (SMA). The trigger for the development of this alternative technique was the desire to simplify the surgical procedure using classic standard middle ear surgical procedures and the thought that mastoidectomy is not crucial for performing cochlear implantation. The SMA is based on the retro-auricular approach that is well familiar to otologic surgeons. A classic tympanomeatal ﬂap, like in stapessurgery is performed. The electrode array is inserted into the cochlea through a tunnel drilled in the suprameatal region lateral to the posterior attic at about 1 o’clock position to the external auditory canal. This can be deﬁned as a superior antrotomy. SMA is a simple and safe technique, which does not endanger the facial nerve or the chorda tympani. It enables wide exposure of middle ear and is especially suitable for malformed cochlea, anteriorly placed facial nerve or small facial recess. Exclusion of mastoidectomy minimizes amount of drilling and shortens duration of surgery. In light of the success of this technique it is gaining acceptance among more and more cochlear implant surgeons as a safe and valid surgical alternative for cochlear implantation.

OIC 2 Otological and neurootological disorders in divers: diagnosis, treatment and prevention C. Klingmann, P. K. Plinkert Heidelberg, Germany Diving is becoming an increasingly popular leisure time activity. Otological disorders are very common in divers and therefore every ENT specialist should be aware of diving-related otological/neurootological disorders. Especially the outer and middle ear is frequently involved. Disorders of the inner ear occur less frequently but can result in permanent failure of inner ear function. Therefore, a fast and consequent treatment (hyperbaric oxygene, sealing of the round window membrane) is required. In the past diving used to be very exclusive and only an activity of trained and healthy individuals. Nowadays patients with a history of middle ear surgery, hearing loss, vestibular disorders, impaired middle ear ventilation and many other otological disorders seek the advice of an ENT specialist. It is common believe that patients after tympanoplasty are not allowed to dive. However our experience with more than 400 treated divers suggests that diving after a tympanoplasty type I, II and IIIa, b is possible. After stapes surgery and tympanoplasty Type IIIc certain diagnostic prodedures in a specialized centre are required.

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OIC 3 Infratemporal approaches J. P. Lavieille Department of Otorhinolaryngology, CHU Nord, Marseille, France The different infratemporal approaches (ITA) provide a limited or a wide extradural exposure of the lateral skull base, according to the lesion (for instance: paragangliomas, meningiomas, cholesteatomas…). New neuroradiological diagnosis, better knowledge of pathologies, management of carotid artery and facial nerve overcome the obstacles of injury of facial nerve, lower cranial nerves or carotid artery. We will describe the infratemporal approaches popularized by U. Fisch and the preauricular, tranzygomatic-subtemporal approach presented by LN. Sekhar. The Fisch’s ITA type A combine middle ear exclusion and facial rerouting, leads mainly to the jugular foramen. The type B, without facial rerouting, reachs the clivus, the petrous apex and the internal carotid artery. The type C offers a wide access to the petrous bone and the internal carotid artery, the infratemporal fossa and the nasopharynx for large tumors. The preauricular trans-zygomatic approach provides a fast and wide access to the lateral skull base and infratemporal fossa, without middle ear exclusion. We will focus on the infratemporal procedure with a limited facial nerve rerouting, without middle ear exclusion, initially described by Glasscock. We will present some modiﬁcations with a better access to the internal carotid artery (site of Fisch C2 tumours) by removing temporarily part of the bony external ear canal. For each approaches, anatomical landmarks and surgical procedures will be presented step by step and indications will be illustrated by pathological cases.

OIC 4 Tips and tricks in surgery of the lateral skull base W. Mann Mainz, Germany This course details our experience in surgery of acoustic neuromas using three different approaches. Examples of surgery for lesions of the petrous apex using endoscopic and microscopic techniques and of a variety of lesions of the petrous pyramid and the jugular foramen with intra-extra-dural extension are demonstrated. Interdisciplinary approaches and purely otologic techniques are demonstrated based on the experience of treating these patients during the last 25 years. Preoperative considerations and handling of possible postoperative neurologic deﬁcits are discussed.

OIC 5 Therapy of inner ear disorders by intratympanic drug delivery Stefan K. Plontke Department of Otorhinolaryngology and Tu¨bingen Hearing Research Center, E.-Aulhorn Str. 5, 72076 Tu¨bingen, Germany

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 There is an increasing interest in the treatment of inner ear disorders by local drug delivery to the inner ear. This course reviews the current state of pharmacology, safety, efﬁcacy and technical considerations of this promising treatment regimen based on recent preclinical and clinical studies. Speciﬁcally, the course will focus on the following subjects:

1. 2.

3. 4.

5.

An overview is given over the increasing number of preclinical studies using various substances for the treatment of different inner ear disorders. Since rational local pharmacotherapy of the inner ear requires an understanding on how drugs move in the inner ear, principles of drug dispersal within the inner ear ﬂuids are demonstrated and relevant pharmacokinetic studies are reviewed. Clinically, the focus will be on the treatment of sudden sensorineural hearing loss through intratympanic drug administration by providing an overview over clinical studies. As more candidate substances for the treatment of inner ear disorders are being discovered, it is equally important to develop appropriate drug delivery systems ranging from simple intratympanic injections of ﬂuids to the use of controlled release devices like pumps or biodegradable biopolymers. Currently available drug delivery systems are reviewed with a focus on their safety-beneﬁt aspects. Finally, an outlook is given on future developments in local drug delivery to the inner ear.

OIC 6 Ofﬁce-based diagnosis and treatment of otolith function disorders Martin Westhofen1, Arne Ernst2, Patrice Tran Ba Huy3 1 Department of ORL, Plastic Surgery, University Aachen, RWTH, Germany; 2Department of Otolaryngology at UKB, Hospital of the University of Berlin (Charite Medical School), Berlin, Germany; 3Hopital Lariboisiere, Clinique ORL, Paris, France Differentiatioin of uni- and bilateral vestibular dysfunction can be made by otologists between canal, otolith and combined function disorders by means of screening tests and further investigation of vestibulo-ocular responses. The clinical application of inventories, short-term screening tests and ofﬁce-based neurotologic examinations are demonstrated. Quantitative and semiquantitative procedures are compared. The diffentiation of clinical entities and the diagnostic localisation of malfunction is demonstrated by means of diverse neurotologic function tests. The investigation of the ocular tilt reaction and ocular torsion under static tilt, the recording of the subjective vertical and horizontal, the improvement of the VEMP (vestibular evoked myogenic potentials) recording in daily situations, position and positional oculomotor reactions and ofﬁce-based treatment options are demonstrated. Methods of otolith function tests in vestibular rehabilitation are proposed. Interactive training with case demonstration of patients will be performed with the participants.

Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264

LECTURES Audiology OL 1 Intratympanic steroids for sudden idiopathic sensorineural hearing loss S. Y. Kosyakov, A. H. Atanesyan Russia Medical Academy For Postgraduate Education The treatment of sudden sensorineural hearing loss (SSNHL) remains one of the challenging problems of modern otorhinolaringology. There are different treatment protocols for SSNHL, however, for today steroid therapy is considered as the most effective one. Objectives: Following research is aimed to study the efﬁciency of intratympanic steroid therapy in treatment of SSNHL and compare the intratympanic route of administration of steroids with the intravenous route in case of sudden idiopathic sensorineural hearing loss. Methods: Thirteen patients with idiopathic SSNHL were observed in pilot study. 6 patients with SSNHL were treated with intratympanic steroids (through a tympanostomy tube) and seven patients were treated with intravenous steroids. Pretreatment and posttreatment pure-tone audiograms were compared. Results: The patients, who were treated with intratympanic steroids, showed the mean improvement of more than 25 dB in the pure-tone audiogramms. The patients, who received intravenous injection of steroids showed the mean improvement of 10 dB. Conclusions: Thus, our preliminary observations indicated that intratympanic administration of steroids is more effective method for treatment of idiopathic SSHNL, than systemic steroid therapy, and requires further research.

OL 2 Early cochlear hearing loss in vestibular schwannoma Haralampos Gouveris1, Anja Victor2, Wolf Mann1 1 Department of Otorhinolaryngology, Head and Neck Surgery, The University of Mainz Hospitals and 2Institute for Medical Biometry, Epidemiology and Informatics, University of Mainz, Mainz, Germany Objective: To test whether early hearing loss in vestibular schwannoma (VS) patients is cochlear in origin Methods: Retrospective case review of a group of 19 VS patients with normal/symmetrical hearing and a group of 20 VS patients mith mild hearing loss (threshold at any tested frequency better than 45 dB HL) on the tumor ear side. Differences of the amplitudes of the distortion-products of otoacoustic emissions (DPOAEs) between the tumor- and the non-tumor-ear were studied at frequencies 1, 1.4, 2, 2.8 and 4 kHz. The Wilcoxon’s test was used to compare between ears for both groups. Results: DPOAE amplitudes do not differ strongly between ears in VS patients with normal/symmetrical hearing (two-sided P-values: 0.050 at 1 kHz, 0.182 at 1.4 kHz, 0.378 at 2 kHz, 0.293 at 2.8 kHz and 0.238 at 4 kHz) but are decreased compared to the non-tumor

S155 ear at frequencies 1, 1.4, 2 and 2.8 kHz in VS patients with even mild hearing loss (two-sided P-values: 0.013 at 1 kHz, 0.007 at 1.4 kHz, 0.033 at 2 kHz, 0.010 at 2.8 kHz and 0.156 at 4 kHz). Conclusion: DPOAEs amplitudes begin to decrease even at the early stages of hearing loss in VS patients suggesting a cochlear origin of early hearing loss in these patients. DPOAEs may be used in a clinical setting to monitor progression of cochlear damage at the early stages of hearing impairment in VS patients.Key words: Cochlea, Otoacoustic emissions, Hearing, Vestibular schwannoma

OL 3 Otorhinolaryngological effects of barotrauma Neil Sharma Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham, UK, B15 2TH Objective: To summarise the otorhinolaryngological consequences of barotrauma. Summary: The effects of barotrauma on the head and neck are presented, in particular with respect to the ears and paranasal air sinuses. A comprehensive literature review is provided. The effects, although more commonly documented during diving, can also occur at high altitude.

OL 4 Detailed Audiometric Evaluation of Recovery after Impulse Noise Acoustic Trauma Jean-Bertrand Nottet1, Annie Moulin2, Ire`ne Giroult1 1 Hoˆpital d’instruction des arme´es Desgenettes, Bd Pinel, Lyon, France; 2UMR CNRS 5020, Universite´ C. Bernard, lyon 1, France Objectives: To detail the audiological recovery of military personnel after an accidental unilateral impulse noise acoustic trauma (AT). Methods: Fifty patients were speciﬁcally referred to our unit to be assessed less than 24 hours after an AT (session 1), 3 days later (session 2) and then 2 weeks later (session 3) using standard audiometry and detailed audiometry up to 16 kHz (Audioscan). The reproducibility of the Audioscan procedure was investigated in a control group of 50 normally hearing ears, using the same equipment as for the patients, and 3 sessions. Results: As expected, hearing loss was the greatest on the 4 to 6 kHz range. However, comparison between ﬁrst and second sessions revealed the presence of a 1 to 3 dB signiﬁcant threshold shift at all the low frequencies (from 0.25 to 2 kHz) that was not due to a possible learning of the task as such shift was absent in the control group. Similar threshold shift was obtained for the whole frequency range in the contralateral ear, although no hearing loss was detected in that ear. In addition, comparison between sessions 2 and 3 showed the possibility of a further recovery occurring more than 4 days after the AT. Conclusions: Impulse noise acoustic trauma affects not only 4 to 8 kHz regions, but also all frequencies (including low frequencies), and recovery can occur 4 days or more after the AT.

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OL 5 Intratympanic steroids for treatment of sudden sensorineural hearing loss and Menie`re´s disease G. Plaza1, C. Herraiz2 1 Department of Otolaryngology, Hospital de Fuenlabrada, Madrid, Spain 2Department of Otolaryngology, Fundacio´n Hospital Alcorco´n, Madrid, Spain Objectives: To describe our experience on intratympanic (IT) steroid treatment of sudden sensorineural hearing loss (SSNHL) and Menie`re´s disease (MD) and to review the literature on this issue. Methods: A non-randomized prospective clinical trial on IT in SSNHL refractory to intravenous treatment, a case series on IT for SSNHL, and another case series on IT for MD will be presented. A total of 30 patients presenting with SSNHL have been treated by IT steroids, and recovery of hearing was reported as improvement of more than 15 dBs in Pure Tone Average, whereas a total of 25 patients presenting with MD have been treated by IT steroids, with a minimum follow-up of 12 months. Results: IT steroid treatment improved hearing loss in 55% of SSNHL cases after failure of intravenous treatment. This is signiﬁcant when compared to those cases that refused intratympanic treatment, which showed no further improvement at all (P < 0.05). In the MD group, IT steroids have improved hearing outcome in 10 dB, whereas the number of vertigo crisis has been reduced from 3.75 to 1.1 per month, with signiﬁcant differences. Conclusions: Intratympanic steroids signiﬁcantly improve the recovery outcome of sudden hearing loss and the hearing and vertigo evolution of Menie`re´s disease. These ﬁndings will be discussed during the course, and the literature on IT steroids will be reviewed.

OL 6 Auditory and vestibular medicine: to be or not to be L. Luxon1, M. Hamid 2 1 Institute Of Child Health, London, UK; 2The Cleveland Hearing & Balance Center, Cleveland, OH, USA Auditory dysfunction is the commonest sensory disability and balance disorders affect 40% of the population by the age of 60 years, conferring a signiﬁcant economic and social morbidity. Interest in the evaluation and management of this group of patients has increased in the past 10 years, not least because of the better understanding of the underlying pathophysiology, novel investigative techniques and the success of appropriate and directed multidisciplinary intervention. This is evident both nationally and internationally. Several medical and non-medical professionals have seen ﬁt to establish centers dedicated to this discipline. Access, evaluation, tests and treatments differ signiﬁ-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 cantly. Turf issues have also become evident. The purpose of this course is to introduce the concept of Auditory and Vestibular medicine as a uniﬁed and integral part of medical practice. Several approaches to set up such practices for ENT and Neurology physicians, in conjunction with allied health care personals (Audiologists, Psychologists and Physical and Occupational Therapists) will be discussed with emphasis on management of the underlying medical problems. The instructors, who have signiﬁcant experience in the ﬁeld, will address pitfalls and the cost of non-medically supervised centers. Recent advances and cost effective management of selective cases will be discussed.

OL 7 Prospective double-blind study on ototoxicity of antimalarial drugs Artemether/Lumefantrine, Quinine and Atovaquone/Proguanil R. Gurkov1, T. Eshetu3, I. Barreto Miranda2, E. Krause E1, T. Loscher 2, J. M. Hempel1 1 HNO-Klinik LMU Muenchen; 2Abteilung fuer Infektions- und Tropenmedizin LMU Muenchen; 3Department of Microbiology Jimma University Objectives: Artemisinin-based combination therapies (ACTs) are now generally considered as the best current treatment for uncomplicated falciparum malaria. New reports on a possible otoor neurotoxic effect of these drugs have excited a critical discussion in view of their fast-spreading use. The aim of this study was to evaluate any adverse audiological effects by using a comprehensive test battery in a double-blind study setting. Methods: One hundred and three patients with uncomplicated malaria in an endemic area in Aethiopia were allocated to one of three drug regimens with standard dosage: (1) Artemether/Lumefantrine, (2) Atovaquone/Proguanil or (3) Quinine. Serial measurements of pure tone audiograms, distortion product otoacoustic emissions and brainstem evoked response audiometry (BERA) and clinical assessment were performed immediately before and on days 7, 28 and 90 after initiation of antimalarial treatment. Results: Exclusively the Quinine treated patients showed a temporary threshold shift by audiometry. Correlating deterioration of otoacoustic emission levels conﬁrmed this effect to be due to a cochlear impairment. None of the treatment groups showed a signiﬁcant prolongation of BERA interpeak latencies. By comparison with normative data, interpeak latencies were prolonged in one patient in the Quinine group (Jewett III-V) on day 28, but not on day 90. He had no hearing loss or neurological involvement. Conclusion: Our study shows no ototoxic effects of Artemether/ Lumefantrine on the cochlear or brainstem level. Furthermore we were able to demonstrate that Quinine-induced hearing loss is due to cochlear damage.

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OL 8 Intratympanic dexamethasone perfusion for the treatment of sudden hearing loss

OL 10 A survey of relationship between rheumatoid arthritis and hearing disorders

Efthimios Kyrodimos, Ioannis Aidonis, Aristides Sismanis Department of Otolaryngology, Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA

M. H. Baradaranfar1, M. R. Vahidy 2, A. Doosti3 1 Department of otolaryngology, Head and Neck Surgery, Yazd University of Medical Sciences; 2Yazd University of Medical Sciences; 3Yazd University of Medical Sciences

Objective: To evaluate the efﬁcacy of intratympanic dexamethasone perfusion for hearing improvement in patients with sudden hearing loss. Setting:A retrospective study in a tertial referral center. Materials and methods: Intratympanic perfusion of 24 mg/ml of dexamethasone was administered under the surgical microscope into the posteroinferior aspect of the tympanic membrane. Oral steroids (40 mg prednisone) were also administered for 10 days approximately in all patients. Outcomes were determined by audiometric evaluation (pure tone average and speech discrimination score) at the ﬁrst post-perfusion visit, 4–6 weeks later. Results: Between June 1999 and December 2004, 17 patients (9 women and 8 men, aged 32–62 years, mean age: 47 years) with sudden hearing loss underwent intratympanic dexamethasone perfusion. Follow-up ranged from 12 to 48 months (mean 30 months). Six patients (43%) had a moderate hearing loss, ﬁve patients (36%) severe and three patients (21%) a profound hearing loss. Five patients (29%) demonstrated a greater than 20 db improvement in PTA, while in 12 patients (71%) the improvement in PTA was less than 20 db. Seven patients (41%) had an increase in SDS of at least 15% and in four patients (23.5%) the increase in SDS was over 40%. No middle ear or tympanic membrane complications were identiﬁed. Conclusion: The intratympanic dexamethasone perfusion may provide improvement in hearing in patients with sudden hearing loss, especially an increase in speech discrimination score. These patiens can further beneﬁt from the use of a hearing aid.

OL 9 Special cases diagnosed by DPOAE Susan Abdi, PhD Tehran University of Medical Sciences, Tehran, Iran Objectives: The aim of this study is to examine a new way to address patients who are complaining of sense of fullness and hearing loss in their ears with normal clinical examinations and hearing test like PTA. These patients did not show any other impairments or abnormality in their Tympanometry, Acoustic Reﬂexes and ABR. In this study, we used DPOAE in our adult patients suffering from hearing problem. The result of it showed that all of these patients have some signiﬁcant changes in their tests. The idea was to check the function of outer hair cells of inner ear by using Otoacoustic Emission (OAE’s). Methods: Sixty enrolled patients were studied for 6 months and examined by Tympanometry, PTA, MCL, UCL, SRT, SDS, ABR, DPOAE. The time for examination was done at ﬁrst visit and 6 months later. Results: As a result we could see that only DPOAE showed abnormality and on the other tests we had normal results (P < 0.05). Conclusions: DPOAE’s have become a quick and easy way to rule out hearing loss in many difﬁcult cases and it can be used for patients who have some complains of hearing but in the other tests they have normal results. This test can be used for early detection of sensoryneural hearing loss.

Rheumatoid arthritis (RA) is a chronic multisystem disease with a variety of systemic manifestations. One of these manifestations, is hearing disorder, so study of the relation between RA and hearing disorders is seem important. This was a case-control study which has done from December 2004 to August 2006. This study compared 50 patients with RA, with age,sex and job-matched as control. Audiometric tests in different frequencies show that hearing threshold in high frequencies specially in 8000 Hz had a signiﬁcant difference between two groups, also acoustic reﬂexes were absent in case groups and had signiﬁcant difference between two groups too. The evaluation of sensory neural hearing loss showed that this hearing loss is sensory not neural. Based on this study, frequent evaluation of audiometric tests is recommended for controlling hearing disorders by therapeutic and rehabilitation procedures in RA patients.

OL 11 Inﬂuence of chronic mobile phone exposure on hearing status in humans Annie Moulin1,2, Jean-Bertrand Nottet3, Gwenaelle Tourlonias1, Sandra Peyraud1, Lionel Collet1,2 1 UMR CNRS 5020, Universite´ C. Bernard, lyon 1, France, 2 Hospices civils de Lyon, Pavillon U, E. Herriot Hospital, Lyon, France, 3 Hoˆpital du Service de Sante´ des Arme´es Desgenettes, Bd Pinel, Lyon, France Objectives: To investigate the possible inﬂuence of chronic mobile phone exposure on hearing status in humans. Methods: A questionnaire detailed the mobile phone use of 302 normally hearing subjects, free from any previous otological problem. Standard audiometry was performed on each subject and transiently evoked otoacoustic emissions, which are known to reﬂect outer hair cell’s status, were recorded using Otodynamics’s ILO88, with a 80 dB pSPL non-linear click stimulus, on both ears. Results: No statistically signiﬁcant correlation was obtained between otoacoustic emissions amplitude and mobile phone use, regardless of whether daily use or cumulative use over the years was considered. A group of light users ( < 10 min daily) and heavy users (>30 min daily) were deﬁned: no signiﬁcant difference was obtained. Similarly, no signiﬁcant differences were obtained between recent users (less than 6 months) and veteran users (more than 3 years) of the same age. Conclusions: Although no detrimental effect of mobile phone exposure was observed on hearing status in this study, to rule out safely any damage due to mobile phone exposure, more sensitive hearing tests need to be used. Furthermore, longer term mobile phone exposures must be considered, as most of our subjects reported mobile phone use of less than 4 years.

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OL 12 Possible role of CMV intracochlear reactivation in idiopathic sensorineural hearing loss W. Di Nardoa, P. Cattanib, T. Lopizzob, I. Cantorea, P. Melilloa, F. Cianfronea, M. Simonea, A. Scorpeccia, G. Faddab, G. Paludettia a Institute of Otorhinolaryngology, bInstitute of Microbiology, Catholic University of the Sacred Heart, Rome, Italy Objectives: At least 30% of sensorineural hearing loss are considered to be idiopathic. The viral hypothesis is often proposed, but hardly ever demonstrated by clinical, serological and instrumental data. Direct activity of a viral agent within the cochlea could be assessed by means of detection of its genome. The aim of our study was to identify eventual viral activity within the inner ear extracellular compartment in patients with bilateral severe sensorineural deafness. Methods: Four patients,aged from 2 to 7 years, affected by sensorineural hearing loss, underwent endolabyrinthine ﬂuid sampling during cochlear implantation surgery. The sample was subsequently submitted to polymerase chain reaction (Multiplex and RT-PCR) for CMV, EBV, VZV, HSV-1, HSV-2 and Enterovirus genomes. Results: One patient resulted positive for intracochlear CMV. A different CMV-PCR conﬁrmed our ﬁndings. No EBV, VZV, HSV and Enterovirus were detected in the four patients. Negative and positive controls were as expected. Conclusions: Multiplex-PCR and RT-PCR are reliable in order test for more than one virus type at a time even on the small volume of endolabyrinthine liquid collected from children during implant surgery. Our ﬁnding of CMV genome within the cochlea of a patient without any evidence of CMV intrauterine infection suggests its possible role in post-natal inner ear damage. In particular, there being no evidence of acute infection at the time of surgery, it could be hypothesized a local reactivation of a latent CMV infection which may determine a cochlear damage without systemic clinical and serological signs.

OL 13 Audiological performance compared to plasma SDF-1a in NIDDM Benjamin Loader1, Dejan Stokic2, Sonja Hickmann1, Michaela Katzinger1, Michaela Riedl3, Anton Luger3 and Nikolaus Wick4 1 Department of Otorhinolaryngology, Complex Systems Research Group, 2Department of Endocrinology, 3Department of Clinical Pathology, 4Medical University of Vienna, Wa¨hringer Gu¨rtel 18– 20, A-1090 Vienna Objectives: Although the occurrence of diabetic microangiopathy is widely acknowledged in the case of other organs, its effect on the inner ear still remains unclear. In this study we aim to show raised blood plasma levels of stromal cell derived factor 1a (SDF1a), a chemokine and mediator of microangiopathy, to be associated with impaired hearing in type II diabetics. Methods: Eighteen randomly selected type II diabetics (mean age 52a) were compared to a matched control group in order to identify possible diverging thresholds in pure tone audiometry and speech recognition levels. Speech recognition was measured with

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Freiburger Number Tests. The plasma level of SDF-1a of each patient was determined using an R&D Systems Quantikine ELISA. To our knowledge, a novel statistical comparison was performed between absolute SDF-1a values and functional audiometry thresholds. Results: Pure tone audiometry showed a marked hearing impairment in type II diabetics across all frequencies, increasing in the presbyacustic range. The Freiburger Number Test revealed a difference in the 50% speech recognition at 1 kHz between type II diabetics and non-diabetics, which corresponded exactly with pure tone audiometry values at the same frequency. The plasma concentration of SDF-1a was signiﬁcantly higher in diabetics than in non-diabetics (P = 0.017). Statistical analysis showed no direct linear or logarithmical correlation between audiometry and plasma values (r = 0.262). Conclusions: In our study, type II diabetics showed impaired auditory performance associated with a raised plasma level of SDF-1a, a microangiopathic mediator. Thus, in our opinion, microangiopathy should not be fully excluded as a pathogenetic factor in diabetic hearing loss.

OL 14 Early detection of cysplatinum ototoxictity in UCNT patients using otoacoustic emissions Branka Mikic, Ivica Pendjer, Snezana Andric-Filipovic, Bojan Pavlovic Institute of ENT and HNS, Clinical Centre of Serbia, Belgrade, Serbia The authors have studied a group of 57 patients treated for UCNT with combination of cysplatinum and irradiation. The patients were tested by tympanometry, pure tone audiometry and otoacoustic emissions. In order to distinguish between cysplatinum ototoxic effects and radiation induced hearing loss we had two control groups of patients. First control group consisted of 12 children treated for various malignancies by cysplatinum (SIOPEL protocol) and the second control group consisted of 19 patients with radiation of the head for other types of cancer. The patients with UCNT treated by combination of chemotherapy and irradiation have shown the highest rate of sensorineural hearing loss. Pure tone audiometry have revealed hearing loss in more than half of the patients (31/57). Decrease in TEOAE and DPOAE was found in vast majority of the patients in that group (45/57). In the group of children treated by SIOPEL protocol hearing loss was conﬁrmed by pure tone audiometry in 2/12 and incipient ototoxicity by TEOAE and DPOAE in 4/12. In the group of patients treated by head irradiation for various malignancies hearing loss exceeding age appropriate, was conﬁrmed in 5/19 patients. Decreased otoacoustic emissions were found in 9/19. Conclusion: Combination of cysplatinum and head irradiation for UCNT is highly ototoxic, exceedeing isolated rate of ototoxicty of either of them. Otoacoustic emissions are decreased much before the pure tone audiometry reveals ototoxic effects of cysplatinum and/or head irradiation.They could be a useful tool for monitoring incipient hearing impairment during the treatment for head and neck cancer.

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OL 15 Middle ear pressure and measurements of distortion product otoacoustic emissions

Conclusions: There was a high prevalence of hearing loss in Rheumatoid Arthritis, though there was no statistical signiﬁcant difference between the study group and control group. The longer the duration of RA the more severe is the hearing loss. There was variation in the prevalence of hearing loss depending upon the ethnicity (P = 0.0001).

Anemone Luca1, Thomas Janssen2 1 Neomed Clinic, Str.Crisului nr.1, Brasov, Romania; 2 ENT-department, Technical University Munich, Germany The measurement of distortion product otoacoustic emissions (DPOAEs) depends on the middle ear characteristics, since DPOAEs are transmitted retrograde from the outer hair cells (OHC) through the middle ear into the external auditory canal. For a reliable assessment of OHC function, reﬂected by the DPOAE measurements, the middle ear inﬂuence on DPOAE recording has to be minimized. Objectives: The aim of the study was to investigate to what extend DPOAEs are inﬂuenced when the pressure in the tympanic cavity is increased during Valsalva-manoeuvre. Methods: In 15 normally hearing subjects with normal middle ear pressure and 15 patients with mild sound conductive hearing losses and type C tympanogram, DPOAEs were measured using the Cochlea-Scan device (Natus, USA) at test-frequencies f2 = 1.5, 2, 3, 4, 6 kHz before and after asking the subject to do a Valsalva-manoeuvre. Each time ﬁrst the middle ear pressure was determined by using a Madsen tympanometer. Results: In the normally hearing subjects there was less evidence of an inﬂuence of middle ear pressure on the DPOAE amplitude. Patients with negative pressure within the tympanic cavity exhibited after Valsalva-manoeuvre increased DPOAE amplitudes especially at the low test-frequencies. Conclusions: DPOAE measurements are inﬂuenced by middle ear pressure, especially by negative pressure, the most at f2 = 1.5 and 2 kHz. A Valsalva-manoeuvre before doing DPOAE measurements seems to be useful for a more reliable evaluation of cochlear impairment.

OL 16 Hearing loss in rheumatoid arthritis Sambandam Elango*, Suk Chyn Gun**, Esha Das Gupta*, Gopalan Nair**, Keng Yin Loh* International Medical University*& Hospital Tuanku Ja’afar**, Seremban, Malaysia. Objectives: To obtain the prevalence of hearing loss in Rheumatoid arthritis (RA), and to ascertain the association between hearing loss and the duration of RA. Methods: Pure tone audiometry and tympanometry were performed in 101 patients with RA and 46 healthy matched subjects (control). Results: The mean age of the patient group was 47.8. Male female ratio was 1:9. The prevalence of hearing loss in RA was 23.76% and 18.47% in control. There was no statistical signiﬁcant difference in the prevalence of hearing loss between the study group and control group. Abnormal tympanometric pattern was present in 15.84% of rheumatoid arthritis patients and 9.78% of the controls. There was a signiﬁcant correlation between hearing loss and positive rheumatoid factor and the use of DMARDs, NSAIDs and Steroids (P = 0.001). The longer the duration of Rheumatoid arthritis, the more severe is the hearing loss (P = 0.001). Mean disease duration of 9.8 years was associated with mild hearing loss and mean disease duration of 11.8 years was associated with moderate hearing loss. There was a statistical signiﬁcant difference in the prevalence of hearing loss among the different ethnic groups (P = 0.0001); Indians were associated with higher prevalence of hearing loss compared to other races in this study.

OL 17 Stochastic resonance on the intensity of DPOAE’s F. To´th, A. L. Nagy, R. Vajtai*, Z. Gingl *, L. Rovo´, J. Jo´ri, J. G. Kiss University of Szeged, Department of Otorhinolaryngology, Head and Neck Surgery, *Department of Experimental Physics, Szeged, Hungary Objectives: If we have a system with periodic excitation and with the addition of white noise the signal-to-noise ratio (SNR) on the output increases at least for small noise intensities, we call this phenomenon stochastic resonance (SR). Our goal was to elucidate how white noise inﬂuences the intensity of DPOAE. If there is emission then that speciﬁc ear surely has non-linear behaviour, which in turn is the basic property needed for SR. Methods: We carried out our DPOAE experiments on 10 healthy, normal hearing persons. The input noise was applied with contralateral stimulation via earphone. The DP-grams were taken at 60 and 70 dB SPL measure-tone intensities, respectively. The intensity of the contralateral white noise was changed by steps of 10 dB. Results:Increasing the external noise, the output SNR of DPOAE ﬁrst increases. After reaching about 40–50 dB SPL noise intensity the DPOAE amplitude begins to decrease. The effects are frequency-speciﬁc: signiﬁcant changes could only be found at three frequencies: 2,531, 3,187, 4,000 Hz (F1 values). Conclusions: Our results show that there is a connection between the external noise and the DPOAE signals. This behavior is similar to the effect of stochastic resonance.

OL 18 Evaluation of differences between audiometric and ASSR thresholds Lech S´liwa, Krzysztof Kochanek, Anna Piotrowska, Adam Pika, Henryk Skar_zyn´ski Institute of Physiology and Pathology of Hearing, Warsaw, Poland The aim of the study was to determine the differences between audiometric thresholds and ASSR thresholds measured with different devices in groups of normal and hearing impaired subjects. An additional objective was to assess threshold variability. Three systems were used in the tests: GSI Audera, BioLogic MASTER, and GN Otometrics Chartr EP. ASSRs were measured at four audiometric frequencies using procedures recommended by manufacturers. The ASSR thresholds were also compared with ABR thresholds. The investigation showed that signiﬁcant differences between behavioural and ASSR thresholds may appear irrespective of the applied measuring system. Intra- and intersubject variability of the ASSR thresholds is also meaningful. The estimation of audiometric threshold based on ASSR measurement must take into account speciﬁcity of the patients’ population and the applied signal detection method. Threshold variability must also be considered as a factor limiting estimation accuracy.

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OL 19 Investigation of potential effects on hearing of EM ﬁelds of GSM and UMTS mobile phones I. Uloziene1, V. Uloza2, E. Gradauskiene2 1 Institute for Biomedical Research of Kaunas University of Medicine; 2 Department of Otolaryngology, Kaunas University of Medicine, Lithuania Objectives: Objectives of the study were to assess the potential changes in hearing function as a consequence of exposure to lowintensity electromagnetic ﬁelds (EMF) produced by GSM and UMTS mobile phones. Methods: The within-subject study was performed on 60 volunteers (age 18–30 years) with normal hearing to assess possible acute effect of EMF. Thirty participants underwent 10 min GSM mobile phones EMF exposition and another 30 participants underwent 20 min UMTS mobile phones EMF exposition. Participants attended two sessions: genuine and sham exposure of EMF. Hearing threshold levels (HTL) on pure tone audiometry (PTA), transient evoked otoacoustic emissions (TEOAE’s) for the GSM group and PTA and distortion product OAE for the UMTS group were recorded before and immediately after genuine and/or sham exposure of mobile phone EMF. The administration of genuine or sham exposure was double blind and counterbalanced in order. Results: Statistical analysis revealed no signiﬁcant differences in the means HTL of PTA and mean shifts of TEOAE’s before and after genuine and/or sham mobile phone EMF 10 min exposure. Conclusions: It could be concluded that a 10-min close exposure of EMFs emitted from a GSM mobile phone had no immediate aftereffect on measurements of HTL of PTA and TEOAEs in young adult human subjects. The results of assessment of hearing function of the UMTS mobile phones group will be presented. *This study was sponsored by Commission of European Communities ‘‘Directorate C-Public Health and Risk Assessment’’, ‘‘Health & Consumer Protection’’ Directorate General) project ‘‘Exposure at UMTS electromagnetic ﬁelds: study of potential adverse effects on hearing (EMFnEAR)’’. Agreement number: 200417.

OL 20 Perception of sounds of any frequencies and intensity E. L. Ovchinnikov Samara State Med. University, Samara, Russia Under law Weber, Fechner two sounds, of standard fc and any frequency f, have equal loudness if in internal ear obvious condition E*nf = E*nc satisﬁes, or I*nf = I*nc. Using parities for sound’s energy W, we shall receive W*nf/W*nc = (Lf/Lc).(v*c/ v*f) = G(f), where L—distances between receptors, v—speeds of waves with frequencies f and fc in perilymph. On eardrum Wnf/Wnc = I*nf/I*nc as energy falls on the same surface and duration of passage by waves of air space in external ear

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 is possible to count identical. Transformation of energy occurs under the law of conservation of energy. As Wnf/Wnc = W*nf/W*nc it results to Inf/Inc = W*nf/W*nc = G(f) and explains, that for its performance it is necessary to increase volume of indignant ear liquids because of growth of distances between receptors. Calculation shows, that in the normalized size at any frequencies and belonging to an interval [0, 1] show log G(f) log e = Œ(f)—frequency function for tones of equal loudness. For a sound of any frequency on n-level of loudness Enf for which a level of intensity Lnf = log(Inf/Io), B, law Weber–Fechner will be transformed to a kind Lnf = k ln(Inf/Io) = k ln (Inc/Io) + k ln (Inf/Inc) = k ln (Inc/Io) + k log G(f) = Lnc – Zn Œ(f), where Zn = Lnf– Lnc and Zn = const for n-level of loudness. Then E(I,f) = Lnf – ZnŒ (f). It is possible to show, that Zn = Lmo – Lnc is a difference of the maximal intensity of a sound and n-level. Then we receiveE(I,f) = [log(I/Io) – L.moŒ(f)] / [1 – Œ(f)], decafon.It is law Weber–Fechner in the author’s form for calculation of levels of loudness of a sound of any frequencies and intensity.

OL 21 Audiometric conﬁgurations and hearing loss secondary to acoustic trauma Slobodan Spremo, Stupar Zdenko ENT Clinic, Clinic Center, Banja Luka, Bosnia and Herzegovina Objectives: To assess the conﬁguration of audiograms and hearing threshold for patients exposed to acoustic trauma. Setting:Clinic for otorhinolaryngology, Clinic Center Banja Luka. patients and desing: We evaluated objective auditory function by pure tone audiograms for 136 patients aged 18 to 66 years who were exposed to acoustic trauma 5 to 8 years prior to exam and 73 patients with cochlear related sensorineural hearing loss who created control group. Main outcome measures: Pure tone audiogram conﬁguration was analyzed in relation to hearing loss, age, and etiology of cochlear impairment. Results: After age and hearing loss were adjusted for groups we identiﬁed 262 pathologic audiograms in acoustic trauma group. 139 audiograms (53%) showed downward slope at or above 2 kHz, 57 audiograms (21.7%) dip at 4 kHz, and 66 ﬂat audiograms (25.3%). The audiological measurement results were summarized in 4 age groups and 3 hearing loss related groups (mild, moderate, severe and profound). Tinnitus, hearing impairment and loudness sensitivity were common symptoms related to the degree of hearing loss. Unlike in sensorineural hearing loss group, dip audiogram was statistically more frequent, (p = 0,004) in the acoustic trauma exposed patients. Conclusion: Downward slope at or above 4 kHz and dip audiograms were characteristic of acoustic trauma associated hearing loss. We assume that the inner ear trauma, as a result of strong acoustic injury is different from the white noise induced hearing loss.

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OL 22 Reﬂection of bounce audiological phenomenon into EOAE magnitude: dependence upon stimulus parameters Zurab Kevanishvili, Irina Burdzgla, Gert Hofmann, Thomas Zahnert Centre of Audiology and Hearing Rehabilitation, Chavchavadze Avenue 33, 0179 Tbilisi, Georgia; Otorhinolaryngological Clinic, Technical University, Fetscherstrasse 74, 01307 Dresden, Germany Objectives: The bounce phenomenon, alteration of hearing acuity after presentation of low-frequency loud tones, has been investigated earlier in humans predominantly via psychoacoustic approach. In the present study it was inspected objectively. Methods: Evoked otoacoustic emissions, EOAEs, have been recorded in normally hearing subjects and the dependences of bounce indices upon exposure- and test-stimulus intensities and frequencies were systematically evaluated. Results: Generally, the bounce manifested in post-exposure EOAE augmentations that followed by depressions. At relatively low exposure intensities, 65–75 dB SPL, augmentations exceeded depressions. At higher intensities, 80–95 dB SPL, both bounce phases were of similar magnitudes. At highest intensity, 100 dB SPL, EOAE drop did not preceded by any augmentation. Under lower exposure-tone frequencies, 250, 500 Hz, the bounce possessed similar indices. Under higher frequency, 2000 Hz, a conventional bounce has not been seen, a trend to the overall EOAE depression being observed only. The post-exposure EOAE changes were more prominent at lower than at higher test-stimulus intensities, 15 vs. 35 dB nHL. Under different test-stimulus frequencies, 250, 500, 2000 Hz, the bounce was of similar magnitudes. Conclusions: The augmentation phase of the bounce seems to be determined by the shift in operating points of cochlear receptor cells from less sensitive positions to more sensitive ones. It appears to follow to the total displacement of the basilar membrane that induced by low-frequency sounds. The reduction phase manifests likely a psychoacoustic process known as a temporary threshold shift: both events reﬂect a direct action of exposures upon cochlear receptors.

OL 23 Treatment of idiopathic sudden sensorineural hearing loss Luminita Radulescu, Corina Butnaru, S. Cozma, A. I. Curca, C. M. Martu University of Medicine and Pharmacy ‘‘Gr.T.Popa’’ Iasi, Romania The etiology of sudden sensorineural hearing loss is still unclear and therefore there is no consensus regarding treatment modalities. Objective: The study purpose was to determine the efﬁcacy of high dose intravenous steroids versus intravenous pentoxifylline in the management of idiopathic sudden sensorineural hearing loss. Method: We conducted a retrospective study of patients with sensorineural hearing loss. Forty patients were evaluated before the treatment, including: audiometry, complete blood cell count,

S161 complete blood chemistry, auditory brainstem evoked response and magnetic resonance imaging. Audiological assessments were performed also after the treatment. Twenty-ﬁve patients were treated with pentoxifylline and ﬁfteen patients were treated with steroids. Results: Although the rate of recovery was 66.67% for the steroid group and only of 47% in the pentoxifylline group, statistically there was no signiﬁcant difference between the two groups but, it was a signiﬁcant difference between the patients treated within 7 days and those treated 8 days or more after onset, independently of the treatment that was administrated. Conclusions: We conclude that sudden sensorineural hearing loss is a medical emergency, the best results being achieved if the treatment is initiated as early as possible. The treatment of choice is with steroid in high dose.

OL 24 Prothrombotic factors and sudden hearing loss Pasquale Capaccio, Lorenzo Maria Gaini, Giuseppe Sambataro, Viria Contaldo, Lorenzo Pignataro Department of Otorhinolaryngological and Ophthalmological Sciences, Policlinico Foundation I.R.C.C.S., University of Milan, Italy Objectives: Idiopathic sudden sensorineural hearing loss (ISSNHL) is a frequent otologic disease, and different mechanisms have been hypothesised, such as viral infections, autoimmunity and ischemic events; independenlty of the cause, impaired cochlear perfusion is likely to be the most important event. Different prothrombotic risk factors and their related genetic alterations have recently been correlated with vascular disorders. Methods: We investigated 100 patients with otherwise ISSNHL for the presence of acquired or inherited prothrombotic risk factors, and 200 healthy volunteers as controls. All of the subjects underwent hematological examinations such as MTHFR C677T and A1298C, prothrombin G20210A, platelet GlyIIIaA1/A2, V Leiden G1691A genotyping, ﬁbrinogenemia, cholesterolemia, homocysteinemia, and folatemia. Genomic DNA was isolated from peripheral blood leukocytes using standard methods, and gene mutations were investigated using a LightCycler DNA analyser and PCR. Results: A statistically signiﬁcant association was found between SSNHL and the MTHFR C677T/A1298C polymorphisms, the prothrombin G20210A transition, and the platelet GlyIIIaA1/A2 and V Leiden G1691A mutations. The patients had signiﬁcantly higher levels of ﬁbrinogenemia, cholesterolemia and homocysteinemia, and lower levels of folatemia, than the controls (p < 0.0001). Conclusions: The association between inherited and acquired prothrombotic factors and sudden hearing loss suggests that the microvascular impairment causing SSNHL may be due to a multifactorial mechanism. All patients with otherwise ISSNHL should undergo a comprehensive hematological investigation of inherited and acquired prothrombotic factors to identify patients at risk of recurrent hearing loss.

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Aktive Middle Ear Implants OL 25 Signal analysis of a direct drive implant Geoffrey R. Ball Vibrant MED-EL, Fuerstenweg 77, A-6020 Innsbruck Direct drive middle ear implants are a new class of devices that impart mechanical vibrations directly to a vibratory structure of an ear. One of the major theoretical advantages for the direct drive approach over conventional acoustic devices has been the potential to provide improved sound quality to hearing impaired subjects. Patient reports of improved sound quality for direct drive devices of various types have been previously been published by many authors (Heide, Goode, Hough, Maniglia, Yanigihara). In the past we have been able to measure ossicular vibrations of the middle ear in response to pure tones (Goode, Ball et al.) with the laser Doppler vibrometer. As the sensitivity and noise ﬂoor of the laser vibrometer has continued to be improved, it is now possible to make dynamic audio measurements of middle ear transducers in the temporal bone model. This is our ﬁrst attempt to objectively analyze complex audio signals for evidence to support the theoretical advantages of direct drive systems. There are many key factors that contribute to perceptual improvements in sound quality and objective improvement in signal delivery range. Reduction in acoustic feedback, insertion loss and occlusion can be objectively measured I the clinical setting. We will report on objective measures of complex signals (such as speech) and describe in detail what factors contribute to perceptual improvements in sound quality for patients as well as comment on speciﬁc observations made during clinical investigations of direct drive.

OL 26 Direct drive implants and children Geoffrey Robert Ball Vibrant MED-EL, Fuerstenweg 77, A-6020 Innsbruck Direct drive hearing implants in the future may offer a new opportunity for treatment of hearing loss in children who are not candidates for traditional acoustic hearing ampliﬁcation and are not candidates for existing bone anchored hearing device(s) or cochlear implants. In many patients suffering from chronic conductive and/or mixed hearing loss, acoustic ampliﬁcation offers little to no functional improvement and use of external, or percutaneous bone conduction systems may not be either appropriate or suitable due to medical condition(s). Trans-cutaneous direct drive hearing systems may offer some of these patients a new treatment option. It is well known that early stimulation of the

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 cochlea is key to appropriate neural development and communication ability. Cochlear implants initially were utilized in adults prior to being implemented (and generally with good success) into younger populations. For direct drive implants there are important aspects of device design, human factors and life quality that must be considered before implementation. There are many theoretical positive aspects of utilization of implants in children, it is key that all factors including the role or the parent(s), educators, peer group(s) and health care professional roles that must be weighed prior to implanting a child. Key words: Direct drive implants, Soundbridge, Implantable hearing, Children

OL 27 A study of the biomechanical coupling of direct drive implants Geoffrey R. Ball Vibrant MED-EL, Fuerstenweg 77, 6020 Innsbruck Recently transducers directly coupled to the inner ear membranes have been attempted with promising results. Direct stimulation of the cochlea by either the round window, or stapes footplate has striking potential when applied to patients suffering from hearing loss not responsive to standard otologic technique. We present the results of a series of laboratory studies that correlate the observed results in patients and relate these to input and output as a function of frequency. The precise measurement of the vibratory energy delivered by any mechanical transducer as a function frequency and input level is the standard technique utilized to quantify a transducers output and frequency response. Utilizing advanced measurement techniques, including a laser Doppler vibrometer we are able to compare the vibratory responses for both calibrated sound input and for input for the human ear when stimulated with direct drive mechanical transducers. Utilization of our method with human temporal bone model produces equivalent sound output levels for direct drive implants and to measures the effect of transducer installation on the biomechanical function. Using this method we have been able to accurately evaluate the effects of different transducer designs for several transducer placement options. Placement of transducers results in different frequency response and output levels dependent on location, technique and coupling. Results will be presented for the effect of transducer placement on biomechanical functions that are predictive of the ‘‘in vivo’’ hearing response for the placemen of transducers for the several key anatomic positions of the transducer. Key words: FMT, Floating Mass Transducer, Soundbridge, Middle ear implant, Laser Doppler vibrometer, Stapes footplate, Sensorineural hearing loss, Conductive hearing loss

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OL 28 Round window stimulation by the otologics fully implantable hearing device in mixed conductive sensorineural hearing loss Philippe Lefebvre1, Christian Martin2, Alain Yazbeck3, James Kasic3, Nick Pergola3 1 Deparment of ORL, University of Lie`ge, Belgium; 2Department of ORL, CHU Bellevue, Saint Etienne, France; 3Otologics LLC, Boulder, CO, USA Objectives:The safety and performance of the Otologics Fully Implantable Hearing Device whose transducer was placed on the round window membrane was assessed in adult patients with mixed conductive and sensorineural hearing loss. Methods: The subcutaneous microphone of the CarinaTM Fully Implantable Device picks up ambient sounds and converts them into an electrical signal. The digital signal processor ampliﬁes the signal according to the wearer’s needs and sends it to an electromechanical transducer METTM V. The transducer tip is modiﬁed to hold a titanium TORP prosthesis which is positioned in contact with the round window. The transducer’s mechanical motion stimulates directly the inner ear ﬂuids and enables the wearer to perceive the ampliﬁed sounds. Intra operative ABR measurements via the implanted transducer are used to ensure inner ear stimulation. The implanted battery is recharged daily via an external charger and the wearer can turn the implant on and off with a hand held remote control. Pre and postoperative air conduction, bone conduction, as well as aided and unaided thresholds and speech scores with the implant were measured. Results: No signiﬁcant differences between preoperative and postoperative pure tone averages were noted. A signiﬁcant improvement of functional gain was observed across audiometric frequencies. Word recognition scores and patient beneﬁt scales demonstrated signiﬁcant differences between unaided and implant-aided conditions. Conclusions: Preliminary results of the Phase I trial of the Otologics Fully Implantable Hearing Device provide evidence that this fully implantable device can stimulate the inner ear ﬂuid through the round window membrane and may be a desirable alternative to currently available hearing aids in patients with mixed conductive and sensorineural hearing loss.

OL 29 The application of the active middle ear implant vibrant soundbridge to patients with osseous aural atresia Barbara Wollenberg, Henning Frenzel Department of Otorhinolaryngology and Plastic Operations, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lu¨beck, Germany Objectives: Patients with high-grade microtia suffer from a combined malformation of outer and middle ear leading to an air bone gap. The long-term results of simultaneous middle ear reconstruction with tympanoplasty are insufﬁcient due to persistent air bone gap over the years and new techniques in hearing rehabilitation are required. The middle ear can be circumvented by directly stimulating the cochlea with vibratory energy delivered via an active middle ear

S163 device. Here we present our results of hearing rehabilitation using the active middle ear implant Vibrant Soundbridge in atresia patients. Methods: During the plastic auricular reconstruction the framework is lifted anteriorly and the mastoid plane over the atretic bone exposed. Applying a navigation system an anterior access to the middle ear was drilled. The Vibrant Soundbridge could be placed attached to the dysplastic ossicular structures via the titanium clip or via a subfacial approach directly onto the fascia covered membrane of the round window. Results: Standard audiological measurement were performed preand postoperatively comparing the unaided and aided condition. Bone conduction thresholds were unaffected and no operative complications were observed. The Air-Bone-Gap was lowered from 60 to < 20 dB HL and the free-ﬁeld speech recognition improved from 0% to 90–100% at 65 dB HL. Conclusions: This approach represents a promising new rehabilitation option for high-grade microtia patients suffering from a combined outer and middle ear malformation. We conclude that the procedure is safe and effective and can be implemented in the outer ear reconstruction. Intraoperatively the device can be easily adapted to the given anatomical situation.

OL 30 Inﬂuence of coupling parameters on the FMT output level at the round window A. Arnold, C. Stieger, C. Candreia, F. Pﬁffner, M. Kompis, R. Ha¨usler Departement of ENT, Head- and Neck surgery, Inselspital, University of Berne, Switzerland Objectives: With the direct placement of a Floating Mass Transducer (FMT) at the round window niche, a new approach of coupling an implantable hearing aid to the cochlea has been introduced successfully by Coletti in 2005. In this study we investigated coupling parameters which inﬂuence the output of the FMT. Material and methods: Experiments were performed with Laser doppler vibrometry on a life size mechanical ear model as well as on human cadaver whole heads ﬁxated according to Thiel. A regular mastoidectomy and facial recess approach was performed to gain access to the middle ear cavity structures. These were stimulated with sound through the external auditory canal and directly with an FMT, after its placement to different sites at and around the round window. The movements of the tympanic membrane, the components of the ossicle chain, the oval and round windows and the promontorial bone were measured for each setup. Results: Results show a substantial impact of coupling parameter variations on the output of the FMT, e.g. a load on the cable alone already has an effect up to 20 dB in the frequencies important for speech intelligibility i.e. 500–1500 Hz. Our LDV measurements of the FMT placed at the round window of heads ﬁxated according to Thiel are similar to those of fresh temporal bones known from literature. Conclusion: At the time of the FMT placement, the inﬂuence of coupling parameters must be considered. Secondary, our experiments showed similar LDV characteristics of heads ﬁxated according to Thiel and fresh temporal bones.

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OL 31 Active middle ear implant vibrant soundbridge in high frequency sensorineural- and conductive hearing Loss Klaus Boeheim, Alexander Nahler, Max Schloegel Landesklinikum St. Po¨lten, Probst-Fu¨hrer-Straße 4, 3100 St. Po¨lten, Austria Objectives: Despite recent advances in hearing aid technology, hearing aids are helpful to only some patients with sensorineural hearing loss. This is especially true for patients with high frequency hearing loss who also have difﬁculties wearing hearing aids for reasons such as occlusion or feedback. Conductive hearing impairment is usually treated with middle ear reconstructive surgery. Results vary widely, however, with postoperative air bone gaps depending on intact ossicles, biology of middle ear diseases and ventilation. Methods: We have inserted the active middle ear implant Vibrant Soundbridge (VSB) in 44 ears. In case of sensorineural hearing loss the transducer was placed onto the incus. In case of conductive hearing loss the transducer was placed on the round window. Results: In case of sensorineural hearing loss gain was in proportional representation to the individual hearing losses. In a subgroup of patients with ski slope high frequency hearing loss functional gain was remarkably high in the high frequencies up to 8 kHz. Also speech recognition scores in quiet and in noise were signiﬁcantly higher with the implant as compared to the unaided situation. In case of conductive hearing loss initial results showed an overclosure of the air bone gap, and speech recognition was remarkably improved. Conclusions: VSB in sensorineural hearing loss was particularly powerful in the high frequencies up to 8 kHz, and improved speech understanding. VSB in conductive hearing loss provided a signiﬁcant functional improvement in patients who suffered from insufﬁcient beneﬁt with passive middle ear prosthesis.

OL 32 Vibroplasty a new surgical technique for therapy of mixed hearing loss Wolf-Dieter Baumgartner, Alexandra Jappel, Sonja Reiss, Geoffrey Ball Medical University Vienna; Vibrant Med El Innsbruck Up to 2005 the Vibrant Soundbrigde semi-implantable hearing aid was used in sensineural hearing loss only in patients with good function of the ossicular chain. In 2005 Vittorio Colletti from Verona invented a new technique—the Vibroplasty, where the FMT of the Vibrant Sound-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 bridge is not longer placed on the long process of the incus. In this technique the FMT can be placed in the round window niche, or on remnants of the stapes, or on the oval window, or a fenestration like surgical procedure! This allows opening the indication criteria to combined hearing loss and malformations. Since January 2006 22 patients were implanted with the Vibroplasty technique in Vienna—seven patients were operated under local anaesthesia. In these patients the implant was programmed immediately and the patients were tested with Freiburger numbers and monosyllables as well as music during the operation. There was no complication, neither during operation nor in the postoperative time. All patients are very satisﬁed. Speech perception was assessed using Freiburger monosyllable tests and (OLSA) Oldenburger sentences in quiet and noise. Air- and bone conduction was controlled pre- and postoperative. Outcomes show an improvement in all speech perception scores over time. The Vibroplasty is a safe and efﬁcient method for therapy of patients with combined and sensorineural hearing loss, especially in patients with otosclerosis or radical cavity or middle ear malformations.

OL 33 The vibrant-soundbridge as active PORP and TORP W. Hohenhorst, U. Reinecke, A. Park, J. Lamprecht Alfried Krupp Krankenhaus, 45117 Essen, Germany Objectives: The Vibrant Soundbridge (VSB) as a semiimplantable hearing aid is usually implanted with the ﬂoating mass transducer (FMT) attached to the long process of the incus. It was intended to show the applicability of the VSB in a defect ossicular chain as active PORP and active TORP. Methods: In 2005 and 2006 four patients with severe mixed hearing loss have been implanted with the VSB into a defect ossicular chain. All patients had been preoperated. In two patients the FMT was placed as a PORP onto the stapes. In two other patients the FMT was placed directly onto the footplate respectively the fascia, obturating the oval window after platinectomy. In all cases surgery was performed endaurally (transcanal approach). The FMT was integrated into a palisade cartilage tympanoplasty. Results: The VSB as PORP and TORP improved conductive thresholds up to 35 dB. The aided threshold in all patients was less than 30 dB. The unaided preoperative threshold was 50–80 dB. Conclusions: The VSB as an active PORP and TORP is an effective option for patients with severe mixed hearing loss, even in total defects of the ossicular chain. A palisade cartilage tympanoplasty provides optimal surgical preconditions.

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OL 34 VibrantSoundbridge (VSB) in aural atresia C. Streitberger1, N. Giarbini2 1 Department of ENT, Head and Neck Surgery, F. Tappeiner Hospital, Meran, IT; 2Med-El Worldwide Headquarters, Innsbruck, AU Aural atresia is a birth defect that is characterized by hypoplasia of the external auditory canal, often in association with dysmorphic features of the auricle, middle ear and, occasionally, the inner ear structures. The incidence of congenital aural atresia is approximately 1 in 10,000 to 20,000 live births with unilateral atresia occurring three to ﬁve times more commonly than bilateral atresia. This defect often occurs sporadically isolated or as part of genetic syndromes characterized by craniofacial anomalies. In most cases, a signiﬁcant conductive hearing loss with preservation of the inner ear function resulting in good bone conduction thresholds is founded; nevertheless a sensorineural component can be associated resulting in a mixed hearing loss. The option of a conventional bone conduction hearing aid usually results in poor auditory performance in long term aspects. A bone anchored hearing aid (BAHA) is an alternative; however complications such as adverse skin reactions and the need for revision surgery due to appositional growth of the temporal bone are common, especially in children. In some cases a functional reconstructive surgery can be performed, but the hearing results are not always satisfactory in the long term. The VSB has proved to be a very ﬂexible device allowing different positioning of the FMT in order to adapt to the various conditions of the middle ear. We report our experience with the VSB in 2 children and 2 adults. The positive results achieved by these patients demonstrate the viability of the VSB as an option for severe conductive or mixed hearing loss due to aural atresia.

Cholesteatoma OL 35 Inside-out technique cholesteatoma surgery in Bern from 1992 to 2006 T. Roth, R. Ha¨usler Universita¨tsklinik fu¨r Hals-, Nasen- und Ohrenkrankheiten, Hals-, Kiefer- und Gesichtschirurgie, Inselspital Bern (Direktor: Prof. R. Ha¨usler) Objectives: In this retrospective study we present the anatomical and functional results of 577 patients or 595 ears with cholesteatoma operated on by the inside-out technique between 1992 and 2006.

S165 Methodes: With the inside-out technique cholesteatoma is eradicated from the epitympanum towards the mastoid: little cholesteatoma can be removed by a transcanal approach, medium size cholesteatoma by a retroauricular atticotomy and cartilaginous reconstruction of the canal wall. Extended cholesteatoma is eradicated by a classical canal wall down radical cavity. Functional reconstruction of the middle ear by tympanoossiculoplasty type I-V is performed during the same intervention. Results: Using the inside-out technique we have achieved the complete removal of cholesteatoma in 95% of adults and 89% of children (mean postoperative follow up 8,5 years). 93% of the ears were dry and trouble free postoperatively. In 78% the postoperative air bone gap was below 30 dB and in 61% of all cases hearing was postoperatively improved. Conclusions: The inside-out technique allows the safe removal of cholesteatoma from the epitympanum towards the mastoid according to the extent of disease. This technique combines the advantages of the canal wall down technique, with respect to radicality of cholesteatoma removal, and of the canal wall up technique with respect to functional results, with the added advantage of single stage reconstruction.

OL 36 Epidemiologic evaluation of middle ear cholesteatoma in patients with chronic otitis media in south of Iran Behrooz Gandomi, Mohsen Raﬁee, Fazlolah Mojahed Shiraz University of Medical Sciences, Shiraz, Iran Objectives: Prevalence of cholesteatoma among COM patients ranges from 6% to 41% in different studies. We tried to determine the prevalence of cholesteatoma in patients with COM who have undergone surgery in Khalili Hospital, a referral center in south of Iran. Methods: In a retrospective study,we reviewed the charts of all patients with chronic otitis media in Khalili Hospital during 1998–2003. Data including, sex, duration of disease,presence of cholesteatoma,were recorded.Presence of cholesteatoma was approved by observation during surgery and was also veriﬁed by pathology. Results: From 411 cases,193(47%) were male and 218(53%) were female.Mean age of the patients was 33.5 ± 12.3 years(range:6– 73 years).About half of the patients suffered from COM for at least 5 years.Cholesteatoma was reported directly and pathologically to be present in 101 patients(24.6%).The presence of cholesteatoma showed a statistically signiﬁcant relationship with the duration of the disease;ie:the longer the duration of the disease,the more the chance of having cholesteatoma. Conclusion: In our study cholesteatoma was found to be present in about 1/4 of the patients,which is a relatively high prevalence compared with the prevalence reported in the literature.The only significant relation in our study was between the presence of cholesteatoma and duration of the disease,ie:the longer the duration of the disease,the more the chance of having cholesteatoma.

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OL 37 The intra-rater reliability of the Sade´ and Tos staging systems of retractions of the tympanic membrane David D. Pothier, Paul Nankivell, George G. Browning ENT Department, Royal United Hospital, Combe Park, Bath, UK Objectives: To assess the intra-rater reliability (test/re-test reliability) of the Sade´ and Tos staging systems used to record retractions of the tympanic membrane. Methods: Fifty digital photographs of retractions of the tympanic membrane were shown to 41 Otolaryngologists (25 of retractions of the pars tensa, 25 of the pars ﬂaccida). Participants were asked to score each image according to the Sade´ or Tos staging system. The same slideshow was then repeated either 24 or 48 hours later, with the images in a different order and the process was repeated. Results: When using the Sade´ staging system, participants chose the same stage for identical images in both series a mean of only 53.7% of the time (range 28–88) and a mean of only 45.4% of the time (range 20–72) when using the Tos system. The median kappa score for agreement for participants when using the Sade´ system was 0.314 (p < 0.001) and 0.316 (p < 0.001) for the Tos system, well below the standard of 0.6 to 0.8 required for a reliable clinical staging system. There was no statistically signiﬁcant correlation between years of experience and agreement. Conclusions: This is the ﬁrst documented research to assess the intra-rater reliability of the Sade´ and Tos systems. From the results of this study, it appears that neither the Sade´ nor the Tos systems should be relied upon to record or monitor retractions of the tympanic membrane in the absence of other recording systems. Research that has relied on these systems may be unreliable.

OL 38 Surgical treatment of middle ear cholesteatoma Dragan Dankuc, Ljiljana Vlaski, Zoran Komazec Clinical Center of Vojvodina, ENT Clinic, Novi Sad, Serbia Basic surgical techniques in the treatment of middle ear cholesteatoma include the intact-canal-wall and canal-wall-down tympanoplasty and combined method, i.e. the mobile-bridge tympanoplasty. Techniques including reconstruction of the posterior bone wall of the external auditory canal are combination of formerly mentioned methods. These tympanoplasty procedures involve partial or complete removal of the posterior bone wall of the meatus. Subsequently, after elimination of pathological process, the reconstruction of the middle ear is performed. The aim of this study was to present the main principles of tympanoplasty and outcomes of middle ear cholesteatoma surgery through a comparative analysis of the applied tympanoplasty techniques. The closed ICW and open CWD tympanoplasty were

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 compared with the combined mobile-bridge technique with reconstruction of the posterior bone wall of the external auditory canal. 210 patients with middle ear cholesteatoma, who underwent various microsurgery procedures, were monitored and evaluated in the period 1998–2006. The incidence values for the recurrent cholesteatoma in closed tympanoplasty and in cases of open techniques with radical trepanation of the temporal bone were 6% and 10%, respectively. In cases of combined mobile-bridge tympanoplasty with reconstruction of the posterior bone wall of the auditory canal the incidence of residual cholesteatoma was 2.5%. Postoperative rejection of the replanted bone was observed in 2.5% of the patients. The selection of the appropriate surgical procedure is determined by the type and extent of pathological process, anatomic features of the pneumatic space of the middle ear, available microsurgical equipment and otosurgical skills of the surgeon.

OL 39 Application of stapedotomy in advanced pathology of the middle ear H. Skarzynski, P. Mlotkowska-Klimek, M. Porowski International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Mokra 17 st, Kajetany, 05– 830 Nadarzyn, Poland Objectives: Stapedotomy is a routine procedure in otosclerosis both in children and adults. The aim of this study is to present the results of stapedotomy application in congenital malformations, tympanosclerosis, chronic otitis media, especially following the earlier operations. Methods: Our material was 387 ears, their postoperative observation was minimum 3 years. One or two-stage surgical procedures were applied. First, our aim was to eliminate an infection and then after 6–8 months, when there was no danger we performed a middle ear reconstruction. All ears were found to have a ﬁxation of the stapes footplate. Therefore a typical procedure was applied—the hole was drilled in the footplate so a prosthesis could be inserted. Depending on the footplate thickness a prosthesis was attached to the preserved remnants of the chain or directly together with a piece of cartilage to a tympanic membrane. Each time a piston surroundings was sealed with a venous blood clot. Results: We have observed good and constant audiological results in most of the patients. Deterioration of hearing was observed in 17 ears after 1 year on the 3,2 dB. There was no improvement in 12 ears. The next control showed deterioration of hearing with air-bone gap in the next 13 ears. Patients were provided hearing aids. Conclusions: Obtained results allow us to extend previous indications to apply stapedotomy in various pathologies of the middle ear but it will always require extraordinary caution for the beneﬁt of the patients and their ears.

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OL 40 Congenital cholesteatoma: the Singapore experience

children. The age varied from 2 to 18 years old. We have divided those children into two groups: in group A there were younger children where only objective hearing assessments could had been performed, and in the minor group B there were older children who could participate in subjective hearing tests. Most cases were operated only by anterior tympanotomy approach. Discontinuity of the ossicular chain, predominantly disruption of the long limb of the incus, was repaired using glass-ionomeric cement. The postoperative results were assessed 1, 6, 12 and 36 months after the operation. Results: Noticeable hearing improvement was achieved in majority of patients. In older children the air-bone gap closure at the level of 10 dB was observed in 95 percent. The need of secondlook operation was in 10 cases and revealed a 20 percent recurrence rate. Conclusions: In congenital cholesteatoma the success rate depends predominantly on early detection of the disease. In these cases we can achieve excellent outcome. All children with operated ears for congenital cholesteatoma must be carefully followed-up because of the recurrent cholesteatoma and possibilities of revealing the second, independent locus.

Chwee Ming Lim, Henry Kun-Kiaang Tan Department of Otolaryngology, Kandang Kerbau Women’s and Children Hospital, 100 Bukit Timah Road Singapore 229899, Republic of Singapore Aim: The aim of the study is to describe our local experience of congenital cholesteatoma (CC) in a tertiary centre in Singapore and to evaluate the usefulness of CT scan in the management of this condition. Methods: Retrospective chart review of all cases of congenital cholesteatoma operated in Kandang Kerbau Children Hospital from Nov 1999 to April 2006 were collated and studied. Results: Twenty one patients were identiﬁed and all patients presented with hearing loss. Ten (47.6%) patients were diagnosed clinically on otoscopy. Five (23.8%) patients had normal otoscopic ﬁndings and diagnosis was clinched only with the aid of a computed tomography scan. Six patients (28.6%) presented with serous otitis media and diagnosis was made on myringotomies in 3 patients. Twenty patients had a preoperative computed tomography (CT) scan. Using Potsic staging criteria, there were 0 patients in stage 1; 2 (10%) in stage 2; 6 (30%) in stage 3 and 12 (60%) in stage 4. By comparing intraoperative and CT ﬁndings, CT was accurate in diagnosing 95%(19/20) cases of ossicular erosion and 90%(18/20) cases were accurately staged with regards to the extent of disease. Conclusion: Our study shows that a majority of patients with congenital cholesteatoma still present at a late stage of disease. A high index of suspicion is necessary when patients present with conductive hearing loss or even serous otitis media. Computed tomography scan is invaluable in diagnosis when otoscopic ﬁndings are normal and it is also useful in delineating the extent of disease preoperatively.

OL 41 Congenital cholesteatoma in children: early recognition, surgical management and postoperative care H. Skar_zyn´ski1,2, R. Podskarbi-Fayette 1, J. Wysocki1,2 1 International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Mokra 17, Kajetany, Warsaw, Poland; 2Department of Otolaryngology Clinic, Medical University in Warsaw, Poland Objectives: The purpose of the study was to analyze hearing results obtained after surgical treatment of congenital cholesteatoma in children and to discuss the possibilities of early recognition of this condition. Methods: 30 operations improving hearing are performed everyday in Clinical Center of ORL-Surgery on children and adults. We have selected on group of 25 cases of congenital cholesteatoma in

OL 42 Cholesteatoma management in Cluj ENT department M. Cosgarea, A. Maniu, N. Violeta, M. Dinca, S. Pop, E. Tomescu ENT Department Cluj, Napoca, Romania Objectives: Cholesteatoma remains one of the most challenging ear diseases, its evolution leading sometimes to serious complications. Surgical treatment is always required.. Methods: we reviewed the operative reports of 534 cases treated between 1998–2005. Patients ages ranged from 3 to 81 years, with a mean age of 30. The surgical procedure was to follow the cholesteatoma extension from the tympanic cavity to antrum and mastoid cavity. We used incus body, malleus and temporal cortical bone for ossicular chain reconstruction. For the reconstruction of the eardrum and the canal wall we used perichondrium, cartilage with perichondrium (palisade technique), or only cartilage. Patients with complications underwent the canal wall-down technique. Results: recurrence of supuration was noticed in 28% of cases, requiring a second intervention. The hearing improvement occurred in 58% of cases, 19% of the patients had only satisfactory results and 23% showed no improvement of the hearing. The best outcomes in the hearing recovery were obtained by using the head of the malleus or the incus as a PORP prosthesis(40%). Tragal cartilage was used as the columella between the eardrum and the stapes with good results(15%). We also used temporal cortical bone grafts as TORP prosthesis with good results(13%). Conclusions: The cholesteatoma must always be operated, the technique being individualized from case to case.

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OL 43 Anatomical and functional reconstruction after modiﬁed radical operations H. Skar_zyn´ski, M. Mro´wka, Mlotkowska-Klimek, M. Porowski Clinical Center of Oto-Rhino–Laryngosurgery, International Center of Hearing and Speech of Institute of Physiology and Pathology of Hearing, Warsaw Objectives: The aim of the radical operation is to remove the inﬂammation from the middle ear. Such operation lies in keeping even small remnants of the ossicular chain, so they could not be a source of infection and at the same time they could provide effective reconstruction of the conductive apparatus. Reconstruction surgeries may be performed at the same time or if it is necessary in the next stage. Methods: Our analysis was performed on 1376 patients. The minimum observation time was 36 months. The results were assessed after 1, 3, 6, 12, 24, 36 and 48 months, accordingly to the follow-up procedure established at the Institite of Physiology and Pathology of Hearing. The surgery included reconstruction of a tympanic membrane part to the VII canal, applying alloplastic materials, and reconstruction of the ossicular chain. Results: Our observations conﬁrm that even in advanced chronic otitis media with cholesteatoma or bone destruction, granulation, or all these lesions together it is possible to provide effective reconstruction. Conclusions: 1 Radical operation without closure of the tympanic opening of the auditive tube does not mean loosing the possibility to improve hearing. 2 socially effective hearing obtained in 2/3 of operated patients should be taken into consideration as a proposal to apply the procedure as a procedure of choice in patients after prior or at the same time performed radical operations.

Carotid Artery + Imaging OL 44 Sonotubometry with perfect sequences in juvenile individuals Ercole F. N. Di Martino, Viorel Nath, Aulis Telle*, Anne Kellner, Peter Vary* Diako Ev. Krhs., ENT Department, Bremen/Germany; *Institut f. Nachrichtengera¨te u. Datenverarbeitung RWTH Aachen/Germany Objective: To study the use of sonotubometry applying Perfect Sequences (PS) in juvenile patients for eustachian tube (ET) testing Methods: ET function in thirty-one healthy juvenile volunteers (10–16 yrs.) was analysed using a custom made sonotubometry device. Manoeuvres for ET opening were swallowing, yawning and Valsalva. A total of 515 measurements were performed. Results: The method was able to detect an ET opening in 431 (83.7%) measurements. Dry swallowing caused an ET opening in 91.8%, water swallowing in 92.1%, yawning in 84.1% and Valsava in 68.8% manoeuvres. Decongestion did not cause better results (P < 0.08). Regarding the side of signal application there was no signiﬁcant difference found for the measured signal intensity in either ear (P < 0.15) A multivariant analysis showed signiﬁcant differences for the various manoeuvres (P < 0.0001) in the measured signal intensity. Conclusions: Sonotubometry with PS can detect ET activity with a high reliability. The nasal status seems to play a minor role for the

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 measurement. Due to a better compliance in juvenile patients Valsalva is a more feasible manoeuvre than in small children.

OL 45 Virtual endoscopy of the middle ear Mario Milkof, Diliana Vicheva, Iwan Tzenev, Dimitar Kovachev Eye–ear clinic Objectives: Virtual endoscopy is a computer-built simulation of ﬁbro-optic endoscopy for middle ear examination. Now the virtual endoscopy (VE) is a noninvasive method for direct 3-D imaging of the anatomic structures of the middle ear. Methods: The growing interest of otorhinolaringologysts toward transtympanal endoscopy (TE) leads to the need of imaging the anatomy of the middle ear via virtual endoscopy. Results: In practice this method images the anatomy of the middle ear in ﬁne details, but it is not enough precise and is practically used for surgical orientation. We examined by virtual endoscopy 22 patients before surgery for chronic otitis, 14 patients with diagnosis otosclerosis and 9 patients with tympanosclerosis. Conclusions: We concluded that the virtual endoscopy of the middle ear gives great opportunities for the pre-surgical estimation of the patients, as well as for the examination of the ossicules and middle ear pathology and it can be used as an adjunctive method together with CT.

OL 46 Responses of the primary auditory cortex to monaural stimuli as assessed by functional MRI D. C. Wild*, J. R. Foster+, D. A. Hall+ *Queens Medical Centre, Nottingham, Hearing Research, Nottingham UK

+

MRC Institute of

Objective: to investigate the response of different regions of the human auditory cortex to monaural sound stimuli Methods: 10 healthy, right handed, normal hearing volunteers were subjected to a random sequence of monaural sound stimuli and silence, whilst undergoing functional magnetic resonance imaging (MRI) in a 3 Tesla scanner. The sound stimuli consisted of narrowband noise (250 Hz and 4000 Hz), as well as wideband noise (250–4,000 Hz). A signal averaging algorithm was used to detect the response in the primary auditory cortex and a laterality index was calculated. The experiment was repeated in all 10 volunteers after 3–6 months. Results: The auditory areas of both hemispheres showed activity in response to monaural stimuli, but the responses were consistently greater in the contralateral primary auditory cortex. Wideband stimuli produced the greatest degree of contralaterality and the largest response across the auditory cortex. The responses to high and low frequency stimuli were found to be conform with established tonotopic organization of the primary auditory cortex: High frequency stimuli elicited the greatest response in the medial aspect of Heschl’s gyrus in contrast to low frequency stimuli that showed more activation in central or lateral aspects. No difference was found in the laterality index between sessions. Conclusion: We have developed a non-invasive way to investigate the response pattern of the primary auditory cortex to sound stimuli using functional MRI. A consistent response to monaural stimuli was found in healthy volunteers. Further research will show how hearing loss inﬂuences the balance of auditory brain activation compared with the normal pattern.

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OL 47 Magnetic resonance imaging screening for acoustic neuroma

OL 49 Advances in cochlear implants/implantable hearing devices

Jonathan R. Newton, Muhammad Shakeel, Bhasker Ram Department of Otolaryngology, Aberdeen Royal Inﬁrmary, Aberdeen, Scotland, AB252ZN, UK

Gauri Mankekar PD Hinduja National Hospital, Mumbai, India

Objectives: Magnetic resonance imaging is the deﬁnitive investigation for detection of an acoustic neuroma. It is however an expensive resource and pick up rate of a tumour can be as low as 1% of all patients scanned. This study aims to examine referral patterns for MRI screening for patients presenting with asymmetrical sensorineural hearing loss (ASHL). A second aim was to suggest appropriate screening criteria. Method: All 132 MRI scans performed for ASHL in the year 2005 were reviewed retrospectively along with their case records and audiograms. In addition, MRI scans and case records were reviewed for the last 30 patients diagnosed with acoustic neuroma. Information was analysed using 3 published protocols and additional frequency speciﬁc deﬁned criteria. Results: Three acoustic neuromas were picked up out of 132 scans performed. Of the scans performed for ASHL, a third did not ﬁt with any of the published criteria. Of the 30 positive scans for a tumour, the patients’ audiograms revealed that 10% did not ﬁt the published criteria despite the patients having no other audiovestibular symptoms. Conclusion: There appears to be no universally accepted guidelines on screening in ASHL with clinical acumen being used by most ENT consultants in this region. Applying protocols may reduce the number of scans performed but up to 10% of tumours may be missed by this approach.

OL 48 Central auditory prosthesis (audiotory midbrain implant): new approach for patients with NF2 related deafness T. Lenarz1, H. Lim1, J. Patrick2, M. Samii3, G. Reuter1, M. Lenarz1 1 Medizinische Hochschule Hannover, Germany; 2Cochlear Limited, Lane Cove, Australia; 3International Neuroscience Institute, Hannover, Germany Audiotory rehabilitation in NF2 patients with bilateral neural deafness can be achieved with audiotory brainstem implants. However the results are worse than in non-tumor patients. A special neural damage is assumed in those patients. To overcome the limitations which are also related to the complex tonotopic organization of the cochlear nucleus a new penetrating multichannel electrode for the inferior colliculus has been developed. The 22 band electrodes are equally spaced to stimulate frequency bands in the inferior colliculus which has an orderly tonotopic organization. The paper presents the concept of the approach of electrophysiological and histological results from animal studies, the surgical approach and ﬁrst clinical results. 3 patients have been implanted so far. They show audiotory sensations, orderly pitch and some degree of speech understanding. The future perspectives of speech processing and multi-channel electrodes will be discussed.

Hearing impairment is one of the most prevalent but ignored sensory deﬁcit with 1 in 800 children being born with a serious hearing impairment and more than 60% of people over 70 years suffering hearing loss. Of these, 95% will beneﬁt with conventional hearing aids. The remaining 5%, who are not beneﬁted with hearing aids, may require surgically implantable hearing devices. Advances in cochlear implants and other implantable hearing devices in today’s competitive global communication era, enables a hearing impaired person to become an independent and productive member of the society. The instructional course will provide an overview of the types of hearing losses, the surgically implantable currently approved hearing devices available for their correction ranging from the cochlear implant to the BAHA, Vibrant soundbridge, Brain stem implant and MET. The indications for use of these devices, surgical aspects and expected problems will be discussed. Participants will be able to see and get a feel of the various devices and answer a short quiz at the beginning and end of the course.

OL 50 Navigation surgery in cochlear implantation Ga´bor Re´pa´ssy1, Marianna Ku¨stel1, Ka´roly Hraba´k1, Zolta´n Fent1, Ron von Jako2 1 Semmelweis University Faculty of Medicine, Department of ORL and HNS, Budapest, Hungary; 2GE Healthcare Navigation and Visualization Inc, General Electric Company, Lawrence, USA Background: Image guided surgery is used for sinus surgery all over the world, but its application in otology has been limited. In difﬁcult cases of ear surgery potential danger of facial nerve injury has to be taken into consideration. For better visibility and control of the delicate structures of the middle ear we began combining cochlear implantation with image-guided surgical navigation. Study design: During the last 4 years a modiﬁed suprameatal approach (SMA) has been used at our department in most of the cases. Since 2004, three-dimensional intraoperative localization technology was introduced with the modiﬁed SMA technique in twelve cochlear implant patients with GE Healthcare’s InstaTrak 3500 Plus ElectroMagnetic Surgical Navigation System. Results: Surgery was successful in all cases and there were no complications in the image guided navigation group. However, use of image guided surgery led to a slight increase in operative time that is expected to be offset by improved enhancements to workﬂow. Conclusions:Image-Guided Surgery offers a safe and reliable method facilitating cochlear implantation. It enables exact determination of the anatomical landmarks during surgery and helps to avoid possible injury to the facial nerve. In the case of unusual anatomy, congenital malformations, ossiﬁed cochleas and revision cases, the surgical navigation option offers increased accuracy and safety.

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OL 51 Robotic insertion of cochlear implant electrodes to minimize cochlear trauma Scott Reichert, Jian Zhang, Kai Xu, Nabil Simaan, Spiros Manolidis Columbia University, Otolaryngology, Head and Neck Surgery 16E 60th Street, New York, NY 10022, USA Introduction: The application of robotic surgery has become a reality in many disciplines of surgery. The advantages of performing robotic surgery are improved patient outcomes, reduced hospitalization stays and reduced morbidity. The only emerging application in otolaryngology today is transoral resection of upper aerodigestive tract malignancies. Hypothesis: Robotically controlled insertion of cochlear implant electrodes reduce the force of insertion which is related to cochlear injury and thus residual hearing loss. Experimental setup: Electrode insertion was modeled based on snake like robots. A parallel robotic module was designed for control of electrode insertion into a progressively realistic 3D cochlear model based on Cohen’s extended template. Next we designed and manufactured steerable cochlear implant electrodes which were coupled to the robotic insertion module. Reverse kinematic calculations were used to deliver appropriate bending of the electrode for speed of insertion and cochlear shape. Experiments: Two sets of experiments were performed with three insertions each in both plannar and 3D cochlear models. The ﬁrst involved insertion at a constant speed of 2 mm/ sec, the second involved variable speed based on force feedback. Results: Compared with non steerable insertion of the elctrode, the steerable (but non force feedback mode) achieved a 68% reduction of force of insertion. When steerable electrode insertion at variable speed was used, the reduction of force was 78%. These results were consistent in all repeated experiments. Conclusions: It is possible to achieve signiﬁcant reduction in force of electrode insertion in the cochlea by removing the human element in this step of cochlear implantation. This should impact in our ability to preserve residual hearing in these operations.

OL 52 Ceramic versus titanium housing cochlear implants: differences in surgery Milan Profant, Zuzana Kabatova University ENT Department, Medical School of Comenius University, Antolska 11, 851 07 Bratislava, Slovak Republic Objectives: Modern cochlear implants have ceramic and titanium housing to be implanted into the skull. There are several arguments to prioritize titanium housing against the ceramic one. The most frequently mentioned arguments are: duration of surgery, retroauricular placing without conﬂict with head set and complication rate. In 20 consecutive surgeries (10 ceramic and 10 titanium housing) previously mentioned parameters were evaluated. Methods: Following parameters were measured during the surgery done by the ﬁrst author in well pneumatised temporal bones with

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 patent cochlear canal: Duration of surgery and its particular parts; Distance of the centre of magnet form the posterior wall of mastoidectomy; Size of posterior tympanotomy; Size of cochleostomy. Results: The average duration of surgery in the series with ceramic housing was 56 minutes, vs. 54 minutes in titanium housing implants; Duration of bone level bed for implant receiver was 9,5 minutes for titanium housing and 1,8 minutes in ceramic housing implant. In titanium housing implant the distance between posterior wall of mastoidectomy and magnet centrum was 52 mm, while in the ceramic housing implant it was 37 mm. There was no early postoperative complication in the presented series. The other measured parameters did not show signiﬁcant differences. Conclusions: The results of our measurements do not conﬁrm signiﬁcant differences in the duration of surgery between ceramic and titanium housing cochlear implant if the surgeon wants to place the implant to the bone level. The conﬂict between receiver and ear level processor can be avoided by proper placement of the receiver bed.

Cochlear Implants OL 53 The evolution of cochlear implant electrodes in the next decade Claude Jolly, Stefan Nielsen, Fabrice Beal, Wolfgang-Dieter Baumgartner MED-EL—Medical Electronics, Fu¨rstenweg 77a, 6020 Innsbruck The cochlea implant electrode provides the crucial interface for triggering meaningful action potentials in the remaining auditory neurons of patients affected with neuro-sensory deafness. The ﬁrst step in interfacing the electrode with the nerve is preservation of the neural tissue and sensory epithelium. The second step consists of placing stimulation contacts in all regions where excitable tissue is located, preferably from base to apex. It is most likely that future electrode arrays will deliver therapeutic agents. Advanced prototypes show that medicine can reach intra cochlea tissue in ﬂuid form at slow ﬂow rates. Coated and eluting electrodes can also deliver a single dose spread over some time and in all or selected cochlea locations. Drugs in nanoparticule form could provide a precise targeting. Electrodes based on thin ﬁlm technology have the potential to further enhance effectiveness by reducing the size of the device in the scala tympani and at the cochleostomy and enhancing mechanical characteristics. Number of true contacts could be increased, which in conjunction with usable virtual channel would provide additional information channels to the patient. For the patient responding to electric and acoustic stimulation the electrode design would be optimum if deep insertion could be achieved with complete preservation of the sensory epithelium. Only basal contacts would be used for the electrical stimulation. Apical contacts would be available to take over the acoustic stimulation in the event of sudden or progressive residual hearing loss.

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OL 54 Endoscopic cochlear implantation a new procedure, primary results in 23 subjects Mazen M. Alhajri FRCSI, FRCSED, Ph.D., ENT consultant at the prince medical center in UAE Background: The classical surgical procedure for cochlear implantation include mastoidectomy and posterior tympanotomy known since 1979. In 2000 Kronenberg introduced the suprameatal approach (SMA) as an approach that avoids mastoidectomy and posterior tympanotomy in which he drill a tunnel not a groove from mastoid cortex to reach the middle ear at the area of the incus. Through a tympanomeatal ﬂap the cochlea is exposed and cochleostomy is done. Objective: To report and compare the results of endoscopic cochlear implantation started 2 years ago. Methods: 23 patients were implanted using the endoscopic transcanal approach. 0 degree 4 mm sinuscope was used to perform the operation instead of a microscope. A tympano-meatal ﬂap was elevated and a groove was drilled using a 2 mm diamond drill and deepened to 5 mm depth to accommodate the active electrode of the implant from the bony annulus just above the exit of chorda tympani to the postro-superior angle of the bony external meatus. 3 to 4 cm length post auricular incision to insert and secure the implant below temporalis muscle. The active electrode was inserted in the cochleostoma, the remaining part was pushed in the groove and covered with pieces of cartilage and soft tissue. Mastoidectomy was avoided. Patients were followed for a range of 1 month to 2 years. Results: Endoscopic approach showed low morbidity compared to classical approach There was 0% facial palsy, 0% meningeal damage or csf leak, 0% ﬂap infection. The chorda tympani were preserved 100%. One case of late perforated ear drum was patched underlay. Conclusion: It is feasible and safe to do cochlear implantation using the endoscope.

OL 55 Results of partial deafness cochlear implantation with round window approach H. Skarzynski, A. Piotrowska, A. Lorens International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland Objectives: Partial deafness cochlear implantation and electric acoustic stimulation have proven to be a useful method of treating adults with a ski-slop type hearing loss. In the case of PDCI, there

S171 is essentially normal hearing in the low frequencies, and often this is not ampliﬁed with a hearing aid. This would allow for electrical stimulation of the high frequencies via the cochlear implant and acoustic stimulation of the low frequencies uses preserved natural low frequency hearing. This study aims to assess long term results of partial deafness cochlear implantation. Material and method: 21 adults and 9 children with partial deafness received Combi 40+ or Pulsar cochlear implant with partial insertion of a standard 30 mm long electrode or shorter 20 mm electrode, using the round window technique for hearing preservation. Pure tone audiometry, monosyllable testing in quiet and noise were conducted pre-operatively, at implant ﬁtting and then at 3, 6, 12, 24 and 36 months after initial device ﬁtting. Results: 28/30 cases demonstrate functional preservation of hearing. Improvements in speech scores over time in both quiet and noise were signiﬁcant. Conclusion: With developed round window surgical procedure and a limited electrode insertion, hearing can be preserved in the majority of patients with partial deafness. Results suggest that partial deafness cochlear implantation is a viable treatment method. However, surgery should only be conducted by an experienced surgeon and parents need to be carefully counseled about the risks and beneﬁts of partial deafness cochlear implantation.

OL 56 Comparitive results between cochlear implanted patients with and without hearing aids J. Spiridonowa, D. Popova Medical University of Soﬁa, ENT clinic, Bulgaria Objectives: The aim of this study is to demonstrate the audiological and linguistic results of two groups of cochlear implanted children. I-group: CI children with hearing aid on opposite ear and II –group: CI children without hearing aid on opposite ear. The children are operated in early age 2–5 years old. Methods: 71 patients are divided in two groups. I-group-48 CI implanted with hearing aid and II group-23 CI implanted without hearing aid. With freeﬁeld pure tone play audiometry we examine these patients every month after Cochlear implantation for about 1 year. We are doing audiometry separately only with CI; only with hearing aid and with CI and HA. Results: These comparative results indicate a signiﬁcant advantage in orientation in sounds, ototopics and quickly adaptation by children with CI and HA. This group shows better understanding and earlier speech development. Conclusions: This study suggests that signiﬁcant beneﬁts can be obtained with the use of hearing aid in the nonoperated ear in combination with Cochlear implant.

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OL 57 Music perception by cochlear implanted patients A. Castro, L. Lassaletta, R. M. Pe´rez-Mora, M. Bastarrica, B. Herra´n, L. Sanz, M. J. De Sarria´, J. Gavila´n La Paz University Hospital, Paseo de la castellana 261, 28046, Madrid, Spain Objectives: Current cochlear implants coding strategies are designed for speech codiﬁcation and they lack of enough resolution for music. This study was designed to evaluate music perception by cochlear implantees. Methods: Twenty-four poslingually deaf patients implanted at our institution with Med-El and Nucleus devices were enrolled in the study. Pitch and rhythm perception were assessed by the Primary Measures of Music Audiation test. Timbre recognition was appraised by the identiﬁcation of musical instruments playing simple melodies. Complex musical patterns perception was assessed by the recognition of popular songs in their original version and in a simpliﬁed version without lyrics. The stimuli were presented through the audio entry of the speech processor in order to avoid environmental interferences. Scores were correlated with demographic and audiological data. Results: Median scores for pitch and timbre recognition were around 70%, while median rhythm recognition was 82%; these differences reached statistical signiﬁcance. The identiﬁcation of popular songs in their original version was very high (median 100%, range 57%-100%), while the identiﬁcation of songs when the speech cues were omitted decreased signiﬁcantly (median of 24%, range 0%–83%). No signiﬁcant correlation was found between these scores and the demographical and audiological data. Conclusions: Current cochlear implant technology allows the identiﬁcation of music attributes when presented in simple musical patterns. However, when the musical stimulus is more complex, the speech cues become crucial for recognition. The complexity of music perception an enjoyment cannot be simply addressed as a function of accuracy of perception.

OL 58 Assessment of immediate verbal memory in cochlear implanted children Branka Mikic, Danica Miric, Sanja Ostojic, Nenad Arsovic Institute of ENT and HNS, Clinical Centre of Serbia, Belgrade, Serbia Immediate verbal or auditory memory is of utmost importance for development of receptive and expressive speech in both hearing and hearing impaired children. It plays active role in speech perception, discrimination, processing, understanding and responding to the verbal messages. Objective: To assess immediate verbal memory in cochlear implanted children and compare their achievement to profoundly deaf children wearing hearing aids.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Sample and methodology: Experimental group consisted of 20 cochlear implanted children aged 4 to 12 years and control group of 20 profoundly deaf children with hearing aids of the same age. All of the children were enrolled in auditory verbal training during intensive speech and hearing rehabilitation. The children in this study were tested by a Test of immediate verbal memory by Spasenija Vladisavljevic. Results: The children in the experimental group with cochlear implants have shown considerably better results on the test of immediate verbal (auditory) memory as compared to the profoundly deaf children with hearing aids. Marked differences were observed on the longer speech segments and sentences. Conclusion: Cochlear implanted children have shown better performance on the test of immediate verbal memory than profoundly deaf children with hearing aids of the same age. It could be attributed to much better hearing thresholds in cochlear implanted children than aided thresholds in children with hearing aids. Better auditory input following cochlear implantation alleviates development of immediate verbal memory and speech and hearing rehabilitation in profoundly deaf children.

OL 59 Speech and music perception with the new ﬁne structure speech coding strategy: preliminary results Dominik Riss, Christoph Arnoldner, Wolf-Dieter Baumgartner, Jafar-Sasan Hamzavi Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18–20, 1097 Vienna, Austria Objective: This study consisted of an intraindividual comparison of speech recognition, music perception and patient preference when subjects used two different speech coding strategies with a Med El Pulsar cochlear implant: Continuous interleaved sampling (CIS) and the new Fine structure processing (FSP) strategy. In difference to envelope based strategies, the FSP strategy also delivers subtle pitch and timing differences of sound to the user and is thereby supposed to enhance speech perception in noise and increase the quality of music perception. Subjects: 14 postlingually deaf patients using a Med El Pulsar cochlear implant with a mean cochlear implant experience of 0,98 years were supplied with the new FSP speech coding strategy. Subjects consecutively used the two different speech coding strategies. Speech and music tests were performed with the previously ﬁtted CIS strategy, immediately after ﬁtting with the new FSP strategy and 4, 8, and 12 weeks later. Results: Speech and music test scores improved statistically signiﬁcantly after conversion from CIS to FSP strategy. 12 of 14 patients preferred the new FSP speech processing strategy over the CIS strategy. Conclusions: Taking into account the excellent results with signiﬁcant improvements in the speech tests and the very high satisfaction of the patients using the new strategy, this ﬁrst implementation of a ﬁne structure strategy could offer a new quality of hearing with cochlear implants.

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OL 60 The impact of music perception on quality of life following cochlear implantation Luis Lassaletta, Alejandro Castro, Marta Bastarrica, Rosa Pe´rez-Mora, Bele´n Herra´n, Lorena Sanz, Mª Josefa de Sarria´, Javier Gavila´n Department of Otolaryngology, La Paz University Hospital, Madrid, Spain Objectives: To evaluate music perception and enjoyment in cochlear implant (CI) users, and to assess their inﬂuence on QOL. Method: Seventy-ﬁve postlingually deaf CI recipients were enrolled in this study. A musical questionnaire evaluated musical background, listening habits, and quality of musical sound through the CI. The validated Glasgow Beneﬁt Inventory (GBI) was used to quantify changes in QOL. Results: Sixty-two patients answered the questionnaires. Listening habits (music enjoyment and hours listening music per week) signiﬁcantly decreased following implantation when compared to the same parameters prior to deafness. Nevertheless, 52% of the patients enjoyed music postimplantation. The quality of musical sound was rated over 50 (0–100 scale) for the adjective pairs ‘‘likedislike’’, ‘‘sounds like music-doesn’t sound like music’’ and ‘‘natural-mechanic’’ by most users. Med-el users obtained better scores in the adjective pair ‘‘sounds like music-doesn’t sound like music’’ than Cochlear users. Recipients rating higher scores for quality of sound enjoyed music postimplantation and had higher total GBI scores than those rating lower scores. Conclusion: Despite the decrease in listening habits, about half of the patients still enjoy music postimplantation. Better quality of sound through the implant improves music enjoyment and contributes to achieve better postoperative quality of life (QOL).

OL 61 Device failures in cochlear implants R. D. Battmer1, B. Linz2, Th. Lenarz 1 1 Department of Otorhinolaryngology; Medizinische Hochschule Hannover; Germany; 2German Federal Institute for Drugs and Medical Devices, Bonn, Germany Objective: Since the beginning of the Hannover Cochlear Implant Program in 1984 all explantations and reimplantations of cochlear implant devices have been monitored. From a population of now approximately 3300 implant users, 226 subjects had to be revised due to various reasons. These reasons can be divided into two major groups: subjects with medical problems leading to explantation and subjects with device failures. Medical problems mainly

S173 infections and electrode dislocation, which could be observed in 61 cases. In 165 cases the reason for explantation was a device failure. Methods: In a retrospective study all device failures since 1984 were analyzed. Information was gathered from patient ﬁles as well as from the device failure reports of the manufacturer (Cochlear Ltd and Advanced Bionics Corp.). All these information were analyzed statistically. Results: As result is was found that independent of the brand leakage (35%) and mechanical impact (29%) were the major reasons for device failures. Other failures could be grouped into: electronic circuit failures, electrode array defects and others. Conclusions: This result lead to the development of a new tests for leakage and impact, which became part of the new European standard for cochlear implants: EN 45502–1 ‘‘Active Implantable Medical Devices’’. Although the manufactures of medical devices have already to comply to extended regulatory requirements this new tests may help to improve device reliability. However, the overall high cumulative survival percentage of more than 99% for present devices demonstrates the efforts of the manufactures to produce highly reliable and save devices.

OL 62 Update on hearing improvement with bilateral cochlear implants Pascal Senn, Martin Kompis, Mattheus Vischer, Rudolf Ha¨usler Department of Otorhinolaryngology, Head and Neck Surgery, University of Berne, Inselspital, 3010 Berne, Switzerland In the last 7 years, a total of 78 patients have been implanted with bilateral CI in Berne. The vast majority of those patients reported clearly improved hearing compared to using a unilateral CI only, especially in background noise. Out of this collective, three adults and 9 children with bilateral CI have been investigated in detail over several years. Speech intelligibility and sound localization were signiﬁcantly improved using bilateral CI compared to using monaural stimulation only, corroborating the reports of the entire patient collective. Our study additionally revealed room for improvement for the current CI systems: due to the microphone placement above the pinna, sound localization on the side of the patient’s head was poor and due to software limitations, phase information could not be extracted out of the sound signal leading to poor interaural time discrimination. In summary, we found that bilateral cochlear implantation is signiﬁcantly superior to unilateral cochlear implantation with respect to many aspects of hearing and should therefore be aimed at, especially in children.

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OL 63 Complications after cochlear implant surgery Gabriela Georgescu, Romeo Calarasu, Dana Stanescu Institute of Phono Audiology and ENT Functional Surgery, 21 Mihail Cioranu Street, Bucharest 050751 The study focused upon the postoperative complications in patients who underwent cochlear implantation between 2000–2006 in our institute. The medical records of 47 patients implanted were analysed retrospectively and were noted: etiology of deafness, age at the time of implantation, postoperative complications and their onset, the management methods and the results obtained. The patients implanted were 35 children aged between 2–10 years and 12 adults between 17–48 years. The etiology of deafness was: congenital in 31 cases (66%), idiopatic progressive 6 cases (13 %), meningitis 5 cases (11 %), ototoxicity 3 cases (6%) and traumatic 2 cases (4%). Postoperative complications appeared in 8 cases (17%), out of which 4 minor complications: 2 cases of seroma and hematoma, 1 case of transitory facial palsy completely solved with medical treatment and 1 case of acute supurative otitis media, successfully solved with antibiotic therapy and drainage miringotomy. There were 4 major late complications (8%): 2 cases of device failure, 1 case of device extrusion after head trauma, all three successfully reimplanted and 1 case of retraction cholesteatoma with electrode exposure. In this speciﬁc case, due to the well functioning of the device, the patient decided not to take the risk of revision surgery. No major intraoperative or early postoperative complications were encountered. The data presented indicate that in our limited experience, cochlear implant surgery is a reliable and safe procedure. 7 out of 8 cases of postoperative complications were successfully solved. The most common cause for reimplantation was device failure.

OL 64 The assessment procedure for cochlear implantation across key countries in former Eastern Europe Monika Lehnhardt PhD. Cochlear AG, Switzerland Objective: This paper will review the assessment procedures for Cochlear Implantation in various countries in the former ‘‘Eastern Europe,’’ in particular focusing on the use of objective measures and the availability of the test equipment. Sixteen former Eastern European countries are currently being surveyed for their standard assessment procedures, in particular

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 their use of objective measures, and it is anticipated that whilst many of the key clinics (often in the capital city) are well equipped, the more regional centres do not have access to many of the recommended objective tests. The British Cochlear Implant Group recommendations will be used as a professionally accepted (and published) standard for assessment and other clinics compared against this. The discussion will focus on how to better equip these clinics and how to train the clinic teams to ensure early and accurate diagnosis of deafness, and thus early and appropriate treatment by hearing aid or cochlear implantation.

OL 65 Looking at the development of musical activities in children with a cochlear implant 1

Debi Vickers, 2Gunay Kirkim, 3Levent Olgun, Armagan Incesulu, 5Esra Yucel, 6Sevginar Onder, 7 Nurdan Aygener 1 Advanced Bionics, Cambridge, UK; 2Dokuz Eylul University Hospital, Izmir, Turkey; 3SB Izmir Bozyaka Hospital, Turkey; 4 Eskisehir Osman Gazi University Hospital, Turkey; 5Hacettepe University Hospital, Ankara, Turkey; 6SB Ankara Numune Hospital, Turkey; 7SB Ankara Diskapi Hospital, Turkey 4

Objectives: Many children receiving a cochlear implant at an early age acquire language rapidly and often fall within the normal range on many speech tests. This is not a true reﬂection of everyday performance in all areas of perception, e.g. many children do not enjoy listening to music. A questionnaire was set up to look at musical behaviours and how they develop. Method: The Questionnaire contains 26 questions and 6 main categories. The questions within each category have a hierarchical structure. The 6 categories are: 1) General Information, 2) Sound Awareness and general reaction 3) Exposure to Music, 4) Melody and Dynamics Changes, 5) Rhythmical Changes 6) Emotional Aspects. This study assesses development in musical behaviours using this ‘‘Musical Stages Proﬁle’’. The questionnaire is presented via parent interview at ﬁrst switch on, and at regular intervals up to 1 year post switch on. Results: It has been evaluated with a group of 21 children; the results at the six month stage will be presented. The families reported that they found the proﬁle easy to follow and interesting to talk about. Results will be reported showing how the musical behaviours develop in this group of children. Conclusions: The Musical Stages Proﬁle is a useful tool for exploring development in musical behaviours and the structure follows a developmental path as intended.

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OL 66 Cochlear implantation: a 3-year experience in ENT clinic Cluj-Napoca, Romania

Conclusions: The use of hearing aids in moderate and severe neurosensorial hearing loss has proved to be satisfactory for the patient in only about 30–40%, which have determined the need for new therapeutical solutions.

M. Cosgarea, Violeta Necula, Alma Maniu, S. Pop, Magdalena Chirila University of Medicine ‘‘Iuliu Hatieganu’’ Cluj-Napoca, ENT Clinic, Romania

OL 68 Maps of cochlear implanted children: NRT, behaviour or linear proﬁle

Objectives: The cochlear implant, the most important achievement of modern technology, has allowed rehabilitation of hearing in patients with severe and profound hearing loss regardless of the age, alltogether with a better social reinsertion of the deaf-mute patients and better future hopes for them. Methods: The rigurous selection of patients that beneﬁt from cochlear implantation has made possible for our clinic to implant 15 patients; among them there was a 36 year-old woman with postlingual hearing loss and multiple organic defﬁciencies (chronic renal failure, bylateral hip prosthesis, crystalin implants, profound hearing loss) and a 16-year old female patient with Usher syndrome (also presenting progressive retinitis pigmentosa). The other patients were from different social environments with ages from 1,6 to 10 years. Results: The surgical procedures have developed within normal limits, the electrodes were completely introduced without any major postoperative complications. From the 15 implanted patients only one represents a failure by sporadically wearing the implant. For the other fourteen the speciﬁc logopaedic tests show a favourable outcome with improvement of responsive and expressive speech in older patients and its development in very young implanted children. Conclusions: The multidisciplinary, logopaedic and psychopedagogic treatment besides the family support and the professional help provided by the specialists in rehabilitation schools show visible progress in these patients’s recovery. The reduced number of patients does not allow us to formulate any relevant conclusions but the good results encourage us in continuing this type of treatment.

Doncho Donchev1, Slavina Lozanova2, Tanja Dimitrova2, Ventzislav Tzvetkov1, Borislava Velichkova3, Hristo Zlatanov1, Borislava Doncheva1 1 Military Medical Academy, 3, Georgi Soﬁjsky Street, Soﬁa, Bulgaria; 2Soﬁa University; 3MEBOS, Bulgaria

OL 67 Cochlear implant in ENT Deptartment Timisoara Stan Cotulbea, MHoratiu Stefanescu, Virgilius Draganescu, Delia Trales, Gheorghe Iovanescu ENT Department Timisoara Objectives: This study reviews the therapeutical possibilities of patients with sensorineural hearing loss, emphassising the advantages of cochlear and middle ear implant over conventional hearing aids. Methods: Patients with bilatheral profound sensorineural hearing loss are completely evaluated audiologicaly, imagisticaly, neuropsichological and the development of the speach is carefully assesed. As the indication of cochlear implant is estabilished, the patient undergo surgery, and the electrod array of the device is inserted in the cochlea, and the internal processor is embaded in the temporal bone. Four weeks later the external processor, which is behind the ear, is activated. Middle ear implant is destinated to less severe sensorineural hearing loss, and only for postlingual onset of the hearing loss. Results: In our clinic there were already made 24 cochlear implants.

Objectives: Which is the better way of cochlear implants stimulation to very young children? Methods: Twelve children between 11 months and two years of age. NRT, behaviour audiometry and linear proﬁles have been applied. Results: Effects of the proﬁles have been evaluated by LIP tests. Conclusions:Results of LIP tests revealed better use of linear than NRT and behaviour proﬁle mapping for young children.

OL 69 Cochlear implant channel separation and its inﬂuence on speech perception: Implications for a new electrode design Jafar-Sasan Hamzavi, Christoph Arnoldner, Dominik Riss, Wolf-Dieter Baumgartner Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18–20, 1097 Vienna, Austria There are a variety of factors which can inﬂuence cochlear implantation outcome. Channel interaction is one of the variables responsible for audiological performance deterioration in multichannel implants. Electrode design is—among others—one way to decrease the incidence of channel interaction. So far, electrodes differ in overall length, diameter, contact design and distribution, but none of the electrodes available have a distinct variability in the amount of space between contacts across the electrode’s length. The aim of this study was to investigate whether a new electrode design featuring larger contact spacing in the apical part of deeply inserted electrodes would lead to an increase in speech perception. Eighteen postlingually deafened patients ﬁtted with MedEl Combi 40+ or MedEl Pulsar cochlear implants using the MedEl implementation of continuous interleaved sampling participated in this study. Patients were tested in 6 conditions, in which we artiﬁcially varied the channel spacing and distribution of electrode contacts in each patient by activating or deactivating different channels. Performance was tested immediately after each change in setup with a monosyllable and sentence test (HSM). Our results showed the condition with the highest distance between contacts in the apical part (up to 6.4 mm instead of 2.4 mm) to have a distinct advantage. The results in this condition were found to be signiﬁcantly better than the standard 12 channel condition for the sentence test and just under statistical signiﬁcance for the monosyllable test. Based on these ﬁndings, we have introduced a new electrode design which seems to be promising for gaining further increases in speech perception.

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OL 70 Fine structure coding in cochlear implants: the FSP strategy P. Nopp1, P. Schleich1, A. Mo¨ltner 1, C. Zierhofer2 1 Medical Electronics, Innsbruck, Austria; 2Christian Doppler Laboratory for Active Implantable Systems, Institute of Applied Physics, Innsbruck, Austria It is well known that in normal hearing, the pitch of a complex sound is coded in both cochlear place and the temporal structure of the neural response, as deﬁned by the basic harmonic, as well as amplitude modulations in the neural responses in the higher frequency regions as produced by unresolved harmonics. Although the relative contributions of these components are still under debate, it seems clear that AM modulations in high-frequency neural responses only provide a a relatively weak cue for pitch. However, it is AM modulations mainly which serve as the primary information carrier for pitch in cochlear implants, which might be an explanation for why cochlear implant users on average show pitch sensitivity which is inferior to that of normal listeners. With the PULSARci100 cochlear implant, MED-EL is presenting a new concept of coding strategies which is designed to overcome the limitations of the envelope-based coding strategies in use to date. In this concept, Channel-Speciﬁc Sampling Sequences (CSSS) are used as a tool to provide a more salient temporal code so that in combination with conventional CIS channels, for low frequencies, the ﬁne structure of a signal is both coded in time and place, and for high frequencies, the ﬁne structure is coded in place only, as is the case in normal hearing. AM modulations will be transmitted in both frequency regions here. The FSP (Fine Structure Processing) strategy implemented in the new MED-EL system is the ﬁrst strategy to apply FineHearing technology. The concept of, and ﬁrst results with, the FSP strategy will be presented and discussed.

OL 71 Use of accessories and understanding in every day listening situations of cochlear implant users Martina Brendel1, Beate Krueger1, Carolin FrohneBuechner1,2, Anke Lesinski-Schiedat1, Andreas Buechner1, Thomas Lenarz1 1 Medical University of Hannover, Department of Otolaryngology, Hannover, Germany; 2Advanced Bionics GmbH, Hannover, Germany Objectives: During the last years the hearing success of Cochlear Implant (CI) users has continuously improved. Nowadays most users hope for almost natural oral communication, good music perception, the ability to use the telephone and speech understanding in noisy surroundings. Methods: This ongoing study was to evaluate how well CI users do in every day life situations and whether they use any accessories to enhance their speech understanding in different surroundings. The implantees were asked to answer to a questionnaire containing four areas of interest: telephone use, music appreciation, social activities and professional interactions. An improved questionnaire version will give more information about the use of accessories of CI users implanted with an older implant system. More than 40 adult CI users were enrolled in this survey. They were all implanted with the CII or HiRes90K implant system and had more than six months experience. Results: The results show that CI user with the behind the ear (BTE) processors mainly used the pinna microphone (TMic) in an

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 every day listening situation while the users of a body worn processor sometimes used an FMsystem or telephone adapter or induction systems to enhance their understanding in more difﬁcult hearing situations. Conclusions: The results of this study are important for the future development of accessories. Faster connects to the BTEs or smaller accessories for the body worn processor would mean a greater wearing comfort for the CI users.

OL 72 3 years experience with the ﬂex soft electrode and the Pulsar CI100-cochlear implant Wolf-Dieter Baumgartner, Alexandra Jappel, Sonja Reiss, Christian Mu¨ller, Christoph Arnoldner, Dominik Riss, Jafar-Sasan Hamzavi, Ilona Anderson Medical University Vienna, Med El Innsbruck, Austria In january 2004 the worldwide ﬁrst Flexsoft electrode was implanted in Vienna. The Flexsoft electrode array is designed for easy and atraumatic deep insertion. Therefore the front end of the Flexsoft has been optimized. So far more than 100 patients were implanted with the Flexsoft electrode. The very thin (0.2 · 0.2 at the tip) Flexsoft electrode is designed to preserve cochlear structures by requiring low insertion force. Preservation is most important when considering implantation in young children. The paediatric population relies on intact cochlear structures for the rest of their life during electric hearing. The PULSAR and SONATA CI100 are the current cochlear implants. In comparison to the COMBI 40+, the new implants features stimulation at higher rates, stimulation of channels simultaneously, and the possibility of using triphasic pulses for stimulation. The PULSAR and SONATA CI100 implants are made for the next generation speech processor OPUS II. The ﬁrst implantation of Med EL Pulsar CI100 worldwide took place in Vienna in March 2004. In the meantime more than 105 patients are implanted with the Pulsar CI100 in Vienna, 45 adults and more than 60 children. Speech perception outcomes from Flexsoft electrode as well as from PULSAR CI100 cochlear implant were assessed using Freiburger number and monosyllable tests and sentences in quiet and noise. Preservation of residual hearing was controlled using pure tone audiogram pre- and postoperative. Subjective beneﬁt was assessed using the Nijmegen Cochlear Implant Questionnaire.

OL 73 Rate-dependence of electrically elicited stapedius reﬂex thresholds Alois Mair Universita¨tsklinik fu¨r Hals-, Nasen- und Ohrenkrankheiten, Salzburg The measurement of the electrically evoked SRT is widely regarded as an important help in the determination of the upper limit of the dynamic range for electrical stimuli. Therefore it is of practical importance to study the relationship of rate vs. threshold and rate vs. psychophysical loudness sensation. This experimental study is to be collocated in the wider context of a loudness model for electrical hearing (McKay, McDermott), which includes temporal integration and refractory effects.

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OL 74 Comparative study with ArabEARS for native Arab speaking children in normal hearing and cochlear implanted children

cochlear nuclei, limiting the number of independent channels of spectral information An alternative hypothesis, the bypass hypothesis, formulates that the difference in speech understanding between CI and ABI is caused by the ABI bypassing or distorting activation of specialized neural circuitry occurring in the CN. For these considerations, it has always been considered a logical consequence that patients ﬁtted with the ABI could receive only limited acoustic information that could be compared to the one obtained by single channel CIs. Recently, the ABI was applied to a series of patients that presented disconnection of the central auditory system from the external sound environment because of a variety of cochlear or cochlear nerve malformation or disruption,e.g., aplasia or hypoplasia of the cochlear nerve, skull basal fracture, VIII nerve avulsion, cochlear ossiﬁcation, etc. (Colletti et al. 2000, 2004, 2005; Colletti 2006). A signiﬁcant number of these patients showed surprising auditory performance, being able to understand speech at a level comparable with the most successful CI users, including conversational telephone use. No NF2 ABI patient has achieved this level of performance. These observations indicate that stimulation of the cochlear nuclei (CNs) can produce functional hearing in the absence of tumors but that the tumours or tumour removal process may cause damage to the CNs that signiﬁcantly diminishes speech understanding. Furthermore they disprove both the selectivity and bypass hypotheses because they demonstrate that the existing surface electrode ABI can produce high levels of speech understanding. The differences between these two patient groups appear to be subtle: both groups have no functioning auditory nerve, and both groups have the same ABI device with the same stimulation strategy. Yet, there is a large difference in performance that is related to the etiology. The existence of this patient dichotomy provides us with considerable leverage on some key questions in auditory processing and in clinical practice concerning the rationale for ﬁtting the ABI in non NF2 patients: 1st Are there specialized physiologic pathways for speech recognition? 2nd Why is it so surprising that stimulation of the cochlear nucleus can provide good speech understanding? 3rd What is the real difference between CIs and ABIs? 4th Provided proper placement of the ABI’s array, can we expected ABIs to perform as well as CIs, if the neurons of the cochlear nucleus are healthy as is the case in most of the non NF2 patients? 5th How important is it to stimulate the CN cells according to the tonotopic organization (and to perform hours of exasperated pitch ranking)? 6th What is the role of neural plasticity in the outcomes of the ABIs ? 7th Are the limitation of CIs to stimulate auditory nerve ﬁbers that normally respond to lowest and highest frequency sounds absent in connection with the ABIs? 8th Is there the possibility that correctly placed ABIs electrode arrays and advances in ABIs stimulation strategies could circumvent some of the limitations of CIs and stimulate all neurons that normally respond to sounds within the entire audible hearing range? 9th Do ABIs have the potential of providing better hearing than CIs? All these questions will be the topic of the presentation.

Anwar Esriti, Salah Giuma, Mohamed Alzourgani TMC, Tripoli Medical Center, ENT Department, Ain Zara, Tripoli, Libya Objectives: A comparative study with two controlled groups of children was initiated to monitor the results of cochlear implanted children against a group of normal hearing children with the same age of hearing. Methods: Each group consists of 15 children with a hearing age of 30 to 36 months. One group, the control group, is a group of normal hearing children where each child was tested with free-ﬁeld audiogram to check normal hearing. The group of investigation is a group of cochlear implanted children. The surgery for the investigation group was performed at age from 2 to 6 years. The ArabEARS test battery was adapted to Arabic language. The parents of each group were asked 35 questions about the capabilities of the child to respond to acoustic stimulation. Results: The results showed in signiﬁcant correlation between these two groups. So the adopted ArabEARS test battery can be used for the minority of native Arab speaking people living in Europe. Conclusions: Due to the fact that social capabilities are one major key factor for the indication for cochlear implant candidate the difference in these two groups can be considered mainly a result of this fact.

OL 75 The rationale for ABI in non tumor patients Vittorio Colletti ENT Department, University of Verona, Italy Patients with profound hearing loss with an intact auditory nerve may proﬁte from cochlear implants (CIs). CIs allow most adults to converse on the phone, and most children to be educated in mainstream classrooms. Patients who lost hearing and the cochlear nerve after surgery for removing bilateral vestibular schwannoma, neuroﬁbromatosis type 2 (NF2), may proﬁt from an auditory brainstem implant (ABI) that directly stimulates the auditory nuclei at the brainstem and might restore hearing. The auditory results of ABI in NF2 patients are generally poorer than those obtained in patients treated with CIs and signiﬁcant functional auditory-alone speech recognition is the exception rather than the norm. The cause of the large difference in performance of the CI and ABI is not clear. Few theories were elaborated to explain the rationale for the rather poor outcomes of the ABIs. One hypothesis, the selectivity hypothesis, suggests that the ABI does not make selective contact with the tonotopic dimension of the

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OL 76 Preliminary results of the adult SmartNRI study

OL 78 Adult multicentral European HiRes 120 study

L. Arnold, P. Boyle Advanced Bionics, 76 rue de Battenheim, 68170 Rixheim, France

B. Kienast, P. Boyle Advanced Bionics, 76 rue de Battenheim, 68170 Rixheim, France

Objectives: Neural Response Imaging (NRI) recordings may sometimes be difﬁcult to interpret due to presence of noise and overlap of stimulus artefact with neural response. An automatic statistically based method (SmartNRI) was developed to determine if a neural response is present and to more reliably obtain the thresholds. The aims were to validate this algorithm and to compare behavioural to SmartNRI based implant programs. Methods: In a pilot phase, NRI measurements taken with the SoundWave ﬁtting software were classiﬁed as ‘‘responses’’ or ‘‘no responses’’ by experienced clinicians, and then processed through the automatic SmartNRI algorithm. Manual and automatic classiﬁcations were compared to validate the algorithm. In a second phase, SmartNRI was used (research software) to measure NRI. The time required to perform the recordings was monitored. Subject programs were created based on SmartNRI thresholds. Results: 114 NRI recording series (approximately 1000 traces) were examined. 75% of the series were unanimously agreed upon and processed by the algorithm. The objective method correctly identiﬁed 100% of records labeled as responses and 80% of nonresponses. The time taken to record waveforms and estimate thresholds was shorter than with the current NRI paradigm. Conclusions: The SmartNRI system appears reliable and promises to be useful in decreasing the amount of time needed to collect NRI responses. More data are necessary to reﬁne the use of SmartNRI in ﬁtting.

Over the years, new sound coding strategies have been devoloped resulting in contineous improvement of performance. Recent research has shown that using spectral bands through stimulting areas between two electrodes have a beneﬁt for the subject. This ‘current steering’ approach known for years is the basis for the newly implemented HiRes Fidelity with 120TM Sound Processing, refered as HiRes 120 strategy. Objectives:1) Investigate the beneﬁt of HiRes vs. HiRes 120 speech coding strategy; 2) Determine beneﬁt of Auria+ Harmony sound processor1 vs. own processor; 3) Identify variables to predict beneﬁt of HiRes 120 speech coding strategy; 4) Develop ﬁtting guidelines. Methods: The beneﬁt of HiRes 120 is evaluated with subjects that have at least 3 months of HiRes with their own processor who are switched over to HiRes 120. Another protocol option looks at ﬁrst ﬁtting with HiRes 120 with the new Auria+ Harmony sound processor. Performance, as well as speech quality and music appreciation, are investigated. Results: A clear beneﬁt of the new HiRes 120 speech coding strategy can be seen with a PSP, as well as with a new Auria+ Harmony processor. Especially encouraging, is the beneﬁt of HiREs 120 when lisientng in noise. This beneﬁt is also seen in the subjective data collected. Data evaluated about the new Auria+ Harmony processor show very satifying rating for the processor. Conclusions:The new Hires120 strategy proves itself as beniﬁcal in subjective and objective measurments. The new behind the ear Auria+ Harmony processor is very reliable and stisfatory.

OL 77 Recent trends in objective measures for the purpose of cochlear implantation George Tavartkiladze National Research Centre for Audiology and Hearing Rehabilitation, Moscow, Russia Recent developments in cochlear implant systems and software design as well as international experience in the objective methods application permit us to reconsider the place and the validity of some of these measures. The results of the electrically evoked stapedial muscle reﬂex (EESR), NRT and electrically evoked brainstem response (EEBR) recordings obtained at different stages of cochlear implantation are analysed with the subsequent psychoacoustic comparisons. The widening of the selection criteria, implantation in patients with partial deafness and the use of bimodal stimulation stipulated additional research, new electrode and speech coding strategies development. Special attention in this study was drawn to the applicability of EESR, NRT and EEBR, development of the useful recommendations at surgical and post-surgery stages of implantation. It was concluded that NRT recorded intraoperatively could be successfully used for the ﬁrst ﬁtting sessions and its validity decreases subsequently. At the same time, the recording of late responses in CI patients becomes more and more signiﬁcant. For a separate group of candidates for bimodal stimulation the use of the steady-state auditory evoked potentials is recommended.

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OL 79 Tempo + versus Opus 1. Hearing results at 12 month in children Horatiu Stefanescu, Stan Cotulbea, Marioara Poenaru, Virgilius Draganescu, Nicolae Balica, Delia Trales Objectives:Speech coding strategy, or speech processing strategy, is a method of converting sound waves into patterns of electrical pulses. The aim of the study was to compare hearing results at 12 months after cochlear implant surgery using both Tempo+ and Opus 1 speech processors. Methods: There were two groups of children: ﬁrst group—10 children—implanted with a Tempo+ speech processor and the second group—7 children—implanted with Opus 1. The mean age in the ﬁrst group was 4.6 years and in the second 4.1 years. Hearing results at 12 month were compared. Results: We compared the results of 3 speech perception tests at 12 months after surgery: monosyllables—45,5% in the ﬁrst group, 50,1% in the second group; sentences—69.2% in the ﬁrst and 77.3% in the second; sentences in noise (10db SNR) 41,8% and 46,5% respectively. Conclusions: The results of the speech perception tests were signiﬁcantly better in the Opus 1 group. Using the latest advances in microchip technology, the OPUS 1 offers the implant users greater sound detail and clarity particularly beneﬁcial for difﬁcult listening situations.

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OL 80 Remote ﬁtting of cochlear implant system A. Wasowski, A. Lorens, A. Obrycka, H. Skarzynski International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Kajetany Mokra 17, 05– 830 Nadarzyn, Poland Objectives: Optimal ﬁtting of cochlear implant system is necessary for implanted patients to obtain maximum possible hearing beneﬁts. Fitting of the system usually requires frequent visits in cochlear implant center and repetitive ﬁtting session. Development of informatics and telecommunication technologies, especially the Internet, opens new possibilities. New internet communication and videoconferencing applications allows remote ﬁtting with use of internet connection. This possibility may prove to be very useful in clinical practice. The aim of this study was to assess usefulness and safeness of remote ﬁtting via internet connection. Methods: Material of the study consists of 19 adult cochlear implant users, implanted in the Institute of Physiology and Pathology of Hearing. The patient is connected to the clinical interface on distant computer. The specialist, using remote desktop application, takes control over distant computer, and performs ﬁtting and electrical hearing tests. Patient’s satisfaction questionnaire is used for comparison of remote ﬁtting and standard ﬁtting methods. Results: The setup for remote ﬁtting and experiences of application of new technology was described. Patient’s satisfaction, quality and time effectiveness of the new method were evaluated. Risk of using this technology, connected with danger of overstimulation, connection breakdowns etc. was also assessed. Conclusions: Based on the results, remote cochlear implant system ﬁtting seems to be a useful and safe technology, which could be used in clinical practice.

OL 81 Auditory DYS-sinchrony and cochlear implantation Jagoda Vatovec, Anton Gros, Dusan Butinar University Department of Otorhinolaryngology, Medical Center Ljubljana, Zaloska 2, 1000 Ljubljana, Slovenija; University Department of Neurology, Medical Center Ljubljana, Zaloska 2, 1000 Ljubljana Objectives: auditory dys-sinchrony is a hearing disorder that presents with abnormal or absent evoked auditory potentials associated with normal otoacoustic emissions. Hearing aids are of little beneﬁt in persons with this kind of hearing impairment. There has been growing interest in rehabilitation with cochlear implants in such patients. Methods: in the time from march 1996 till december 2006 there were 145 patients who were implanted in Slovenija. They were all operated on in Ljubljana University Dept. of Otorhinolaryngology. There were 41 adults and 104 children They all had preoperatively pure tone audiogram, audiogram in free ﬁeld with hearing aid, tympanometry, otoacoustic emissions, auditory evoked potentials, cochleography and electrically evoked potentials. Four patients had characterizations of auditory dys-sinchrony. They got multichannel cochlear implants. Their auditory performance was estimated by free ﬁeld audiometry and Nottingham category list.

S179 Results: at ﬁrst ﬁttings the hearing thresholds were on the level of 40 dB to 50 dB. In time all four of them reached 30 dB hearing thresholds. They percept and recognise environmental sounds, they percept and recognise common frases. In one girl the understanding of speech is not in progress, others are communicating by oral mode. Conclusions: electrical stimulation by cochlear implant can improve dyssinchrony of auditory nerve. With hearing screening by otoacoustic emissions this entity can be overlooked, so it is necessary to check hearing in childhood several times.

OL 82 Listening to music after cochlear implantation Zsuzsanna Kiss, Marianna Ku¨stel, Ga´bor Re´pa´ssy Semmelweis University, Department of Oto-Rhino-Laryngology, Head and Neck Surgery, 1083, Budapest Szigony u 36. Hungary Objectives: The Cochlear Implantation Team of our clinic have studied the subjective experience and objective results in the ﬁeld of listening to music of cochlear implanted patients. Methods: A questionnaire was constructed in order to examine the subjective experience of listening to music of patients having been implanted previously. Volume, pitch and timbre sensation was also examined with the help of a test. In the implanted group adults and children more than 10 years of age were examined having used the device at least for 2 years. The control group consisted of normal hearing individuals. In both groups there were patients practicing music and ones who did not learn how to play a musical instrument earlier. Results: A remarkable difference was observed in both the implanted and the control group in favour of patients practicing music in contrast to those having had nothing to do with it. Conclusions: According to the results musical activity (learning music, expertise in instrumental music) and developed habits of listening to music (where and in what circumstances they listen to music, and how much time they spend with listening to music) are similar in implanted patients and normal hearing adults. On the basis of the results in authors’ opinion enjoyment of music is available for the implanted patients as well.

OL 83 Cochlear implants in infants Richard T. Miyamoto, Derick Houston, Tonya BergesonDana Arilla Spence De Vault Previous research with hearing aids and with cochlear implants has clearly demonstrated the advantage of early intervention. With the advent of universal newborn screening programs, infants with profound hearing loss are now being identiﬁed in the newborn nursery. The current project was initiated to determine if cochlear implantation below the current FDA accepted lower limit of 1 year is advantageous. Fifteen infants below the age of 1 year have been implanted at our center. Methods to document their perceptual capabilities have been developed and longitudinal assessments of language progress are under way. Early results using language quotients at various ages are highly positive.

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Inner Ear Biology OL 84 Auditory development in pmn(progressive motor neuropathy)-mouse mutants S. Volkenstein1, D. Brors1, S. Hansen1, R. Mlynski2, A. Berend2, B. Holtmann3, M. Sendtner3, S. Dazert1 1 Department of Otorhinolaryngology, Head and Neck Surgery, Ruhr-University of Bochum, St. Elisabeth-Hospital, 44787 Bochum, Germany; 2Department of Otorhinolaryngology, Head and Neck Surgery, University of Wuerzburg, 97080 Wuerzburg, Germany; 3Institute for Clinical Neurobiology, University of Wuerzburg, 97080 Wuerzburg, Germany A missense mutation in the tubulin-speciﬁc chaperone E (Tbce) gene in the mouse mutant progressive motor neuronopathy (pmn) is a model of human motoneuron disease. This recessive inherited disease causes in homocygous mice a degeneration of the ﬁrst motoneuron beginning in the third week of life and goes on with a progressive weakness of the muscles until it ends up letal due to a paralysis of breathing muscles between ﬁfth/sixth week after birth. The Tbce-gen product is involved in the formation of functional microtubules. This pathomechanism could be involved in inner ear disease as well. Auditory brainstem response audiometry (ABR) was performed in 25 animals from the beginning of hearing (day p12) until their death to analyse their auditory development. In addition histological and histomorphometrical studies of the cochlea were accomplished as well as in vitro investigations for neuritogenesis of spiral ganglion cells and Nucleus cochlearis cells (ﬁrst and second neuron of auditory pathway). After a normal development of hearing in the beginning ABRthresholds in homocygous pmn-mice declined signiﬁcant in the following period of life until their death. The proven hearing loss in pmn-mice could be caused by a damage of microtubules in hair cells or spiral ganglion cells. Further in vitro investigations studying the possibility of protection against this hearing loss should be performed as well as scanning electron microscopy to look for damages in these systems.

OL 85 Culture and characterization of cochlear tissue of adults’ guinea pigs Ricardo F. Bento, Jeanne R. O. Ramalho, Luiz Carlos M. Barbosa Junior,Luciana A. Haddad, Ana Carla Batissoco, Regina C Mingroni Netto Department of Otolaryngology and Department of Genetics and Evolutive Biology, University of Sa˜o Paulo School of Medicine, Sa˜o Paulo, Brazil Objectives: To culture cochlear cells is still a big challenge, but standardize and characterize it are the main steps to provide sources for molecular, gene and stem cell therapy. The aim of this study was to describe a method for culturing the organ of Corti cells without trophic manipulation and to characterize them from

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 speciﬁc markers. Methods: 16 adults guinea pigs were anaesthetized, temporal bones removed and under stereo microscope organ of Corti, basilar membrane, stria vascularis and spiral limbus were micro dissected and chemistry dissociated with elastase, collagenase, trypsin, 15 minutes incubation at 37C. Tissue was centrifuged twice for 2 minutes at 13000 rpm. Cells were mechanically dissociated with ﬁre-polished Pasteur pipettes and 50 ll of supernatant planted in a 6-well tissue culture containing 3 ml of DMEM F12 with 20% FBS per well. Cells were cultured at 37C in 5% CO2 incubator and media changed every 48 hours for 2 weeks. Cells types were than characterized by immunohistochemistry using anti-nestin and anti-myosin VIIA antibodies as markers for immature neurons and hair cells respectively. Results: In this experiment natural culture of the cochlear cells has been established and maintained for 2 weeks without passages or trophic factors. At 7 days in vitro cells grew uniformly to 40% conﬂuence and achieved 80% to 100% after two weeks. The cells were 5% positive to nestin and 15% to myosin VIIA. Conclusions: The immunoassaying conﬁrmed that some of the cultures cells derived from cochlear sensory epithelia which maybe valuable for future inner ear studies.

OL 86 High incidence of SLC26A4 mutations in Czech CI users with bilateral EVA Pourova R.1, Janousek P., Dvorakova M., Raskova D., Malikova M., Bendova O., Leonardi E., Murgia A., Astl J., Seeman P.1 1 2nd School of Medicine, Charles University, Department of Child Neurology, DNA Lab, V Uvalu 84, Prague 5, 150 06, Czech Republic Objectives: Mutations in the SLC26A4 are considered to be the second most common cause of inherited hearing loss. Aims of our pilot study was to determine frequency and spectrum of the SLC26A4 mutations in Czech CI (cochlear implant) users and to test chosen diagnostic criteria, based on temporal bone HRCT ﬁndings—Enlarged Vestibular Aqueduct (EVA) or/and Mondini dysplasia (MD), uni- or bilateral- and hearing loss progression. Methods: From the group of 238 CI users we chose 13 unrelated patients with highest probability of the SLC26A4 mutations according to clinical data and CT ﬁndings. We performed direct sequencing of all 21 exons of the SLC26A4. Results: Detailed retrospective evaluation of all 108 available CT scans of our patients revealed 1 MD, 2 Mondini-like (ML), 11 EVA (10%), 9 of them bilateral, and 64 EVA/MD negative scans. Among 13 selected patients we detected 8 different mutations (all described as pathogenic) in 6 patients (46%). Biallelic mutations were found in 5 patients (38.5%). All patients with mutations showed bilateral EVA and vice-versa. Unilateral EVA, MD or ML was observed only in association with wild type alleles. Conclusions: Detection rate of the SLC26A4 mutations can be high using evidence-based clinical selection criteria. Presence of bilateral and not unilateral EVA proved to be very efﬁcient selection criterion for the SLC26A4 gene analysis among Czech CI users.

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OL 87 Gene expression in mouse strains susceptible and resistant to noise damage A. Eleftheriadou1,3, M. A. Gratton2, J. Garcia1, E. Verduzco1, A. E. Va´zquez1 1 Department of Otolaryngology, University of California, Davis 95616, USA; 2Department of Otolaryngology, University of Pennsylvania, Philadelphia, PA 19104, USA; 3Department of Otolaryngology, G.Gennimatas Hospital, Athens, Greece Objectives: To investigate the early post-noise changes in gene expression in inbred mice that vary in their susceptibility to noiseinduced hearing loss (NIHL). We hypothesize that noise will affect the expression of molecules important to the development of NIHL and that inbred mice with different susceptibilities would exhibit different changes in cochlear gene expression after noise exposure. Methods: Mice of 129 and B6.CAST strains were divided into control and noise groups. The ‘‘noise’’ groups were exposed to a 105-dB SPL, octave band centered at 10-kHz for 1 h. Although the noise protocol results in no permanent threshold shift for the 129Sv mice, it induces permanent elevation of hearing threshold in the B6.CAST strain. The mice were sacriﬁced 6 h post-noise, and the membranous labyrinth was quickly microdissected. Total RNA was isolated and used in gene array experiments. Results: The expression of 91 genes was signiﬁcantly changed after noise in the 129 mice (p < 0.05). In contrast, only 13 genes were signiﬁcantly changed in the B6.CAST mice. These included a subset of transcription factors upregulated after noise in both mice strains regardless of susceptibility to NIHL. Our results conﬁrmed the results of investigators who have reported the involvement of heat shock proteins in protection from NIHL. Heat shock proteins were signiﬁcantly upregulated in the resistant strain only. Conclusions: Gene expression changes follow noise exposure in mice that are resistant and susceptible to NIHL. The roles of these molecules in NIHL susceptibility and how they are involved in hearing loss awaits further investigation.

OL 88 Robust postmortem survival of murine vestibular and cochlear stem cells Pascal Senn1,2, Kazuo Oshima2, Dawn Teo2, Christian Grimm2, Stefan Heller2 1 Department of Otorhinolaryngology, Head and Neck Surgery, University of Berne, Inselspital, 3010 Berne, Switzerland; 2 Departments of Otolaryngology, Head and Neck Surgery, Stanford University, 801 Welch Road, Stanford, CA 94305–5739 Potential treatment strategies of neurodegenerative and other diseases with stem cells derived from non-embryonic tissues are

S181 much less objected to ethical criticism than embryonic stem cellbased approaches. Here we report the isolation of inner ear stem cells, which may be useful in cell replacement therapies for hearing loss, after protracted postmortem intervals. We found that murine inner ear tissues, including vestibular and cochlear sensory epithelia, display remarkably robust cellular survival, even after 10 days postmortem. Similarly, isolation of sphereforming stem cells was possible up to 10 days postmortem. We detected no difference in the proliferation and differentiation potential between stem cells isolated directly after death and upto 5 days postmortem. At longer postmortem intervals, we observed that the potency of stem cells to differentiate into mature cell types diminishes earlier than their potential for self-renewal. In summary, our results demonstrate that the mammalian inner ear is suited for post-mortem tissue donation to isolate stem cells.

OL 89 Genotypes of various nonsyndromic hearing losses of genetic origin J. G. Kiss, A. L. Nagy, R. Csa´ki, F. To´th, J. Klem, K. Kova´cs, J. Jo´ri University of Szeged, Department of Otolaryngology, Head and Neck Surgery, Department of Biotechnology, Alfa-Biosoft Kft., Szeged, Hungary Objectives: Nonsyndromic hearing loss of genetic origin is one of the most abundant human sensory disorders, and can be found in 1 out of 1000 newborns. The phenotype varies from moderate hearing loss to almost complete deafness. Most of the phenotypical alterations can not be attributed to one single mutation. There is a high probability that most of these disorders are polygenic. Methods: We collect blood from patients with probable hereditary hearing loss, or deafness. We carry out allele-speciﬁc PCR (ASPCR) reactions on each sample. We have analysed our samples looking for 35delG mutation in the GJB2 (Cx26) gene. Since then we are in the process of screening our population of patients with Denaturing High Performance Liquid Chromatography (DHPLC), which enables us to screen for 43 genetic regions in total. Results: We found numerous patients with 35delG mutations, both heterozygous and homozygous forms. Most of these mutations have different phenoypes. Other genetic proﬁles we get from the mutation screening are being compared to the audiological ﬁndings of the examined patient. Conclusions: Our plan is to develop a method that can detect the risk of hearing loss of genetic origin with high probability, at best after birth, from only a little blood sample. This goal is very hard to reach, considering the high number of genes involved in the physiology of hearing. Still, our experiments can get us closer to the desired objective.

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OL 90 Rare genetic syndromes in otorhinolaryngology H. Skarzynski, R. Podskarbi-Fayette, M. Mrowka, P. Mlotkowska-Klimek, B. Skarzynska, J. Wysocki, A. Szkielkowska International Center of Hearing and Speech of The Institute of Physiology and Pathology of Hearing, Warsaw, Poland. Department of Anatomy, Medical University in Warsaw, Poland Objectives: Diagnostic protocol and treatment of otorhinolaryngological symptoms in cases of the EEC, Goltz and Branchiooculo-facial syndromes were presented. Methods: Treatment of hypoacusis and skin disorders were the primary issues in presented cases. In both the EEC and Goltz syndromes our priority was to achieve and maintain a socially efﬁcient level of hearing. Patient with the Branchio-oculo-facial syndrome received a cochlear implant at the age of 13 months and was surgically treated for bilateral retroauricular ﬁstulas. Results: In both cases of dysplasia otosurgery and conservative treatment were applied. Socially efﬁcient hearing level and good local condition were achieved. Preliminary prognosis and future treatment in case of deterioration of hearing were discussed. Patient with Goltz syndrome underwent CO2 laser treatment for papillomatous lesions on her face and neck. Good aesthetic result with no recurrence in follow-ups were achieved. Baby with Branchio-oculo-facial syndrome is rehabilitated in our Cochlear Implant Center and the ﬁstulas healed without complications. Conclusions: Due to the rarity and multiplicity of symptoms of presented syndromes a standard therapy has not been established yet, however, it is of crucial importance focus on hearing improvement to maintain a socially efﬁcient hearing level. Other treatment, such as reconstruction procedure or implantation of hearing prostheses: CI or BAHA can be suitable solutions.

OL 91 Expression of Aquaporin 5 in Menie`re’s disease Diana Arweiler-Harbeck1, Freschta Saidi1, Daniela Solzbacher1, Michael Adamzik2 1 Department of Otorhinolaryngology, University of DuisburgEssen, Germany; 2Department of Pharmakogenetics, University of Duisburg-Essen, Germany Objectives: The presence of aquaporins (water channels) in the inner ear is well known. Aquaporin 5 (AQP5) is localized in the spiral prominence as well as in the lateral wall of the external sulcus cells of the cochlea, limited to the apical turn. As we also know the symptoms of Menie`re’s disease are caused by an imbalance of ﬂuid and electrolytes within the endolympahtic space leading to low tone hearing loss. The investigation of DNA of 102 patients with Menie`re’s disease (MD), familiary Menie`re’s disease (FMD) and single endolymphatic hydrops (EH) should answer the question whether there are typical genetic polymorphisms of AQP 5 for the different entities. Methods: After informed consent as approved by the local ethics committee, DNA of 102 patients, 39 with MD, 54 with FMD and 9 with EH was isolated from blood probes and investigated for genetic polymorphisms concerning AQP 5 by reverse-transcriptase-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 polymerase-chain-reaction. Results: Concerning the genotypes we found type AA in 65,7% (22 MD, 37 FMD, 8 ED), type AC in 23.5% (12 MM, 11 FMD, 1 ED), and type CC in 3,9% (1 MD, 3 FMD). On the ﬁrst sight there is no signiﬁcant correlation between one of the different entities and the expression of AQP 5. Conclusions: Results have to be re-evaluated with special emphasis on individual course of illness and success of different therapies. Investigation of polymorphisms concerning other aquaporins present in the inner ear is needed.

OL 92 Peciﬁc cochlear or vestibular toxicity induced by new semi-synthetic aminoglycoside (AGAs): implications for the treatment of Me´nie`re’s Disease (MD) M. A. Hyppolito, R. Demarco, J. A. A. Oliveira, J. G. Silva, I. Y. Ito, I. Carvalho, A. P. Corrado (1) Departments of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery (Division of Otorhinolaryngology) and (3) Pharmacology, Faculty of Medicine of Ribeira˜o Preto, University of Sa˜o Paulo.Brazil (2) Department of Pharmaceutics Sciences and Clinical Analysis of the Faculty of Pharmaceutics Sciences of Ribeira˜o Preto, University.of Sa˜o Paulo. Brazil The AGAs, are nearly all potent bactericidal agents that share general range of antibacterial activity, pharmacokinetic behavioral and important side-effects, represented by impairments of renal and inner ear functions. The ototoxicity includes the concomitant damage of cochlear and vestibular hair cells. However, there are AGAs mainly cochleotoxic(CT) such as neomycin, and fundamentally vestibulotoxic(VT) such as streptomycin and gentamicin. In the MD, there is a cochlear and vestibular damage which unable episodes of vertigo, progressive deafness and humming. The vertigo may disappear by chemical labirintectomy in the sick ear using mainly AGAs VT, frequently however an undesirable hearing loss side-effect can occur by the use of non-speciﬁc AGAs VT. Therefore the present study concerns the obtention of new AGAs with selective CT-dissociated VT. For this, from the most potent ototoxic AGA, neomycin, we obtained the three molecular fractions: neamine (N), methyl-neobiosamine-B(NMB) and 2deoxy-streptamine(2-DS), and from neamine(N): (I-N)tetra-azido-neamine, (II-N)tetra-N-acetyl-neamine, (III-N) tetra–Ncarboxymethyl-neamine, (IV-N)tetra-N-carboxybenzyl-neamine and (V-N) tetra-p-methoxybenzylimino-neamine. The all fractions were evaluated in cochlear and vestibular assays: (1) the brainstem evoked auditory potential (BEAP), (2) distortion product otoacoustic emissions(DPOAE) and (3) scanning electron microscopy(SEM). Only (NMB) showed to be selective VT agent, without damage of inner and outer hair cells comproved by SEM, DPOAE and BEAP in all animals studied. This is the ﬁrst compound with this characteristic to be able to use in clinical trials for the treatment to MD. The 2-DS, I-N, II-N and III-N were unable to induced ototoxicity. Interesting IV-N and V-N caused only cochleotoxicity at the outer and inner hair cells respectively.

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Otosclerosis OL 93 Otosclerosis: Mid-term results of cochlear implantation Manuel Sainz, Juan Garcia-Valdecasa, Jose Manuel Ballesteros Hospital Clinico Universitario S. Cecilio, Granada, Spain Objectives: constant histological changes in cochlear otosclerosis lead to a progressive hearing loss which may end up in a profound hearing loss and then be treated by cochlear implants. These progressive changes could be followed by changes in cochlear implants ﬁtting and speech discrimination results throughout the years. The aim of the study is to correlate the progressive histological changes to the cochlear implant clinical outcomes (ﬁtting and speech discrimination results). Design: A 5 years prospective case and control (match-paried) study was performed. Materials and methods: 15 otosclerosis patients were included in the study. Preoperatively temporal bone High Resolution Computed Tomography, Electrically evoked Auditory Brainstem Responses and speech discrimination tests were performed. Results: not only difﬁculties at the electrode guide insertion are referred during the surgery, but also difﬁculties at ﬁtting due to the difﬁculties to spread the electrical stimuli which provokes increasing thresholds, maximum comfort levels and charges needed to stimulate hearing cells in the basal and medial turn electrodes (p < 0,05) which lead to deactivate basal and medial turns electrodes in order to improve the cochlear implant effectiveness. The results demonstrated no statistical differences in speech discrimination in otosclerosis patients compared to the control group (p > 0,05). Conclusions: Although progressive histological changes in otosclerosis lead to increasing thresholds, maximum comfort levels and charges needed to stimulate hearing cells, speech discrimination results demonstrate no statistical differences compared to control group which support the cochlear implantation in otosclerosis.

OL 94 KTP laser-stapedotomy with Nitinol piston Imre Gerlinger, Bako´ Pe´ter, Jo´zsef Pytel Department of Otorhinolaryngology, Head and Neck Surgery, Medical School, Pe´cs University, 7621 Pe´cs, Munka´csy u. 2. Hungary Objective: To assess clinical safety and efﬁcacy of the kalium-titanilphosphat (KTP) laser with the use of the self-crimping Nitinol piston in stapes surgery in the short run; to deﬁne and optimize parameters that render the procedure safe for the inner ear. Study design: In a prospective pilot clinical study patients with otosclerosis underwent laser stapedotomy during the period of 14 months. The ﬁrst postoperative audiograms were obtained 6 weeks after surgery. Setting: Tertiary otorhinolaryngological university department. Participants: 11 patients with otosclerosis, entering this pilot study. Results: All patients experienced a hearing improvement of 20.4 dB, on average. 81 percentage of patients achieved a reduction of their air-bone gap to less than 10 dB and 100 percent having their airbone gap closed within 20 dB—averaged across 0.5, 1.0, 2.0, 3.0 kHz. The hearing level improved signiﬁcantly in the air and in the bone conduction thresholds. Conclusion: The results of our preliminary clinical study conﬁrm signiﬁcant improvement in hearing status and showed that the combination of KTP laser, self-crimping Nitinol piston poses no risk to inner ear function in the short run. Continuation of the study is in progress.

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OL 95 Stapes microsurgery, technique and functional results Horatiu Stefanescu, Marioara Poenaru, Mariana Valean, Karina Marin, Gheorghe Iovanescu ENT Department, University of Medicine and Pharmacy, ‘‘Victor Babes’’, Timisoara Objectives: The main techniques used today in stapes surgery are: total stapedectomy, partial posterior stapedectomy and stapedotomy. The advantages of stapedotomy are: less trauma to the inner ear and a better stability of the prosthesis. The stapedotomy opening can be made with manual perforators, with a diamond microburr or with the laser beam. Methods: Between september 1998 and december 2006 a total of 135 stapedotomies were operated in the ENT Department of the University of Medicine and Pharmacy Timisoara. In 82 cases a Fisch type teﬂon and stainless steel piston with a diameter of 0,4 mm was used and the stapedotomy opening was made with manual perforators. In 53 cases a Causse type teﬂon piston with a diameter of 0,4 mm and 0,6 mm was used and the stapedotomy opening was made with a diamond microburr. Results: There was no signiﬁant difference in the results of the two methods. A postoperative air-bone gap of 0 –10 dB was obtained in 83,4% of the cases. A partial sensorineural hearing loss, only on high frequencies, occurred in one patient. Postoperative vertigo was rare and of short duration. Conclusions: The Stapedotomy technique produces litle trauma to the inner ear and good functional results.

OL 96 The use of CO2 laser in stapes surgery Sergije Jovanovic Charite´, University Medical Center, Campus Benjamin Franklin, ENT Department The aim of CO2 laser stapedotomy is noncontact removal of the stapes suprastructure and creation of an adequately large (0.5– 0.6 mm), nearly round, reproducible footplate perforation with no appreciable thermal or acoustic strain on middle or inner ear structures. Minimization of the total energy to avoid inner ear damage and optimization of the perforation technique is best achieved by a single application of the focussed laser beam with the aid of scanner systems (SurgiTouchTM scanner). Based on experimental results, safe and effective parameters were determined for ‘‘one-shot’’ CO2 laser stapedotomy and introduced into the clinical routine. Our clinical experience in over 300 patients shows that, compared to the technique applied thus far, use of the new scanner system enables more precise and better controlled management of the stapes footplate. The course points out the advantages of the new CO2 laser stapedotomy technique with a scanner system. The surgical technique is presented and the varying demands made on the laser beam when working on the stapedius tendon, crura and footplate are discussed. Using the one-shot technique with scanner systems for laser stapedotomy helps to further optimize this high-precision intervention. Compared to conventional techniques the CO2 laser irradiation enables precise and contact-free procedures on middle-ear structures. The risk of chain luxation, particularly footplate mobilization (ﬂoating footplate) or damage to the adjacent middle and inner ear structures is practically impossible with the limitation of the energy parameters used here.

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OL 97 Hearing results regarding location and histologic activity on stapedial footplate in otosclerosis A. Gros, J. Vatovec, S. Battelino Department of Otorhinolaryngology and cervicofacial surgery, Medical center Ljubljana, Slovenia Objective: The goal of this study was to quantify the relationship between location and the stage of histologic changes of the stapedial footplate in otosclerosis. patients: The study included 30 patients (ears) with conductive or mixed hearing loss who were operated on for otosclerosis. The criterion for including a patient in the study was otosclerosis conﬁrmed by histologic examination of the stapedial footplate. Main outcome measures: On the basis of histologic examination of otosclerotic lesions on the stapedial footplate was divided into 4 groups: a) the stapedial footplate was effected on the anterior part, b) an otosclerotic focus was found on the posterior part, c) the footplate was involved in the anterior and posterior direction, d) whole footplate was affected. By histologic features of the stapedial footplate, the stage of otosclerotic lesion was classiﬁed as spongiotic, ﬁbrotic, or sclerotic. Preoperative and postoperative air-conduction and bone-conduction were calculated as an average of ﬁve frequencies (0.5, 1, 2, 3 and 4 kHz). Results: The mean preoperative and postoperative air-bone gap was the highest in patients where the anterior and posterior part of the stapedial footplate was involved. The best closure of the airbone gap was obtained in patients where the stapedial footplate was affected on the anterior part. The main preoperative and postoperative, air-conduction threshold levels, bone conduction threshold levels and air-bone gap was the highest in patients with spongiotic type of otosclerotic lesion. Conclusions: The activity and location of an otosclerotic lesion on stapedial footplate have inﬂuence on the preoperative and postoperative air and bone conduction threshold levels.

OL 98 Microdrill versus ﬁne pick perforator during stapedotomy Haluk Yavuz*, Fulya Ozer*, Fatma Caylaklı*, Levent Naci Ozluoglu* *Baskent University Faculty of Medicine, Department of Otorhinolaryngology Head and Neck Surgery, Ankara, Turkey Objective: To compare the postoperative hearing levels of ﬁne pick and microdrill perforator use in patient with otosclerosis. Methods: The medical records of patients who underwent stapedotomy with the diagnosis of primary otosclerosis between 2000 and 2005 were reviewed retrospectively. All patients had at least a follow-up time of 12 months. Preoperative and postoperative audiological examinations were done in all patients. The result of the postoperative 12th month audiological examination was considered for the comparison. A ﬁne pick or a microdrill with 0,7 mm diamond burr was used to perforate footplate during stapedotomy in all patients.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Results: A total of 123 operated ears were included in this study. Otosclerosis was found to be annular in 96 (78,1%), diffuse in 25 (20,3%) and obliterative in 2 (1,6%) ears respectively. The ﬁne pick and the microdrill were used in 52 ears and 71 ears respectively. No signiﬁcant differences were found between the ﬁne pick and the microdrill group with regard to postoperative bone and air conduction thresholds and air-bone gaps (p = 0,347, p = 0,487, p = 0,861). Also, the hearing gain of bone and air conduction levels after the operation was not differ signiﬁcantly for the both groups (p = 0,406, p = 0,441). Hearing results are comparable in two groups. Conclusion: Our results conﬁrm that the microdrill stapedotomy is effective as classical ﬁne pick stapedotomy on the postoperative hearing levels. The microdrill use is a safe and reliable option with its easy application, shorter perforating time and lack of need to seal around the piston following stapedotomy. Also, it is superior to ﬁne pick perforator particularly in cases with a thickened footplate.

OL 99 Indications, results and limits of malleovestibulopexy Fabio Carducci, Christian Streitberger Department of Otorhinolaryngology, Head and Neck-Surgery, Hospital ‘‘Franz Tappeiner’’, Merano, Italy In selected cases malleovestibulopexy can represent the only surgical option in the treatment of recurrent conductive hearing loss after ear surgery and of multiple sites ﬁxation of the ossicular chain during primary operations as well. Aim of this retrospective study on the malleovestibulopexies performed at our institution was to identify advantages and limits of this operation. Between August 2000 and December 2006 we performed 22 malleovestibulopexies, 13 on the left and 9 on the right ear, on 19 patients. In particular 16 patients were operated once on one ear, 1 patient, affected by osteogenesis imperfecta, underwent bilateral surgery and 2 further patients were operated twice on the same ear for persisting conductive hearing loss. For 18 patients the malleovestibulopexy was a re-operation after stapes surgery or different types of tympanoplasty, associated or not with mastoid surgery, and, in 2 cases, after malleovestibulopexy. Only in 4 ears, 3 with otosclerotic ﬁxation of the footplate and incus-malleus ankylosis and 1, of a patient with osteogenesis imperfecta, malleovestibulopexy was performed as primary surgery. We observed different degrees of hearing improvement in 16 patients and unchanged threshold in 6 cases, among whom one with a blunting of the eardrum and another with extrusion of the prosthesis. No patient developed sensorineural hearing loss. In 3 patients an accidental small perforation of the eardrum was noticed and immediately closed with perichondrium or fascia. 6 patients developed transient vestibular disturbances. It can be concluded that malleovestibulopexie, in experienced hands, represent an effective, even if not always resolutive, surgical approach for complex forms of conductive hearing loss.

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OL 100 Short- and long-term results of stapedotomy, hemistadectomy and total stapedektomy with a teﬂon piston prosthesis in surgical treatment of otosclerosis Erdal Samim, Zeynep Kizilkaya, Kursat Ceylan, Unal Bayiz, Hatice Emir, Ilhan Unlu, Hakki Uzunkulaoglu, Ahmet Yavanoglu, Hakan Gocmen Ministry of Health Ankara Research and Training Hospital Ear Nose and Throat Department, Ulucanlar Cad. No:1 Mamak Ankara, Turkey Objectives: To compare the short- and long-term surgical results of stapedotomy, hemistapedectomy and total stapedectomy with teﬂon piston prosthesis in surgical treatment of otosclerosis. Methods: The patients had been performed primary surgery with teﬂon piston prosthesis between November 1995 and December 2002 were retrospectively chart reviewed. 92 patients had come to regular follow-ups at least 1 year were included in the study. Functional success was accepted as mean residual air-bone gap less than 10 dB in 0.5–1–2 kHz frequencies. Short-term evaluation was performed at the end of ﬁrst month whereas long-term audiometric control was performed at least in the end of ﬁrst year postoperatively. Results: Statistically signiﬁcant difference was observed in long-term evaluation between hemistapedectomy and total stapedectomy. Conclusions: Although stapedotomy is ﬁrst choice surgical approach with teﬂon piston in surgical treatment of otosclerosis, hemistapedectomy can be performed safely and reliably when necessity exists peroperatively.

OL 101 Comparative study of use of K piston and clip piston in stapes surgery A. G. Pusalkar D.Y. Patil Medical College, Nerul, Navi Mumbai 400 706, India There are several implants recommended for use in stapes surgery. Titanium is in vogue these days. This presentation is a comparative study of K piston and Clip piston (Awengen). The study comprises of comparison of 67 cases of Clip piston and 750 cases of K piston. Though the numbers of cases studied in 2 types vary, there is a signiﬁcant comparable data. The biggest problem of comparing implants in stapes surgery is, the comparison cab be made only between the successful surgical results because to justify advantage of one implant over the other, one needs only successful cases. There are innumerable variables in success and failure of stapes surgery hence either success or failure can not be attributed to a single thing like a types of implants. The presentation mainly deals with advantages and disadvantages of one over the other implants during surgical procedure.

Pedaudiology OL 102 Early progredient hearing impairment with homozygous connexin-26 mutation

S185 We report a girl with well documented progredient familiar hearing impairment. Her brother also suffering from severe hearing loss. The girl S.K. * 1.7.2001 had shown changing OAE results. A BERA examination on 30th Nov. 2001 showed a Jewlett IV potential at 35 dB Hl and at 40 dB. April 8th, 2004 after a BERA control examination a JV potential of 90 dB was measured. Behaviour audiometry showed a hearing threshold at 80–90 dB at frequencies of 500–8000 Hz. Conventional hearing aids were initiated. July 2nd, 2002 behaviour audiometry was identical. Sep. 3rd, 02 behaviour audiometry showed a decline of the hearing capacity. Sep. 28th, 02 an additional BERA demonstrated no JV potential on both sides, cochlea implantation was performed. An additional molecular genetic investigation shows GJB2 (connexin26) homozygous mutation c.del35G in both children. Over the last 5 years about 50 children were examined in Freiburg showing normal OAE results at birth, but severe to profound hearing impairment after 12 –18 months. In most cases a familiar background could be demonstrated, and after DNA sequence analysis the mutation c.35delG (homozygous and heterozygotes) could be identiﬁed in 15 of these children. Conclusions: The girl S.K. with GJB2 Mutation demonstrate a progressive hearing impairment during the ﬁrst 15 months of her life. The results of other children with normal OAE results after birth and hearing impairment at the age of 12–18 months support the hypothesis that familiar progressive hearing impairment during the ﬁrst year of life occurs quite often.

OL 103 Role of otoacoustic emissions in children with middle ear effusion and grommets Yousuf Saleem, Sudhakar Ramachandran, Laxmi Rammamurthy, Nicholas J. Kay Stepping Hill Hospital, Stockport, United Kingdom Objectives: The aim of our study is to determine the role of Otoacoustic emissions (OAEs) in children with middle ear effusion (MEE) and grommets. Methods: This is a prospective study for patients undergoing grommet insertions for middle ear effusion (MEE). A total of 90 ears were studied. The age group of the patients were between 2 and 15 years. Patients diagnosed with MEE and listed for grommet insertion were included in the study. Pure tone audiometry (PTA), Tympanometry and OAEs were done and recorded preoperatively and 3–6 months after the grommet insertion. Results: Out of the total 90 ears studied, pre-operatively 63 ears showed evidence of conductive loss on PTA and the remaining 27 ears had normal hearing. 59 of the ears preoperatively had an absent/reduced OAEs and the remaining 31 ears had OAEs present. All the 59 patients who had an absent/reduced OAEs had a conductive hearing loss on PTA and 27 of the 31 ears that had an OAE response had a normal PTA. So, there was a strong correlation between PTA and OAEs pre-operatively. Post-operatively after grommet insertions, all patients who had a normal PTA had OAEs present. Conclusions: We found that both PTA and OAEs were closely correlated both in patients with MEE and in patients with Grommets. As the demonstration of hearing in young and difﬁcult to test children can be problematic and time consuming, we suggest that OAEs can be used as an alternative to PTA and Tympanometry in patients with MEE and Grommets.

E. Lo¨hle, R. Birkenha¨ger University ENT Clinic, Freiburg, Germany

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OL 104 Follow-up approaches in children with hearing losses George Tavartkiladze National Research Centre for Audiology and Hearing Rehabilitation, Moscow, Russia The gold standard for children with hearing loss is early detection and early intervention. Many programs of the universal hearing screening were developed and widely used all over the world. The successful rehabilitation of children with deafness was achieved with early cochlear implantation. At the same time, the follow-up algorithms for the babies who failed screening as well as for children after cochlear implantation still await resolution. Based on own and international experience as well as on the recommendations of the International Society of Audiology it is concluded that the development of algorithms for screening follow-up and post-implantation rehabilitation is of primary importance.

OL 105 Parental attitudes and anxieties towards neonatal hearing screening Annie Moulin1,2, Ce´cile Barnel1, David Lamure2, Eric Truy1,2, Lionel Collet1,2 1 UMR CNRS 5020, Universite´ C. Bernard, lyon 1, France, 2 Hospices civils de Lyon, Pavillon U, E. Herriot Hospital, Lyon, France Objectives: To describe the impact upon parents of false-positives of a newly implemented 3-stage neonatal universal hearing screening programme using automated auditory brainstem responses (A-ABR). Methods: A ﬁrst A-ABR test was performed within 48 hours of birth. A failed test in one or both ears led to a second test 24 hours later, before discharge from the maternity ward. If the second test showed a failed response in one or both ears, the child was referred for full audiological evaluation (FAE). A ﬁrst questionnaire (Q1) was given to parents on the maternity ward, to evaluate ﬁrstly, their anxiety (on a 4 point scale: not anxious, a little, anxious or profoundly) before and after the test, secondly, their views regarding how the baby endures the test and thirdly, the usefulness of the programme. A second questionnaire (Q2) was given to parents coming for FAE to evaluate the anxiety generated by failed screening tests. Results: 231 Q1 and 34 Q2 were collected. Q1 showed a level 2 anxiety in 14% and no anxiety in 77 % of parents before the test. Amongst the parents having to undergo a second test, 56% showed a level 2 anxiety between both tests and 6 % level 3. Q2 revealed a level 4 anxiety in 9%, level 3 in 26% of parents having a FAE, but 88 % of them would still have the test done on their next child. Conclusions: An overwhelming positive response towards hearing screening was obtained, including from parents whose child failed twice the screen, but anxiety must be considered.

OL 106 Assessment of auditory function after neonatal screening Rene´ Dauman, Isabelle Gavilan-Cellie´, Franc¸oise Baldet, Monique Delaroche, Quitterie Daubech, Franc¸oise Duriez, Ce´line The´as, Nathalie Michas

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Paediatric audiology, Department of ENT, University hospital of Bordeaux, France Background: This investigation was undertaken in the framework of a prospective multicentric study supported by the National Insurance Authority (Caisse Nationale d’Assurance Maladie des Travailleurs Salarie´s, CNAMTS) and organized by the French Association for Screening and Prevention of Handicaps in Children (AFDPHE). The screening procedure is based on a two-stepAABR (automated auditory brainstem responses) using the Algo3 device (Natus). Methods: The present report is limited to the hearing-impaired children identiﬁed in all the wards of Bordeaux over the period ranging from March to December 2005, in order to have a followup of at least 1 year for all children. Results: The target population consists of children with sensorineural (or mixed) hearing loss of at least 40 dB HL in the better ear. Timing of auditory brainstem responses and behavioural audiometry will be discussed, as well as preliminary results on psychomotor development. Conclusions: Hearing-impaired children referred from neonatal screening are identiﬁed much earlier than non screened children, but hearing assessment requires repeated measures over time to warrant adequate hearing aid ﬁtting.

OL 107 Endoscopic lazer surgery in malfunctions of the auditory tube in children with unpurelent diseases of the middle ear M. M. Polunin, R. V. Kotov, T. I. Garashtchenko, I. V. Rahmanova The Russian State Medical University, ENT Department, Pediatric Faculty, Ostrovitianova Street. 1, 117997 Moscow Objectives: Malfunctions of the auditory tube, which is the main cause of conductive diminished hearing especially in childhood, predispose to the development of unpurelent diseases of the middle ear that can lead to steady diminished hearing. Such pathologic processes in the nasopharynx as adenoid vegetation hypertrophy, hypertrophy of tubal tonsils and toruses, pathologic reﬂux can result in disorders of the auditory tube. Methods: We have studied 120 children at the age of 2 to 14. Examination of children included otoscopy; audiology examination, i.e. acoustic impedance with registration of the functions of the auditory tube; endoscopic study of nasopharynx. Results: 67 patients underwent surgical interference. Operations on lymphoid structural units of nasopharynx were made under the control of endoscopic devices by means of semiconductive laser; photocoagulation of tubal tonsils. In addition to this, selective laser vaporization of adenoid tissue was carried out. Scars, granulations in the pharyngeal mouth of the auditory tubes. Children who showed exudation behind the tympanic membrane were given laser tympanostomy. Conclusion: So, diagnostic endoscopy of the nasopharynx allows us to determine the causes of disorders of the auditory tube and diminished hearing; results prove the effectiveness of methods which remove mechanical occlusion in the pharyngeal mouth area of the auditory tube and in the middle ear simultaneously by means of laser.

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OL 108 Changing trends in pediatric audiology Psarommatis Ioannis, Kostagianni Georgia, Vaslamakis Theodoros, Antoniou Konstantinos, Douniadakis Dimitrios ENT Department, ‘‘P. & A. Kyriakou’’ Children’s Hospital of Athens, Thivon & Livadias, 11527-Goudi, Athens, Greece Objectives: The aim of this paper was to investigate the reliability and applicability of a new algorithmic approach for evaluating hearing in infants and preschoolers. Methods: One hundred forty-eight consecutive infants and young children suspected of having hearing loss were included in the study. Otoscopy and history taking preceded the audiologic assessment which consisted of two distinct stages: speech and language skills evaluation and otoacoustic emissions measurements bilaterally (ﬁrst stage) was followed by a formal, appropriate-for-age audiologic approach (second stage). All children had a follow-up examination 1 year after their ﬁrst audiologic evaluation. The diagnostic effectiveness of the combination ‘‘speech evaluation+otoacoustic emissions’’ was compared with the conventional methodology, in terms of sensitivity, speciﬁcity, examination time, safety, cost and compliance. Results: The combination ‘‘speech evaluation + otoacoustic emissions’’ was proven to be a highly sensitive and speciﬁc method in reliably sorting out young children with normal hearing thresholds bilaterally. Moreover, this approach is by far more practical, safe, non-invasive and it gives reliable results in a drastically faster way, thus increasing compliance and applicability in very young children. Conclusions: Most infants and preschoolers can have their hearing reliably tested by using the triplet ‘‘history/otoscopy ﬁ speech evaluation ﬁ otoacoustic emissions’’. We propose a new algorithmic approach for this age group.

OL 109 High-frequency tympanometry in infants M. Jurovcˇı´ k 1, P. Mysˇ ka1,2, Z. Kabelka 1,2 1 ENT Clinic of the 2nd Medical Faculty, Charles University, Motol, Prague (2MF CU); 2Motol Hospital, Foniatric dpt., Mra´zovka, Prague Objectives: To assess the role of High-frequency tympanometry/ 1000 Hz/ as a complementary audiologic diagnostic tool in infants bellow 8 month of age. I.e. in diagnosis of middle ear effusion or other conductive patologies.The comparison with OAE or SSEP/ Steady State Evoked Potentials/ ﬁndings. In infants there is greater mass contribution to middle ear impedance, standard 226 Hz frequency probe tone tympanograms are therefore more likely to show false patterns.

S187 Methods: Prospective study including 76 ears examined by 226 Hz and 1000 Hz tympanometry in infants under 8 month of age. Results: Abnormal B pattern tympanometric results using standard 226 Hz examination were obtained in 35% of the ears which had previously in tympanometry 1000 Hz type A pattern. All these ears were OAE examined with normal ﬁndings in 78%. Conclusions: High-frequency tympanometry is very promising objective method that could address the need to differentiate conductive hearing loss from sensorineural hearing loss in infants under 6–8 month of age, but more studies and normative data are needed. Ideally middle ear effusion would be diagnosed surgically via tympanocentesis. By using high-frequency tympanometry we could avoid this invasive procedure. Supported by Research Intent FNM 00000064203/ 6501

OL 110 Middle ear risk index and hearing loss in children V. Chrobok 1,2, A. Pellant 1,2, M. Meloun3, K. Pokorny´1, E. Sˇima´kova´ 4 1 Department of Otorhinolaryngology and Head and Neck Surgery, Regional hospital Pardubice, Pardubice, Czech Republic; 2 Faculty of Health Studies, University of Pardubice, Pardubice, Czech Republic; 3Faculty of Chemical Technology, University of Pardubice, Pardubice, Czech Republic; 4Department of Pathology, University Hospital, Hradec Kra´love´, Czech Republic The risk factors of MER index (MERI) by Kartush are otorrhea, perforation of tympanic membrane, cholesteatoma, ossicular status, granulation or effusion of middle ear, previous surgery and smoking. The aims of this study are to review the effect of MERI on preoperative and postoperative hearing loss. We compared MERI and type of surgery in two groups—children and adults. Material and methods: It is retrospective study of 67 children and 88 adults with chronic otitis media with or without cholesteatoma between 1996 and 2004. The follow-up period ranged from 1 to 9.5 years; mean 3.3 year. Results: The risk factors of MER index and risk value were otorrhea before surgery: dry ear 22 cases, occasionally wet 84 cases, persistently wet 49 cases; perforation of tympanic membrane: none 69 cases, present 86 cases; cholesteatoma: none 57 cases, present 98 cases; ossicular status: normal 60 cases, defect of incus 41 cases, defect of incus and stapes 21 cases, defect of malleus and incus 13 cases, defect of malleus, incus and stapes 20 cases; middle ear: normal mucosa 77 cases, granulations or effusion 78 cases; previous surgery none 106 cases, revision 49 cases; 118 nonsmokers and 37 smokers. Statistical analysis was performed. Conclusions: We concluded patients with higher MER index had worse preoperative and postoperative air-bone gap. Negative prognostic factors for postoperative hearing loss were cholesteatoma and granulations of middle ear in children group.

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OL 111 Effects of adenoidectomy on the outcome of secretory otitis media (SOM) Mila Bojanovic, Milan Stankovic, Dejan Rancic, Misko Zivic, Dusan Milisavljevic ORL Clinic University of Nis, Nis, Serbia Objectives: The aim of this study was to investigate the effectiveness of adenoidectomy in the management of patients with SOM. Methods: A total of 1023 children, 3–11 years of age, were treated surgically (adenoidectomy) at ORL Clinic, University of Nis, from June 1999 to August 2005. Children in whom chronic effusion was detected (27%) were followed up for 1 year after operation. Subjects with SOM were seen at entry and at 4 weeks following entry for otomicroscopy, timpanometry and audiometry. Statistical signiﬁcance was determined by use of a x2 test. Results: At entry there were 15% C2 and 85% B tipe of tympanogram. The presence of ﬂuid level or bubbles was found in 76% the ears and normal otomicroscopical ﬁnding in only 0,1%. Audiometry at entry showed abnormal hearing at more than 80% of children with SOM. (21–30dB, 49%; 31–40dB, 32,1%; 41– 50dB, 2,8%) Conclusions: Our results suggest that adenoidectomy signiﬁcantly (p < 0.05) affects the type of tympanogram, mainly from the second month after surgical treatment, and lasts until the VI month after Subjects with bilateral effusion at entry were more likely to have reccurent disease (bilateral),then subjects with unilateral effusion.

OL 112 Inﬂuence of hypertrophy of pharyngeal tonsil on dysfunction of auditory tubes in children Karimov Jakhongir, Arifov Sayﬁddin, Karimova Zebo Tashkent Medical Academy,Tashkent city, Uzbekistan Objectives: The purpose of the given research was the estimation of inﬂuence of a hypertrophy pharyngeal tonsil on current dysfunction of auditory tubes at children with studying parameters before and after adenotomy. Methods: We had been investigated 19 children in the age of 5 till 8 years. Among them girls 8, boys 11. In development have been included children at whom other factors resulting in dysfunction of auditory tubes have been whenever possible excluded, i.e. a hypertrophy of pharyngeal tonsil, was unique reasonable factor of the given disease. At all patients before operation estimated complaints, carried out endoscopic research of an ear, a cavity of a nose and a nasopharynx, research of hearing acuity (acumetry) and tympanometry. In given endoscopic researches of a nasopharynx at 6 patients the hypertrophy of pharyngeal tonsil covered more than 3=4, in 10–0.5, and in 3 less than 0.5 heights of shovel. According to the international classiﬁcation of hearing disorder at 6 patients it is revealed I degree and 13-II degree of reduction of hearing. It was registered tympanogram type C on classiﬁcation of J. Jerger in all patients. Estimation of inﬂuence of operation on dysfunction of auditory tubes began in 1 month, i.e.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 after calm down of the reactive phenomena in a nasopharynx. Repeated investigations of children carried out in 3 and 6 months after surgical intervention. In the postoperative period treatment of dysfunction of auditory tubes it was not carried out. Results: By the end of time of observation in 17 children have not presented complaints. Endoscopic picture corresponded to norms and it was registered tympanogram type A, i.e. at these patients full clinical recovery is achieved. At 2 children clinical improvement that was expressed by complaints to moderate reduction in hearing is established, i.e. in them was I degree of deafness with positive dynamics after operation, presence of insigniﬁcant indrawn of eardrums though at them registered tympanogram type A. For the period of observation efﬁciency of adenotomy at an estimation of results only on full clinical recovery has made 89,5 %. Conclusions: The hypertrophy of pharyngeal tonsil is the causal factor of development of dysfunction of auditory tubes at children. Adenotomy is positively inﬂuences a functional condition of ear organs as a whole and an auditory tube in particular at children with dysfunction of an auditory tubes.

Paraganglioma + Cerebellopontine Angle OL 113 Combined endoscopic and microscopic technique for total removal of big petrous apex lesions Gerhard Oberascher, Gerhard Moser, Cem Mec¸o Clinic fo Otolaryngology Salzburger Landeskliniken, Paracelsus Private Medical University Purpose: Total removal of petrous apex lesions is a signiﬁcant surgical challenge due to the important surrounding structures including internal carotid artery, internal acoustic canal and cochlea. Throughout the extended translabyrinthine, transcochlear and transotic approaches the labyrinth and cochlea must be destroyed. The transtemporal (middle fossa) approach enables total removal of only small lesions. The purpose of this study is to evaluate the combined endoscopic and microscopic technique for total removal of also big petrous apex lesions. Method: By additional use of rigid endoscopes (45 degree) it is possible to view anatomic compartments which are normally not visible with the operating microscope. This is especially advantageous for middle fossa approach, during which the areas caudal to the internal carotid artery, internal auditory canal, cochlea and along the jugular bulb can be additionally seen thus, be controlled. Between November 1999 and December 2004 we have operated 6 big benign lesions (5 Cholesterol granulomas, 1 Dermoid cyst) of the petrous apex with this combined technique. Result:In all patients it was possible to remove the lesions totally by using appropriate angled rhinosurgical instruments in addition to otoneurosurgical instruments. None of the patients had intraoperative or postoperative complications. Until now the MRI controls have shown no residual or recurrent disease. Conclusion: The combination of operating microscope and rigid endoscopes enable for the ﬁrst time total removal of big benign pathologic lesions of the petrous apex through a transtemporal approach by preserving all functional structures.

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OL 114 Surgical management of intracranial facial nerve schwannoma E. Sauvaget, J. F. Cornelius, R. Kania, P. Herman, B. Georges, P. Tran Ba Huy Departments of Oto-Rhino-Laryngology and Neurosurgery, Lariboisiere hospital, Paris, France Objectives: Facial nerve schwannomas (FNS) are rare and slowgrowing tumours that occur all along the facial nerve. The diversity of tumour locations results in various clinical presentations and the necessity of different surgical strategies, especially for intracranial tumors. Moreover, as quality of life has become the mainstay of management for benign tumours, the management strategy of FNS should be discussed. Methods: Retrospective study reviewed 10 consecutive patients operated for intracranial FNS between 1992 and 2005. Results: Symptoms were facial palsy (n = 3) or hearing deterioration (n = 7). Most tumours were multisegmental involving the CPA in 60%, the IAC in 70%, the geniculate ganglion in 30%, the tympanic segment in 20% and the middle fossa in 10%. Different routes, in one or more procedures were done. Exploration was done in 3 cases, allowing facial nerve preservation for 1, 6 and 7 years, followed by reintervention when facial palsy occurred. Subtotal resection was done in 3 cases, allowing facial nerve preservation in 2 cases during 4 and 6 years, followed again by reintervention. Total resection was performed as a primary or a secondary procedure in 7 out of 10 cases. As a consequence, the facial palsy was rehabilitated by hypoglossal-facial anastomosis or graft, that resulted in House-Brackman (HB) £ III in 4 cases and ‡ IV in 3 cases. Conclusions: Diagnosis of FNS is nowadays ascertained by MRI in most cases, except in CPA and IAC where confusion with vestibular schwannoma can be made. Decision for surgery is taken when aetiology is unclear, when the tumour is large or when symptoms appear. At the time of surgery, complete resection is the mainstay of treatment, but subtotal resection might be considered in some cases.

OL 115 Endoscopic transsphenoidal surgery for cholesterol granulomas involving the petrous apex: a safe and effective approach R. Kania, C. Georgalas, E. Bayonne, E. Sauvaget, W. El Bakkouri, P. Tran Ba Huy, P. Herman Department of Oto Rhino Laryngology, Hospital Lariboisie`re, Paris, France

S189 apex. However, some of them seem to develop primarily in the sphenoid. Cholesterol granulomas may be clinically silent or produce headache and lesions of cranial nerves. Lateral approaches achieve drainage of the granuloma, but are associated with signiﬁcant morbidity. The aim of this study is to evaluate whether results achieved by a transnasal approach differ following the situation of the cyst. Methods: In the last decade, four patients have been treated in our institution for a cholesterol granuloma involving both the petrous apex and the sphenoid. Results: Two patients were operated for a primary petrous apex lesion, because of headache in one case, and because of hearing loss with facial palsy in the other. Surgery was successful in both cases, symptoms resolved, and the lesion disappeared on longterm MRI follow-up while the connexion with the petrous apex closed. The other two patients had a primary sphenoidal lesion extending to the petrous apex and revealed by a VI palsy or loss of vision. Patients recovered after wide marsupialization which remained patent. Conclusions: Two categories should be considered to address the treatment of cholesterol granulomas: primary petrous apex or sphenoid lesions. Primary petrous lesions originate in the deep petrous apex but may develop toward the sphenoid, at the level of the horizontal portion of the ICA. Drainage and removal can be performed through the sphenoid sinus only if they extend to the clivus medially to the ICA, but drainage passage will close with healing of the operative ﬁeld. The primary ‘‘sphenoid’’ lesions extend to the whole sphenoid sinus, may come in close contact with the optic nerve, can be widely drained and will remain marsupialized.

OL 116 Instructional course on temporal bone dissection by translabyrinthine approach, transcochlear approach, middle cranial fossa approach and retrosigmoid approach Andre´ A. Sultan Meatoplasty or canalplasty is the ﬁrst approach of the middle ear surgery. For years, we heard about intact canal wall technique and posterior tympanotomy. The author wants to demonstrate that the posterior tympanotomy has to be utilized just for the placement of cochlear implants or sensorineural hearing loss implants. In the majority of the middle ear surgeries, it is necessary to see very well by large canalplasty the sinus tympani and the facial recess in order to have a better view of the geography of the middle ear, the way of good columellization with a sufﬁcient vibrating surface all around the head of the columella. A DVD shows the implementation of these theories.

Objectives: Cholesterol granulomas involving the petrous apex are expansile, cystic lesions which usually originate within the petrous

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OL 117 Clinical value of vascular compression at the cerebellopontine angle Fulya Ozer*, Cem Ozer*, Can Alper Cagıcı*, Ozlem Alkan**, Haluk Yavuz*, Levent N. Ozluoglu* *Department of Otorhinolaryngology, Head and Neck Surgery, Baskent University, Faculty of Medicine, Ankara, Turkey; **Department of Radiology, Baskent University Faculty of Medicine, Ankara, Turkey Objective: The aim of this study was to evaluate clinical symptoms and audiological ﬁndings in patients with vascular compression of abnormally localized vertebral artery at the cerebellopontine angle (CPA) and its relationship with ipsilateral audiological symptoms. Methods: MR scans for the last 2 years with the compression due to angulated or lateralized vertebral arteries were included in this study. Imaging status of the relationship between the vertebral artery and the cranial nerve VIII were recorded. The patients’ medical records were independently reviewed and the presence and sideness of tinnitus, hearing loss, vertigo and the results of mean hearing thresholds on pure tone average (PTA), speech discrimination (SD) mean scores, V latency and I-V interpeak latency on auditory brain stem responses (ABR) were noted. Results: The close relationship between the vertebral artery and cranial nerves was detected in 28 MR scans. The position of the vessel was categorized as closed but not on nerves in 5 patients, in contact with nerves in 17 and contact as vascular loop in 6. There were no differences between vascular compression of vertebral artery and ipsilateral symptom patterns in all groups. In the groups, ipsilateral results of PTA, SD and ABR were found abnormal compared with contralateral results but failed to show istatistical signiﬁcance. Conclusion: Vascular compression due to abnormal localized vertebral artery may cause many neurological ﬁndings such as trigeminal neuralgia, hemifacial spasm. However, according to our study, it has no signiﬁcant clinical value of vascular compression with ipsilateral audiological ﬁndings.

OL 118 Controversies in the management of paraganglioma of the jugulare foramen Patrice Tran Ba Huy, Rania Benhamed Lariboisie`re Hospital Objective: To compare the results of radiotherapy and surgery for management of jugulare paraganglioma (PG) in terms of function and oncologic features and to deﬁne a treatment algorithm. Methods: 41 patients treated by conventional radiotherapy were retrospectively compared with 47 patients treated by surgery. Following endovascular embolization, 47 patients with type C

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 and/or D jugulare PG underwent surgery involving most of the main steps of the infratemporal fossa between 1984 and 1998 with transposition of facial nerves in 18 cases. A complementary neurosurgical procedure was performed in 14 cases. The radiotherapy series comprised 41 cases of type C jugulare PG treated between 1988 and 2003. Conventional radiotherapy and, since 1995, conformational radiotherapy delivered a total mean dose of 45 Gy (44–50 Gy). Results: Surgical resection, total or subtotal, yielded an overall 86% rate of either cure or tumour remnant stabilization. Radiotherapy achieved local control in 96% of patients. For surgery, the main postoperative complications included swallowing disorders and facial paralysis. Radiotherapy resulted in minor disabilities. Conclusions: For a nearly the same oncologic outcome as for surgery, radiotherapy carries a markedly lower iatrogeny. Our data could favour a case for radiotherapy as treatment for jugulare PG but both treatment modalities are not the same (i.e., eradication of tumour with surgery versus stabilization of tumour for radiotherapy). The search for the best quality of life should be weighted against the uncertainty of the long-term evolution of the tumour.

Tinnitus OL 119 Distortion product otoacoustic emissions (DPOAE) in tinnitus patients with normal hearing D. Psiﬁdis, V. Nikolaidis, A. Psiﬁdis Aristotle University, ENT Department, AHEPA Hospital, Thessaloniki, Greece Objective: The aim of the study was to examine the relation of DPOAEs with tinnitus Method: 150 patients, underwent audiologic evaluation and have been assessed to have normal hearing and normal middle ear function. DPOAEs were obtained with the GSI 60 DPOAE system using the diagnostic protocol developed by J. Hall III (1997). Results: Seventy ﬁve patients complained of bilateral tinnitus and 75 patients complained of unilateral tinnitus. The duration of tinnitus was 0.25–48 months and the mean frequency value of tinnitus was 3880 Hz and the median value 4 kHz. DPOAEs were normal in 53 out of 150 right ears (35.3%) and were abnormally reduced in 97 (64.7%). DPOAES were normal in 42 out of 150 left ears (28%) and were abnormally reduced in 108 (72%). Normal DPOAEs were measured in 23 tinnitus right ears (15.3%) and 22 left ears (14.7%) while abnormal DPOAEs were measured in 77 tinnitus right ears (51,3%) and 103 left ears (68.7%). According to the results of the study DPOAE abnormalities in tinnitus ears with normal hearing were found to be statistically signiﬁcant in relation with non tinnitus ears with normal hearing (statistical signiﬁcance: < 0.005, twotailed, conﬁdence interval 95%). Conclusion: Abnormal DPOAEs may indicate abnormal cochlear function at a frequency region close to the frequency of tinnitus in an otherwise normal hearing ear.

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OL 120 Otoneurological ﬁndings in Tinnitus patients Alija Gezˇo, Mirza Dzˇinic´ Poliklinika ORL ‘‘dr Gezˇo’’, Sarajevo, Bosnia and Herzegovina Objectives of the research have been to investigate electrophysiological methods in identiﬁcation of the source of tinnitus, and electrophysiological properties of the auditory system associated with the tinnitus. Methods: groups of subjects included: 1st, .patients with tinnitus and sensorineural hearing loss; 2nd patients with tinnitus and without sensorineural hearing loss; 3rd, control group of healthy subjects. All subjects were examined otomicroscopically, and tested by tympanometry, tonal audiometry, tinnitometry, OAEs and ABR. Results: 1. Statistically signiﬁcant difference of the tinnitus intensities in SPL between the 1st and the 2nd groups (p < 0.01); 2. Statistically signiﬁcant lower average level of the white noise masking effects on tinnitus in patients from the 2nd group as compared to the levels found in patients from the 1st group (p < 0.01); 3. Stronger SOAEs of the ears with tinnitus, 4. Ears in the 1st group showed absence of TEOAEs, these emissions were reduced in ears from the 2nd group, and were normal in the control group. Conclusions: These results have conﬁrmed that absence of TEOAEs most exactly veriﬁes sensorineural lesions which generate tinnitus at the cochlear level. It can also be reasonably supposed that even subclinical lesions of the auditory system can generate tinnitus.

OL 121 Differential diagnosis in chronicle tinnitus and the role of hyperacusis Helmut Lebisch, Manfred Pilgramm Tinnituszentrum-Detmold, Elisabethstr. 85, 32760 Detmold In the beginning of last year we have started the Tinnitus-Intensive-Weekend-Seminar for tinnitus-patients, treating them by focal point therapy, i.e. we focus the diagnosis on the highest psychological strain in order to ﬁnd out what is the main problem of the patient. For the differential diagnosis we use our ABIBogen, a questionnaire in order to ﬁnd the focal point of strain. It contains 18 questions and each question refers to one of the four focal points: hearingloss, hyperacusis, tinnitus and ear pressure. The audiogram will complete the diagnosis with further ﬁndings like the stigma of hearing loss, problems of concentration, phonophobical tendency and overreaction at measurement. During the consultation the initial situation will be discussed by working out the individual problems. Results: The average tinnitus penetration of 83 patients treated by individual anamnesis and differential diagnosis have improved signiﬁcantly the pre-/posttherapeutic difference of tinnitus shows 25% in the ABI and 33% in the TF questionnaire. In the follow up survey of 61 patients after 6 months the ABI kept unchanged, and the TF improved even further, i.e. according to our 2 years experiences and results we can summarize: ‘‘an intensive individual anamnesis and differential diagnosis and the individual focal point therapy leads in most cases to an unperceptible tinnitus with longterm stabilisation.

OL 122 Integrated healthcare of chronic tinnitus, a therapy model of the future?

S191 Tinnituszentrum-Detmold, Elisabethstr. 85, 32760 Detmold Within the last 5 years we have developed a strategy built on four pillars to overcome tinnitus: ‘‘information’’, ‘‘problem solving’’, ‘‘guidance of awareness’’ and ‘‘support’’ and was realised with over 2400 patients. The recently announced paragraph 140A of the German social insurance code is dealing with the integrated healthcare and demonstrates a solution of the mentioned crisis. Integrated healthcare means the cooperation of doctors in private practice with specialist centres, hospitals and health insurance without the existence of an ofﬁcial association of CHI doctors. The aim is to improve the performance, to reduce costs, to build and foster emphases and to provide an opportunity for reputable specialists. An ENT-doctor, a psychologist and an audiologist will undertake the integrated healthcare for chronic Tinnitus. Results: From Feb. 2005 to Nov. 2006 83 patients with an average age of 49,5 years were treated. The parameters of measurement were taken from our ABI-questionnaire and a Tinnitus questionnaire (Go¨bel & Hiller). All parameters have shown a pre-therapeutic and post-therapeutic difference. A follow-up survey has shown that these parameters kept unchanged or even lower 12 months after the therapy. On the basis of our 2-year experience and our follow-up survey, this concept of tinnitus diagnostic and tinnitus therapy in terms of integrated healthcare can be seen as successful, effective and well priced.

OL 123 The relationship between hypozincemia and tinnitus Osmar Clayton Person1,2, Jose´ Carlos Nardi3, Maria Cristina Lancia Cury Fe´res4 1 Faculty of Medicine of ABC; 2Centro Universita´rio Sa˜o Camilo; 3 Faculty of Medicine of Marilia; 4Faculty of Medicine of Ribeira˜o Preto, University of Sa˜o Paulo, Brazil. Address: R. Henrique Calderazzo, 321- Bairro Paraı´ so, Santo Andre´ 09190–610/SP, Brazil Introduction: Zinc is considered to be the principal protective component against reactive oxygen species in the cochlea, and it also acts as a synaptic modulator in some glutamatergic systems. Its participation in synapses in the auditory system and in the treatment of tinnitus has been largely studied in the past few years. Objectives: To investigate the serum zinc levels in patients with tinnitus, before and after the treatment with drugs containing zinc, and to compare them with a control group. Methods: We evaluated 41 patients (22 with tinnitus and 19 control) that were split into two groups (I and II), respectively. Both groups were submitted to audiologic evaluation, metabolic and biochemical exams, including determination of the serum zinc levels in order to attend the criterion of approval or not. The patients were treated with drugs containing zinc for 90 days, and after that they were submitted to exams to determinate the serum zinc levels again. Results: In terms of serum zinc levels, the relationship between the group with tinnitus and the control group was not statistically signiﬁcant, but the treatment signiﬁcantly increased the serum zinc levels in the group with tinnitus, making it closer to the control group. 45,5% of the patients treated with zinc presented a reduction in their tinnitus. Conclusion: Patients with tinnitus and normal population did not present different serum zinc levels in this study.

Manfred Pilgramm, Helmut Lebisch

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OL 124 The characteristics of tinnitus patients with normal hearing threshold in our Tinnitus clinic G. Bartnik, D. Raj-Koziak, A. Fabijanska, L. Karpiesz, B. Borawska Institute of Physiology and Pathology of Hearing, Warsaw, Poland The purpose of this study was to characterize tinnitus patients with normal hearing in regard to following: (1) the epidemiological occurrence of tinnitus, (2) their audiological proﬁle (results of the audiological tests). The material consists of 400 tinnitus patients with normal hearing threshold ( < 25 dB HL), normal middle ear function (Type A tympanograms and acoustic reﬂexes present at normal limits), ABR latencies within normal limits, and to rule out any history of head or neck injury. All participants had a constant, subjective tinnitus for at least 6 months prior to their enrolment in this study. The suspected aetiology associated with the onset of tinnitus was most often stress, noise exposure and viral infection. About 75 % of patients demonstrated subtle changes in their DPOAEs that otherwise remained undetected in the pure–tone audiogram. In addition, there was a correlation between tinnitus pitch and the abnormal value of DPOAE for the cases with tinnitus pitch located in the range of DP-frequencies. These ﬁndings suggest that pathology represented among tinnitus patients with normal hearing threshold and responsible for tinnitus origin is consistent at the level of cochlea and can be indicated by DPOAEs. The relation between perceived tinnitus pitch and the frequencies of the abnormal level of DPOAE seems to conﬁrm that suggestion.

OL 125 Combined statoacoustic ﬁndings in tinnitus cases Ionut Gabriel Hantascu1, Anemone Luca2, Aureliana Serban3, Claus-F Claussen4, DI Armin Bernhard5, Elemer Nagy6, Ing. Gabor Bencze7, Beata Bencsik8 1 Str. Frumoasa, Nr. 2, Bl. 918, Tr. I, Et. 7, Ap. 28, IASI, Romania; 2Str. Stefan Mironescu nr. 4 Bl 27 Sc A ap 10 et 2, 500222 BRASOV, Romania; 3Str Unitatii nr 128 bloc B4A Ap 14 sc A etaj 2, Sector 3 Bucuresti, Romania; 4Neurootologisches Forschungsinstitut der 4-G Forschung E.V., Kurhausstraße 12, 97688 Bad Kissingen, Germany; 5 Tinnitronics GmbH, Fuhrmannsgasse 8, 1080 Wien, Austria; 6 H-2134 O¨sz u. 53., Szo¨d, Hungary; 7Central Hospital of Ministry of the Interior, 1071 Varosliget fasor 9–13, Budapest, Hungary; 8Department of OtoRhino-Laryngology and Head and Neck Surgery, Semmelweis University, 1083 Szigony u.36, Budapest, Hungary Objectives: Neurootology deals with the functional analysis of the human cranial senses. Amongst these senses equilibrium and hearing are playing a most important role. Due to the fact, that many patients are suffering from vertigo and tinnitus simultaneously, the international HUROKI-team (from Hungary, Romania, Kissingen) was stimulated to quantitatively analyzing

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 neurootological parameters in human cases for statistically proving a statoacoustic interaction. Methods: In 3352 patients with tinnitus the HUROKI-team studied the audiometric results together with the differentiated vestibular ENG ﬁndings in the caloric and perrotatory tests. This also includes the occurrence rates of the different Claussen-Butterﬂy patterns as well as of the Vestibular Stimulus Response Intensity Comparison (VSRIC). Results: Different patterns are being found exhibiting recruitment and decruitment types of VSRIC in patients with an acoustic pathology. Typical combined pathology is demonstrated by statistical results as well as by clinical cases. Conclusions: Considering the functional interaction between vestibular and acoustic data processing within the human brain, it is necessary to investigate other possibility of statoacoustic interaction.

OL 126 Modern neurootological classiﬁcation of tinnitus Beata Bencsik1, Elemer Nagy2, Ing. Gabor Bencze3, Claus-F Claussen4, DI Armin Bernhard5, Anemone Luca6, Ionut Gabriel Hantascu7, Aureliana Serban8 1 Department of Oto-Rhino-Laryngology and Head and Neck Surgery, Semmelweis University, 1083 Szigony u.36, Budapest, Hungary; 2H-2134 O¨sz u. 53., Szo¨d, Hungary; 3Central Hospital of Ministry of the Interior, 1071 Varosliget fasor 9–13, Budapest, Hungary; 4Neurootologisches Forschungsinstitut der 4-G Forschung E.V., Kurhausstraße 12, 97688 Bad Kissingen, Germany; 5 Tinnitronics GmbH, Fuhrmannsgasse 8, A-1080 Wien, Austria; 6 Str. Stefan Mironescu nr.4 Bl 27 Sc A ap 10 et 2, 500222 BRASOV, Romania; 7Str. Frumoasa, Nr. 2, Bl. 918, Tr. I, Et. 7 Ap. 28, IASI, Romania; 8Str Unitatii nr 128 bloc B4A Ap 14 sc A etaj 2, Sector 3 Bucuresti, Romania Objectives: Neurootology basically covers 4 complexes of neurosensorial functions, i.e. equilibrium, hearing, taste and smell. For this paper the authors are looking closer into the background of the subjective signs of tinnitus, i.e. an annoying sound perception. Methods: The authors are presenting typical examples of patients with different types of tinnitus investigated by vestibular and audiological methods, by which they mark up typical parameters for this differentiation. Results: Nowadays, tinnitus can be differentiated at least into 4 entities, as has been proved by the data system NODEC and the archives of the 4GF-Institute in Bad Kissingen: (1)bruit, (2) endogen tinnitus, (3) exogenous tinnitus and (4) syndrome of the slow brainstem. An objective bridge between the subjective perception and a physically veriﬁable annoying signal is the type I ‘‘bruit’’. The endogenous tinnitus, which includes about half of all the disturbing tinnitus cases, is the type II of ‘‘Tinnitus aurium’’ or ‘‘maskable tinnitus’’. The type III of annoying tinnitus is called ‘‘exogenous tinnitus’’. The type IV for generating the subjective symptom of tinnitus is the ‘‘syndrome of the slow brainstem’’. Conclusions: The tinnitus complex nr 2 and 4, endogen and slow brainstem syndrome, demonstrated that they are interacting between the statoacoustic pathways projecting up to the upper gyrus of the temporal lobe.

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OL 127 Tinnitus and anxiety-depression. Is there any correlation? Zs. Zsilinszky1, G. Nagy2, Tama´s L1 Jahn F.-De´lpesti Hospital ENT Department1, Psychiatric Departmentt2 Objectives: Is there any difference between the normal and tinnitus population in occurrence of anxiety-depression? Is there any connection between the severity of tinnitus and presence of depression? Methods: We processed 127 patients with tinnitus. We used the Beck Depression Inventory: normal (0–9), mild (10–18), medium (19–25), serious (>26) to determine the presence and the severity of anxiety-depression in these patients. We made a comparison between patients suffering from tinnitus and the healthy Hungarian population. We used the Gerhard Goebel-Wolfgang Hiller Tinnitus questionnaire to determine the severity of tinnitus (group I-II. compensated, III-IV decompensated). Results: Beck Depression Inventory results: normal:normal population (NP): 75,7%-patients with tinnitus (TP) 65%, mild:NP: 16,8%-TP: 22,2%, medium:NP: 4,6%-TP: 9,5%, serious:NP: 2,9%-TP: 3,2%. Tinnitus severity tests results: compensated (77%) I: 44% II: 33%, decompensated (21,25%) III: 11,8% IV: 9,45%. Conclusion: Patients with compensated tinnitus are also affected in mild or medium severe anxiety-depression, so it is necessary to examine the presence of this pathology in these patients because in these cases the complex treatment may help.

Tympanoplasty OL 128 Otosurgery for chronic otitis media in remote areas: a ﬂy in and ﬂy out project in Greenland P. Homøe, C. Siim, P. Bretlau Department of Otolaryngology, Head and Neck Surgery, H:S Rigshospitalet, University Hospital Copenhagen, DK Objectives: Otosurgery has not been performed systematically in Greenland despite chronic otitis media (COM) occurs very frequently. Otosurgery in Greenlanders has formerly taken place at Rigshospitalet, Denmark but with unsatisfactory results with only 39% closure rate, 70% dry ears and 58% with hearing improvement. Methods: Therefore we established an otosurgical project in Greenland. A database was developed containing pre- and postoperative variables and follow-up. Patient characterristics: Of the 274 operated patients, 2% had cholesteatoma, 34% had suppurative COM and 61% had dry perforations. Type II and III tympanoplasty were applied in 12% and 4% had a mastoidectomy. 62% had mucosa pathology in the middle ear. The ossicular chain was intact in 70%. Results: In total 97%, 75% and 54% were followed up at 3 weeks, 1 and 2 year. The closure rate was 67%, 72%, and 76%. After 1 and 2 years 73% and 67% claimed to be satisﬁed. Hearing improvement after three weeks, 1 and 2 years was found in 83%, 78%, and 78%, respectively and hearing improvement greater than 10 dB in 62%, 62%, and 54%, respectively. The median hearing gain was 15 dB, 15 dB, and 12 dB. Conclusions: The closure rate and hearing results after ﬂy in and ﬂy out otosurgery in Greenland were acceptable but still below western standard. The study provides evidence of continuing the otosurgical project in Greenland and ﬂy in and ﬂy out surgery for COM can be recommended for populations living in remote areas.

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OL 129 Radiofrequency-assisted mitomycin-enhanced tympanotomy Preben Homøe, Christian Siim, Paul Bretlau Rigshospitalet, University Hospital of Copenhagen Objectives: To conduct a prospective, randomized, controlled trial determining the feasibility of radiofrequency with or without topical mitomycin C application in delaying the closure time of human tympanostomy. Methods: 96 patients (180 ears) who were to undergo surgical intervention for recurrent acute otitis media or otitis media with effusion were included in this study. Sixty ears with a diagnosis of recurrent acute otitis media were equally randomized to three procedures: cold knife myringotomy (Group A), radiofrequency tympanostomy (Group B), and radiofrequency tympanostomy with topical mitomycin C application (Group C). One hundred twenty ears diagnosed as having otitis media with effusion were equally randomized to the last two procedures only Results: Groups B and C showed a signiﬁcantly slower rate of closure than Group A. At the same time, Group C demonstrated a slower rate when compared with Group B. No recurrence of acute otitis media was reported in 10, 45, and 80% of Groups A, B, and C, respectively. Fifty-nine percent of Group C showed no clinical or tympanometric signs of otitis media with effusion 3 months after closure of tympanostomy. In contrast, Group B reported a lower cure rate (28%), with a statistically signiﬁcant difference between both groups. The success rate was higher in patients who underwent adenoidectomy, but this did not reach statistical signiﬁcance except in Group C Conclusion: Radiofrequency and mitomycin C delay the closure rate of human tympanostomy. The efﬁcacy of mitomycin C seems to be ampliﬁed in the presence of an inﬂamed tympanic membrane

OL 130 A double ﬂaps approach to extensive disease n the middle ear T. Karchev, E. Bogdanov ENT Department, Medical University, Soﬁa The essence of the method is as follows: Usually under local anaesthesia, are formed 2 ﬂaps from the skin of the posterior wall of the ear canal. The ﬁrst one is in fact, the well known tympanomeatal ﬂap, which is moved inferiorly and anteriorly. The second is called concho-meatal ﬂap and is retracted superiorly and posteriorly. After placement of the second ear retractor is achieved a broad view, including the external surface of the mastoid and the posterior bony canal wall. The soft tissues over the mastoid surface are excised to the level of the temporal muscle, which must remain intact. In this way it is possible to manipulate into the mastoid cavity and tympanic cavity without moving the microscope. This method is applied in the ENT – Department of MU Soﬁa for more than 30 years and in more than 2000 cases, with perfect vision during the whole intervention-removal of pathology and eventual reconstruction. Approximately half of the patients had chronic otitis media with cholestatoma and the other half-granulating osteitis. The posterior bony canal wall is preserved and the two ﬂaps are approximated closely at the end of the operation, so that postoperatively is achieved an intact external auditory canal.

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OL 131 Piezosurgery in otorhinolaryngology Angelo Salami, Renzo Mora, Massimo Dellepiane ENT Department, University of Genoa, Italy Objectives: the aim of this work has been to test Piezosurgery as a new and alternative method to the conventional bone tissue management in otorhinolaryngology. Methods: we have performed Piezosurgery in stapedotomy, atticoantrotomy, classical intact canal wall mastoidectomy, posterior tympanotomy, facial nerve decompression and exeresis of glomus tympanicum tumours. The piezoelectric device uses low frequency ultrasonic waves (24.7–29.5 kHz), the applied power can be modulated between 2.8 and 16 W, and is programmed in accordance to the density of the bone. The equipment consists of two handpieces, two inserts and two peristaltic pumps: the microvibrations that are created in the piezoelectric handpiece cause the inserts to vibrate linearly between 60 and 210 lm. Results: in all the patients, Piezosurgery allowed a rapid and easy intra-operative management and a precise and safe cut; the operating ﬁelds were blood free without any sign of surgical and thermal damage to the adjacent soft tissues. The micrometric oscillation allowed easy control of the osteotomy and osteoplasty, increasing the tactile control of the instrument and the cutting precision. Conclusions: Piezosurgery is a new and revolutionary osteotomy technique utilizing the microvibrations of scalpels at ultrasonic frequency, so that soft tissue will not be damaged even upon accidental contact with the cutting tip. The vibration frequency of Piezosurgery is optimal for mineralized tissue and doesn’t cut the adjacent soft tissue (higher frequency waves need to be utilized), minimizing the risk of harming the adjacent tissues. These characteristics render the piezoelectric device ideal for osteoplasty and osteotomy in otorhinolaryngology.

OL 132 Endoscopic management of anterior drum perforations Andrey V. Davydov, Alexander V. Starokha, Tomsk Branch of the Federal State Institution ‘‘Research-Clinical Centre of Otorhinolaryngology’’, Nakhimova Street 3, 634034, Tomsk, Russia Objective: In more then 25% cases the margin of the drum perforation is not visible with an operating microscope. Literature review demonstrates that the common causes of the drum reperforations are non-adequate preparation of the perforations’ margins and non-adequate adaptation of the ﬂap in anterior tympanomeatal angle. The addition of endoscopic visualization to traditional microsurgical approaches allows clear identiﬁcation of the perforation edge for certain preparation and proper free ﬂap adaptation. Aim: to improve tympanoplasty results in cases of obscured view of the perforation edges by combined application of rigid endoscope and traditional otomicroscope.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Methods: 68 endoscopically assisted tympanoplasties were performed. Anterior quadrants of the ear drum were hampered due to severe protrusion of the ear canal wall. For closure of drum perforations the cartilage plates and perichondrium were used. Results: In cases of hampered view of the perforation margins closure rate made of 97.1% (n = 66). The techniques used were underlay in 88.2% of the patients (n = 60), overlay in 2.9% (n = 2) and sandwich in 8.8% (n = 6). Analysis of the 66 successful cases showed statistically signiﬁcant improvement in air conduction thresholds after myringoplasty at 500 Hz (P < 0.01), 1 kHz (P < 0.05), 2 kHz (P < 0.01) and 4 kHz (P < 0.01). The operation’s duration decreased to 1/3 in compare with traditional approaches. Conclusion: This endoscopic-assisted technique allows exquisite views and avoids blind surgical procedures, thereby expanding the indications for minimally invasive myringoplasty.

OL 133 Long-term results of tympanoplasty Vishnjakov Victor Moscow State University of Medicine and Dentistry, Russia, Moscow 127206, Vuchetycha str.21, Clinical Hospital No. 50, ENT Department The results of tympanoplasty with use of prosthetic auditory ossicles of bioceramics in 95 patients with chronic suppurative otitis media in produced. The operation was produced two ways‘‘close’’ (with preservation of the bony posterior meatal wall) and ‘‘open’’ (with remove of the bony posterior meatal wall). The material used for tympanum membrane restoration was perihondrium and tragus cartilage. Ossiculoplasty was produced with use of worked out by us prosthetic auditory ossicles of bioceramics There were two kinds of prosthetic auditory ossicles of bioceramics used for ossiculoplasty-‘‘partial’’ (with preserved stapes) and ‘‘complete’’ (for lack of all auditory ossicles). During placing the prosthetic were used an interposition of cartilage between prosthetic and tympanum membrane. Long-term results were estimated in 5 years. Good anatomo-morphological result was obtained in 92% patients. Dynamic result of tympanoplasty was calculated by estimation of air-bone gap on frequency 0,5– 4 kHz. Socially suitable hearing (air-bone gap < 20 dB) was obtained in 74 patients (74%). For lack of positive result for 9 patients a reoperation was made. Three the most frequent among causes of failure were selected: 1) displacement of prosthetic, 2) prosthetic tearing away, 3) recidive perforation of tympanum membrane. The analyse of possible causes of unsatisﬁed results showed that the main cause is dysfunction of eustachian tube. The conclusion was drawn that good dynamic results of most patients with chronic suppurative otitis media could be obtained with use of modern effective methods of operation on middle ear and with application new methods of reconstruction tympanum membrane defects and ossicular chain.

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OL 134 Our experinece in tympanoplasty, techniques and utilized materials Alin Horia Marin, Stan Cotulbea, Marioara Poenaru, Horatiu. S¸tefanescu, Karina Marin ENT Department Timisoara Objectives:Tympanoplasty includes the grafting of the tympanic membrane, named myringoplasty and the reconstruction of the ossicular chain through different types of ossiculoplasties. Most frequently used in the reconstruction of the tympanic membrane are autografts like temporalis fascia, tragal perichondrium and cartilage. For the reconstruction of the ossicular chain, autografts like the own ossicles or aloplastic implants made from biocompatible materials can be utilized. Methods: The authors present their personal experience in a number of 156 tympanoplasties. 82 of them were type I tympanoplasties, also called by some authors simple myringoplasties and 74 included ossicular chain reconstructions. Results: The most frequently used grafting material, in the reconstruction of the timpanic membrane, was temporalis fascia (83%). Tragal perichondrium was used in 10% of the cases and the composite graft consisting of perichondrium and cartilage was used in 7%. Incus interposition was the most frequently used procedure for ossicular chain reconstruction (39%). Hidroxyapatite and titanium TORPs and PORPs were also used. Conclusions: The status of the ossicular chain is of great importance for the postoperative hearing results. A mobile stapes and an intact stapes suprastructure improves the chances of obtaining good functional results in ossiculoplasties.

OL 135 Optimal time for auricular reconstruction at children with Microtia Murod M. Jafarov ENT Department, Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan Objectives:In Uzbekistan on epidemiologic evidence of microtia occurrence is 1:500 newborn in near Aral Sea and in central city is 1:900. The choice of optimum time will help to ﬁnd rational period of surgical operation. Methods: Given works was done during 2002–2005 in Department of Plastic Surgery of Tashkent Pediatric medical institute. It was examination 24 patients with microtia, in the age of from 8 till 18 years. By all patients it was made operation with two separate procedures: ﬁrst-harvesting the rib cartilage, and second-inserting the carved, sculpted cartilage into a skin pocket under the Microtia ear. The rehabilitation period has made 30–40 days. Pa-

S195 tients were divided into two groups. Results were evaluated in 6 months after operation. Results: It was comparing 2 groups of patients. In the ﬁrst group were 9 children in the age of from 8 till 12 years; in the second group were 15 children 12–18 years. Results are estimated on the following parameters: on surgical investigation, postoperative rehabilitation and an aesthetic condition of an ear after 6 months. On surgical intervention by the optimum period there were ﬁrst and second groups due to more elasticity of a cartilage at construction of a framework ear. Postoperative rehabilitation was smoother at the second group then ﬁrst group. But aesthetic result on the exact size of a reconstructed ear was in the second group. Conclusions: The optimum period for operative intervention in the sum of three parameters of estimation is the age 12–18 years. Because in this period of a structure of an ear is more approached to the sizes of an adult ear. And aesthetic result more naturally at this age.

OL 136 Surgical management of congenital malformations of the middle ear H. Skar_zyn´ski1, M. Porowski1, B. Skarzynska2, R. Podskarbi-Fayette1 1 International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Mokra 17, Kajetany, Warsaw, Poland; 2Department of Anatomy, Medical University in Warsaw, Poland Objectives: The aim of the study was to develop a standard for diagnostics and surgical management of congenital malformations of the middle ear. Methods: Congenital malformations were found in 637 ears in the material of over 30 000 surgically treated ears. For the purpose of this study, 429 ears were considered, for which the postoperative follow-up period was minimum 3 years. Middle ear malformation was initially diagnosed based on radiological examination, and then veriﬁed intraoperatively. In 369 of cases exploratory tympanotomy was performed applying the approach through the meatus. In some ears it was widened. In the remaining cases, total reconstruction of the canal was necessary. Results: In 394 ears preserved remnants of the middle ear elements were used for reconstruction of the malformed or immobile ossicular chain. In 33 ears application of different kinds of allogenic materials was necessary. Improvement of hearing sensitivity was obtained in 89.7% of operated patients. Conclusions: The results conﬁrm great progress in surgical treatment of ear malformations. Allogenic materials proved to be very useful in the middle ear reconstruction. Final effects, however, depend on complexity of the malformation within the middle ear and in other parts of facial skeleton.

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OL 137 Cartilage ‘‘shield’’ tympanoplasty: an effective and reliable procedure Efthimios Kyrodimos, Ioannis Aidonis, Aristides Sismanis Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA Objective: To report our experience and the hearing results following cartilage ‘‘shield’’ tympanoplasty in selective cases with chronic otitis media necessitated total tympanic membrane replacement. Study design: Retrospective chart review at a tertiary referral center. Methods: Conchal cartilage, shaped as a shield, was used to replace the entire tympanic membrane. Graft take was evaluated in follow up examination and hearing results were determined by comparing pre-operative and post-operative pure tone air bone gap (PTA-ABG) and speech audiometry. Results: Between December 1999 and December 2005, 132 patients with chronic otitis media (38 children and 94 adults) were treated in our Institution. The mean age of these patients was 34 years (range 7–72 years). The mean follow up was 33 months (range 6–60 months). In 77 patients (58.3%) the procedure was primary and in 55 (41.6%) was revision. Sixty-four patients (48.4%) suffered from chronic tympanic membrane perforation, 45 (34%) from cholesteatoma, 20 (15%) from atelectatic tympanic membranes and 2 (1.5%) from atresia. Graft take was successful in all but one patient (99%). Audiometric results were available for comparison in 100 patients. The average pre-op PTA-ABG was 32.18 ± 13.9 dB and the post-op was 20.7 dB ± 10.6dB, with an average improvement of 11.42 dB (P < 0.0001). A post-operative ABG of 25 dB or less was achieved in 72 (72%) of the patients. Speech discrimination scores remained unchanged post-operatively. No complications were identiﬁed. Conclusions: Cartilage ‘‘shield’’ tympanoplasty is an effective and reliable technique in selected patients with chronic otitis media and hearing results are satisfactory.

OL 138 Middle ear risk index (MERI) as a prognostic factor in pediatric ossicular reconstruction Munahi Al-Qahtani, Khalid A. Al-Mazrou King Saud University, PO 245, Riyadh 11411, Saudi Arabia Objectives: to study hearing results in children after ossicular reconstruction and to determine if the middle ear risk index (MERI) is useful in predicting the outcomes. Design: Retrospective case-series. Setting: A tertiary academic hospital. Patients: Forty-four children who underwent ossicular reconstruction Intervention: Ossiculoplasty using autologous or allograft ossicular prothesis. Methods: Forty-four children who underwent ossicular reconstruction from 1995 to 2005. Patients’ audiograms were evaluated preoperatively and postoperatively for pure-tone average (PTA),

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 air-bone gap (ABG). Each ear was scored using the MERI and a total index was calculated. Results: Twenty-three boys and 21 girls were included in the study. The mean age was 15.1 years (range 7–18). Forty-two patients (95.5%) had chronic supportive otitis media. Autologus grafts were used for ossicular reconstruction in 22 patients (50%) and allograft prostheses in 21 patients (47.7%). The mean preoperative ABG was 38 dB, and the mean postoperative ABG was 25.3 dB. The MERI was 3.40, 4.42, 4.45, and 4.06 for excellent results (postoperative ABG 0–10 dB), good results (postoperative ABG 10–20 dB), fair results (postoperative ABG 20–30 dB), and poor results (ABG >30Db) respectively (P > 0.05). Complications included; perforation of tympanic membrane (13.6%), worsening conductive hearing loss (6.8%), retraction pockets (9.1%), recurrent cholesteatoma (6.8%), high frequency sensorineural hearing loss (4.45%), and prosthesis extrusion (2.3%). Mean follow-up was 14 months. Conclusion: Children have poorer hearing results after ossicular reconstruction compared to adults. The MERI was not accurate in predicting hearing results after ossicular reconstruction in children. Age below 18 years has a signiﬁcant inﬂuence on prognosis. Including young age as a preoperative prognostic factor in calculating MERI is recommended.

OL 139 Comparison of autograft ossicles versus titanium for ossiculoplasty Jim C. W. Fong, Philip Michael, Vivek V. Raut New Cross Hospital, ENT Department, Wednesﬁeld Road, Wolverhampton WV10 0QP Objectives:Prospectively compare the hearing outcomes of autograft versus titanium ossiculoplasty at one year Methods: Two consecutive groups of patients with chronic suppurative otitis media with and without cholesteatoma suitable for ossiculoplasty either primarily or as a staged procedure, were prospectively recruited for the study. The ﬁrst group of patients had an autograft ossiculoplasty and the second group had a titanium ossiculoplasty. Hearing results were statistically compared at 1 year between the two groups. Results: A total of 52 patients who underwent an autograft ossiculoplasty were compared with 50 patients who underwent a titanium ossiculoplasty. In the titanium ossiculoplasty group 34 cases (68%) had a post-op air-bone gap of < 20dB using the four-frequency average (FFA) criteria which using the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) criteria, was 76% (38cases). In the autograft ossiculoplasty group 34 cases (65%) had a post-op air-bone gap of < 20 dB using the FFA criteria or 71% (37 cases) using the AAO-HNS criteria. The difference between the two groups using either criteria did not reach statistical signiﬁcance. Conclusion: The results in this small study suggest that titanium ossicles are not superior to autograft ossicles using hearing as an outcome measure. However, the ease of use, availability in various sizes of titanium and the inability to use autograft ossicles in the presence of cholesteatoma, make titanium a superior material for hearing reconstruction.

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OL 140 Cartilage tympanoplasty: an elective operation Elio De Seta, Giorgio Balsamo, Gianluca Rispoli, Roberto Filipo University of Rome ‘‘La Sapienza’’, Viale del Policlinico 155 Rome, Italy In the last few years cartilage tympanoplasty has been reported in literature with very encouraging results on selected patients. It was well established that cartilage tympanoplasty is recommended for re-perforations, allergic patients, children and all cases of presumed poor Eustachian tube function. A routinary use of cartilage graft instead of temporalis fascia for surgical treatment of chronic otitis is proposed. Fifty three consecutive ears with near total perforation, underwent simple tympanoplasty in the last year using a tragal condro-pericondral composite graft. The shape of the graft was a modiﬁed island cartilage slice, placed in underlay position. Although this technique slightly increased the length of surgery, in a 3 months to 1 year follow-up we had no cases of reperforation and mean post-operative pure tone thresholds not statistically different from fascia temporalis graft. A more long term follow-up will allow us to evaluate the rate of other complications, including graft retraction, the most frequent evolution of tympanoplasty with fascia.

OL 141 The reversible tympanoplasty Gregorio Babighian Department of ORL-Otosurgery, Azienda Ospedaliera-Universita`, Padova, Italy Objective: To validate a tympanoplasty technique that combines the anatomical advantages of the canal wall down (CWD) mastoidectomy with the functional advantages of the intact canal wall, double approach, technique (ICW or CWU). Methods: ‘‘reversible tympanoplasty’’ means the temporary removal in one single block of the lateral attic and posterior canal walls. This method has been adopted by the Author since 1990 in selected cases of tensa and sinus cholesteatoma, tympanosclerosis, glomus tympanicus, cochlear implantation in the ossiﬁed cochlea, neuroma of the tympanic segment of the facial nerve. It recalls the methods reported by S.R. Wullstein in 1972 and by H. Feldmann in 1978 and it has been used between 1989 and 2002 in 124 cholesteatoma cases operated on by the author in a tertiary referral academic center. The clinical records have been retrospectively reviewed. Results: mean postoperative follow up was 5.5 years, at the last follow up recurrent cholesteatoma was detected in 3.3%, residual cholesteatoma in 6% of the operated ears. The latter were mainly localized at the attic and/or at the level of the sinus tympani. Auditory outcomes, deﬁned according to the Committee on Hearing and Equilibrium Guidelines, showed an average PTA threshold improvement of 20 dB at the last follow up. Neither sensorineural drops nor other complications were noticed. Conclusions: in Author’s opinion reversible tympanoplasty explicitly offers both the anatomical advantages of the CWD mastoidectomy and the functional advantages of CWU technique.

OL 142 Bioactive glass in ﬁlling of radical cavities in chronic otitis media P. Stoor1, J. Pulkkinen2, R. Gre´nman2

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Department of Maxillofacial Surgery, Helsinki University Central Hospital, P.O. Box 263, 00029 HUS, Finland; 2Department of Otolaryngology, Head and neck Surgery, Turku University Central Hospital, P.O. Box 52, 20521 Turku, Finland Objectives: Chronic otitis media and cholesteatoma can be surgically treated by canal wall-up or canal wall-down mastoidectomy. Often a cavity remains, which collects crust and becomes repeatedly infected. Such surgically created cavities can be eliminated by ﬁlling after thorough cleaning of all mucosa with musculoperiostal ﬂaps and/or bone chips. Our aim was to treat patients with radical cavities due to chronic suppurative otitis media or cholesteatoma surgery by ﬁlling the cavity in the mastoid area with granules of the bioactive glass (BAG) S53P4 (AbMinTMgranules) to avoid further retraction formation, which has been seen in patients treated with autografts and/or mucoperiosteal ﬂaps. Methods: In seven patients the radical cavity was reduced in size by ﬁlling with granules of BAG S53P4 through a retroauricular incision using a mucoperiosteal ﬂap according to Palva et al. A mastoidectomy or revision was performed. The area was ﬁlled with granules of the BAG and closed with a musculoperiosteal ﬂap and temporalis muscle fascia to keep the BAG in position. In three patients the ossicular chain was reconstructed at the same time. The patients were followed up for 9–98 months, the mean follow-up being 57 months. Results: In all seven patients the cavities decreased clearly in size, which reduced the accumulation of crust and infections. The radical cavity was totally eliminated in one patient and was reduced to a small dry cavity in six patients. One patient had slight formation of granulation tissue in the area. In six patients the hearing improved after surgery. No BAG-associated infection or extrusion of the material was seen. Conclusion: The BAG S53P4 has showed no disadvantages for the patients during the follow-up and the cavities in the mastoid cell area decreased clearly in size in all patients treated.

OL 143 A study on autogenous ossicular prosthesis reconstruction by in situ bone tissue engineering technique Sun Jianjun, Li Xuesheng Center of Otolaryngology, PLA, Navy General Hospital, Beijing 100037 Objective: To make ossicular prothesis using little columnar acellular cancellous bone combined with BMP-2, and implant into rabbits’ acoustic vesicle, observe the osteogenesis in situ. Methods: To prepare the acellular cancellous bone combined with BMP-2 as ossicular prothesis, the same material without BMP-2 were used in the control group, the osteogenesis of the materials induced by BMP-2 were observed by endermic implantation. Then from retroauricular approach, to make a hole in the posterolateral bone wall of the acoustic vesicle, and the prepared materials were implanted. After 3 month, we observed the osteogenesis of the prothesis with macroscopical anatomy and pathology. Results: The rabbits recovered soon after surgery, the implanted acellular cancellous bones were banded tightly with the bone of the acoustic vesicle bone wall. The surface of all materials were covered with mucosa. No obvious transformation of the materials were observe, and in the material with BMP-2, osteogenesis occured. Conclusion: The acellular cancellous bone with BMP-2 could induce osteogenesis in acoustic vesicle with primary shape, this material might be use to reconstruct the defects of ossicular chain.Keywords: BMP-2, Ossicular prothesis, Recontruction, In situ tissue engineering.

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OL 144 Application of allogenic cartilage in otosurgery of otitis media O. G. Khorov, V. D. Melanin Grodno State Medical University, Belarus, Grodno, ENT-Department, street Gorky, 80, Grodno 230015, Belarus We use allogenic tissues as plastic material at operations on a ear widely. We have elected cartilage as optimal tissue for such operations. From numerous methods of preservation of tissues we have preferred a method of preservation of this tissue in solutions of aldehydes on principles V. Parphentjeva and S.Boltrukevich.

I.

II.

We reduced the pathological cavity, derivated in a mastoid, up to the sizes of normal antrum for patients chronic purulent otitis media. This purpose is reached with the help of mastoidoplasty by fragments of an allogenic cartilage. Cartilage plate are applied to reconstruction of a tympanic membrane at chronic perforation otitis media widely. We cut a plate on a microtome from a piece of a rib.The plate have a thickness of 0,3 mm. We are storable them in solution of aldehydes before operation. They will be used:

(1) under neotympanic flap on a teflon or osteal prosthesis; (2) for the formation antrum and posterior canal wall at tympanomastoidoplasty; (3). for the formation of a small tympanic cavity after radical operation; (4) for formation lateral wall of attic at reconstruction of a middle ear after an atticotomy. We have applied a triangular cartilage fragment as a bearing of a plate. The basis of a cartilage placed in hypotympanum.

III.

We is carried out for reduction of terms of treatment for an patients acute mastoiditis primary-deferred mastoidoplasty.

We created a muscle-periosteal mobile flap on two legs. The flap covered cartilage grafts, which one spacefilled trepanational cavity. The use of a plastic allogenic cartilage enlarges resources of otosurgeon considerably.

Vestibular Disorders OL 145 Vestibular evoked myogenic potentials: VEMP and their diagnostic value K.-F. Hamann ENT Hospital Rechts Der Isar, Mu¨nchen, Germany This instructional course offers after an introduction about the physiological basics of the VEMP a demonstration of different stimulation and recording techniques. In the third part clinical VEMP recordings from the daily routine are presented. Finally the clinical importance of the VEMP will be discussed.

OL 146 Study of positional nystagmus in dizzy patients Miha´ly Kisely, Andrea Bagoly, Krisztina Bartalis, Attila Liszt, Zsolt Pozsgai Markusovszky Hospital of Vas County, Department of OtoRhino-Laryngology and Head and Neck Surgery, Szombathely, Markusovszky u´t 3. 9700, Hungary

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Objectives: To reveal the frequency of positional nystagmus in dizzy patients and to determine the most frequent origin of the complaint. Methods: A study of otoneurology outpatients. 215 patients were investigated. The ﬁndings of case history, videonystagmography (including caloric and positional tests), posturography, MRI, and vestibular evoked myogenic potential (VEMP) tests were evaluated and compared with results in the literature. Results: The prevalence of positional nystagmus was less frequent in our population than in the literature (8.8%). The lecture points out the frequency of benign paroxysmal positional vertigo (BPPV) compared to other types of positional nystagmus (BPPV 57.8 %). The other types were: peripherally originated transition positioning nystagmus (31.15 %), mixed type (positional and positioning together) 5.2%, atypical positioning 5.1 %. Conclusions: The results suggest the importance of accurate discrimination of isolated and mixed types of BPPV (posterior, horizontal or anterior canal origin).The paper calls attention to the importance of other types of peripherally and centrally originated nystagmus.

OL 147 Children with sensorineural hearing loss present VOR and balance impairment compared to healthy controls E. Ionescu1, P. Froehlich2,3, C. Dubreuil4, C. Ferber-Viart1,3 1 Audiology, Centre Hospitalier Lyon Sud, Pierre Be´nite, France; 2 ENT Department, Hopital Edouard Herriot Lyon, France 3UCB Lyon I UMR 5020 Neurosciences et syste`mes sensoriels, Lyon, France; 4ENT department, Centre Hospitalier Lyon Sud, Pierre Be´nite, France Objective: To study balance control and vestibulo-ocular reﬂex (VOR) in children with sensorineural hearing loss, and to compare them to normal healthy control. Methods: Twenty-six children were involved in the study, four females and nine males aged 9.8 (±1.9) years. 13 were healthy control (group C) and 13 were suffering from sensorineural hearing loss needing hearing aids (group P, mean bilateral PTA loss: 82.6 ± 10.dB HL). The following parameters were recorded: (1) equilibrium scores (ES: %) and (2) sensory Organization Tests (SOT: %) using two dynamic platforms (Equitest and BalanceQuest), (3) VVOR, VOR1 and VOR2 gain using angular horizontal rotations. Results: (1)- ES on BalanceQuest were lower in Group P in condition 2 (P = 0.04). ES on Equitest in conditions 3, 4, 5, 6 (P = 0.05, P = 0.0005, P = 0.004, and P = 0.01 respectively. (2) SOT were lower in group P on BalanceQuest (somesthesic: P = 0.02) and on Equitest (visual: p = 0.01, vestibular: P = 0.02). (3) VVOR, VOR1 and VOR2 gain were lower in the group P (respectively P = 0.01, P = 0.03, and P = 0.004). Conclusion: Our results suggest that children with hearing impairment present balance disorders too. They conﬁrm previous results in otitis media (Casselbrandt et al. 1995, 2003). They also demonstrate that these children have a weaker VVOR and VOR than normal hearing control, which has never been described as yet.

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OL 148 3D motion analysis in evaluation of posture on moving platform M. Molcˇan, J. Majernik, D. Sˇimsˇ ik ENT clinic FN Nitra, Faculty of medicine UPJSˇ Kosˇ ice, Technical University Kosˇ ice Object: Balance control is based on information from proprioceptive, visual and vestibular system. Changes of posture, mainly during acute phase of vestibular diseases, is important for clinical examination. It is a motion capture system based on optical technology, which gives us a more precise information about maintenance of erect posture. It can execute the 3dimensional reconstruction of trajectories of certain parts of the body. The points are sign with a small reﬂective markers. Acute vestibular disturbance in healthy person was simulated with caloric stimulation. We also examined the patients in acute phase of vestibular neuritis. The patients and healthy persons were examine during the standing on stable and moving platform with eyes open and close. Results: In healthy persons there was only a small difference in standing parameters on stable platform after the caloric stimulation in the closed eyes condition. Healthy persons, after caloric stimulation, were unstable on moving platform but we never seen fall from platform. Patient with vestibular neuritis were more unstable but falling from platform we have seen only in central vestibular or proprioceptive diseases. Conclusion: Motion analysis—SMART system is excelent for analysis of balance and gait. Changes of the vestibular information, which participated on body orientation in space, disturb the posture mainly on moving platform, when proprioceptive information is missing. The degrees of disturbance depends on affected part of vestibular system and on size of vestibular dysfunction. During examination it was possible to establish which type of balance strategy (ankle, hip) was used by the patient. Keywords: 3D Motion analysis, SMART system, Vestibular disturbance

OL 149 The clinical value of earlier and later components of vestibular evoked myogenic potentials (VEMPs) in Acute acoustic trauma A. Eleftheriadou1, S. N. Deftereos 2, G. Panagopoulos2, T. Chalastras3, S. Sfetsos 1, C. L. Karageorgiou2, E. Ferekidou 3, D. Kandiloros3 S. Korres 3 1 Department of Otolaryngology, G Gennimatas Hospital, Athens; 2 Department of Neurology, G Gennimatas Hospital, Athens; 3 Department of Otolaryngology, University of Athens, Hippokration Hospital Abstract: Aim of the study: To evaluate VEMPs in patients after acute acoustic trauma. To investigate the relationship between VEMPs and hearing outcome and to clarify the role and the clinical utility of the second VEMPs components n34p44.

S199 Materials and methods: Nine patients with severe hearing loss after acute acoustic trauma, without vestibular symptoms, were studied. VEMPs responses have been recorded and assessed. Results: p13n23 waves were normal in the unaffected ears of all patients. In the affected ear, p13n23 was normal in 7 patients, prolonged in 1 and absent in 1 patients The n34p44 wave was bilaterally present in 3 patients, bilaterally absent in 1 patients and unilaterally absent in the affected ear in 5 patients. All patients were intravenously administered with steroids. Two months later, those 3 ears with the normal p13n23 and n34p44 after the acoustic trauma, presented hearing improvement. Conclusion: Although it is a prospective study, these ﬁrst ﬁndings state that:

1. 2.

The association between hearing improvement and normal VEMPs response after the acoustic trauma could be probably an indicator of good prognosis. The fact that absent n34-p44 was clearly correlated in most of the cases with the hearing loss stands as a support to the hypothesis that n34p44 are of cochlear origin.

OL 150 Unilateral isolated lesion of macula utriculi: diagnostic and clinical characterisation Kai Helling, Uwe Scho¨nfeld, Haralampos Gouveris, Andrew H. Clarke ENT-Department Johannes Gutenberg Universita¨t Mainz, Charite´ Universita¨tsmedizin Berlin, Germany Objectives: Over the last decade reliable techniques have been developed for unilateral testing of the individual otolith organs. Thus, vestibular evoked myogenic potentials (VEMP) and unilateral centrifugation test procedures enable unilateral functional evaluation of the saccule and utricle. We report on a number of cases of unilateral isolated utricular lesions, which were identiﬁed during clinical screening. Methods: During the period from 2000–2006 a total of more than 450 patients with indication of peripheral vestibular disorder were examined. In all patients, bithermal caloric irrigation, VEMP and subjective visual vertical (SVV) during unilateral centrifugation were performed. This combination of test procedures permitted the identiﬁcation of those cases with unilateral utricular dysfunction. Results: Twenty patients were diagnosed for an isolated utricular lesion. The acute symptoms were characterized by tilting sensation and movement illusions, accompanied by non-speciﬁc chronic complaints. None of the patients complained of rotational vertigo sensations. Conclusions: The pattern of pathological ﬁndings from the unilateral otolith tests proved consistent in 20 patients. This is strong evidence that unilateral utricular dysfunction can occur, representing a new entity in the differential diagnosis of the peripheral vestibular function.

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OL 151 Experimental and clinical observations upon perilymphatic ﬁstula Jo´sef Mierzwin˜ski1, Wojciech Kaz´mierczak1, Katarzyna Pawlak-Osin˜ska1, Henryk Kaz´mierczak 1 Department of Otolaryngology; Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland Objectives: The aim of the study was to explain the role of ﬁstula location in the clinical symptoms differences. Methods: In the experimental part of Investigations in 4 pigeons ﬁstula was drilled on lateral, posterior canal, oval window was open surgically, ﬁstula on the vestibular wall between lateral and posterior ampulla was drilled. Head nystagmus and postural disturbances were evaluated. In the clinical observation VNG registration of nystagmus and posturography were performed in 10 ﬁstulas on the lateral canal and in 5 cases of oval window ﬁstulas conﬁrmed by CT and otosurgery. Results: Our analysis showed that canal ﬁstulas created mainly nystagmus in experimental and clinical groups contrary to other sites ﬁstulas which caused postural disturbances mainly. Conclusions: It means that otoneurological symptoms differences depend upon the site location of lesion.

OL 152 The effect of vestibular irritation on the labyrinth receptors state Valery Chekan Belarusian Medical Academy of Post-Graduate Education The intercorrelation of labyrinth systems is clinically manifested by simultaneous disorders of auditory and vestibular functions in various pathology. We analysed auditory dynamics in 37 patients with vestibular disorders following stapedoplasty. The direct correlation between the surgery outcomes and vestibular manifestations was determined. The more active vestibular damage, the worse the results of improving the hearing. We studied the spontaneous otoacoustic emission (SOAE) changing neurodynamics of vestibular receptor by caloric stimulation of the opposite ear (water t = 200 C; 80.0 ml; 10 s). 74 subjects were investigated: Meniere’s disease—26, sensory neural damage VIIIn. at a receptor level –22, neurinoma VIIIn. –8, multiple sclerosis –5, 13 healthy subjects. The spontaneous otoacoustic emission were revealed in 36 subjects (48,6%). SOAE changes were registered in 91 % of them: increased SOAE amplitude in 60%, decreased in 31%. The changes in SOAE amplitude were more common in the ears with receptor damage VIIIn. –75, 9%. At a retrocochlear damage the changes were registered in 24, 1%. The changed activity of vestibular part after the caloric stimulation leads to changed SOAE, which conﬁrms the intercorrelation of auditory and vestibular inner ear parts. Increased SOAE amplitude is the most typical reaction of outer hair cells of the Corti’s organ to caloric stimulation of the vestibular department of labyrinth. Vestibular disorders following stapedoplasty are considered to be a poor prognostic sign and can be an indication to the speciﬁc medical therapy.

OL 153 VEPPs and their origing G. Magliulo, M. Gagliardi, D. Parrotto, F. R. Alla, C. Novello

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Department of Otorhinolaryngology, Audiology and Phoniatrics ‘‘G. Ferreri’’, University ‘‘La Sapienza’’ of Rome, Italy Objective: To evaluate the behavior of vestibular evoked potentials in a variety of pathologies (vestibular schwannoma, Meniere’s diseaase, vestibular neuritis) to verify their origin. Methods: Fifty-two patients were examined. In Meniere’s disease (twenty patients) the experimental investigation consisted of a glycerol test measured with both conventional pure-tone audiometry and with VEMPs adn VEPPs. When difference between pre and postglycerol testing exceed 20%, the outcomes for latencies and ampklitudes were considered signiﬁcant. In vestibular neuritis (ten patients), both VEMPs and VEPPs were measured after symptomatology resolved. In vestibular schwannoma (twenty-two patients), both VEMPs and VEPPs were measured after surgery. Results: Meniere’s disease: in three patients a postglycerol increase in the amplitude of both VEMPs and VEPPs was detected. Three patients had postglycerol improvement of VEPPs, while in three patients only the amplitude of VEMPs increased.; Vestibular neuritis: one patient preserved VEMPs, but not the VEPPs,. In another patient an ooposite observation was seen.; Vestibular Schwannoma: two patients had postoperative preservation of bothe VEMPs and VEPPs even if theis latter decreased in amplitude. One patient had VEPPs preserved, while the VEMPs disappeared. Conclusion: Our observations support hypothesis that the origin of the VEMPs and VEPPs differs in part. VEMPs originate exclusively from the saccule, while in the genesis of VEPPs both saccule and utriculus seem to be involved.

OL 154 The effect of physical therapy on balance of patients with parkinson’s disease Milan Stankovic, Ivona Stankovic ORL Clinic, Clinic for Physical therapy Nis, Serbia Objective: Parkinson’s disease is a chronic progressive neurological disturbance with signiﬁcant effect on movements, cognitive functions, autonomous systems and psychosocial activities. The effects of physical therapy are rarely reported and not sufﬁciently studied. Methods: Prospective study comprised of 40 persons with Parkinson’s disease, stage III according to Hoehn and Yahr (1967) aged over 50 years and 20 healthy controls with the same age. Patients that were medically stabile and without other neurological deﬁcits, postural hypotensia, visual disturbances and musculoskeletal deﬁcits. Balance tests before and after physical therapy were analyzed according to Smithson et al. (1998). Results: Tests of balance in patients with Parkinson’s disease resulted in signiﬁcant differences of values for tandem stance, one leg stance, step test and external perturbation when compared to control, and between groups with and without falling tendency. Conclusion: Tandem stance, one leg stance, step test and external perturbation can be used for differentiation between groups with and without tendency to fall.Physical therapy resulted in signiﬁcant improvement of these tests in both analyzed groups. Systematic application of physical therapy, as part of team treatment, improves balance of patients with Parkinson’s disease.

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OL 155 Intratympanic gentamicin perfusion for the treatment of Meniere’s disease Ioannis Aidonis, Efthimios Kyrodimos, Aristides Sismanis Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA Objective: To evaluate the efﬁcacy of intratympanic gentamycin perfusion for the control of the vertigo spells in patients with Meniere’s disease. Materials and methods: The AOO criteria were used for the diagnosis of Meniere’s disease. Intratympanic perfusion of 40 mg/ ml of gentamycin was administered into the tympanic membrane in patients who failed to respond to previous medical treatment (diuretics, low-salt diet, intratympanic or oral steroids). Outcomes were determined by subjective assessment of vertigo control and by audiometric evaluation at the ﬁrst post-perfusion visit, 4– 6 weeks later (short-term results) and at least 12 months later (long-term results). Results: Between May 1999 and November 2005, 22 patients (13 women and 9 men, aged 40 to 85 years, mean age: 58.5 years) with Meniere’s disease underwent intratympanic gentamycin perfusion. Follow-up ranged from 12 to 48 months (mean 30 months). In the short-term, complete cessation of vertigo reported by all patients (100%), while audiometric results remained unchanged. In the long-term vertigo control was achieved in 20 patients (91%), 1 patient demonstrated a greater than 10 dB improvement in PTA, 1 patient had a decrease in hearing of more than 10 dB, while in 8 patients SDS was decreased over 15%. No middle ear or tympanic membrane complications were identiﬁed. Conclusion: The intratympanic gentamycin perfusion may provide an effective control of the vertigo spells of the patients with Meniere’s disease. In the short-term vertigo control achieved in most of study patients, while in the long-term complete cessation of vertigo was achieved in 91%.

OL 156 Vestibular function in Hiv positive patients: personal experience R. Teggi, L. Giordano, V. Pistorio, C. Bellini, M. Bussi San Raffaele Hospital, Vita e Salute University, Via Olgettina 60, 20132 Milano Objectives: To investigate if a central or peripheral vestibular damage may occur in HIV+ patients even without an acute vestibular episode. Methods: 60 Hiv+ patients belonging to all 3 classes (A-C) of CDC classiﬁcation referring dizziness but no acute vertigo in clinical history underwent an Electronystagmography with bithermal stimulation, preceeded by a study of spontaneous, positional nystagmus and eyes movements registration. Oculomotor alterations, positional and rebound nystagmus was suggestive for central damage. Angular velocity of slow phase was the main value of labyrinthine function.

S201 Results: 20 of 30 A Class patients (66.6%) had normal ENG results, 9 (30%) showed only peripheral damage for Labirinthine or Directional Preponderance and 1 (3.4%) peripheral and central signs. 9 of 20 B Class patients (45%) had normal ENG, 6 (30%) pure peripheral pattern, 3 (15%) both central and peripheral and 2 (10%) only central signs. None of C Class patients had normal ENG; 4 (40%) showed peripheral and central signs and 6 (60%) only central. Conclusions: Percentage of ENG anomalies increase from A to C class (33.4, 55, 100%). Peripheral signs on opposite seem to be almost constant in 3 classes (33.4, 45, 40%) while central damage with or without peripheral asymmetry increase signiﬁcantly from A to C Class (3.4, 25, 100%). In our opinion the peripheral damage may occur in early phase of HIV infection as a direct viral labyrinthine infection, while central damage establish later for sovrainfections or vascular causes.

OL 157 Superior semicircular canal dehiscence: speciﬁcity of high-resolution CT Jean-Franc¸ois Cloutier1, Manon Be´lair2, Issam Saliba1. 1 Otolaryngology, Head and Neck Surgery, Centre Hospitalier de l’Universite´ de Montre´al; 2Neuroradiology, Centre Hospitalier de l’Universite´ de Montre´al. 1560 Sherbrooke street, East Montre´al, QC, H2L 4M1, Canada Objectives: Patients with superior canal dehiscence (SCD) syndrome have vertigo and oscillopsia evoked by loud sounds and changes in middle ear or intracranial pressure. The computed tomographic scanner (CT) is the key to the diagnosis, with a reported positive-predictive value of 93%. The purpose of this study is to evaluate the sensibility of neuroradiologists to detect this entity and to re-evaluate the positive predictive value of the CT in a larger population of patients. Methods: All temporal bone CT scans with 0.55 mm collimation and reconstruction in the superior semicircular canal (SSC) plane performed over a 1-year period at 2 university-based tertiary referral centers were analysed. CT-positive cases had their clinical data reviewed and patients were re-examined, if available. Results: Five hundred and eighty one temporal bone CT-scans were reviewed. A dehiscent-appearing SSC was seen in 4.0% of studies while pathologic studies report that only 0.5% of temporal bones SSC have a dehiscence. Of the 21 patients with positive temporal bone CTs, only 1 presented with sufﬁcient clinical clues to identify the syndrome. Three additional patients did not have symptoms consistent with the diagnosis, but had surgery for tegmen dehiscence. When our ﬁndings are compared to published data, the positive predictive value of temporal bone CT-scanning drops from 93 to 57%. Also, only 26% of initial reports by neuroradiologists mentioned this anomaly. Conclusion: The prevalence of dehiscent-appearing superior canal on thin-section CTs with reformation in the SSC plane is substantially higher than anticipated by pathologic studies. Even with 0.55 mm-collimated helical CT, the risk of overdiagnosis is present.

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OL 158 Assessing dizziness: the clinical experience (N = 22,335 patients) Athanasios Katsarkas Department of Otolaryngology, McGill University, 687 Pine Ave. W., Montreal, QC, H3A 1A1, Canada Objectives: Causes of dizziness in a referral specialized center. Methods: A retrospective study of 8,204 men and 14,131 women evaluated and followed up by the author (58,825 visits). Data denote frequency per diagnosis. Results: Causes of dizziness: (1) No deﬁnite diagnosis [N = 5,798 (22%) cases]. In most cases, the symptoms were transient, mild and vague. (2) Non-CNS, non-vestibular, medication or psychogenic [4,453 (17%)]. (3) BPPV by history [N = 6,046 (23%)]. (4) BPPV clinically conﬁrmed [N = 3,433 (13%)]. (5) Meniere’s disease [N = 1,224 (6%)]. (6) Vestibular neuronitis [N = 1,313 (5%)]. The loss of unilateral vestibular function was permanent (N = 573). The vertigo was recurrent (N = 125). (7) Cerebrovascular disease [N = 578 (2%)]. (8) Sudden unilateral hearing loss frequently accompanied by vertigo (N = 552). (9) Dizziness (non-BPPV) due to head injury (N = 458). (10) Tumors (N = 327). (11) Other diagnoses: (a) multiple sclerosis (N = 153); b) migraine (N = 120); c) ototoxicity (N = 158); brain stem-cerebellar disease (N = 209); autoimmune disease (N = 62); sensory neuropathy (N = 68); epilepsy (N = 66); inner ear ﬁstula (N = 58); Parkinson’s disease (N = 55). (12) Other diagnoses less frequent. Conclusions: (1) An accurate diagnosis was possible in 78% of cases. (2) Some patients suffered from dizziness induced by more than one cause. (3) BPPV was the most common peripheral syndrome. (4) Vestibular neuronitis (one or multiple episodes) induced, at times, permanent vestibular dysfunction. (5) The history and the clinical examination are the main tools in reaching a diagnosis.

OL 159 Contribution of static computed posturography to balance quantiﬁcation and neurootological differential diagnosis Drsˇ ata Jakub, Vokurka Jan, La´nsky´ Miroslav, Cˇelakovsky´ Petr, Sˇkoloudı´ k Luka´sˇ , Haas Vojteˇch, Sila Petr ORL klinika Fakultnı´ nemocnice, 500 09 Hradec Kra´love´, Czech Republic Objectives: the diagnostics of balance disorders is by far not satisfactory, no method of neurootological functional investigations is paramount. This presentation aims to rate the contribution of static computed posturography (SCPG) for quantiﬁcation and differential diagnosis of balance disorders, based on evaluation of results from the ENT Dept. Teaching Hospital in Hradec Kra´love´, Czech Rep. Methods: 1398 SCPG measurements were performed in the years 2001–2004. Group characteristics: and healthy control group

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 (n = 89), patients with standardly deﬁned diagnoses (n = 1309) – 52% of women with age distribution 3–91 years (24.28% within 51–60 years). Results: deﬁnition and veriﬁcation of scale for SCPG quantiﬁcation of equilibrium impairment, determination of most important parameters for quantiﬁcation and topographical differential diagnosis. While Wf and Ws parameters are of a dominant value in quantitative assessment of balance, others (especially Wf, Af, ALf, Als, RW, RA) are more useful in topodiagnostic reasoning. Sensitivity for correct topodiagnostic evaluation was 29.2% in the observed data collection, with 76,8% speciﬁty. No speciﬁc relation to a particular neurootological diagnosis could be found. Conclusions: SCPG is a suitable methodics for quantiﬁcation of balance disorders and detection of latent postural instability. The contribution of SCPG to the differential diagnosis is less signiﬁcant.

OL 160 Vestibular disorders in old age vertigo Agnes Szirmai Semmelweis University, Faculty of Medicine, Department of OtoRhino-Laryngology and Head and Neck Surgery, 1083, Szigony u 36, Budapest, Hungary Objectives: Good health is not only a privilege of young generation but also of elderly people. Nowadays 13% of the population has reached the age of 65, and one third of them have vertiginous attack at least once in their life. 45–70% of the elderly has one or more drop attacks yearly. Methods: In the Semmelweis University Otoneurological Department, 24% of the patients are more than 65 years old. Detailed audiological and otoneurological examination was performed. Results: The origin of vertigo was extravestibular, like depression and anxiety disorder in 28% of the patients and vascular in 42%. Only in 30% speciﬁc balance system disease was observed. Together with presbyacousia a slight loss in balancing appears. Gradually, elderly patients start noticing some unsteadiness or fear to keep moving. The presbyvertigo and presbyataxia are caused by the slow degeneration of vestibular end organs and brainstem pathways. The deterioration of sensorial organs and the central signal processing problems mean that our brain is getting old due to age. Conclusions: The reasons of the old age vertigo are the decreased physical activity, concomitant diseases, increasing occurrence of vascular risk factors, degeneration of the cervical mechanoreceptors, and anxiety disorders with depression. The possibilities of the treatment: vasoactive and neuroprotective drug administration, adequate treatment of the concomitant diseases. The early mobilisation of patients with vertigo is very important so as to avoid sedative drug administration.By means of improving diagnostic procedures, successful prevention and therapy the disability can be avoided.

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OL 161 Vertebrobasilar abnormalities and cochleovestibular disorders Elizabeth Vitte1, Abderrezak Zouaoui2, Marc Labrousse3, Fre´de´ric Tanke´re´1, Andre´ Chays3, Georges Lamas1 1 ENT Department, Pitie´-Salpeˆtrie`re, Paris, France; 2Neuroradiological Department, Pitie´-Salpeˆtrie`re, Paris, France; 3ENT Department, Reims, France Vertebrobasilar system including vertebral and basilar arteries act as a unit in supplying the posterior circulation. This system is unique regarding his anatomy and his functionality. Objectives: The authors present 10 cases of patients suffering of sudden unilateral sensoryneural hearing loss with or without balance disorders following long lasting ﬂexion or extension of the neck. Methods: Patients underwent cochleovestibular examination and/ or MRA or CTAngiography (CTA). Results: Cerebral imaging (FLAIR and Diffusion) was normal (without any ischemic lesion) but angiography disclosed a dominant vertebral artery arising from the arch of the aorta or ascending behind the oesophagus (arteria lusoria) while the other vertebral artery was hypoplastic. Conclusion: Abnormalities of the vertebrobasilar system and clinical applications will be discussed according to their embryology and physiology.

S203 Objectives: deﬁnition of a state of auditory function at multiple sclerosis patients. Methods: 32 multiple sclerosis patients (MS) were the subject of studying. 19 patients have complained of depression of audition, a periodic tinnitus, disturbance of legibility of speech. All the patients were examined on the threshold pure-tone audiometry and high frequency audiometry up to 20 kHz, SiSi test, registration of acoustic reﬂex (AR), research of auditory brainstem responses (ABRs). Results: The 19 patients with auditory disturbances at pure-tone audiometry discloset had bilaterial in 14 cases, unilateral sensorineural hearing loss in 5 cases average of 15–30 dB. At a high-tone audiometry the 32 patients are recorded sensorineural hearing loss average 30–50 dB 16 kHz most expressed. Unilateral and contralateral AR are increased or abaissement from two sides more expressed rising of thresholds are taped at stimulation less a hearing ear on frequency 4 kHz. Pathological ABRs changes are also from received also all the 32 MS patients, SiSi test was positive only in one case. Conclusions: The central auditory disturbances of MS patients found are taped. Most typical rising of thresholds in the ﬁeld of high frequencies 16 kHz. On ABRs changes II-V of peaks, abnormal AR with the most changes on frequency 4 kHz.

OP 2 Algorithm for diagnosis and monitoring of perilymphatic ﬁstula

OL 162 Intratympanic Perfusion for Meniere’s disease

Madalina Georgescu, Alexandru Pascu Institute of Phono-Audiology and E.N.T. Functional Surgery, 21 Mihail Cioranu str., 050751 Bucharest, Romania

Mohamed Hamid The Cleveland Hearing and Balance Center, Cleveland, OH, USA

Objective: To propose an algorithm for diagnosis and monitoring of perilymphatic ﬁstula based on a case study of a 11-years old boy who performed too many dives in a short period of time. Methods: We evaluated periodically cochlear and vestibular function of this patient who came for sudden severe neurosensorial hearing loss and imbalance. Hearing was monitored by standard air and bone conduction PTA and cochlear function by TEOEA. Vestibular function was evaluated by VEMP. Latter investigation was performed in standard conditions: acoustical stimulus (click) transmitted via insert phones, 200 sweeps, recording electrodes on upper third of SCM muscle and sternum. Intensity of the stimulus decreased from maximum (100dB nHL) to threshold level. Follow-up sessions were at 7, 30 days and 4 month after the onset. Results: After couple of days of i.v. treatment with cortisone and vasodilatators, only preventive life style continued in order to avoid increase of endolymph pressure. Periodic evaluation revealed progressive closure of the perilymphatic ﬁstula, based on documented cochlear function recovery and normalization of VEMP threshold value. Conclusions: Preventive life style was sufﬁcient in this case for closure of the perilymphatic ﬁstula, process which can be monitored by investigation algorithm proposed in this poster.

Inner ear perfusion treatments with Gentamicin and Dexamethasone have effectively controlled Meniere’s diseases, by targeting the underlying pathophysiology as opposed to symptomatic treatment of the disease. Gentamicin perfusion effectively controls vertigo episodes and drop attacks of Tumarkin but is associated with signiﬁcant hearing loss. Steroids perfusion leads to 90% vertigo control and, more importantly, a 30% recovery of speech discrimination especially in early stage of the disease. This presentation will address the different medications and their mechanisms in controlling Meniere’s disease. Results of an 8 year data base will be compared to medical treatment and to the natural history of the disease.

POSTERS OP 1 Demyelinating hearing loss at multiple sclerosis patients I. M. Kirichenko, N. A. Dayhes, N. S. Alekseeva The Russian Federal Scientiﬁc Clinical Center of Otorhinolaryngology, Scientiﬁc Research Institute of the Neurology of Russian Academy of Medical Science, Moscow

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OP 3 Condition of the hearing of the patients of St. Petersburg City Geriatric Center Golovanova Larissa St. Petersburg City Geriatric Center, Audiology department, Russia, 190103, St. Peterburg, Fontanka emb., 148 Objectives: It is very important to know medical and social problems of old people because it give us possibility to plan medical and social help. Methods: We investigated the condition of the hearing of the old persons, who received medical and social rehabilitation. The group of the patients 60–107 years old was formed. Anamnesis and otoscopy, pure ton audiometry, impedansometry were taken for every person. Results: During our investigation the normal hearing were diagnostic in 20%±6%. Others (80%) had hearing loss. 40,6% ± 7,3% persons had mild hearing loss, 31,8% ± 1%—moderate, 7,1% ± 3,8%—moderately severe, 0,5% ± 1,2%—severe. People with normal hearing and slight hearing loss prevailed among the patients 60–74 years. Among the patient older then 75 years—slight and moderate hearing loss. 39,4% of persons of our group had moderate and severe hearing loss. It means that they need in hearing rehabilitation, ﬁrst of all in hearing aid. Only 5,2% ± 3,3% used hearing aid. Conclusions: The biggest part old people did not used hearing aid, so they have no any rehabilitation. Therefore they have difﬁculties in social life, problems in there familiars, low quality of the life.

OP 4 Cross sectional study on relationship between plasma homocysteine levels with degree of sensorineural hearing loss Raja Ahmad*, Azizi Ayob**, Wan Ishlah*, Raﬁdah H. Mokhtar** * Department Otolaryngology-Head & Neck Surgery, Faculty of Medicine, International Islamic University Malaysia; **Department Basic Medical Sciences, Faculty of Medicine, International Islamic University Malaysia Sensorineural hearing loss (SNHL) is one of common clinical problem presented in daily otological practice. The pathological problems can be either in the cochlea or in the retrocochlear region. The aetiologies are unknown. Majority of researchers postulated that compromised cochlear blood ﬂow has been considered to be a principal aetiologic factor causing sensorineural hearing loss. The fact that homocysteine play an important role in vascular diseases and in the involvement of the pathogenesis of atherosclerotic plaque. There are possibilities that homocysteine may have an association with the aetiopathological

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 in sensorineural hearing loss. This association however remained to be established. This is prospective cross sectional study where 85 patients who met the inclusion criteria were recruited along with 38 persons who does not have hearing problem as control. Majority of the patients were having left sensorineural hearing loss. The ﬁndings show a positive relationship between plasma levels of homocysteine with the sensorineural hearing loss particularly of the left ear (r = 0.338, p < 0.01). In conclusion higher level of homocysteine concentration is a feature found in a patient with sensorineural hearing loss. Result from this study will enable us or other researcher in the future to conﬁrm the possible effect of hyperhomocysteinaemia on hearing loss in animal study. This is important to establish the relationship between the two variables at cellular and molecular level. This study may also have an implication on improvement in medical intervention of sensorineural hearing loss and ﬁnally the possible impact on public health preventive measures for sensorineural hearing loss. Key words: Sensorineural hearing loss, homocysteine, presbyacusis

OP 5 Acoustical environment and audiological evaluation of military musicians Jean-Bertrand Nottet1, Annie Moulin2, Yoann Pons1. 1 Hoˆpital d’instruction des arme´es Desgenettes, Bd Pinel, Lyon,2UMR CNRS 5020, Universite´ C. Bernard, Lyon 1, France Objectives: To investigate the audiological complaints of military musicians, and to evaluate noise exposure during their daily musical practice. Methods: Fifty musicians involved in the group ‘‘Musique re´gionale Terre Sud-Est’’ were investigated using pure tone and high frequency audiometry (Audioscan). Noise exposure was evaluated using, ﬁrst, individual dosimetry for six subjects and second, dosimetry during daily practice of the whole music band. Results: Dosimetry averaged across 7 practice sessions showed a general amplitude of 94.3 dBA, and a peak exposure of 134.9 dBA. Individual data revealed a general amplitude of 94.1 dBA, with peaks at 145.9 dBA. A hearing threshold greater than 20 dB at any of the octave frequencies from 0.25 to 8 kHz was present in 26% of the musicians. No signiﬁcant difference according to the type of instrument practiced was obtained for frequencies lower than 8 kHz, but high frequencies (8 to 16 kHz) revealed a greater hearing threshold in brass and wood-wind musicians comparatively to percussion musicians. Amongst musicians showing a hearing loss at frequencies above 8 kHz, 44% showed normal thresholds below 8 kHz. Conclusions: The levels of noise exposure recorded justify fully the use of hearing protectors for musicians and a yearly follow-up using high frequency audiometry.

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OP 6 Bilateral deafness due to a ﬁght with bilateral temporal bone fracture J. Montojo, V. Garcı´ a, G. Plaza Department of Otolaryngology, Hospital de Fuenlabrada, Madrid, Spain Objectives: 1. Describe a case of bilateral deafness due to bilateral temporal bone fractures following a ﬁght. 2. Understand the management of patients who suffer temporal bone fractures with associated sensorineural hearing loss. Methods: Case report and literature review. Results: We report a case of a 20 year-old man who presented a head trauma produced during a ﬁght in a discotheque with a loss of conciousness for about 15 minutes. The otoscopy and facial nerve functions were normal, the CT scan showed both lesions in the bones (bilateral temporal bone fractures and occipital fracture) as well as in the brain (temporo-parietal hematoma and cortical hemorrhagic contusions). The temporal bone fractures were transverse and violating both otic capsules. The pure tone and speech audiometries showed bilateral deafness, and the brainstem auditory-evoked potentials showed bilateral absence of auditory-evoked responses. After 3 months, another CT scan and a MRI were done to rule out the obstruction of the inner ear spaces and predict cochlear patency. A cochlear implant was proposed to the patient, who was referred to another hospital. We are waiting for the results as the patient hasn’t been implanted yet. Conclusions: Temporal bone fracture patients are susceptible to various types of trauma involving the auditory system. This case illustrates the importance of the sensorineural hearing loss in this kind of fractures.

OP 7 Bilateral profound hearing loss and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) following bilateral temporal bone fracture: a case report Theodoros Papadas, Nicholas S. Mastronikolis, Gabriel Tsiropoulos, Dimitrios Chorianopoulos, Evangelos Papadeas, Panos D. Goumas Department of Otorhinolaryngology, University Hospital of Patras, Patras, Greece Objective: The objective of this case report is to hilight the complexity of manifestations and the serious short-term and long-term implications that a head injury might produce. Case report: A 59 year-old male patient sustained a head injury following a fall from a relatively low height. The injury resulted in bilateral profound hearing loss, vertigo and behavioral impairment i.e. depressed mood and aggressiveness. Imaging studies of the head demonstrated bilateral temporal bone fractures and multiple brain contusions in both frontal lobes and cerebellum. Within the ﬁrst few days of his admission the patient developed SIADH. He initialy received the appropriate conservative treatment and underwent full evaluation and investigation of his hearing loss. The patient was considered to be an excellent candidate for cochlear implant surgery. After a short convalescent period he underwent the aforementioned procedure succesfully. Conclusion: We report a case of a patient who has experienced multiple coexisting neurological, psychiatric, endocrine and otological manifestations of a head injury, which resulted in a seri-

S205 ous disability (deafness) and affected his quality of life dramatically.

OP 8 Hyperbaric oxygen therapy for sudden sensorineural hearing loss in patients failing steroid and vasoactive treatment Dana Brajovic, Ljiljana Cvorovic, Milos Vojinovic*, Mile Strbac Department of Otorhinolaryngology, Head and Neck Surgery; *Department of hyperbaric oxygenation therapy; University Hospital Zemun, Belgrade, Serbia Objectives: At present, there is still no agreement about the therapy of sudden sensorineural hearing loss (SSHL). To investigate the safety and efﬁcacy of hyperbaric oxygen therapy (HBOT) in adult patients with SSHL who fail standard of care steroid and vasoactive therapy. Methodes: Ten adult patients presenting with SSHL with acute onset of hearing loss of greater than 30 dB in three continuous frequencies who failed to show audiometric improvement after systemic steroids and vasoactive drugs were enrolled. Study patients received HBOT at 1.0 atmospheric pressure for 60 minutes while breathing 100% oxygen for 10 days over a 2-week period. Audiological assessments of the patients were performed before and after the HBOT at 0.5, 1, 2, 3, 4 and 8 KHz. Results: Eight patients had a dramatic improvement of hearing. Two patients had no signiﬁcant recovery of hearing. Conclusions: Secondary HBOT after failure of primal therapy may be associated with hearing gains in some patients with SSHL.

OP 9 A double-blind study of medical complaints reported during mobile phone use Annie Moulin1,2, Gyorgy Thuroczy3, Sandra Peyraud1, Gwenaelle Tourlonias1, Ce´cile Barnel1, Lionel Collet1,2 1 UMR CNRS 5020, Universite´ C. Bernard, Lyon 1, France, 2 Hospices civils de Lyon, Pavillon U, E. Herriot Hospital, Lyon, France, 3NIRR, H-1221 Budapest, Hungary Objectives: To see if medical complaints reported during mobile phone use are due to electromagnetic exposure (EMF) generated by the phone. Methods: Fifty two subjects with normal hearing were exposed to 10 minutes GSM (global system for mobile communications)/ UMTS or sham exposure in a double-blind controlled study. This study was part of the EMFNEAR European Project. Both sham and real exposure were performed using a commercially available phone with software controlled power, maintained in place by a plastic positioning system. During both exposures, participants listened to running speech delivered in their outer ear canal via an EAR 3A earphone. After the exposure, participants ﬁlled in a questionnaire asking them to rate, on a scale of 1 to 10, the intensity of the symptoms they experienced (earache, warmth on the face, warmth on the ear, itchy feeling, headache, tinnitus, feeling of plugged ear, dizziness….). Results: The most prevalent symptoms were sensation of warmth on the ear and face, and hyper skin sensitivity around the ear but no signiﬁcant differences were obtained between the real and the sham exposures. Conclusions: Symptoms experienced during mobile phone use cannot be attributed to GSM exposure but to the non GSM/ UMTS electronic function of the mobile phone.

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OP 10 Treatment of acute sensorineural hearing loss with magnesium Dimitrios G. Balatsouras1, Ioannis Anastasakis1, Georgios Kourtis1, Dimitris Achrianis1, Christina Batha1, Nicolas C. Economou1, Stavros Korres2, Antonis Kaberos1 1 ENT Department, Tzanion General Hospital of Piraeus, Zanni and Afentouli, 18536 Piraeus, Greece; 2ENT Department of Athens National University, Hippokration Hospital, Athens, Greece Objectives: Magnesium treatment has been shown to prevent noise-induced hearing loss, protecting the inner ear against noiseinduced impairment of blood ﬂow and oxygenation. Our objective was to study its effect on the permanent hearing thresholds in patients with sudden sensorineural hearing loss. Methods: In a prospective, randomized clinical study, 24 patients with idiopathic acute-onset sensorineural hearing loss were treated with steroids and oral magnesium. Twenty patients with the same diagnosis treated with steroids were used as controls. Standard puretone audiometry was performed, both on admittance and before discharge. Follow-up examinations included post-1-month and post-1-year testing. Results: The study group had a signiﬁcantly greater mean improvement in all frequencies in comparison with the control group. Also, a signiﬁcantly higher proportion of patients treated with magnesium presented with improved hearing across all frequencies tested. Most of them experienced hearing improvement on the post-1-monht examination. Conclusions: Magnesium may be used as a safe and useful convenient adjunct to steroid treatment for the therapy of sudden sensorineural hearing loss.

OP 11 Auditory brainstem responses in hemodialysis patients A. Aspris1, D. Balatsouras2, C. Thodi3, I. Kyamides1, E. Thodis4, G. Thrasyvoulou1, A. Iona1, V. Danielides4 1 Nicosia General Hospital, Cyprus; 2Tzanion General Hospital of Piraeus, Piraeus, Greece; 3Cyprus Audiology Center; 4Medical School, Democritus University of Thrace, Alexandroupolis, Greece Objectives: To evaluate auditory function in patients with chronic renal failure (CRF) prior to and following a session of hemodialysis, and compare it with normal controls. Methods: The experimental group included 31 patients with endstage renal failure on chronic hemodialysis. The control group consisted of 31 healthy volunteers. The patients were examined prior to and following a session of hemodialysis. Measurements included audiometry, tympanometry, acoustic reﬂexes, Auditory Brainstem Responses (ABRs), and blood chemistry parameters. The stimuli were presented at the rates of 10/s and 60/s. Controls underwent the same test audiological battery. Results: All ABR measures were signiﬁcantly prolonged in the experimental group, with the exception of interpeak latency I-III. A comparison between controls and the experimental group following hemodialysis, indicated that wave V absolute latency

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 and interpeak latencies III-V and I-V were signiﬁcantly prolonged in the slow repetition rate paradigm. In the fast repetition rate, absolute latencies of waves I and V and III-V interpeak latencies were prolonged in the experimental group. Comparison of ABR recordings prior to and following hemodialysis showed a signiﬁcant improvement in absolute and interpeak latencies following hemodialysis on all measures except interpeak III-V latency. Conclusions: This study showed that neural conduction along the auditory pathway was delayed in patients with CRF as compared to healthy subjects. Dialysis sessions improved overall neural auditory function. However, patients with CRF showed delayed conduction, even after a session of hemodialysis.

OP 12 Epidemiological study of sudden sensorineural hearing loss Georgia Vergou1, Evdoxia Gerostergiou1, Ioannis Tsitiridis1, Dimitrios Batzakakis1, Ioannis Bardanis2, Panagiotis Karagounis1 1 General Hospital of Larissa, ENT Department, 2 General Hospital of Ikaria, ENT Department Introduction: Sudden sensorineural hearing loss (SSNHL) is a frequent disease and occurs in 1 per 3000 persons pro year. The physiopathologic mechanism of this cochlear disorder is unclear, and a series of causative factors (viral infection, microcirculatory disorders, immunologic factors) can be found in the literature. Solid evidence based guidelines for the treatment of SSNHL do not currently exist. However, the treatment is based on the use of ﬂow promoting drugs, antiviral drugs with or without corticoids. Objective: To present our experience in the confrontation with the disease. Method: During 2005–2006 18 patients with SSNHL were admitted in the ENT clinic of Larissa’s General Hospital. All of them were administered a combination of ﬂow promoting drugs, antiviral drugs and corticoids, except for one suffering from hypertension who was excluded from corticoid treatment. We analyzed their pure tone audiograms before, during and 6 months after therapy. The patients were divided according to their age, sex, the unilateral or bilateral SSNHL and the level and type of their audiogram. Results: All the patients treated in the above mentioned time and place were female aged between 36 and 52 years. 6 of them (33.3%) suffered also from tinnitus and 8 (40%) were practically deaf. 10 patients suffered from SSNHL was only of their left ear (8 of them were practically deaf). 6 suffered from SSNHL only of their right ear and 2 from bilateral SSNHL. The level of the hearing loss was moderate in 10 (60%) patients, whereas the rest 8 (40%) were practically deaf. Conclusions: Interestingly enough, and against current literature, all patients included in this study are female and the minority of them suffered from the rather classical symptom of ‘‘ringing in the ear’’. A possible explanation of these facts could be the limited number of the patients.

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OP 13 The consequences of noise on health I. Tsitiridis1, P. Sirsiri1, G. Psychogios3, D. Batzakakis1, I. Bardanis2, P. Karagounis1 V. Sandris4, 1 Hearing and Speech Department, General Hospital of Larisa; 2 ENT Department, General Hospital of Ikaria; 3Department of Otorhinolaryngology, Head and Neck Surgery, University Erlangen-Nu¨rnberg, Germany; 4Department of Otolaryngology, General State Hospital of Larissa, Greece Introduction: Every annoying sound is deﬁned as noise. Nowadays, noise represents a major source of pollution in industrial world. This single factor deteriorates our environment, as well as the quality of our life. It has been considered as the cause of both corporal and psychic disorders. Objective: To evidence the problems caused by habitual exposure to noise in both occupational environment and everyday life in the city of Larisa. Methods: 180 people working in a noisy environment were examined. The analysis of noise took place in various occupational environments, such as a sugar factory, a spinnery, a button factory, a plastic items factory, clubs, cafes and other noisy sites of the city. Noise was analyzed with a sound analyzer type PHONIC PAA2. The examination of the noise-exposed workers took place in the Hearing and Speech Department of the General Hospital of Larisa. Audiometry was performed with two audiometers (an Amplaid 187 and an Interacoustics AD 226) and tympanometry with a Hortmann tympanometer. Results: The level of the noise in the various sites ranged between 83.5 and 118dB SPL. 28.8% of the examined workers suffered from moderate sensorineural hearing loss, whereas 24.4% suffered from the characteristic four thousand Hertz dip (or C5 dip). 17.7% of them suffered from tinnitus irrespective of their hearing ability. Conclusions: The level of the noise in the above sites was beyond accepted limits, whereas protective measures were almost nonexistent. Consequently, the average hearing loss of the people included in this study was higher than the one expected from current literature.

OP 14 The meaning of speciﬁc autoimmune antibodies in occurrence and prognosis of acute inner ear disorders K. Ratzlaff1, M. Praetorius1, R. Klein2, P. K. Plinkert1 1 University of Heidelberg, 2Tu¨bigen, Germany Objectives: By now the exact pathogenesis of the different forms of acute inner ear disorders like sensorineural hearing loss, sudden deafness, tinnitus and Meniere‘s disease is still unknown. Disorders of inner ear blood circulation are widely discussed just like viral infections and autoimmune processes. The aim of this

S207 study is to examine speciﬁc autoimmune antibodies and their function in occurrence, therapy and prognosis of acute inner ear disorder. Methods: Prospective clinical study with by now n = 60 patients, among 21 female and 39 male, suffering from acute inner ear disorder without any known autoimmune disease. Average age 48.3 years. Patients underwent a therapy consisting of steroids according to Stennert‘s scheme and pentoxifyllin. Hearing was examined regularly using pure-tone audiometry. Speciﬁc autoimmune antibodies were examined at the beginning of the study and 6 weeks after using enzyme-linked-immunosorbent assay and immuno-ﬂuorescene-test. Results: In 68% of all patients there was an occurrence of autoimmune antibodies, in 32% no autoimmune process could be provided. Antibodies against sarcolemma (ASA) and sinusoids were mostly detected (26% and 23%), followed by anti-nucleiantibodies (ANA; 19%). Antibodies were determined against Microsomes, Phospholipids; anti-Endothelium and anti-Smooth muscle antibodies were the lowest ones to be detected (3% each). Conclusion: As described before we do also agree in our study that occurrence of autoimmune antibodies should be considered as one possible mechanism in the pathogenesis of acute inner ear disease. These ﬁndings do not seem to affect the choice of therapeutic treatment.More likely, the clinical value seems to be found especially in regard to the prognosis of disease. Studies going in depth with these ﬁndings are continued.

OP 15 Age related hearing loss: quality of life V. Nikolaidis, A. Hatziavramidis, M. Nalbadian, G. Kekes ENT Department, Aristotle University of Thessaloniki Objectives: Presbycusis constitutes a descriptive term of age-related hearing loss that concerns almost every person from the 5th decade of his life. The aim of this study is to estimate the inﬂuence of age-related hearing loss in various domains of a person’s activity (professional, familial and social) with main tool a suitably structured questionnaire. Methods: 250 individuals have been examined up to today, 113 men (45.2%) and 137 women (54.8%). The mean age was 65.2 (40 to 86) years. Our questionnaire was based on the Hearing Health Quick Test of the American Academy of Audiology. A detailed explanation of the purpose of this study was furnished to the patients, and all consented to participate by personally completing the questionnaire without knowing their audiometric evaluation results. Results: 79.3% of patients mentioned communication problems in daily activities of various degree and social and psychological problems were mentioned by 45.1% of patients. Conclusions:

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OP 16 Acute otitis media related inner ear impairment treated with BETASERC Dilyana Vicheva1, Mario Milkov2 1 Department of Otorhinolaryngology, Medical University, Plovdiv, Bulgaria; 2Department of Otorhinolaryngology, Medical University, Varna, Bulgaria Objective: The treatment of acute otitis media /AOM/ with antibiotics and myringotomy is well established, but sometimes complications affecting the inner ear occur, especially in AOM of viral origin. In such cases we start treatment with Betaserc as soon as possible. The application of Betaserc is directed against one of the pathogenic mechanisms of the AOM related cochleo-vestibular disorder—the damage of the inner ear, caused by the vascular changes associated with the inﬂammation. Methods: A retrospective study of 36 patients with AOM related cochleo-vestibular disorders treated with Vinpocetine was performed. The patients were divided into 2 groups: I group—17 cases with inner ear impairment during the course of AOM; II group—19 cases with post AOM cochleo-vestibular disorders. Results: After the treatment improvement of the sensori-neural hearing loss was found in 13 /65%/ of the cases in the I group, while in the II group no real hearing improvement was found. In both groups a decrease of the level of the subjective noise and stabilization of the vestibular function was noted. Conclusions: Based on the results of the therapy with Betaserc, we recommend the medicine as an effective additional treatment agent in acute cases and as useful supportive one in chronic AOM related cochleo-vestibular disorders.

OP 17 Sensorineural hearing loss in patients suffer from systemic lupus erythematosus D. Milisavljevic, D. Popovic, L. J. Milisavljevic, M. Stankovic, M. Zivic, M. Bojanovic University Clinic of Ear, Nose and Throat Nis, Serbia Introduction: Systemic lupus erythematosus (SLE) is a systemic chronic illness of unknown cause. SLE is an autoimmune multisystem disease that may have very prominent manifestations in the head and neck. Otologic manifestations include progressive sensorineural hearing loss and disequilibrium. Suggested immune mechanisms for this presentation have included a humoral-type antibody attack on inner ear antigen, cell mediated cytotoxicity to inner ear antigen, and immune complex disease in the microvessels of the inner ear. Material and methods: The presence of tinnitus, hearing loss was evaluated in 50 patients suffer from SLE. Patients had to fulﬁll the American College of Rheumatology criteria for SLE to be included in our group. All patients were undergone to a complete ear-nose and throat examination, audiological evaluation with pure tone. Results: We found bilateral hearing loss in 19 patients of 50 examined patients. Patients reported combination of symptoms hearing loss with or without tinnitus. We could not ﬁnd statistically significant differences between patients with hearing loss regarding age, disease duration, and autoantibody proﬁle. Conclusion: SLE may affect every organ in human body even inner ear, causing progressive vestibuloauditory dysfunction. As such the clinician should have a high suspicion, obtain quickly laboratory conﬁrmation and begin immunosuppressive therapy as soon as possible to preserve hearing.

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OP 18 Audiological symptoms in ischemic stroke Tomasz Przewoz´ny, Waldemar Naro_zny, Czesaw Stankiewicz ENT Department, Med. University Gdan´sk, ul. De˛binki 7, 80–211 Gdan´sk, Poland Objectives: 60 consecutive cases of IS diagnosed by clinical features and brain MRI/CT and control group consisted of 68 healthy volunteers. Aim of the study: the quantitative and qualitative estimation of auditory system in patients with early stage of IS. Methods: Otological evaluations were performed during an early stage of stroke (up to 30 days): standard audiometric assessments including PTA (0.5–1–2 kHz), speech audiometry, tympanometry, stapedial reﬂex testing, otoacustic emissions, auditory brainstem responses and sound localization test. Results: The incidence of sudden deafness in patients with IS was 6,7% (4/60), acute tinnitus 13,3% (8/60) and impairment of sound localization 83,3% (50/60). The PTA in patients with IS was 21,1dB ± 18,8 and 10,9dB ± 5,0 in control group (p < 0,05). Audiological testing conﬁrmed sensorineural hearing loss in 87,3% of ears, predominantly cochlear origin. The highest percentage of hearing loss was characteristic for lacunar infarct (78,5%). In cases of contralateral impairment of sound localization dominated lesions of temporal lobe in contrast to homolateral impairment where dominated lesions of parietal lobe. Conclusions: Audiologic symptoms were less common but in some cases only prodromal signs of IS. Audiological examinations suggest that sudden deafness, tinnitus and impairment of sound localization is due to dysfunction of the cochlea resulting from ischemia to the inner ear and central auditory pathways.

OP 19 Application of ABRs elicited by tone pips in diagnosis of retrocochlear hearing loss K. Kochanek1, E.Orkan-Łe˛cka2, J. D. Durrant3, L.S´liwa1, H. Skar_zyn´ski 1 1 Institute of Physiology and Pathology of Hearing, Warsaw, Poland; 2ENT Department of the Medical University of Warsaw, Poland; 3Department of Communication Science and Disorders, University of Pittsburgh, USA The purpose of this study was to assess the sensitivity and speciﬁcity of a test of ABR elicited by short tone-pips, compared to test results using click-evoked ABRs, in the application to retrocochlear hearing loss diagnosis. The group of subjects examined included patients with acoustic neuroma and cerebello-pontine angle tumours. Two methods of eliciting the ABRs were used: the standard click-ABR method and the ABR Tone method. For the latter, the stimuli were tone-pips of Gaussian envelopes. In the test measurement parameter was the latency of wave V and the inter-aural latency difference—IT5, both referred to the respective mean values observed in a normal control group and group of subjects with cochlear hearing loss. The sensitivity of ABR Tone method was better than that of standard ABR method for all tone pips. The combinations of indices gave, for all the stimuli concerned, an improvement of sensitivity (up to 100%) over the sensitivity with single indices. It is concluded that ABRs evoked by tone-pips of relatively long rise times offer greater sensitivity in detecting changes in the cochlear nerve and the brainstem than the sensitivity achievable when a click is used as the stimulus.

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OP 20 ASSR threshold estimation in normal and hearing impaired subjects S. Hatzopoulos2, S. Proser2, K. Kochanek1, L. S´liwa1, H. Skar_zyn´ski 1 1 Institute of Physiology and Pathology of Hearing, Warsaw, Poland; 2Department of Audiology, University of Ferrara, Italy The objective of this paper was to compare hearing threshold information from pure tone audiometry and ASSR estimated threshold values, in normal hearing and sensorineural hearing loss subjects. In particular we were interested in estimating: (a) the error margin of the ASSR estimated threshold levels with a commercial instrument (Audera); and (b) how the ASSR estimated hearing levels depend on the degree of hearing loss. We have tested 32 subjects (17 male and 15 female) for a total of 61 ears. The data show that for the normal hearing subjects the ASSR threshold is approximately around 20 dB (11 dB SD) for the frequencies 0.25–1.0 kHz. For the higher frequencies the ASSR threshold increases up to 40 dB (12.5 dB SD) at 8.0 kHz. Similar patterns were observed in the hearing impaired subjects also. ASSR proved to reliably predict the behavioural threshold (+/– 5 dB) especially in the group or most impaired ears. Our data show that for a 10 dB increment of the behavioural threshold, the ASSR threshold increases 7 dB. This means that the observed differences between the two methods tend to cancel in the hearing loss region of 95–100 dB HL

OP 21 DPOAEs in patients with low-frequency sensorineural hearing loss (LFSNHL) J. Smurzynski2, K. Kochanek1, H. Skarzynski1 1 Institute of Physiology and Pathology of Hearing, Warsaw, Poland; 2Department of Communicative Disorders, East Tennessee State University, USA The purpose of the study was to investigate the relationship between hearing sensitivity and the strength of DPOAEs in patients with LFSNHL. Data were collected for a group of individuals evaluated with a battery of clinical tests, including ABR, CT, and MRI. They all had normal hearing above 1–2 kHz and moderate to severe LFSNHL below 1–2 kHz. DP-grams were recorded for the L1/L2 levels of 65/55 and 55/40 dB SPL, the f2 frequency decreasing from 8 to 0.7 kHz (4 points/oct), and f2/f1 = 1.2. Individual data showed a modest correspondence between the conﬁguration of the pure-tone audiogram and the DP-gram expressed relative to the normal range. However, the highest f2 frequency below which DPOAEs fell out of the normal range was lower than its counterpart on the audiogram. The results indicate that, to some extent, the DP-gram reﬂects the conﬁguration of the pure-tone audiogram. However, DPOAEs measured in the ear canal result from complex generation processes involving multiple sources which are wide-spread along basilar membrane and the most basal cochlear region contributes to the generation of DPOAEs recorded from more apical regions.

OP 22 Examining possibilities of transmitting signals to inner ear employing bone-conductive ultrasound carrier

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Institute of Physiology and Pathology of Hearing, Warsaw, PL; Multimedia Systems Department, Gdansk University of Technology, PL

2

The ultrasound harmonic signal was modulated with some harmonic tones of various frequency and level. The ‘‘ultrasound audiogram’’ was determined on this basis revealing the possibility to transmit low-frequency modulation components to the inner ear basing on ultrasound bone conduction. The bone-conductive ultrasound transmission characteristics were estimated during the experiment in which 2 ultrasound transducers were utilized: the ﬁrst one acting as an excitor and the second one as a monitor. Two ultrasound modulation carriers each having varied frequency were used in the second experiment. The two ultrasound signals produced low frequency harmonic beats that were processed in the cochlea and have been perceived and discriminated by examined subjects. Isolated words were used as the modulation signal in the third kind of experiments showing that it is possible to perceive speech transmitted via ultrasound bone conduction. The ultrasound bone conduction was found suitable medium to deliver speech to the cochlea of normally hearing and also of some severely hearing impaired subjects. The results of similar kind of experiments may possibly pave a way to future applications in the domain of hearing prosthetics.

OP 23 The evaluation of audiometry, DPOAE, ABR results in presbycusis K. S¸erife Boynukalın, Mustafa C¸algu¨ner, Muharrem Gerc¸eker Ankara University Medical School, Otorhinolaryngology Head and Neck Surgery Department Objectives: The aim of this study is to evaluate the changes of peripheric and central auditory pathways in presbycusis by using pure tone audiometry, speech audiometry, Distortion Product Otoacoustic Emission (DPOAE), and Auditory Brain Stem Responses (ABR). Methods: Forty patients with precbycusis, who applied to Ankara University Medical School Department of Otorhinolaryngology, were included. Pure tone audiometry, speech audiometry, DPOAE, ABR was recorded to all patients. Results: Mean value of the Pure Tone Average (PTA) was 44.83 ± 1.78 dB and 44.68 ± 1.75 dB in right and left ear, mean value of speech discrimination ratio (SDR) was 78.83 ± 2.24% and 78.1 ± 2.07% in right and left ear. There was a signiﬁcant relation between the age and the PTA, SDR, Speech Reception Treshold (SRT) levels (p < 0.05). Also there was no signiﬁcant relation between the audiogram types and age (p>0.05). The ratio of DPOAE presence at 1000 Hz was 52%, at 2000 Hz was 27.5%, at 3000 and 4000 Hz was 10%, at 5000 Hz was 5 %. There was no signiﬁcant relation between DPOAE existence and age (p > 0.05). Although ABR wave latencies became 0.2 msn longer, a pathologic change was not seen. I-III, I-V, III-V interpeak latencies were all in normal limits. Conclusion: Aging contributes to an alteration in the pure tone and speech audiometric results and a reduction in the existence of DPOAEs. The presence of outer hair cell dysfunction in other words cochlear damage was seen in elderly. ABR ﬁndings demonstrated that there was not any pathology in brain stem auditory pathways in presbycusis.

A. Czyzewski1,2, B. Kostek1, P. Suchomski2, H. Skarzynski1

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OP 24 Evoked otoacoustic emissions and idiopathic sudden deafness Evdoxia Gerostergiou1, Ioannis Panaras1, Ioannis Tsitiridis1, Dimitrios Batzakakis1, Ioannis Bardanis2 1 Hearing and Speech Department, ENT clinic G.H. of Larissa, Greece; 2General Hospital of Ikaria, ENT Department, Greece Sudden hearing loss SHL is a reduction of sensoneurinal sound perception with a sudden onset. So far, there are no proven objective auditory factors to establish prognosis. Otoacoustic emissions EOE reﬂect the functional integrity of the outer hair cells. Objective: To analyse a possible relationship between the EOE and audition, in sudden deafness. patients and methods: We study 18 patients with diagnostic of sudden deafness the period 2005–2006. Patients were selectioned and audiometric, and EOE was made. Results: In our research we don’t ﬁnd variations statistically signiﬁcative in the EOE. There was, no correlation between EOE threshold and degree of hearing recovery. Conclusions: From these results it seems that EOE testing can’t be clinically applicable for predicting whether or not hearing loss due to SHL can be recovered.

OP 25 Recent advances in auditory and vestibular medicine A. Hamid, L.Luxon Cleveland Hearing and Balance Center, Cleveland USA, Academic Unit of Audiological Medicine, London, UL Auditory dysfunction is the commonest sensory disability and balance disorders affecting 40% of the population by the age of 60 years, conferring a signiﬁcant economic and social morbidity. Interest in the evaluation and management of this group of patients has increased in the past 10 years, not least because of the better understanding of the molecular biology of the inner ear, underlying pathophysiology, novel investigative techniques and the success of appropriate and directed multidisciplinary intervention. The purpose of this course is to introduce the recent advances in the ﬁeld and address the concept of Auditory and Vestibular medicine as a uniﬁed and integral part of medical practice. The instructors, who have signiﬁcant experience in the ﬁeld, will address basic science and clinical applications to the cost effective treatment of common inner ear disorders. Ofﬁce neurotologic examination with Video systems and laboratory diagnostic tests will be discussed. Management of selective case studies of vestibular neuronitis, vestibular migraine, Meniere’s disease, dehiscence of the superior canal and BPPV will be presented.

OP 26 Low redundancy polish speech tests: development and clinical application A. Senderski, H Skar_zyn´ski, K. Kochanek 1 Institute of Physiology and Pathology of Hearing, Warsaw, Poland Objectives: The ﬁrst objective was to develop polish low redundancy speech tests. The second objective was to preliminary test the usefulness of the speech in noise and compressed speech as screening tools of central auditory processing disorder in school

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 age children. Methods: Speech material consisted of 4 half lists of monosyllabic words. The psychometric functions for each list at 80 dB SPL for 4 different S/N ratio and compression levels were obtained for 20 normal hearing subjects (mean age 10 years) twice in different days. Second experiment: 20 children (mean age 11 years) with suspected CAPD were tested twice using only one list at S/N ratio and compression level at which performance in control group was closest to 85% correct resp. Results: For normal subjects 85% percent correct level was at + 5 SNR and 65% compression level for SN test and CS test respectively. Larger variation of the performance in both tests in CAPD children was found. Signiﬁcant differences between normal subjects and CAPD subjects were found. For both group of listeners the test retest correlations were high suggesting that lower performance in group of children with suspected CAPS is not due to normal variations in auditory processing abilities. Conclusions: The developed low redundancy polish speech screening tests may be useful in detection of school age children with central auditory processing disorders.

OP 27 The therapy of sudden hearing loss with hyperbaric oxygen. Our experience P. Theodosis, D. Gourziotis, B. Gregoriou, S. Papaspyrou General Hospital Of Athens ‘‘Eyaggelismos’’ Introduction: The idiopathic sudden hearing loss is a situation of emergency that requires immediate therapy. The majority of suggested therapies tend to improve the blood supply and to restore the concentration of oxygen in the inner ear. By this study we present the contribution of hyperbaric oxygen therapy (HBO) as a supplementary therapy of idiopathic sudden hearing loss. Material and method: We treated the last 2 years 59 patients with sudden hearing loss, both male and female, between 16 years to 80 years old. Most of the patients suffered severe unilateral hearing loss to the level of practical deafness. The admittance to the hospital in the majority of the patients was in the ﬁrst 48 h up to 15 days since the beginning of the symptoms. The ﬁrst group of (38) patients underwent drug treatment with long action corticoids, i.v. vasodilators, i.v. diuretics, per os trimedazide and famciclovir. The second group of (21) patients received drug treatment and HBO therapy at the same time. The sessions of the HBO were daily for a period of 5 to 10 days. Restrictions for HBO therapy were claustrophobia and severe cardiovascular disease. Both groups hospitalized for 5 days. The follow up with audiological tests was up to 9 months. Results: At the ﬁrst group of patients who received only drug therapy, 42,1% had full recovery, 36,9% had an improvement of 20 to 40 dB and 21% had no improvement at all. At the second group with the addition of the HBO therapy, 66,6% had full recovery, 19,1% had an improvement of 20 to 40 dB and 14,1% had no improvement at all. Conclusions: Our 20 years of experience at the ﬁeld of sudden hearing loss and the alternative drug therapy were similar results as those mentioned at the international literature. Trying to achieve better results we combined drug and HBO therapy. The results so far are positive and encouraging for the supplement of the HBO therapy. It is important to notice that better results depend on, the immediate beginning of the combined therapy at the same time.

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OP 28 Auditory neuropathy and pituitary stalk interruption syndrome: report of a case

Conclusion: We think that VS is good implantable hearing device, which remarkably improves the hearing quality.

Psarommatis Ioannis, Delinikolas Michail, Hatziathanasiou Charalambosa, Skarpa Vasilikia, Douniadakis Dimitrios a ENT and Endocrinologic Department, ‘‘P. and A. Kyriakou’’ Children’s Hospital of Athens, Thivon & Livadias, 11527-Goudi, Athens, Greece Objective: Auditory neuropathy (AN) is a newly recognized clinical entity with many unexplored aspects, like its epidemiology, etiology and prognosis. Patients meeting the proﬁle of auditory neuropathy may be phenotypically healthy or they may suffer from various and seemingly dissimilar pathologies. The aim of this study is to present a singular case of a child suffering from pituitary stalk interruption syndrome (PSIS) combined with audiological ﬁndings of auditory neuropathy. Case report: The diagnosis of AN was set at the age of 2 years when the child had his ﬁrst audiologic evaluation for a mild speech delay. Auditory brainstem responses were completely absent on the left side and severely abnormal on the right while otoacoustic emissions were present bilaterally. Pituitary stalk interruption and the accompanied multiple endocrine deﬁciencies were deﬁnitively diagnosed few months before the age of 5 by magnetic resonance imaging of the gland and a detailed endocrinologic work-up. Today the child is 9 years old, he is under replacement therapy, he doesn’t wear ear-phones for hearing loss and he shows normal speech skills. Conclusions: The combination of PSIS and AN represents a poorly understood pathology of unknown pathogenetic mechanism. It could be attributed to genetic interactions during the fetal growth, between genes which are involved in the embryogenesis of hypophysis and those that probably are responsible for the AN. The possibility the co-existent endocrinologic disorders to be responsible for the expressed AN proﬁle can not be excluded.

OP 29 First croatian vibrant soundbridge: 1 year follow-up Robert Trotic, Boris Pegan, Branko Kekic, Mihael Ries, Petar Drvis, Jakov Ajduk Department of Otorhinolaryngology and Head and Neck Surgery, ‘‘Sestre milosrdnice’’ University Hospital, Zagreb, Croatia Objective: Vibrant Soundbridge (VS) is the ﬁrst implantable middle ear hearing device to receive FDA approval. It is not a hearing aid, it is designed to vibrate the bones in the middle ear. VS avoids problems commonly associated with hearing aids including blocked ear canals, feedback, background noise, poor sound quality, and uncomfortable ﬁt. Soundbridge works by directly vibrating the ossicles in the middle ear; therefore, providing an enhanced signal to the inner ear. Methods: After 10 years of cochlear implantation and 255 implanted CI, in our CI center in Zagreb–Vinogradska we made the ﬁrst Soundbridge implantation on 77 years old patient. We implanted the device into his right middle ear in april 2006. via mastoidectomy and posterior tympanotomy. Four weeks later we activated the device. Results: After ﬁrst ﬁtting the results were very good. One year follow-up showed that percentage of understanding close and open sets of words and sentences is between 85 and 100%.

OP 30 Vibrant soundbridge Clinical experiences Markus Hu¨tter, Jane M. Opie, Geoffrey Ball, Peter Grasso, Peter Lampacher Vibrant MED-EL Hearing Technologies GmbH, Fu¨rstenweg 77, 6020 Innsbruck, Austria Objective: The purpose of this presentation is to review current clinical experiences with the Vibrant Soundbridge, a semiimplantable hearing system that is used to treat mild-to-severe sensorineural hearing losses in adults. In the hearing aid industry, speech performance continues to be an important factor in evaluating aided beneﬁt; however, the industry is also increasingly focusing its attention on other aspects that inﬂuence patient satisfaction. As a result, more and more products are being developed to have a high degree of wearing comfort, albeit sometimes at the cost of speech performance. Such devices are referred to as using an ‘‘open-ear ﬁtting,’’ which may present challenges in effectively transferring acoustic energy to the ear. The Vibrant Soundbridge attempts to overcome these obstacles by stimulating structures closer to the inner ear. Results: Clinical studies in several countries have shown that the implantation of the Vibrant Soundbridge in persons with medical conditions affecting the outer ear canal, or in persons who require an open-canal ﬁtting, or, most particularly, in persons with skislope hearing losses may be especially beneﬁcial.

OP 31 Vibrant Soundbridge clinical investigations: Expanding indications for use Jane M. Opie, Geoffrey Ball, Markus Huetter, Peter Grasso, Samia Labassi, Nadia Giarbini Vibrant MED-EL Hearing Technologies GmbH, Innsbruck, Austria Objectives: The objective of these studies is to evaluate expanding indications for use of the Vibrant Soundbridge to include persons with conductive and mixed hearing losses. The Vibrant Soundbridge is a partially implantable ‘‘direct-drive’’ hearing system for the treatment of hearing loss and is currently indicated for use in adults who have mild-to-severe sensorineural hearing loss. Recently, the device has been applied to persons with mixed and conductive hearing losses to provide ampliﬁcation to residual sensorineural hearing. In order to appropriately place the device in disordered and malformed ears, the manner and/or location of placement of the device is altered, and, in some cases, the device is used in conjunction with commercially available, passive middle ear prostheses. Methods: Subjects were implanted with the Vibrant Soundbridge implantable hearing aid, using either the Vibroplasty or Round Window Vibroplasty surgical technique. A single-subjects, repeated measures design is used to evaluate the safety and efﬁcacy of the Vibrant Soundbridge in persons with conductive and mixed hearing losses. Results: An overview of the study and its procedures, as well as results to date, will be presented.

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OP 32 New application of vibrant soundbridge middle ear implant in the ears with mixed hearing loss H. Skarzynski, A. Piotrowska, A. Obrycka, A. Lorens, K. Łaze˛cka International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland Objectives: According to the classic indications high frequency moderate to severe sensorineural hearing loss could be treated with middle ear implant and then the FMT is attached to the long process of the incus during the surgical procedure. The aim of the study is to present the beneﬁts after implanting middle ear implant (VSB) in the ears with mixed hearing loss using round window technique and direct stimulation of cochlear ﬂuids. Methods: Ten patients with mixed hearing loss after unsuccessful middle ear surgeries in the past have been implanted with round window based implant technique. A round window placement of the FMT is a new approach that allows to directly drive the cochlea and to bypass the middle ear mechanism. Pure tone audiometry, monosyllable testing in quiet and in noise in different aided conditions were conducted preoperatively, at speech processor ﬁtting and then at 1, 3 and 6 month intervals. The APHAB questionnaire was completed by the subjects pre-operatively and then at 1 and 6 months after receiving the processor. Results: Signiﬁcant improvement both in speech comprehension and subjective assessment is observed. Conclusions: Vibrant Soundbridge Middle Ear Implant with round window technique is feasible and very promising method of treatment for patients with mixed hearing loss after unsuccessful middle ear surgeries.

OP 33 Hearing loss treatment in various acquired and congenital ear malformations with the use of bone anchored hearing aids (BAHA) M. Mro´wka, H. Skar_zyn´ski, M. Porowski Clinical Center of Oto-Rhino–Laryngosurgery, International Center of Hearing and Speech of Institute of Physiology and Pathology of Hearing, Warsaw, Poland Objectives: The aim of the study was to compare hearing thresholds of classic bone coduction hearing aid, previously used by patients, to BAHA. Methods: Our method of choice of treatment of hearing loss in patients with different malformations of the ear is implantation of titanium ﬁxture and installation of abutment with subcutaneous tissue reductions (without taking skin-graft). It was done as a one-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 stage procedure in adults, good bone quality and uneventful surgery or as a two-stage procedure in patients with poor bone quality and small children. After surgery the ﬁxture was allowed to integrate for a period of 3–4 months before the sound processor was ﬁtted (BAHA Classic 300, BAHA Compact or BAHA Divino). After one and six months of using the sound processor full audiometric tests were made. Our material contents 51 patients with conductive and mixed hearing losses including 32 children from 3 year of age (with congenital malformations) and 19 adults up to 60 year of age (most of them with acquired defects). Results: The acoustic results are good and constant. In our patients opinions there is better sound quality, higher comfort and cosmetic appearance with BAHA comparing it with the previous aid. Conclusions: Results of using BAHA system in patients with this indications shown, that is good, from audiological point of view, and comfortable for patients method of treatment.

OP 34 Combined BAHA and mastoidectomy Alexandra Roper, Jonathon Hobson, Kevin Green Hope Hospital Objective: to assess the combined procedures of bone anchored hearing aid insertion and mastoidectomy in four selected patients. To our knowledge, this is the ﬁrst report of combined BAHA and mastoid surgery. Method: Four patients who suffered from intractable ear discharge and conductive or mixed deafness underwent the procedure. BAHA insertion and mastoidectomy were performed in the standard way. In patients with conductive hearing loss whose middle ear is not amenable to reconstruction, mastoid surgery may ensure a clean, dry ear. BAHA surgery alone may restore the patients hearing, but the untreated middle ear disease may progress8 and continuous otorrhoea is known to damage the cochlea in the longterm9. We did not postulate any speciﬁc criteria for patient selection regarding the length or severity of discharge. The incidence of wound infection following mastoid surgery is 3–6%10;11. Prevention of infection by meticulous care of the BAHA site is routine in the post-operative care of all BAHA patients1. Results: There were no intraoperative or postoperative complications. None of our patients had a post-auricular wound infection or infections of the abutment sites. Conclusion: In patients with a potentially poor otological outcome following tympanoplasty, combined BAHA and mastoidectomy avoids the risks of middle ear surgery but with good outcomes in terms of hearing. In addition (as seen in the third case), patients with a high ASA score having to undergo only one anaesthetic. There is no evidence that the BAHA is in any way compromised by the mastoidectomy or vica versa.

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OP 35 Follow up of cholesteatoma surgery:open versus closed tympanoplasty

OP 37 The activity of lysosomal exoglycosidases in cholesteatoma tissue

Milan Stankovic ORL Clinic, Medical Faculty Nis, Serbia

Ewa Olszewska1, Malgorzata Borzym-Kluczyk2, Slawomir Olszewski2, Krzysztof Zwierz2 1 Department of Otolaryngology, Medical University of Bialystok, Poland; 2Department of Pharmaceutical Biochemistry, Medical University of Bialystok, Poland

Objective: Outcome of surgery for cholesteatoma of different age and localizations are unequal. Methods: Prospective study of 758 patients with cholesteatoma was performed. They were divided in three age groups: children younger than 9 years, adolescents—10 to 16 years, and adults. Cholesteatoma was classiﬁed as: attic, sinus and tensa cholesteatoma. Classical canal wall up, or wall down tympanoplasty was performed in all the cases. Results: During postoperative course after 3 years retraction of neomembrane was found in 23,8% of younger children, 27,6% of adolescents, and in 9,9% of adults. Also, residual and recurrent cholesteatoma were more than twice as frequent in children (19,0%, 20,1%, and 9,4% respectively). Conclusion: Postoperative functional and audiological results of cholesteatoma surgery in children are comparable to adults. Retraction pockets, recurrent cholesteatoma and reoperations are twice as frequent in pediatric group. The worst anatomical and functional results are achieved in tensa cholesteatoma. The age of the patient and localization of cholesteatoma are very important factors that determine the type of surgical procedure and the results of surgery for middle ear cholesteatoma. Closed technique is better for attic and sinus cholesteatoma, while in tensa opened technique seems more appropriate.

OP 36 Are drawings a reliable way of recording retraction pockets? Zaid Awad, David D. Pothier ENT Department, Royal United Hospital, Combe Park, Bath, UK Objectives: To assess the accuracy and reproducibility of drawings used to record retraction pockets of the tympanic membrane. Methods: A series of 10 standardised ‘reference’ slides of retraction pockets were shown to 18 Otolaryngologists. Next to each slide were 10 drawings of a retraction pocket and 10 photographs of retraction pockets. Half of the photographs and half of the drawings were of the same ear as the ‘reference’ image and half were of a different ear, chosen at random. Participants were asked if each drawing and photograph was the same ear as ‘reference’ image, and whether the pathology was the same, more or less severe. Results: Differences between the assessments of the photographs and drawings were dramatic. Where photographs were used, participants were able to identify an identical ear 98.6% of the time and a different ear 81.7% of the time; where drawings were used, this fell to 49% and 65% respectively (p < 0.001). Identiﬁcation of the relative stage of pathology was also signiﬁcantly better with a photograph of a tympanic membrane (96.3%) rather than a drawing (52.9%) (p < 0.001). Conclusion: This is the ﬁrst attempt in the literature to compare the relative diagnostic accuracy of drawings of the tympanic membrane with photographs. A great deal of reliance is placed on clinical drawings of varying quality by clinicians. Digital photography is considerably more accurate than drawings and its use should be encouraged.

Objectives: Cholesteatoma is a destructive lesion that leads to the destruction of adjacent structures. The aim of our study was to investigate the activities of b-Galactosidase (b GAL) and a-mannosidase (a MAN) in cholesteatoma tissue compared with that in normal post-auricular skin. Methods: Cholesteatomas and normal adult post-auricular skin, served as controls were used for the study. To assess the enzymes activities Chatterjee et al. method in the modiﬁcation of Zwierz et al. was used. Results: We observed signiﬁcantly higher activity of investigated enzymes in cholesteatoma tissue compared with control tissue (post-auricular skin). Mean activity of a-MAN from the cholesteatoma cells was 1.75 fold higher as compared to controls. Mean activity of b-GAL from the cholesteatoma cells was 1.77 fold as compared to controls. Differences in observed activity were statistically signiﬁcant. Conclusion: Lysosomal exoglycosidases a-MAN and b-GAL are signiﬁcantly and consistently elevated in cholesteatoma suggest the need to further assess correlations between levels of a-MAN and b-GAL and cholesteatoma bone resorption.

OP 38 Bone lesions due to middle ear cholesteotoma Alma Maniu, M. Cosgarea, Anamaria Gocea E.N.T. Clinic Cluj-Napoca Objectives: The main objective of the present study is the comparative research of bone lesions due to middle ear cholesteotoma in adult and in children, upon the post-surgery characteristics of the tympanic membrane. Methods: A retrospective clinical study was performed on a number of 350 patients operated for cholesteotoma within the ENT Clinic of Cluj-Napoca during 2003–2005. The patients were divided in several groups upon the following criteria: age, the type of tympanic membrane perforation, location of the cholesteotoma, the ossicular lesions identiﬁed intrasurgery, the presence of complications. The Salleh and Mills classiﬁcation was employed within the last three criteria. A non parametrical statistical data analysis, the Sperman R (p < 0,050) test was applied. Results: The cholesteotoma associated with type 1 perforation habitually connected with S2, o3, while the cholesteotoma associated with type-2 perforation most frequently connected with S3, o2 (p < 0,050). Complications of the disease occurred regularly with type-2 perforation (11,4%) when compared to type-1 perforation (7,43%). No signiﬁcant statistical differentiations were observed regarding bone lesions and complications in adults when compared to children. Conclusions: The presurgery characteristic of the tympanic membrane can be considered a good criterion for establishing a functional prognosis for the operated ear. The type-2 perforation of the tympanic membrane represents an unfavourable prognosis factor, irrespective the patient age.

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OP 39 Results of disease-pursuant approach to cholesteatoma surgery; a 4-year prospectively-documented series J. W. Loock ENT Department, University of Stellenbosch, Cape Town, South Africa Aim: To evaluate the disease extent; surgical techniques; surgical and audiological results of cholesteatoma surgery at Tygerberg Hospital, Cape Town, South Africa. Method: Tygerberg Hospital serves public health patients of a low socio-economic group. It is essential that the technique of surgery avoids residual or recurrent disease. ‘‘Combined approach’’ surgery is contra-indicated. Our surgery is thus based on the principle of following cholesteatoma from its origin to its full extent, with bone removal only as required—‘‘small cavity’’, ‘‘front-to-back’’ or ‘‘disease-pursuant’’ surgery. Removal of squamous epithelium from the mesotympanum with reconstruction of the middle ear is actively pursued. Extensive data has been collected prospectively since January 2003 on all patients undergoing cholesteatoma surgery. Data collected includes pre-operative assessment; ﬁndings at surgery; surgical procedures performed; surgical and audiological results. We analyse results from January 2003 to January 2007 on 164 patients with a minimum follow-up of 6 months. Results: Cholesteatoma in our experience arises from attic (36%), posterior-superior retraction pockets (29%), and other mesotympanic (42%), sources. The spread of disease is analysed. Ossicular chain disruption is common (83%). Using this surgical approach, disease was cleared with reasonable conﬁdence from the mesotympanum in the vast majority of cases. Recurrent or residual disease is rare (3%) although the relatively short follow-up period of some of the cases must be taken into account. Very few cases of any cavity problems or otorrhoea occur after this surgical approach. While good hearing results are sometimes obtained, in general hearing remains unchanged. A degree of sensorineural hearing loss occurred in 6%. Conclusions: Disease-pursuant surgery minimizes residual and recurrent disease, and mastoid cavity size and problems. Cholesteatoma is as much a mesotympanic as an epitympanic disease. Mesotympanic squamous epithelium can be safely removed in most cases, even from the facial recess and sinus tympani, and the mesotympanum grafted. Hearing conservation and repair should be attempted for the few cases which derive advantage from it.

OP 40 Correlation between immunohistological and clinical characteristics of acquired cholesteatomas Nada Milanovic, Miodrag Colic, Jovan Dimitrijevic, Violeta Jacimovic, Zoran Milanovic ENT Clinic, Military Medical Academy, Belgrade, Serbia Many points of the pathogenesis of cholesteatoma seem to be related to immune cell inﬁltrates in stroma and to epithelial cell migration and proliferation. In those processes two-way com-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 munication between the cells of the natural immunity (macrophages and other cells) and different subpopulation of activated effector lymphocites is of the key importance for development and persistance of chronic inﬂammation, destruction of the middle ear bone structures and reparation of the damaged tissue. In this paper we report the results of an immunohistopathologic study carried out using the immunohistochemical technique of monoclonal antibodies on 30 cholesteatoma samples taken during radical mastoidectomy or tympanoplasty. Histomorphologic and immunophenotypic parameters were compared to clinical parameters (degree of bone destruction and presence or absence of infection as well as degree of cholesteatoma extension). In cholesteatomas with the bone destruction the vast majority of cells consisted of CD3+, CD4+, CD68+ (macrophages) and the intraepithelial CD8+ cells comparing to the cholesteatomas with less bone destruction. The number of the HLA-DR+ cells, CD1a+ (Langerhnas cells), mast cells, B cells and plasma cells did not show statistically signiﬁcant difference between the groups. In cholesteatoma with the presence of infection the large number of the B cells and plasma cells as well as c-kit+ mast cells was noticed. There were no statistically signiﬁcant differences in immunohistological parameters between the cholesteatomas grouped according to the degree of cholesteatoma extension The characteristics of the inﬁltrating cell population suggest an antigen-driven process in cholesteatoma. Such studies may help in giving a more precise deﬁnition to the pathogenesis and clinical behavior of middle ear cholesteatoma.

OP 41 Reliable cover and ﬁxation of the cochlear implant in conditions of limited operating ﬁeld V. Fedoseev, N. Mileshina National Research Centre for Audiology and Hearing Rehabilitation, Moscow, Russia Objectives: The main goal of our study was to increase an effective cover of processor-stimulator (PS) using a decrease of subcutaneous tissue tension in a wound closure, to elaborate an alternative method for the ﬁxation of the cochlear implant (CI) taking into account patient’s age and the reduction of the post-surgical manipulations. Methods: During 2000/2006 years we performed 180 cochlear implantations in children and adults using cutting in post-auricular area, forming vertical fascial-periosteal piece on anteriorinferior leg, which was turn after ﬁxation of CI in horizontal direction and placed without any tension over mastoid and PS. For the ﬁxation disk diamond cutter and original method were used. Results: We haven’t got any tissue post-surgery complications. Using of the disk diamond cutter, titanium clips and cramps allowed us to reduce volume of manipulations on the scalp bone and minimize post-surgical taking care. Conclusions: Presented methods allow keep temporal muscle without cutting and separation. Disk diamond cutter and our original method of PS ﬁxation are irreplaceable in conditions of limited operating ﬁeld and permit to avoid drilling tunnels in the scalp. The rotation of the fascial-periosteal piece produced the reconstruction over the implant even in an incomplete PS settling.

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OP 42 Cochlear implantation (CI) in senior patients Lela Migirov,1 Riki Taitelbaum-Swead,2 Minka Hildesheimer, Jona Kronenberg1 1 Department of Otolaryngology Head and Neck Surgery, 2 Speech and Hearing Center, Sheba Medical Center, Israel Objective: To investigate an incidence of complications and outcome of CI in elderly. Method: The medical records of 17 patients aged 65–80 years at the time of CI were retrospectively reviewed for cause of deafness, complications and audiologic beneﬁt. Speech perception performance was evaluated using two open-set tests: monosyllabic words test and words in sentences test. Results: The cause of deafness was unknown in 10 patients, otosclerosis in 3, Menier’s disease in 2, ototoxicity in 1 and iatrogenic in 1. Foreign body reaction required explantation with subsequent implantation in 1 patient. Delayed facial nerve paralysis completely resolved within 2 months in 1 patient. Vertigo was found to be the most common post-operative complication (4/17) followed by wound infection (2/17) and seroma (2/17). Four patients suffered from tinnitus prior to CI: 2 of them noted decreasing of the tinnitus with the device switched on. One patient dead due to general health problems unrelated to CI 6 years after surgery. Audiologic outcome of the patients varied from high (5/17) to minimal (5/17) scores in open set recognition. Generally, 12 patients are satisﬁed with their implant. Conclusions: Most medical complications in elder CI recipients are self limited or can be treated conservatively. However, appropriate counseling before surgery is necessary. Despite relatively short time of implant use senior patients can signiﬁcantly improve their hearing abilities and quality of life.

OP 43 The development of speech recognition after early cochlear implantation

S215 exhibited poorer speech perception and recognition skills ﬁrst year after switch-on. Conclusions: Early auditory experience, age at implantation, duration of implant use, performance of multichannel cochlear implants,speech therapist treatment, are predictive value for postoperative speech recognition and language development

OP 44 Cochlear implant in complete remission in a patient with leukemia Kazuhiko Takeuchi, Taku Hottori, Sawako Masuda, Satoko Usui, Koji Oka, Hiroshi Sakaida, Yuichi Majima Department of Otorhinolaryngology, Head and Neck Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan Objectives: Patients with leukemia have an increased risk of developing sensorineural hearing loss. We performed cochlear implantation in a bilaterally deaf patient with leukemia. Methods: A retrospective review of a profoundly deafened patient with acute myelogenous leukemia who underwent cochlear implantation. Results: The patient was a 26-year-old male when he visited our clinic. Earlier, he was diagnosed as acute mylogenous leukemia. Bilateral deafness developed in the course of treatment for leukemia. After allogeneic peripheral blood stem cell transplantation was performed, remission had been maintained for 4 years. He was referred for assessment for cochlear implantation at the age of 26. Four months after tympanoplasty with transcortical mastoidectomy, Nucleus CI24M was implanted without any difﬁculty. To date, with a follow-up of 1 year, the patient has not experienced any complication and has regained useful open-set speech perception. Conclusions: To our knowledge, this is the ﬁrst reported case of successful cochlear implantation in a deafened patient by acute myelogenous leukemia. Patients with leukemia-induced deafness may be appropriate cochlear implant candidates.

Dalibor Vranjes, Sanja Spiric, Predrag Spiric, Zorica Novakovic ENT clinic, Clinic center Banja Luka, Bosnia and Herzegovina

OP 45 Intra-operative objective tests in cochlear implant surgery

Objectives: Does early CI ensure better speech perception and recognition? The beneﬁt of early CI is constant over a long time. Material and methods: 12 children who recieved CI between 1 and 5 years of age underwent a battery of speech perception tests. This study investigated spontaneous auditory behavioural responses including vocalisation, spontaneous alerting to sound and deriving meaning from sound using the MAIS and MUSS questionnaire. The evaluation was performed preoperatively. Performance outcomes in speech perception and recognition were examinated 6 and 12 months after switch-on. Results: 4 children were in group up to 3, and 8 children in group between 3 and 5 years of age at the implantation time. 84% of patients were completely satisﬁed with their CI. We founded greather speech perception and recognition ﬁrst year after switchon from children who received CI at three years of age. Their speech perception and recognition test results achieved 90% 2 years after switch-on. Children who were implanted at age three to ﬁve achieved up to 70% of speech recognition 2 years after switchon. Children with poorer MUSS and MAIS questionnaire scores

A. Shukuryan, V. Bakshinian, I. Harutunian Yerevan State Medical University, ‘‘Erebouni’’ Medical Center ENT Department Objective: Since 2004 till 2006 13 (11 prelingual children and 2 postlingual adults) underwent cochlear implantation after full investigation in the Armenian cochlear implant center. Methods: Neural response Telemetry (NRT) and stapedius reﬂex measurements were applied as objective measures of peripheral neural function in intra-operative tests. Results: The indications are rewiewed, the surgical highlights will be presented and the functional outcome analyzed on an individual basis. Thresholds (T-levels) and maximum comfort levels (C-levels) was also examined. Conclusions: The aim of the study was to assess the reliability of NRT recording with respect to data collection parameters using the NRT Nucleus software. The relation between the electrically evoked compouned action potential (ECAP) thresholds and the MAP.

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OP 46 Speech, language and music skills in adult cochlear implant recipient Sanja Spiric, Dalibor Vranjes, Predrag Spiric, Zorica Novakovic ENT clinic, Clinic center Banja Luka, Bosnia and Herzegovina Objectives: At the beginning cochlear implantation could provide limited auditory skills to people with profound sensorineurals hearing loss. In recent years, with modern cochlear implant system, patinets sholud have additional possibilities especialy in the sound discrimination, speech recognition and music perception. Material and methods: This study investigated speech, language and music skills, degree of personal satisfaction and tinnitus problem in patient with postlingual deafness. 60 years of age, female with diagnosis of Meniere disease, was implanted on 25th of November 2004. at the ENT Clinic, Clinic centre Banja Luka. We used Med-El Combi +. Preoperative ﬁndings shows profound hearing loss on left and 70 dB treshold on right ear. Speech recognition and descrimination with OTICON SUMO was 0%. Results: Postoperative evaluative measures included (1) tests of sound recogniton and discrimination, (2) speech perception and discrimination, (3) personal satisfaction, (4) language skills in two languages:serbian ant german and (5) recognition of melodies, identiﬁcation of songs and possibility of ﬁnd pleasure in music. Conclusion: Adequate preoperative assesment, preparation of the patient especialy in the ﬁeld of expectations, work of speech therapist, postoperative follow up and new processing strategies may improve CI users speech, language and music skills. It is great promotion for postlingual adult patient.

OP 47 Extra-dural haematoma presenting as a sixth nerve palsy post cochlear implantation James Barraclough, Guiresh Solanki, Ken Pearman Birmingham Children’s Hospital, UK Objectives: We present a case of a 13 month old boy who had undergone implantation of an Advanced Bionics cochlear implant. The procedure itself was uneventful but an abducens nerve palsy was noticed twelve hours post-operatively. The clinical course is discussed together with the implications and related cases. Methods: A computerised tomography (CT) scan was arranged following detection of the isolated cranial nerve palsy, which revealed an acute extradural haematoma in the right temporo-parietal region, adjacent to the internal receiver of the cochlear implant. Evacuation of the haematoma was performed and approximately 80 mls was drained via a burr hole placed posterior to the implant device. Results: The neurological deﬁcit resolved after evacuation of the haematoma and the patient made an excellent recovery. Conclusions: Intracranial complications after cochlear implantation are rare; this is the ﬁrst report of an extradural haematoma following cochlear implantation causing a cranial nerve palsy. This case highlights the need for particular care when creating a bed for a cochlear implant device.

OP 48 Cochlear Implantation in Estonia 2000–2006: a review of 64 cases Heisl Vaher, Katrin Kruustu¨k, Rita Teek, Priit Kaseno˜mm,

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Mart Kull Ear Clinic of Tartu University Hospital, United Laboratories of Tartu University Hospital, Human Genetic Center Objectives: The objective of this study was to investigate the causes of hearing impairment (HI) among children and adults, genetic mutation in case of hereditary hearing loss and the complication rate for all cochlear implant (CI) operations performed between 2000 and 2006 in Estonia. Methods: We analyzed a series of 64 operations performed on 15 adults (age range 14–54 years, mean age 31.5 years) and 49 children (age range 1.4–14, mean age 4.6 years). Fifty-ﬁve cases were genetically consulted. Since 1999 the geneticists have investigated 35delG mutation in GJB2 gene and since 2005 they have investigated the genotype of patients HI by arrayed primer extension (APEX) method covering 201 mutations in 8 genes. Results: The etiology of deafness: genetic 29 cases (43.76%), meningitis 8 cases (12.5%), there was no mutations found in 13 cases (20.3%), APEX test was not done 10 cases (15.63%), trauma 2 cases, prematuritas 2 cases. The genetic causes of HI were: mutations in GJB2 gene (35del/35delG, 35delG/R143W, 35delG/ M34T, 35delG/167delT genotype), Kearns-Sayre syndrome in 1 case. We found one surgical complication: leak of perilymph during surgery. Conclusion: Genetic etiology was the main cause of HI in children. Meningitis was the most common cause of hearing loss in adult patients The rate of complications for CI was similar to data found in literature.

OP 49 Facial nerve stimulation after cochlear implantation in patients with far-advanced otosclerosis G. Psillas, I. Konstantinidis, G. Kyriaﬁnis, V. Vital 1st Academic ENT Department, Aristotle University of Thessaloniki, AHEPA Hospital 1, Stilponos Kyriakidi St., GR 540 06 Thessaloniki, Greece Objectives: The aim of this study was to describe a programming technique in order to control facial nerve stimulation after cochlear implantation in patients suffering from far-advanced otosclerosis. Methods: Five patients, 2 males and 3 females, with previous surgical intervention as a treatment of their otosclerosis and with an air conduction level in excess of 85 dB and with bone conduction nonmeasurable in any of the speech-hearing frequencies on a standard clinical audiometer were included in this study. The standard procedure for cochlear implantation consisted of a cortical mastoidectomy, posterior tympanotomy and electrode insertion through a cochleostomy. All patients received Cochlear Contour device with speech processor 3G. Postoperatively, the implanted patients were programmed with ACE speech coding strategy in Monopolar 1 + 2 stimulation. Results: Intraoperatively, in all otosclerotic patients the basal turn was identiﬁed and a full insertion was achieved. One patient, three months after the implantation experienced facial nerve stimulation as a visible movement of facial musculature during cochlear implant activation involving the basal electrode 4. Then, the comfort level in this speciﬁc electrode was reduced by 10 CL and the facial nerve stimulation was effectively eliminated. The pulse width remained stable to 25 ls with no need to increase to higher values. Conclusions: Postoperative facial nerve stimulation as a result from an electrical shunt between the offending electrode in the implant and the facial nerve, can be managed successfully by setting the current levels for comfort level below the facial nerve activation.

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OP 50 Evaluation of surgery and ﬁtting in adults and children implanted with a SONATA100 TI cochlear implant

OP 52 The intensity/pitch relation in cochlear implant recipients: mono-versus bipolar stimulation

Ilona Anderson, Joachim Mu¨ller, Benoit Godey, Anders Freijd, Sten Harris, Constantino Morera, Wolf-Dieter Baumgartner, Wolf Mann, Wolfgang Gsto¨ttner MED-EL, Medical Electronics, Fu¨rstenweg 77a, 6020 Innsbruck

C. Arnoldner, J. S. Hamzavi, D. Riss, M. Brunner, W. D. Baumgartner, A. Mair, W. Gsto¨ttner Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18–20, A-1097 Vienna, Austria

Objectives: The SONATATI100 cochlear implant is the newest cochlear implant from MED-EL. This implant contains the same internal components as the PULSARci100, but in titanium housing. The package dimensions are 17 · 25 · 5.9 mm, with an overall weight of 8.6 g. This study aimed to assess surgical and ﬁtting issues with the new implant. Method: Thirty adults and twenty children received a SONATATI100 cochlear implant, a surgical review was conducted. Followup took place up to 6 months after implantation—ﬁtting was assessed and clinicians completed a user survey. Results: Results showed that surgery with the new device went smoothly, and no immediate post-operative problems were reported. Fitting and subject results demonstrate that the SONATATI100 is safe device to use in both adults and children. Conclusion: the SONATATI100 is a viable new implant for both adults and children.

Objective:Pitch plays a key role in the perception of speech and music. To date, little attention has been spent on the inﬂuence of stimulation level on pitch perception. The aim of this study was to investigate the impact of a sound’s intensity on pitch perception in cochlear implant recipients. We wished to determine, whether the intensity-dependent peak shift of cochlear excitation maxima described in animals can be found in psychophysical studies on human subjects with cochlear implants as well. Methods: Recently we published ﬁrst results of intensity/pitch correlations in patients using monopolar stimulation and lateral (straight) electrodes. In this part of the study we investigated the impact of stimulation mode and electrode type on the intensity/ pitch relation in cochlear implant recipients. 29 patients (average age 53,34 years) took part in this study. All patients were implanted with a MedEl Combi 40/40+ or Nucleus 24 R (NC 24 M) cochlear implant. Results: 23 patients (79 %) were found to perceive a change of pitch with changing intensity of the stimulus. Results will be discussed in relation to stimulation mode,implant and electrode type. Conclusion: Until today, speech coding strategies do not pay tribute to these ﬁndings. Nevertheless, we believe that for the optimized most natural perception of sounds—especially music—the described particularities of pitch perception need to be respected and further investigations on this topic are necessary.

OP 51 Outcome of cochlear implantation under 3 years of age: screened vs. nonscreened children Zuzana Kabatova, Milan Profant University ENT Department, Medical School of Comenius University, Antolska 11, 851 07 Bratislava, Slovak Republic Objectives: Universal newborn hearing screening has the major impact on early identiﬁcation of deafness in children. Deaf children from the screened population reach earlier identiﬁcation, diagnosis and intervention. In this presentation we evaluate outcome of cochlear implantation in two series of children implanted under the age of three: In the ﬁrst group there are children diagnosed by screening while in the second group there are children diagnosed by traditional methods. Material: Group 1: 9 deaf children diagnosed by screening, Group 2: 21 children diagnosed by traditional methods. Following parameters were evaluated: Age at the time of diagnosis; Age at the time of the ﬁrst hearing aid ﬁtting; Age at the time of cochlear implantation; In children that have been using cochlear implant for more than 2 years results of audiological tests, CAP and development and quality of speech were also evaluated. Results: Hearing screening signiﬁcantly reduced the age at the time of diagnosis (6,9 months vs. 15,4 months) as well as the age at the time of the ﬁrst hearing aid ﬁtting (9,3 months vs. 17 months) and age at the time of cochlear implantation (26 months vs. 32 months). Children from the screening program reach better results in speech audiometry: 95% discrimination vs. 84%, monosyllabic tests: 62% vs. 34%, CAP: level 6 vs. level 5, evaluation of spontaneous speech: level 6 vs. level 5, intelligibility of speech: level 5 vs. level 3,5. Conclusions: Universal hearing screening gives a deaf child better chance for successful managing of hearing and speech development with good prognosis in asserting an implanted child in everyday life.

OP 53 Cochlear implant in children: how much rehabilitation? Nikolaos Marangos, Anna Papadoulou, Apostolos Papadopoulos, Konstantina Karra Center of Otorhinolaryngology, Head and Neck and Skull Base Surgery, Athens, Greece Objective:Long and intensive rehabilitation of children with cochlear implant is suggested for their speech development. However, many children develop speech without any rehabilitation, if implanted very early. Method:The speech development of all 100 children with cochlear implant has been monitored for more than 2 years, evaluated and correlated with their age at implantation and the rehabilitative efforts. Results: Thirty two out of 34 children implanted under the age of two developed mother language within 2 years, although only 11 became speech therapy. Out of the 36 children implanted between 2 and 4 years of age, 24 developed mother language within 2 years although 16 became speech therapy. Only 11 out of the 30 children implanted after the age of four developed mother language although all of them became intensive speech therapy. Conclusion: The need of systematic rehabilitation for speech development correlates with the age at implantation. By implanting very young children speech therapy may be not necessary but is recommended for documentation of progress and detection of technical failures.

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OP 54 Minimal access surgery for cochlear implant Anna Papadoulou, Apostolos Papadopoulos, Konstantina Karra, Nikolaos Marangos Center of Otorhinolaryngology, Head and Neck and Skull Base Surgery, Athens, Greece Objective: Surgery for cochlear implant required in the past large incision and long hospitalization. Minimal access surgery will reduce corporal and psychological trauma especially in young children. Methods: Since 2001 all 130 cochlear implant surgeries have been performed through an 1.5 cm retroauricular incision that allows subperiostal dissection and drilling of the receiver-stimulator well and mastoidectomy, posterior tympanotomy and cochleostomy in classical manner. The youngest patient was 157 days old and the oldest 68 years old. Hospitalization did not exceed 12 hours in the day clinic. Results: Surgery and postoperative course were uneventful in all cases. Even in cases with severe malformations it was possible to introduce the array through this small access. Conclusion: The described technique is safe for implanting ﬂexible devices in all cases. It reduces trauma and expenses for implantation and is suitable for very young children as well.

OP 55 The development of auditory skills in Slovak prelingually deaf children-cochlear implant users Daniela Hudecova Department of Speech and Language Pathology, University Hospital Antolska, 11 Bratislava, Slovak Republic The goals of the study were to report the development of auditory perceptual skills in Slovak prelingually deaf children-cochlear implant users. A total of fourteen children were included in the study and were followed up to 2 years post-implantation. We used the Evaluation of Auditory Responses to Speech (EARS) test battery to evaluate auditory perceptual skills. The EARS test battery contains four measures of closed-set speech perception and three open-set tests. The mean test results demonstrated steady improvement on all parts of the EARS test battery. Auditory perceptual skills measured with closed-set tests developed at a quicker rate comparing with those measured with openset tests. Results suggest that children with cochlear implants develop open-set speech recognition after implantation, and these skills develop over a long period of time, highlighting the need for continued therapy to maximize listening and learning.

OP 56 The development of preverbal and early verbal behaviour in Slovak prelingually deaf children: cochlear implant users Daniela Hudecova Department of Speech and Language Pathology, University Hospital Antolska, 11 Bratislava, Slovak Republic

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Important part of the postimplant process is to monitor the progress of the children-assessing the effect of cochlear implantation for the development of communication skills. The most of prelingually deaf children are at the preverbal stage of language acquirement at the time of implantation. Margaret Tait‘s Videoanalysis technique has been shown to be valuable for monitoring the development of preverbal and early verbal skills in young children with cochlear implants. Fourteen children, cochlear implant users for 2 years were enrolled in this study. These children developed an auditory-vocal style of turn-taking behaviour, which developed progressively over time. The use of gesture as a nature pattern of conversation in prelingually deaf children is decreasing.within 2 years after the implantation. Children‘s eye contact in conversation became more appropriate. Their gaze became more sustained, contingent, and integrated with the communication. The tendency to look at the speaker decreased only slightly during 2 years of the assessment. Videoanalysis technique is sensitive to changes in preverbal, early verbal behaviour within 2 years after implantation. Aberrance from the expected behaviour may indicate inaccurate device ﬁtting, device failure or inadequate support.

OP 57 Monitoring and control measures of rehabilitation program after cochlear implantation A. Pankowska, A. Barej, M. Zgoda, J. Putkiewicz, A. Lorens, A. Piotrowska, H. Skar_zyn´ski International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Warsaw, Kajetany, Poland Introduction: As rehabilitation of cochlear implant patients is many-faceted, a multidisciplinary approach is necessary involving not only speech and auditory therapy but also development, educational and social support. Monitoring and control measures have to be applied to ensure the optimized application of the therapy. Methods: Over 1500 patients have been implanted in the Institute of Physiology and Pathology of Hearing in Warsaw/Kajetany. One week stay program in International Rehabilitation Center in Łeba was designed to monitor and control rehabilitation process. It is available for the patient twice a year. 144 patient took part in this program in 2006. Complex assessment includes speech, pedagogical and psychological evaluation and enables to form guidelines and recommendation for individual rehabilitation program. Results: Base on our results of complex evaluation, we found out that in 55% cases the therapy is effective and helpful for the patient, in 35% cases some modiﬁcation were proposed and 10 % showed the need of signiﬁcant change in the therapy program. Conclusions: The implementation of the monitoring and control method of rehabilitation program after cochlear implantation may increase the cochlear implant users’ beneﬁts, what in turn leads to higher improvement in quality of life and cost-effectiveness of the treatment.

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OP 58 Schooling, out of school education- and employment status of young people with cochlear implants

audiology team also picks up any problems and refers to the medical team if necessary. Four patients were identiﬁed and found to have a positive Dix-Hallpike test. They all underwent an Epley manoeuvre, two needing a repeat procedure. Results: 4 patients out of 758 adult cochlear implantations developed BPPV postoperatively. This gives a risk of 0.4%. They either recovered completely (2 patients) or found that their symptoms improved to the point where they only suffered from a very occasional episode of BPPV (2 patients). Conclusions: There is a small risk of developing BPPV after cochlear implantation which should discussed when consenting the patient for surgery pre-operatively. However, we do not feel that this would deter patients from undergoing cochlear implantation given the beneﬁts of the procedure.

Maria Huber1, Wolfgang Hitzl2, Klaus Albegger1 1 ENT Department, Paracelsus Medical University, Mu¨llnerhauptstr. 48; 2Research Department, Paracelsus Medical University, Strubergasse 21, both Salzburg, Austria Objectives: Since its start in 1992, more than 250 deaf children were supplied with Cochlear implants at the CI-center Salzburg. Many of them have now grown up to adolescents and young adults. The purpose of this study was to evaluate schooling, out of school education and employment status of adolescents and young adults with cochlear implants as a critical evaluation of CI in children. Methods: Candidates were all, ranging between 12 and 21 years, pre-perilingual deafened, implanted in our clinic, with at least 3 years of hearing experience with CI. Altogether 64 persons and their parents were asked to complete structured paper and pencil interviews. All adolescents up to the year of 17, parents and teachers were also asked to answer the ‘Strengths and Difﬁculties Questionnaire´ (SDQ). Normal hearing contemporaries (age-matched) served as control groups. Results: 39 out of 52 participants (75%) attend(ed) mainstreamschools. At present 37 are still at school. Two of the 15 alumni are at university, seven do regular apprenticeships, ﬁve are employed and one is unemployed. All wear their CI continuously. All are wearing their CI continuously at a daily basis. The results of the SDQ revealed that the prevalence rate of mental health disorders is not increased, compared to normal hearing people (self p = 0.61; p = 0.40; parents p = 0.77; p = 0.16). Conclusion: Most are integrated in the hearing world, concerning their schooling, out of school education, vocational training- and employment status.

OP 59 Benign positional paroxysmal vertigo after cochlear implantation Alexandra Roper, Sudipta Bannerjee, Deborah Mawman, Martin O’Driscoll, Shakeel Saeed, Richard Ramsden Manchester Royal Inﬁrmary, East Lancashire NHS Trust Objective: to establish the number of patients in the Manchester Cochlear Implant Program who develop benign positional paroxysmal vertigo after cochlear implantation. Methods: all patients who receive a cochlear implant are routinely followed up post-operatively by the audiology team to monitor their progress before and after the implant is switched on. The

OP 60 Bilateral versus monaural pediatric cochlear implantation Wolf-Dieter Baumgartner, Alexandra Jappel, Michaela Katzinger, Sonja Hickmann, Dominik Riss, Christoph Arnoldner, Jafar-Sasan Hamzavi Medical University Vienna From 1996 until 2006 at the Vienna ENT University department 60 children underwent simultaneous or sequential bilateral cochlear implantation. In the same time period 260 other children were implanted unilateral only. Aim of this study was to ﬁnd out, if bilateral cochlear implantation is a beneﬁt for the children, compared to monaural implanted children in terms of pure tone thresholds, speech understanding scores, hearing in quiet and noise, listening skills, development of speech, speech production, social behaviour, type of school education, school results and acceptance of parents and children environment. Although the study group of 320 children is inhomogeneous results in therapy, listening skills and school environment show a difference. In some categories, like school type, bilateral paediatric cochlear implantation gives a signiﬁcant higher chance for a child to attend mainstream school successfully. Beside the pure audiological testing, which has already proven the bilateral beneﬁts of squelch effect, summation effect and directional hearing, even in smaller children, all other beneﬁts of bilateral hearing (f.e. ease and speed of communication) are present in a bilateral paediatric cochlear implant population. Concerning to our data unilateral paediatric cochlear implantation in bilaterally deaf children, shows analogue to unilateral hearing aid support in bilateral hearing impaired children, a poorer outcome than bilateral cochlear implantation or bilateral hearing aid support. As a result we suggest bilateral cochlear implantation whenever indicated (no residual hearing) and possible.

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OP 61 Integration of deaf children with CI in to the mainstream school system Katja Kladnik Stabej University Clinics of Ljubljana Objectives: Integration into the mainstream school system is one of the signs that shows success of joining the deaf child in to the world of normal hearing. The aim of our study was comparison of habilitation between the deaf children with and without cochlear implants (CI). Methods: We tried to access ability of integration of the deaf children in to the regular school system, and the ability of hearing, reading and writing, on a basis of the questionary send to their parents. All of the children were treated at University Department for Otorhinolaryngology and Cervicofacial Surgery in Ljubljana. We sent 65 questionaries. 39 parents ansverd all the questions, 31 of them were parents of children implanted with CI. Results: Hearing abbilities of the deaf children included in our study were acessed on basis of CAP (Categories of auditory performance) scale. We ascertained that (64%) children without and (76%) children with cochlear implants are included into the regular school sistem. Children without CI learned to read all the capital letters at average age of 5,9 years and children with CI learned to read them at average age of 5,7 years. We stated children without CI learned to write down all the capital letters at average age of 6,4 years and children with CI learned to write down all the capital letters at average age of 6,1 years. Conclusions: Improved hearing, speech, reading and writing abilities enable easier integration of children into the regular education classrooms. Cochlear implantation in congenital deaf children enables qualitative changes in acoustic perception and consecutively also better ability for integration in to the regular school system what conﬁrmed also our study.

OP 62 Absorbable systems of osteosynthesis: an intersting alternative of cochlear implant ﬁxation Lars-Uwe Scholtz, Joachim Mu¨ller, Stephan Brill, Gerald Baier, Rudolf Hagen University of Wu¨rzburg, Germany Objectives: The question, if the Cochlear Implant device during the ﬁrst operation should be ﬁxed or not, is under discussion. A crucial step during successful cochlear implantation involves stable ﬁxation of the receiver-stimulator portion of the cochlear implant (CI) against the skull. This is important because device migration can predispose to infection, extrusion, the need for revision surgery and for operations with minimal incision. Secure ﬁxation also allows the device to follow the contour of the skull, minimizing irritation and trauma to the overlaying skin ﬂap.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Methods: A variety of methods are currently used to secure the device. The most common approach involves drilling holes outside of the well and passing a nondissolvable suture over the receiver-stimulator. Alternative methods to enhance efﬁciency of device stabilization use polypropylene mesh or resorbable plating systems (e.g. SonicWeld Rx, KLS Martin Group, Germany). Results: We performed experiments in fresh temporal bones with different Cochlear Implant devices (ceramic and metal). After successful measurements we started the clinical application. Known to the excellent compatibility of the different osteosynthesis device was conﬁrmed in case of ﬁxation of Cochlea Implants. With a follow-up period of 1 year were noted no wound healing problems. Conclusions: Our alternative method are provided an opportunity reducing the time to the ﬁrst ﬁtting of speechprocessor.

OP 63 Evaluation of children cochlear implant candidates in Croatia Petar Drvisˇ , Jakov Ajduk, Robert Trotic´, Branko Kekic´, Mihael Ries, Boris Pegan Department of Otolaryngology, Head and Neck Surgery, University Hospital Sestre Milosrdnice, Vinogradska 29, Zagreb, Croatia Objectives: The retrospective study was carried out to review the etiology of deafness in the group of 270 congenital and prelingually deaf children, candidates for cochlear implantation. Methods: All children had severe to profound sensorineural hearing loss (SNHL) and were considered audiological candidates based on the documented hearing loss. The medical assessment of cochlear implant candidates included the otologic history, physical examination, radiologic evaluation of the temporal bone and audiologic assessment. Results: The age of candidates at time of clinical preoperative evaluation for cochlear implantion ranged 5 months to 14 years (mean age, 3.9 years). A family history of SNHL had 82 (30,4 %) candidates. The meningitis and/or prenatal maternal factors were present in 18 (6,7%) candidates. The prematurity and/or complicated perinatal course was found in 35 (12,9%) of candidates. The radiologic evaluation of the temporal bone showed normal cochleovestibular anatomy in 226 (83,7%) candidates patients. CT-scan analysis identiﬁed 44 (16,3%) patients presenting with an inner ear malformation in the study. The inﬂammatory middle ear changes were present in 15 (5,6%) and the high position of the jugular vein bulb in 32 (11,8%) candidates. Conclusions: Our data show that 30.4% of children undergoing evaluation had a hereditary factor that may have contributed to their hearing loss, these include known syndromes, a family history of hearing loss, and an inner ear abnormality on results of CT scanning. Early newborns screening for SNHL, early implantation and rehabilitation allow these children to reach their full potential.

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OP 64 Cochlear implantation: georgian experience Japaridze Shota1, Gamgebeli Zurab2, Kevanishvili Zurab2 1 Otorhinolaryngological Clinic; 2Centre of Audiology and Hearing Rehabilitation, State Medical University, Vaja Pshavela 33, GEO 0177 Tbilisi, Georgia Objectives: Despite signiﬁcant efforts, aiming to limit the hearingloss incidences in Georgia, the rate of auditory dysfunctions, including their serious forms, remains alarming. The cochlear implantation, CI, is the only perspective of rehabilitation of severe hearing impairments. Correspondingly, the implementations of CI methods were particularly important for Georgia. Methods: The regular CI surgery we began in Georgia in 1994. Up to the present time, 35 individuals were subjected to the CI. 31 from those were pre- and four postlingually affected. The ages of prelingual subjects fell in the range of 3–10 years. In all cases the implants of the MedEl Company have been utilized. Results: Each CI candidates underwent precise audiological investigations, while applying the computer tomography the state of cochlea was carefully inspected. During the surgery a limited anteromastoidectomy and a wide posterotympanotomy were performed and a chorda tympany was visualized. The triangle of a posterior tympanotomy was then widened and the approach to the facial nerve has been created. After cochleostomy and CI imbedding, a procedure of telemetry was carried out and the contractions of stapedial muscle to the electrical impulses were examined. All surgeries were accomplished without complications. In all cases the results were satisfactory. Conclusions: The processes of rehabilitation are faster and reliable in CI children of lower ages and of higher intellectual potencies.

OP 65 The surgical anatomy of the mastoid process-relation to CI surgery Radomir Radulovic Clinical Center of Serbia Belgrade, ENT Clinic, Pasterova 2, 11000 Belgrad, Serbia Current tendency, for early CI implantation (children of 4 months of age, and more),make the knowledge of anatomy of Mastoid process(MP),very important.1500 temporal bones were investigated by classical anatomical procedures, as well as by use of histology, and radiology. These results have been conﬁrmed by personal surgical experience on 2.500 operated patient wit a temporal bone disease.10% of the surgery, was middle cranial fossa approoach. MP, does not exists in ﬁrst year of life. It is morfologicaly developed by the 5th.year of age. Position of the facial nerve, its movement toward the position in adults (position of stylomastoid foramen,formation and positioning of the mastoid part of the nerve) was precisely determined. Relation of the facial nerve to tympanic membrane, and the position of the sigmoid sinus and the dura of middle cranial fossa, which are of importance for the CI surgery, in childhood and in adults has been pointed out. Knowledge of anatomy of the mastoid process, is the key point for the successful CI surgery, with a minimum of surgical complication.

OP 66 Clinical application of the spread of excitation measurement in CI users V. Bakhshinyan, G. Tavartkiladze

S221 National Research Center for Audiology and Hearing Rehabilitation, Russia Objectives: It is extremely important to develop more effective ways to stimulate the surviving auditory neurons of the CI user, which could increase the potential beneﬁt of cochlear implantatio0 n. The aim of this study was to examine the Spread of Excitation (SE) with the Neural Response Telemetry (NRT) for Nucleus 24 CI werers and conﬁrm the effect of modiolar placement on the hypothesized reduced SE, stimulation thresholds and to evaluate its usefulness as a clinical tool. Method: 35 Nucleus CI24 patients were included is this study (15 CI24M, 15 CI24R(CS) Contour and 5 CI24RE(CA) Freedom implant patients). NRT was performed intraoperatively. By plotting the NRT amplitude as a function of masker electrode number, a frequency-selective curve was obtained, which may be interpreted as reﬂecting the SE through the cochlea. Results and conclusion: SE was recorded at all the electrodes with measurable neural responses. SE provides a quick, objective measure of channel interaction. Our results suggest that perimodiolar placement of the electrode array signiﬁcantly reduces the thresholds and SE proﬁle and widths, which improve the selectivity of neuronal stimulation and can be used as an objective clinical tool for better prediction of the auditory performance after cochlear implantation.

OP 67 Sentence comprehension in children with cochlear implants (CI) Peter Hummer, Martin Leyrer, Silvia Pixner, karin Landerl, Klaus Albegger Department of Linguistics, University of Salzburg Objectives: This study addresses paradoxical results of previous research, i.e. reading comprehension problems of our CI-children despite normal basic reading skills (i.e. print to sound conversion). We hypothesize, that an elusive but genuine syntactic delay is to blame for this. Methods: An experimental group of 19 CI-children (NUCLEUS, 8–10 years old), all with age adequate written word decoding skills and normal nonverbal IQ, and a matched normal hearing control group were presented with eight syntactic categories (10 sentences each) both in the written and spoken modality. Reading performance was measured ofﬂine by picture matching and online by tracking children‘s eye-movements using the EYELINK II System. Results: The CI-children performed worse than the controls in both conditions. In a condition x group ANOVA the main effect of group was signiﬁcant, F(1,36) = 12.78, p < .001. The correlation between reading and listening comprehension was highly signiﬁcant (r = .93, p < .001) as was the correlation between number of regressive saccades and reading comprehension, r = .66, p < .001. Conclusions: Overall, the CI group showed lower reading comprehension than the controls, even though not worse in basic decoding. Since the CI-group exhibited inferior listening comprehension too, it is concluded, that a genuine delay in syntactic competence rather than modality speciﬁc deﬁcits is the ultimate cause. This conclusion is corroborated by the success with the eight subtypes of sentences, showing a disproportionate decrease for CI-children with increasing complexity—as determined from the performance of the controls. Similarly, the oculomotor protocols revealed less sensitivity to syntactic hot spots in sentence parsing in CI-children than in controls.

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OP 68 The development of auditory skills in Slovak prelingually deaf children: cochlear implant users Daniela Hudecova Department of Speech and Language Pathology, University Hospital Antolska, 11 Bratislava, Slovak Republic The goals of the study were to report the development of auditory perceptual skills in Slovak prelingually deaf children-cochlear implant users. A total of fourteen children were included in the study and were followed up to 2 years post-implantation. We used the Evaluation of Auditory Responses to Speech (EARS) test battery to evaluate auditory perceptual skills. The EARS test battery contains four measures of closed-set speech perception and three open-set tests. The mean test results demonstrated steady improvement on all parts of the EARS test battery. Auditory perceptual skills measured with closed-set tests developed at a quicker rate comparing with those measured with openset tests. Results suggest that children with cochlear implants develop open-set speech recognition after implantation, and these skills develop over a long period of time, highlighting the need for continued therapy to maximize listening and learning.

OP 69 The development of preverbal and early verbal behaviour in Slovak prelingually deaf children: cochlear implant users Daniela Hudecova Department of Speech and Language Pathology, University Hospital Antolska, 11 Bratislava, Slovak Republic Important part of the postimplant process is to monitor the progress of the children-assessing the effect of cochlear implantation for the development of communication skills. The most of prelingually deaf children are at the preverbal stage of language acquirement at the time of implantation. Margaret Tait‘s Videoanalysis technique has been shown to be valuable for monitoring the development of preverbal and early verbal skills in young children with cochlear implants. Fourteen children, cochlear implant users for 2 years were enrolled in this study. These children developed an auditory-vocal style of turn-taking behaviour, which developed progressively over time. The use of gesture as a nature pattern of conversation in prelingually deaf children is decreasing.within 2 years after the implantation. Children‘s eye contact in conversation became more appropriate. Their gaze became more sustained, contingent, and integrated with the communication. The tendency to look at the speaker decreased only slightly during 2 years of the assessment. Videoanalysis technique is sensitive to changes in preverbal, early verbal behaviour within 2 years after implantation. Aberrance from the expected behaviour may indicate inaccurate device ﬁtting, device failure or inadequate support.

OP 70 The predictive value of measures of preverbal behaviour to language acquisition in Slovak prelingually deaf children with cochlear implants Daniela Hudecova Department of Speech and Language Pathology, University Hospital Antolska, 11 Bratislava, Slovak Republic

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Two years after implantation, most children have not only sufﬁcient understanding of spoken language, but are able to produce simple sentences or retell a simple story. The goal of this study was to compare preverbal communication behaviour in young children before the ﬁrst ﬁtting of the speech processor with their language production assessed 2 years after implantation. Preverbal/vocal factor was constructed from the preverbal measures and characterizes the extent to which each child uses voice as opposed to gesture before the ﬁrst ﬁtting of the speech processor. The language production ability of fourteen cochlear implant users after 2 years post implantation was assessed using Margaret Lahey ContentForm-Use language model (Slovak adaptation). Language production of each of fourteen children was put into one of seven levels of langauge acqusition. The present study shows that children with more positive scores on the preverbal/vocal factor scale before the ﬁrst ﬁtting of the speech processor go on to develop a higher level of language acquisition measured 2 years post implantation. These ﬁndings have direct consequences for cochlear implant programs. To encourage preverbal communication behaviour (vocalization, autonomy in communication) may bear fruit in terms of better speech production in later years post implantation.

OP 71 The predictive value of measures of preverbal behaviour to later auditory skills in Slovak prelingually deaf children with cochlear implants Daniela Hudecova Department of Speech and Language Pathology, University Hospital Antolska, 11 Bratislava, Slovak Republic There is considerable variation among children with cochlear implants in their auditory perceptual skills. There are many factors that might contribute to the variations (age at implantation, etiology and pattern of onset of deafness, mode of communication, preverbal behaviour...). The aim of the study was to discover whether measures of preverbal behaviour in young children obtained before the ﬁrst ﬁtting of the speech processor could predict auditory perceptual skills measured in the certain intervals during 2 years after implantation. Fourteen children-cochlear implant users for 2 years were enrolled in this study. The development of preverbal behaviour was measured using Margaret Tait’s video analysis technique. Auditory skills were measured using closed-set speech perception and open-set tests of EARS test battery. There was a signiﬁcant correlation between measures of preverbal behaviour obtained before the ﬁrst ﬁtting of the speech procesor and auditory skills measured by one of the closed test of EARS test battery (Lip proﬁle). The ﬁnding of this study, that there are quantiﬁable characteristics of preverbal behaviour present before the ﬁrst ﬁtting of the speech processor and related to later outcomes, has important consequences for rehabilitation. It seems that children who are good communicators before the ﬁrst ﬁtting of the speech processor are likely to do well later in auditory perception skills.

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OP 72 Ear and nose foreign bodies in children in Podgorica

Conclusion: The pathogenesis of frostbite involves three simultaneous mechanisms: direct cellular damage, vasoconstriction, and local thrombosis and endothelial damage. Piracetam provided effective vasodilatation against the vascular effects of freezing.

Ognjen Jovicevic, Lejla Rovcanin ENT Department, Institute for children’s diseases, Podgorica, Montenegro Objective: To present different classes of ear and nose foreign bodies found in children, duration of their presence in the ear or nose, as well as complications related to their presence or removal. Methods: The records of all children with a foreign body of either the ear or nose, examined in the ENT ambulance of the Institute for children’s diseases in Podgorica, over a 1-year period (January 2006–January 2007.) were reviewed. Results: 49 children aged 2–14 years with ear or nose foreign bodies were treated—29 males (59%) and 20 females (41%). There were 23 cases (47%) of ear foreign bodies and 26 cases (53%) of nose foreign bodies. In 30 cases (62%) the removal was performed within the ﬁrst 24 h after the body insertion, in 8 cases (16%) within 2–4 days and in 11 cases (22%) within 5 days or more. In 45 cases (92%) foreign bodies were removed in ENT ambulance, while 4 ear foreign bodies (8%) had to be removed under general anesthesia. Complications were observed in 25 children (51%), of which 11 cases were complications of ear foreign bodies and 14 cases were complications of nose foreign bodies. Conclusion: Ear and nose foreign bodies represent emergencies in ENT practice. They require urgent ENT examination and removal performed by specialized personnel in order to avoid potential complications.

OP 73 Frostbite of the ear Csongor Gyo¨rgy Lengyel, Tibor Bala´zs, Ja´nos Szikszai, Erzse´bet Fu¨le Department of Otolaryngology Head & Neck Surgery, Jo´sa Andra´s County Hospital, Nyı´ regyha´za, H-4400, Szent.I. u. 68., Nyı´ regyha´za, Hungary Objectives: The pinna is an unprotected appendage readily accessible to trauma. Trauma can result from cold thermal injury and produce frostbite. Temperatures below –10C block sensory nerve input, depriving the patient of the warning signs of impending danger. January 23, 2006 a cold front was sweeping over the Carpathian Basin, the temperature was –20C. The same day 4 patients (1 female, 3 male) presented with a frostbite injury of the auricle (aged 20–42 years). Three patients had bilateral and one had unilateral injuries. The aim of the present study is to present our cases and the treatment we used, and to give a review of the literature. Methods: Treatment consisted rapid rewarming the frostbitten area with moist pledgets at a temperature of 38C. Later, cod liver oil (oleum jecoris aselli) and sulfa–urea powder dressings were used and changed daily. Auricular blood ﬂow was enhanced by piracetam (Nootropil), a systemic vasodilating agent (12 g IV daily for 5– 10 days). Tetanus toxoid was also given. Results: The characteristic bullae ruptured by the 5–7th day and the all the patients healed with no scar formation. Erythema and sensitivity of the auricle could be detected for weeks to months.

OP 74 Treatment of bat-ears A. Antohi, S. Vetricean, I. Antohi Department of otorhinolaryngology, University of medicine and pharmacy ‘‘NicolaeTestemitanu’’, Chisinau, Republic of Moldova Proposed method of surgical correction of lop ears is efﬁcient, reduces surgical trauma and possible early and late postsurgical complications. Goal of the work: Creation of a new method of surgical correction of lop ears wich will reduce surgical trauma and possible postsurgical complications. Materials and methods:The study was done on patients with lop ears.Were performed 39 surgeries for correction of auricles:27 pacients with congenital lop ears and 12 with posttraumatical deformations of auricles. Outcomes:All patients who underwent otoplasties following our method had good anatomical and aesthetical outcomes,without postsurgical complications. Conclusions: Proposed method of surgical correction of lop ears is efﬁcient,reduces surgical trauma and possible early and late postsurgical complications.

OP 75 ‘‘Lambing Ears’’: a blistering condition affecting farmers at lambing time K. Heathcote, G. B. Heathcote#, J. M.Theaker*, N. Gibbins, P. S. Friedmann+ Departments of ENT Surgery, *Cellular Pathology and + Dermatology, Southampton University Hospitals, Hampshire, UK. #Warborne Farm, Hampshire, UK Background: At lambing time many farmers experience blistering and crusting of the pinnae. This condition has not been deﬁned or investigated previously. Objectives: To deﬁne the condition histologically and explore its pathogenesis Methods: We obtained biopsies from ﬁve sufferers and demographic information from 69. We contacted farming communities in other countries. Results: The histological features are dominanted by a pan dermal perivascular and diffuse, predominantly T cell lymphocytic, inﬁltrate. Only the pinnae are affected and its incidence is related to the degree of involvement a farmer has with the animals around parturition. The condition also occurs in farmers who are calving but less frequently. Sunlight does not appear to be a primary or important factor. Conclusion: This condition has not been previously described and occurs in proportion to close contact with lambing ewes or calving cows. The histology is comparible to other lymphocytic inﬁltrates such as polymorhous light eruption and Jessner’s but its distribution and demograhics are unique.

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OP 76 A randomised, prospective comparision of syringing and microsuction for wax removal S. H. Vyas, J. Picozzi, J. L. Handa ENT Department, Monklands Hospital, Lanarkshire, UK Objectives: To assess which method, syringing or microsuction, is better in terms of wax removal, and leading to minimal patient discomfort. Methods: Patients (age 22–80) with excessive accumulation of wax were included. Those with previous otological conditions/operations such as perforations or mastoidectomies were excluded. Patients were randomised into 2 groups: Group A—standard syringing and group B—microsuction under direct vision. After the procedure, patient discomfort (none, slight, moderate, severe) and other symptoms, such as dizziness, were noted. Clinical assessment of the external canal, in terms of wax removal (none, slight, moderate or complete) was made. The state of the tympanic membrane was also noted. Results: Patient discomfort, group A (n = 75): none 7(9.3%), slight 53(70.7%), moderate 12(16%), severe 3(4%). For group B (n = 80): none 4(5%), slight 56(70%), moderate 16(20%), severe 4(5%). External canal assessment for wax removal, group A: none 1(1.3%), slight 2(2.7%), moderate 10(13.3%), complete 62(82.7%). For group B: none 0, slight 1(1.2%), moderate 2(2.5%), complete 77(96.3%). For both groups, where wax was removed, the tympanic membranes were intact. In group A, 23(30.6%) and group B, 28(35%) had transient dizziness. Conclusions: Both methods are safe and effective in wax removal for healthy patients without any otological history. However, microsuction is better for complete removal of wax. Therefore it would be ideal where available, but syringing still useful in primary care.

OP 77 Swimmer’s ear: otitis externa Radjenovic Gordana, Popovic Mirko, Nedic Jevrem Private ENT Practice ‘‘AlphaGR’’-Bar, Clinical Centar of Montenegro of ENT and MFC, Podgorica Objectives: Otitis externa acuta occurs most often in the warm climate, like, during the summer time, when more people participate in water activities. Data analysis include the reasons for the visit to the otorinolaryngologist, main symptoms,the severity of AOE,concomitant diagnosis, duration of disease, medical procedure and the inﬂuence of the air and the sea temperature to AOE. Methods: For this study we selected 565 outpatients(298 male,125female 142children) with medical ICD (10) diagnosis code H60. The average age of patients was 37.61 for male patients, 39.28 percent for female patients and 8.32 for children. The assessment of severity of AOE rates on the scale from 0–3. Results: 89 percent of all patients were tourists. 41percent of all patients had mild symptoms of the disease,49percent had moderate symptoms and 10 percent had severe symptoms. The duration of the disease before the visit to the otorinolaryngologist was 4.38 days. Before ENT visit 72 percent of all patients received medication. Earache was cited as the main symptom among 69

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 percent of the patients. After a visit to the ENT doctor 82 percent of all patients received topical medication,and 18 percent received both systemic and topical medication. Otitis media is the most frequent concomitant diagnosis. The increase of the air temperature and sea temperature cause the increase of the number of patients with AOE. Conclusions: AOE can be extremely uncomfortable.Earache is the main symptom, which brings patients to an otorinolaryngologist.

OP 78 Castellani tintura rubra versus dexamethason neomycin; an effective cure for external otitis Radjenovic Gordana, Popovic Mirko Private ENT Practice ‘‘AlphaGR’’ Bar, Clinical Centar of Montenegro, Clinic of ENTand MFC, Podgorica Objectives: Otitis externa acuta (AOE) is a common,painful disease, affecting all age groups.The excessive moisture and trauma, both of which, impare the canal natural defence, are the couse of AOE. The present study was undertaken to compare the efﬁcacy and tolerability of Castellani tintura rubra (CTR) versus Dexamethason-neomycin sol (DN). Methods: 98 patients were enrolled in the prospective, randomized, controlled parallel group study. The patients were randomly assigned to one of the two treatment groups CRT (47) and DN(41). The average age of patients was 38.41. Patient were examined on three occasions: on the day of enrollment(visit1), 24–48 hours later (visit2) and 7 days after the enrolment(visit3). We observed the same pattern with respect to swelling, pain, discharge and redness. Twice a day the patients recorded their symptoms using diary cards. All patients were instructed to avoid moisture and wetness of the ear during the course. Results: At visit 2 the patients in CTR group showed a signiﬁcantly greater more quckly in CTRgroup.Castellani rubra provide rapid pain relief after 24 hours. The patients of the DN group were signiﬁcantly less trouble by itching. Conclusions: The results show that treatment with CTR is an effective and rapid method for the treatment of AOE. was effective in the treatment AOE,but our result show that the relief of symptoms was slower.

OP 79 Review of cerumenolytic products: their effectiveness and tolerance Holden H, Drweski P. Department of ENT, Cromwell hospital, London SW5 OTU, UK The available types of material for breakdown and removal of wax is considered. This includes: mechanical items, simple drops which merely modify consistency, those which change physical and chemistry of the wax, and ﬁnally those derived from sea water particularly their ideal concentrations. The bacteriostatic and bactericidal functions are noted and supported by in vivo and in vitro evidence. Finally the acceptability and tolerance of the external auditory canal epithelium is assessed.

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OP 80 Is cranial nerve palsy a predictive factor in malignant otitis externa? Navin Mani, Holger Sudhoff, Sandeep Rajagopal, Ioannis Moumoulidis, Patrick Axon, David Moffat Department of Otolaryngology and Skull Base Surgery, Addenbrooke’s Hospital Cambridge, UK Objectives: Malignant otitis externa is a rare infection of the external auditory meatus which mainly affects diabetic and immunocompromised patients. The aim of this study is to determine if cranial nerve involvement in malignant otitis externa affects or predicts the clinical outcome in terms of morbidity and mortality. Methods: Retrospective case analysis in 23 patients diagnosed with malignant otitis externa in our department. Diagnostic criteria included history of severe pain, otitis externa not responsive to conventional treatments, diabetes mellitus and pseudomonas aeruginosa culture. Results: Ten patients (44%) showed cranial nerve involvement. The following cranial nerves were affected: facial nerve (60%), lower cranial nerves (combination of IX, X, XI, XII) (30%) and involvement of both in 10%. All patients were treated with long term, high dose antibiotic treatment. Conclusions: Cranial nerve involvement did not affect the patient survival rate in our series. All patients with lower cranial nerve palsy recovered normal function, however, the facial nerve palsy was signiﬁcantly less likely to improve by medical treatment.

OP 81 The surgical treatment of the keloid of the ear lobule Murod M. Jafarov, Asror A. Yunusov, Alijon T. Hisamov Tashkent Pediatric Medical Institute Objectives: The auricle is sensitive to anyone exogenous factors, and even small trauma of an auricle as piercing, postoperative and post burn scarring can cause growth of a connecting tissue owing to which there is a scarring and developed the keloid.The purpose of research was to studying mechanisms of occurrence keloid of lobe of the ear, restoration of the anatomical shape of lobe of the ear, decrease of demonstration of symptoms, improvement of cosmetics, prevention of recurrence and perfection of principles of treatment. Methods: Clinical researches were made in Department of Plastic Surgery of Clinic of the TashPMI. For the period 2004–2006 at 9 children (age: -8 till 15 years) made incision keloid of lobe ear, which in 3 cases-after piercing, 2-after operation, 4-postburn. The incision was made atraumatically, ‘intralessinal’ incision with using vasoconstructive agents in local anesthesia. A wound have closed with the minimal tension and put interdermal absorbable

S225 sutures Vicryl 6–0. Results: In the postoperative period we observed patients within 6 months and, all patients didn’t have recurrence. Only at 1 patient for 4 month after operation the line of the incision was slightly redness, and one injection of a Kenalog was required only. ‘Intralessinal’ incision has allowed to lower risk of recurrence after operation to lower need for using of steroids. Simple surgical removing of keloid according to the literature in 55 % of cases synthesis of collagen on surfaces of wound and raised risk of recurrence of keloid in greater size. Conclusion: Thus, ‘intralessinal’ incision reduces risk of recurrence of keloid and need for using steroids. Using of ‘intralessinal’ incision to removing of keloid is most effective at patients with plural scars which have tendency to a thickening keloid.

OP 82 Investigation into the effects of ceruminolytic: an in vitro trial Samit Ghosh1, Ekambar Reddy2, Ye Hong Tham2, Paul Goodyear1 1 University Hospital Aintree, Liverpool, UK; 2North Cheshire Hospitals, Warrington, UK Objectives: Cerumen impaction affects up to 6% of the general population at any time, and can cause signiﬁcant deterioration in quality of life. Surveys have shown the most common ceruminolytic advised by health professionals is olive oil. We studied the effect of commonly available ceruminolytics in vitro. Methods: Wax obtained from 18 patients was homogenised. 9 pellets (0.15 g +/– 0.01 g) were made into 8 mm · 3 mm circles. They were placed in 9 tubes containing 2 mls of the following solutions: water, saline, sofradex, almond oil, olive oil, sodium bicarbonate 5%, urea –hydrogen peroxide 5%, arachis oil 57%, and docusate sodium. Times to external surface fragmentation (ESF), loss of shape (LOS), and complete fragmentation (CF) were recorded. A second series reproduced an occluded ear canal by obstructing a 2 ml syringe (8 mm diameter) with a wax circle. The time for solution to pass the obstruction was measured. Results: In the ﬁrst run, oil based products did not affect the shape of the pellets at all. Saline, water and sofradex effected an immediate change in shape and achieved CF in 125 mins,135 mins,135 mins respectively. Sodium bicarbonate achieved ESF and LOS in 5 mins, 95 mins respectively and CF did not occur by 180 mins. In the second run no oil based products passed the obstruction by 24 hours. Penetration through the obstruction was achieved in 5 mins, 10 mins, and 15 mins by tap water, saline and sofradex respectively. Conclusions: In vitro testing shows that water based products are more effective in wax fragmentation than oil based products.

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OP 83 Searching for gossipyboma in the temporal bone Samit Ghosh, Paul Goodyear, Aman Kumar University Hospital Aintree, Liverpool, UK Objectives: Gossipyboma or retained foreign body (latin—gossypium’’-cotton, Swahili-boma-place of concealment). In otologic surgery, common practice is to use cotton wool balls, often < 5 mm, to assist in raising ﬂaps and achieve haemostasis when soaked with adrenaline. These may be retained post closure and lead to complication. Recommendations state that all material used in body cavities should have radio-opaque markings. We investigated the minimum length of radio-opaque material needed to locate it in the temporal bone on X ray. Methods: Using a ‘‘dummy’’ head with equivalent radioabsorption of the human head we placed neurosurgical swabs with linear radio-opaque markings, in10 mm, 5 mm, and 2.5 mm lengths (1 mm width)over the external ear canal, posterior to the mastoid, and over McKewans triangle. Lateral, and perorbital views radiographs were taken. The images were shown to 5 ENT surgeons and 5 radiologists to locate the marking. Results: None of the participants located the markings on the lateral views. On the perorbital views all participants located the10 mm and 5 mm markings in the posterior mastoid site, 7 (4 radiologists, 3 surgeons) identiﬁed them in the mckewans triangle site. Only 3 participants were able to locate, conﬁdently, the 2.5 mm markings on the perorbital views (posterior mastoid site). Conclusion: Locating radio-opaque lines, accurately, amongst the markings of the temporal bone is difﬁcult. We recommend the minimum length of marking to be used is 5 mm (1 mm width),and perform perorbital 70 KV 46MAS radiographs thus ensuring conﬁdent location or disproving presence in the event of suspected gossipyboma in the temporal bone.

OP 84 Ceruminous adenoid cystic carcinoma of the external auditory canal resembling chronic otitis media Adin Selcuk, Serdar Ensari, Mehmet Ali Cetin, Serpil Dizbay Sak*, Huseyin Dere Ankara Numune Education and Research Hospital, 4th ENT Clinic, Ankara, Turkey; *Ankara University Faculty of Medicine, Department of Pathology, Ankara, Turkey Ceruminous neoplasms of the external auditory canal are rare neoplasms. Incidence, clinical behavior and management of these tumors are controversial. We report a case of adenoid cystic carcinoma originating from the ceruminous glands of the external ear canal, operated with a diagnosis of chronic otitis media with polyp in the ear canal. A 48-year-old man presented with left ear

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 discharge and hearing loss. Clinical examination showed a wellcircumscribed polypoid mass limited to the external auditory canal. No history of bloody ear discharge, facial weakness or radiological ﬁndings of bonny erosion that could be evocative of malignancy. Patient was thought to have chronic otitis media which was complicated with polyp formation and tympanoplasty operation was performed. Histopathological evaluation of the specimen was reported as ceruminous adenoid cystic carcinoma and advanced treatment was attended. The present paper emphasizes that ceruminous carcinomas should be considered in the differential diagnosis of middle and external ear pathologies in cases with soft tissue mass in the external ear canal.

OP 85 Isolated preauricular pits and tags: Is it necessary to investigate renal abnormalities Yezdan Firat, Sule Sireci*, Cengiz Yakinci*, Mustafa Akarc¸ay, Muammer Hakkı Karakas**, Ahmet Kemal Firat**, Ahmet Kizilay, Erol Selimoglu Inonu University, Otolaryngology Department, Malatya, Turkey; *Inonu University, Pediatrics Department, Malatya, Turkey; **Inonu University, Radiology Department, Malatya, Turkey Abstracts:Objectives:Evaluation of renal abnormalities in patients with isolated preauricular pits and tags are controversial. We investigated the role of renal investigation in healthy children with preauricular tags and pits. Methods: Study population comprised 12615 primary school children from the city of Malatya, Eastern Turkey and the patients with the age of 0–18 years which are seen in the Pediatric and Otolaryngologic clinics of our hospital during April 2004 and March 2006. Patients with other craniofasial anomalies were included the study. Otologic evaluation was investigated with otoscopy, otoacoustic emission measurements and temporal computed tomography evaluation in patients with auricular pits and tags. Renal evaluation was made with blood electrolytes, renal function tests, urinalysis and renal ultrasound. Results: 36 patients (16 boy, 15 girl) were determined with preauricular pit and tag. 13 patients with preauricular sinus and tag were determined from school screening and 23 patients were determined from clinics. Seven patients had preauricular tags, 28 patients had preauricular pits and one had multiple tags. While one child with a preauricular tag had right renal agenesis and left hydronephrosis, one newborn baby with multiple preauricular tags and craniofasial anomaly had no renal abnormality. Conclusion: The incidence of renal abnormality in patients with preauricular tags/pits (1/36;%3) was consisted with the incidence of it in normal population. We concluded that, renal investigation is not required in patients with preauricular tags and pits.

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OP 86 Keloid Ear Tashkent Pediatric, A. A. Yunusov Medical Institute, Uzbekistan Keloid management can be difﬁcult and represent the pathological healing appearing after the trauma or injury of the skin and representing medical problems owing to often relapse. The purpose of our research was to study actions of the combined treatment. For the period 2004–2006 have received treatment with keloid ear of 16-patients in the age of 12–36 years. Growth keloid in all cases began at after pirsing in ear lobulae8 patients, and others 4 patients after burn, after trauma ears 2 patients, and 2 patients after surgical treat. Combinations treatment included ‘‘intralessional’’ surgical excision of keloids.. Surgical excisions can be closed by reconstructive techniques. For improvement regeneration properties of the skin during 5 day used Solcoseryl, forming a ﬁlm which result to dehidrotation of skin luck operated as pressing bandage. After closed wound we are injected ‘‘Kenalog- 40’’ (0,3 on 1 cm). We are used in the postoperative period for protectl of irritation and microtraumas of the skin ear surfaces Celestodrm B with garamyciny. After removal suture to make selicon gel Dermatix during 2– 3 months, and one a week during 3 weeks we are intralesional injected ‘‘Kenalog-40’’. From 16 patients only at 2 patients, after 7 months there was marked an itch and condensation of the ear formed gentle scar. Morbidity and reddening was moderate which after a unitary injection ‘‘Kenalog-40’’ inside scar for 2–3 day disappeared sensations of morbidity and reduction of the size of condensation. Also for the prevention of growth keloid have appointed silicon gel ‘‘Dermatix’’ during 2 month alongside with a rate of traditional physiotherapy. At other patients were not marked attributes of relapse keloids.

OP 87 Facial paralysis in chronic otitis media Dragoslava Djeric Institute of Otorhinolaryngology and Maxillofacial Surgery, University Clinical Center, Belgrade, Serbia Chronic suppurative otitis media is a destructive process that can involve the facial nerve and may result in an impairment of its function. In the preantibiotic era, facial paralysis occurred in 2.3% of patients with chronic suppurative otitis media. Although the frequency of otogenic facial paralysis has decreased since the introduction of antibiotics, it still occurs in about 1% of patients with chronic otitis media.

S227 The purpose of the present paper is to report the results of our study of 104 patients with a facial paralysis due to chronic suppurative otitis media. During the 10-year period from 1996 to 2005, about 3800 patients at our clinic had surgery for chronic otitis media and 104 had a preoperative facial paralysis. Otogenic facial paralysis was clinically complete in 66% and incomplete in 34% of the patients. Cholesteatoma was found in 80%. Facial paralysis was more common as an isolated lesion not associated with other complications. When present, bone destruction of the facial canal was most frequently seen in its tympanic portion. The occurrence of facial paralysis did not depend on the extent of destruction of the facial canal. Facial nerve function recovered in 7o%, partially in 24% and failure in 6% of the patients. The degree of recovery of facial nerve function did not depend on the ﬁndings at surgery. In some cases the facial canal was extensively destroyed with pronounced pathological process around the exposed nerve, but after decompression, the facial function recovered completely.

OP 88 Subdural empyema: arare complication of bullous myringitis Neil Sharma1, Mriganka De1, Richard Vaughan-Jones2 1 Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Birmingham NHS Trust, Edgbaston,B15 2TH Birmingham, UK; 2Department of Ear, Nose and Throat Surgery, Worcestershire Royal Hospital, WR5 1DD Worcester, UK Introduction: Bullous myringitis is an acute painful condition characterized by bulla formation on the tympanic membrane and deep external auditory canal. This is the ﬁrst reported case of subdural empyema complicating bullous myringitis. Case report: A 36 year old male presented with left sided otalgia, purulent discharge from the ear, nausea, pyrexia and rigors. Initial diagnosis was bullous myringitis. The patient was initially treated with intravenous clarithromycin and ciproﬂoxacin ear drops. Twelve hours later the patient became acutely confused with a decreased conscious level. A CT scan at this stage showed pockets of intracranial air and opaque mastoid air cells but no other intracranial abnormality. Ceftazadine, metronidazole and gentamicin were added to the intravenous antibiotic regime. On day 7 the patient developed a right hemiparesis and meningism. CT scanning showed a 3 mm subdural collection in the left frontotemporal region, MRI conﬁrmed this to be a subdural empyema. A left frontotemporal craniotomy was carried out and the pus evacuated. The patient went on to make a good recovery, although was left with an unsteady gait.

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OP 89 Prevalence and bacterial aetiology of acute otitis media in Vietnam Viggo H. Balle, Dang Hoang Son* ENT Department, Gentofte University Hospital, Copenhagen, Denmark; *ENT Department Pediatric Hospital no. 1, Ho Chi Minh City, Vietnam Objective: Find prevalence and bacterial aetiology of acute otitis media (AOM) in South Vietnam and issue guidelines for its diagnosis and treatment. Methods: Two cohorts age below 15 years of age were randomly selected by picking from existing vaccination lists at Can Giouc (CG). 1,614 individuals were examined by an experienced otologist using head lamp and pneumatic speculum in spring, 858 individuals were examined in fall. In case of suspected otitis otomicroscopy was carried out. If the diagnosis was conﬁrmed, the child was anesthetized and ﬂuid was aspirated from the middle ear cavity using a sterile needle. In order to compare bacterial aetiology and resistance pattern in an urban and rural environment children admitted with AOM to Pediatric Hospital No 1 (PH1) had cultures taken as well. Results: 23 cases of AOM were found in spring screening, 11 in fall, 1.4- and 1.3% respectively. 68%were below the age of 6 years. 36 ears with AOM were found in CG, 57 in PH1.Twelve ears harboured Str. pneumonia, 9 H.inﬂuenzae, 15 Staph. aureus. None of the above pathogens were found in 5 ears. Two or more pathogens were found in 8 ears. In 60 ears were no growth. Resistance pattern against ampicillin, sulfonamides and trimethoprim (Bactrim) and Cefotaxim for H. inﬂuenzae was found to 50%-86%-27%. For Str. pneumoniae 38%—80% 22% and for Staph.aureus 55%-54% and 15% respectively. No difference in resistance pattern between urban and rural population was observed. Conclusion: Prevalence of AOM is higher than in neighbouring Thailand, but approximately the same as in Greenland. Resistance problems are big and should indicate restricted use of antibiotics in AOM.

OP 90 Facial nerve palsy associated with otitis media in Montenegro Todorovic Miroljub, Jovicevic Ognjen, Jovanovic Maja, Bulatovic Vladimir Otology Department, General Hospital ‘‘Danilo I’’, Cetinje, Montenegro, ENT Department, Institute for children’s diseases, Podgorica, Montenegro Objectives: To present frequency and treatment of facial nerve palsy associated with otitis media.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Methods: This study reviews the cases of all the surgically treated patients with otologic pathology over a 3-year period (January 2004–January 2007.) in the Otology Department of General Hospital in Cetinje, Montenegro. Results: 256 patients diagnosed with chronic otitis media were surgically treated during this period. Of these, 12 patients (4.69%) had facial nerve palsy associated with otitis media, aged 12– 64 years. old—3 females and 9 males. Of these 12 patients, there were 3 cases with malignant tumors involving the middle ear space, 6 cases with cholesteatoma and 3 cases with acute otitis media. In 7 cases tympanomastoidectomy, and in 5 cases tympanoplasty–wall up (type III) with facial nerve decompression were performed. In 8 patients full nerve recovery was achieved, while in 4 patients there were no signs of nerve recovery at all. Conclusions: Facial nerve palsy represents an important complication of otitis media and as such requires surgical treatment with no regards to etiology.

OP 91 Severe acute otitis media in children G. Donovalova´, J. Jakubikova, P. Hroma´dkova´, R. Mohamed Children ENT department, Children´s university hospital Kramare, Bratislava, Slovakia Objective:Acute otitis media (AOM) is one of the most common infection in children. We noticed that there is a great increase in relapse or severe acute otitis media in children recently. Also there is an increase in number of hospitalised children, because of severe AOM, with etiological agent which is resistent to antibiotics. Also we can see rise in infection, caused by high resistant Streptococcus pneumoniae. Methods: We reviewed retrospectively children hospitalised in our ENT department in children hospital Kramare in Bratislava, from January 2005 to December 2006, because of svere acute otitis media. We focused mainly to etiological agent, antibiotics resistance and also alternatives of treatment and prevention of severe AOM. Results: In 2 years there were 70 children in age from 4 month to 12 years hospitalised with severe AOM. The most frecquent etiological agent was Streptococcus pneumoniae in 32 cases, this was in almost 70 % resistant to routine antibiotics. Only in 1 case there was diagnosed mastoiditis and mastoidectomy must be done. Conclusion: To name the right diagnose and to start the proper treatment it is necessary to identify etiological agent and its sensitivity. The increasing bacterial resistance is forcing us to prescribe antibiotics rationaly. When severe AOM occurs, tympanotomy and insertion of ventilation tubes, exeptionaly mastoidectomy is often recquired.

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OP 92 Langerhans cell histiocytosis presenting as bilateral acute mastoiditis in a child Stuart D. Richards, Roma Dasgupta, Sam Majumdar, Jaydip Ray Shefﬁeld Children’s Hospital NHS Trust Objectives:To present a case of Langerhans cell histiocytosis presenting as bilateral acute mastoiditis in an 18 month old child. Methods: A retrospective review of the case notes of a child referred to a tertiary paediatric ENT centre. Results: The child originally presented to a local hospital with acute unilateral mastoiditis, which initially settled after treatment with intravenous antibiotics and cortical mastoidectomy. The child subsequently re-presented with the signs of bilateral acute mastoiditis. CT scan and biopsy conﬁrmed the diagnosis of Langerhans cell histiocytosis, which was treated with vinblastine. Conclusions: Langerhans cell histiocytosis comprises a spectrum of disease from monostotic through to polyostotic and soft tissue involvement. It is characterised by a granulomatous disease with idiopathic proliferation of histiocytes. Temporal bone involvement is present in 15–30% of cases but is rarely the presenting feature; presentation as bilateral acute mastoiditis is particularly unusual. Delayed diagnosis is common due to the variable pattern of presentation. Treatment varies across centres but usually involves systemic chemotherapy with vinblastine. The lesson from this case is to consider an alternative diagnosis when the ﬁndings do not clearly ﬁt with acute bacterial mastoiditis.

OP 93 Epidemiology and treatment of bell’s palsy Evdoxia Gerostergiou1, Dimitrios Batzakakis1, Ioannis Tsitiridis1, Ioannis Bardanis2, Panagiotis Karagounis1 1 General Hospital of Larissa, ENT Department, 2 General Hospital of Ikaria, ENT Department Objective:Bell’s palsy accounts for more than three quarters of all cases of facial palsy. In this survey we tried to compare two different treatments of Bell’s palsy. Method:77 patients suffering from Bell’s palsy were studied in our clinic during 2006. All of them underwent otoscopy, tympanometry, reﬂex decay test and electroneurographyPatients in group A (48) were hospitalised and treated with intravenous administration of prednisone and oral administration of valaciclovir, and compared with group B (29) who were treated only with valaciclovir and vitamins (orally) (without corticoids) because of other diseases (ulcer gastric, hypertension, diabetes mellitus). 3 patients with partial facial palsy denied treatment.

S229 Results: 42 (54,5%) of the patients were male and 35 (45,5%) female. The recovery rate in patients in group A, treated with the combination of valaciclovir and prednisone, was 100%. The corresponding rate in patients in group B, treated with valaciclovir and vitamins, was only 71,38%. 2 of the patients who denied treatment recovered fully, while the third one still suffers from facial palsy grade II. Conclusions: The necessary medicines seem to be the corticoids. That’s why we must always take under consideration their administration, even when they are contraindicated, in close cooperation with other medical specialities in order to prevent possible complications. Male and female in our study are equally affected by Bell’s palsy.

OP 94 Acute mastoiditis in children: 6 years follow-up study Slobodan Spremo, Biljana Udovcic ENT Clinic, Clinic Center, Banja Luka, Bosnia and Herzegovina Objectives: To review our experience with clinical course, diagnostic and therapeutic proﬁle of children treated for acute mastoiditis, and to investigate for possible susceptibility factors. Design:Retrospective review of pediatric patients presenting with acute mastoiditis secondary to acute otitis media over the last 6 years, from 2000 to 2006. Setting:Clinic for otorhinolaryngology, Clinic Center Banja Luka. Patients: Children aged from 1 to 16 years treated for acute mastoiditis and subsequent intratemporal and intracranial complications. Main outcome Measures: Selected clinical parameters, mastoid coalescence and risk factors for necessity of surgical intervention. Results: Medical history review of a total of 13 patients with acute mastoiditis was analyzed. Acute coalescent mastoiditis occurred 11 patients (84%) while non coalescent form of acute mastoiditis occurred in 2 cases (16%). Intracranial complication occurred in 3 patients (2 meningitis and 1 epidural intracranial abscess), while 2 patients had intratemporal complication (subperiostal abscess) associated to coalescent mastoiditis. We observed clinical proﬁle of acute mastoiditis in regard to pathology found on the tympanic membrane, middle ear mucosa and destructions on the bony wall of the middle ear and mastoid. The main signs of progressive infection were tympanic membrane perforation, pulsatile suppurative secretion from the mucosa, and intratemporal abscess. All patients with coalescent mastoiditis (11) required mastoidectomy, while noncoalescent mastoiditis was treated conservatively with broad-spectrum intravenous antibiotics and myringotomy. Conclusion: Acute mastoiditis is uncommon but serious complication of acute otitis media in children associated with signiﬁcant morbidity.

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OP 95 Facial palsy associated with acute otitis media in adults Ljiljana Cvorovic, Dana Brajovic, Mile Strbac, Milan B. Jovanovic Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zemun, Belgrade, Serbia Objectives: Facial palsy secondary to acute otitis media is rare today. The objective of this study is to review treatment strategies and extent of recovery in adult patients with the aim of deﬁning a standard treatment protocol for this rare pathologic condition. Methods: Retrospective chart review. Disease course, management and outcome were recorded. Between 2000 and 2006, six adult patients were admitted for facial nerve paralysis secondary to acute otitis media. There were ﬁve women and one man without a history of chronic middle ear disease, who ranged in age from 26 to 69 years. Facial palsy was graded with the House-Brackmann scale: two patients had Grade III palsy, three had Grade IV palsy, and one patient had Grade V palsy. All patients were treated with parenteral third-generation cephalosporin in conjunction with intravenous corticosteroids and topical decongestants. Myringotomy alone or with ventilation tube application was performed in all patients. A simple mastoidectomy without facial nerve decompression was used in a patient with Grade V palsy without recovery into three weeks of initial treatment. Results: The recovery period was varied and unpredictable, ranging in duration from 1 to 90 days. Conclusions: The treatment of facial nerve paralysis secondary to acute otitis media should be as conservative as possible, using antibiotics and corticosteroids. Myringotomy and a ventilation tube should be added when spontaneous perforation of the tympanic membrane is not present. Mastoidectomy should be performed only when it is necessary to treat otitis media. Facial nerve decompression should not be necessary.

OP 96 Topical treatment of acute otitis externa Ralph Mo¨sgesa, Christian M. Domro¨sea, Ju¨rgen Lo¨fﬂerb a Institute of Medical Statistics, Informatics and Epidemiology, Faculty of Medicine, University of Cologne, Cologne, Germany, b Medicomp GmbH, Planegg-Martinsried, Germany Objectives: The study was designed to investigate the potential contribution of hydrocortisone acetate to the efﬁcacy and safety of an antibiotics ointment in the treatment of acute otitis externa (AOE). Methods: In a double-blind study 151 patients with a unilateral acute bacterial otitis externa were randomized either to receive an ointment with polymyxin-B sulfate (7,500 I.E./g) + bacitracin

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 (300 I.E./g) alone (AB) or the same antibiotic ointment with 10 mg hydrocortisone acetate /g ointment (AB+HC). Outcome measures Primary efﬁcacy endpoint was the change of an aggregate clinical symptom score (CSS) (subscores: redness, swelling, pain and secretion) found at Visit 2 vs. baseline (Visit1). Secondary outcome parameters were the change of the CSS from Visit 1 to the study termination, and the changes in the subscores and of a visual analog scale (VAS) for pain. Results: In the group treated with AB+HC, signiﬁcantly more patients with severe redness (14 (56%) vs. 7 (28%), p = 0.045) or severe secretion (23 (70%) vs. 10 (40%), p = 0.024) at inclusion were symptom-free at the last visit. Fewer pain-relieving tablets (1.1 ± 2.2 vs. 2.3 ± 4.6 paracetamol tablets) were used in the AB+HC-group. In the steroid group there was a slightly larger though not signiﬁcant reduction in CSS at Visit 2 and Visit 3 vs. baseline. Similar results were documented for redness, pain and secretion. No serious adverse events occurred. Conclusion: Both ointments are effective and safe in the topical treatment of AOE. Hydrocortisone acetate combined with the antibiotics improved individual symptoms better as did the steroid-free ointment.

OP 97 Acute mastoiditis complicated with bezold abscess, sigmoid sinus thrombosis and occipital osteomyelitis in a child I. Vlastos, G. Helmis, K. Parpounas, I. Athanasopoulos, M. Houlakis Aghia Sophia Children’s Hospital of Athens, Athens, Greece Objectives: Acute otitis media complications, although rare after the introduction of antibiotics, still remain a difﬁcult problem for the clinicians, not only because they are potential devastating but also because many controversies exist on the diagnosis and treatment of some of them. Our objective by presenting this case report is to discuss methods of early diagnosis and appropriate treatment options. Methods: In this report we describe a pediatric case of upper cervical abscess (bezold abscess), sigmoid sinus thrombosis and occipital osteomyelitis following mastoiditis, presenting with persistent fever and otorrhea. Results: The patient responded well to intravenous antibiotics and wall-intact mastoidectomy. Occipital craniotomy and antigoagulation therapy reported in other cases were avoided. Conclusions: CT-scan with intravenous contrast is very helpful for diagnosis of acute otitis media complications like sigmoid sinus thrombosis. We believe that avoidance of anticoagulation therapy and extended surgical procedures can be a reasonable treatment depended on the patient condition and the extend of the disease.

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OP 98 Treatment of acute otitis externa: triadcortyl versus glycerine-ichthammol

Methods: The study population consisted of 23 asymptomatic children with congenital CMV infection. 12 of them were treated just after diagnosis of CMV infection in the newborn period with Ganciclovir 10 mg/kg bodyweight for 21 days whereas the other 11 were observed without therapy. Results: In the study group of 18 children, SNHL occurred in two cases. Both were not treated with Ganciclovir in their newborn period. In the Ganciclovir treated group none of 9 children showed SNHL. During Ganciclovir therapy moderate neutropenia occurred as side effect in 2 out of 12 (16.6 %) treated children. Conclusion: Asymptomatic congenital CMV infection is likely a leading cause of SNHL in young children. Ganciclovir therapy offers a medical option to prevent subsequent SNHL. Further studies including a greater number of children are needed.

Ioannis Moumoulidis, Ajmal Masood, Shalina Ray, Om Chawla, Jaan Panesar Department of Otolaryngology, Luton and Dunstable Hospital, Luton, UK Objectives: Treatment of acute otitis externa involves aural toilet, followed by the application of a topical preparation. GlycerineIchthammol (GI) solution and Triadcortyl (TAC) cream are commonly used for treatment of acute otitis externa. Although they have both produced encouraging results, they have never been directly compared together. The aim of this study was to compare the clinical efﬁcacy of GI and TAC, in the form of an ear canal dressing, for the initial management of severe acute otitis externa. Method: A prospective single-blind randomized controlled trial was performed to compare the GI solution and TAC cream, both applied as ear canal dressings, in the initial management of severe acute otitis externa. Comparison of the treatment modalities was made by measuring patients’ pain (based on a visual analogue pain chart) and sign score improvement (assessing the ear canal swelling, tenderness and erythema). Results: A total of sixty-four patients with acute otitis externa were treated with either GI or TAC dressing. Both treatment modalities were proven efﬁcacious in the treatment of severe acute otitis externa. Although there was a statistically signiﬁcant difference in patients’ pain improvement in the TAC group in comparison with GI, there was no statistically difference in sign score improvement between those two groups. Conclusion: We recommend that GI dressing can be used instead of an antibiotic dressing (TAC) as initial treatment of severe acute otitis externa on the basis of cost, avoidance of resistance and toxicity.

OP 99 Effect of ganciclovir therapy on hearing in asymptomatic congenital CMV infection Lackner Andreas1, Walch Christian1, Sonja Truschnegg1, Engele Heidemarie2, Halwachs-Baumann Gabriela3 1 Division of Neuro-Otology, Department of ORL, 2Division of Neonatology, Department of Paediatrics, 3Institute of Medical and Chemical Laboratory Diagnostics, Medical University Graz Objectives: Ganciclovir therapy administered in the neonatal period of symptomatically CMV infected infants prevents hearing deterioration, but preventive therapy of asymptomatic congenital CMV disease with Ganciclovir is discussed controversially as side effects like severe neutropenia may occur during therapy.

OP 100 Effect of inﬂiximab on acute suppurative otitis media induced by P. Aeruginosa in rat Dong-Hee Lee, Sang-Won Yeo Department of Otolaryngology, Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea, Uijeongbu St. Mary’s Hospital, 65–1 Gumoh-Dong, Uijeongbu City, Gyeonggi-Do, 480–717, Korea Objective: To investigate the inﬂuence of inﬂiximab (Remicade?) on experimental acute suppurative otitis media induced by LPS of P. aeruginosa in rats. Methods: 54 Sprague-Dawley rats were allocated into the study group. 18 healthy animals served as the control group. Acute suppurative otitis media was induced by intratympanic installation of LPS of P. aeruginosa TNBS. After acute infection was developed in the ears, inﬂiximab was iv administered. Group 1: a dose of 5 mg/kg BW; Group 2: a dose of 10 mg/kg BW; Group 3: a dose of 15 mg/kg BW. Each group was subclassiﬁed by the time of sacriﬁce into 3 subgroups. Group A: on the 3rd day; Group B: on the 7th day; Group C: on the 10th day. The middle ear mucosa was examined the histopathological changes by light microscopy. In order to examine the leakage of the exudates, the middle ear mucosa was examined under ﬂuorescence microscope. To determine the change of microvascular permeability, Evans blue method was used. Results: Signiﬁcant differences concerning the presence of reparable lesions and the extent of middle ear mucosa without active inﬂammation in all groups of animals treated with inﬂiximab compared with controls were found. Signiﬁcant reduction of the extravasated Evans blue dye in all groups of treated animals as compared with the untreated ones was found. Conclusion: Intravenous administration of inﬂiximab reduces the inﬂammatory activity as well as the extravasation in experimental acute suppurative otitis media in rats.

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OP 101 Endoscopic observation of the nasal cavity and nasopharynx in patients with otitis media Fatma Tu¨lin Kayhan1, Mustafa Paksoy2, Cenk Evren2 1 Department of Otorhinolaryngology, Bakırko¨y Research and Training Hospital, 2Department of Otorhinolaryngology; Kartal Research and Training Hospital, Istanbul, Turkey Objective:A probable relationship between nasal and nasopharyngeal pathologies and type of otitis media (OM) was investigated. Methods: One hundred patients with various types of OM, aged from 4 to 72 were compared with 100 control subjects matched on age and sex, the clinical type of OM, nasal and nasopharyngeal ﬁndings based on rigid trans-nasal endoscopy. Endoscopy was performed with 0 degree, 4 or 2.4 mm rigid telescopes. The otoscopy was performed with operating microscopes. Student’s t-test was used for statistical analysis. Results: In endoscopic examinations, edema at the nasopharyngeal opening of the Eustachian tube and purulent secretion in nasopharynx were the most frequently observed signiﬁcant ﬁndings in all cases with OM. Sinusitis was signiﬁcantly frequent in children with otitis media with effusion (OME) and suppurative chronic otitis media (COM). Septal deviation was only signiﬁcantly observed in cases with COM. Although pressure of adenoid mass on tuba opening was more frequent in children with OME and in cases with inactive COM, this was not signiﬁcantly different from control group. Conclusion: A relationship between the type OM and nasopharyngeal and nasal pathologies, especially suppurative forms of OM was found.Keywords: Trans-nasal endoscopy, otitis media

OP 102 Unilateral tuberculosis of middle ear in patient previously treated for rhabdomyosarcoma in the contralateral middle ear: case report Jankowski Andrzej, Pajor Anna, Durko Tomasz, Pietruszewska Wioletta, Durko Marcin Chair of Otolaryngology, Medical University of Lodz, Poland Isolated tuberculosis of middle ear is a very rare entity. In many cases diagnosed on postoperative material. Authors present a case

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 of a female patient surgically treated for chronic otitis media / radical middle ear surgery/ in which basing on postoperative pathology report a speciﬁc inﬂammatory process /tuberculosis/ has been diagnosed. It is pointed out that in this patient there is a history of malignant neoplasmatic process /rhabdomyosarcoma embryonale/ treated previously in the contralateral middle ear.

OP 103 Thrombophlebitis of the sinus sigmoideus in children as an acute otitis media complication Kabelka Z., Hadacova I., Jurovcik M. Head of the ORL UK, 2nd Medical School, Praha, Czech Republic Sinus sigmoideus (lateral sinus) thrombophlebitis (LTS), a rare but potentially devastating complication of otitis media, is managed by broad spectrum antibiotics, surgery and anticoagulation. The management of intracranial dural sinuses thrombosis/ thromboﬂebitis is still controversial and ambiguous. Traditionally, post-operative anticoagulation is achieved by intravenous low-molecular weight heparin derivatives followed by oral warfarin. A retrospective review was conducted of 7 children of otogenic LTS admitted between 1993 and 2005 to our division. All patients underwent i.v. antibiotics, anticoagulation therapy, and 6 of them mastoid surgery. We describe the inical symptoms, effectiveness of antithrombotic therapy, and outcome. In all of our children LTS was the result of acute otitis media. The age of them was by chance just between 6 and 7 years of age, there wasn’t sex prevalence, but in 6 cases the right side was affected. No one suffered from frequent acute otitis media, nor chronic one. Magnetic resonance imaging plays a major role in determining diagnosis and treatment plans. Conservative surgical mastoid intervention including eradication of the perisinus absces seems to be effective. In our cases, antithrombotic therapy has been found to be a safe and effective treatment. Angio-MRI showed recanalization of the sinuses in all patients.

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OP 104 Teaching Basic Ear Care in Uganda: 1986–2006 Edward Turitwenka Introduction: Whereas it is agreed that the solution to the problem to the ear disease in developing countries lies beyond the few urban-based specialists, and that a limited range of activities provided by trained auxiliary personnel can go along way in alleviating suffering, not much is implemented. The 1995 symposium on Primary Ear Care in developing countries was watershed for us in Uganda. Attending the symposium were; Dr. Rubio and Maria Rosa who were already training nurses in Uganda met Drs Sam Zaramba and E. Turitwenka. This led to development of a curriculum following the guidelines of the Manchester Symposium, which was implemented beginning February 1996. The main objective was to create in Uganda, over a 4-year period, a network of trainees in Basic Ear Care to: Provide prompt and adequate treatment of ear disease, implement further national preventive actions of major causes of hearing loss. At the commencement of the course, Uganda’s 20 million people had only 8 otolaryngogists between them and all of them but one in the capital city. Fortunately for Uganda, there exists a group of auxiliary staff; clinical ofﬁcers and Registered Nurses who were targeted for the training. These have had 3 years of medical training and do a lot of medical work in the rural areas where they reside. A two-week course was developed and the training took place in the regional centers of the rural areas. Support came from Ministry of Health, Uganda, the ENT Department, Ruber Hospital and CESAL. Results: Fundamental principles taught were: Detect, Treat, Prevent, Refer and teach others Twenty people were trained each time and four courses were run between 1996 and 1999 to cover the 42 medical districts. The trainers who did well were then invited to participate in training others in a subsequent year. Since 2001, we train 20 people per district and equip them. The funding for subsequent courses came from Uganda Society for Disabled Children. To date about 400 people have been trained. Supervision: Whereas the districts were supposed to supervise these staff, it became apparent that the supposed supervisors has less skills and knowledge in E.N.T.; in a few cases resulting into confrontation not helped by the feeling by some of the trainees that they were now specialists. Fortunately, the Commonwealth Society for the deaf had donated a mobile audiology clinic in 1997, which was used to offer further training, supervision and encouragement as people from the centre worked with them in rural settings. In addition the previous trainees had refresher courses and sharing of experiences. Conclusion: The 10 years have seen the training of about 400 auxiliary staff some of whom have excelled and act as referral even for doctors. There are challenges but they are not insurmountable.

OP 105 Acute mastoiditis in children: treatment Athanasios Skouras, Nikolaos Benis, Nektarios Argyriou, Dimitra Gemeni E.N.T. Department ‘‘Ippokratio’’ General Hospital of Thessaloniki

S233 Objectives: Mastoid cells are part of the cavity of the middle ear, so every inﬂammation of the middle ear leads to inﬂammation of the mastoid cavity. Acute mastoiditis appears only if there is accumulation of infected material and pus under pressure into the mastoid cavity. Acute mastoiditis is an emergency situation which needs immediate treatment, which is the subject of this paper. Methods: In our clinic the last 15 years we had 19 cases of acute mastoiditis in children (between 6 months and 12 years old). All the cases had the symptoms of acute mastoiditis, such as pain and redness of tympanic membrane, in combination with swelling and redness at the skin over mastoid process. In one case there was a subperiosteal abscess, and in another one a temporary paresis of the facial nerve. Results: Antibiotics and anti-inﬂammatory medicines were given, and myringotomy with ventilation tube at the cases where the tympanic membrane was broken. Mastoidectomy was necessary only in three cases, in which at the same time was also a subperiosteal abscess which couldn’t be healed by medicines. Conclusions: Acute mastoiditis in children is an emergency situation which needs immediate treatment. Usually strong antibiotics in combination with drainage of the cavity of the middle ear are enough for the treatment of the disease.

OP 106 Genotyping for Cx26 and Cx30 gene mutations in the cases with congenital hearing loss Evirgen N*, Dereko¨y FS**, Eser B*, Erdog˘an MO¨*, Yıldız H*, Solak M* *Afyon Kocatepe University, School of Medicine, Medical Biology Department; **Afyon Kocatepe University, School of Medicine, Otolaryngology Department Afyonkarahisar, Turkey Objectives: Hearing loss is the most commonly shown perception malfunction which affects the mentality and education of a person and its rate has been shown to be 1 per 1000 newborn. About half of these cases have genetic bases. Mutations in the Cx26 (GJB2) and Cx30 (GJB6) genes are the leading genetic causes in the cases with nonsyndromic congenital hearing loss. Cx26 and Cx30 proteins function at the gap junctions in the cochlea. The defects caused by the mutations of 35delG, 167delT (of Cx26 gene) and delGJB6-D13S1830 (of Cx30 gene) are thought to be affecting the circulation of potassium ions which leads to hearing loss. The aim of this study was to investigate the Cx26 and Cx30 gene mutations in the cases with congenital hearing loss. Methods: A total of 47 deaf students with congenital hearing loss from Afyonkarahisar Deafness School were included in this study. Genotyping were performed for 35delG and 167delT mutations of Cx26 and del(GJB6-D13S1830) of Cx30 genes using the PCRELISA techniques. Results: 35delG mutation was detected in 7 cases (~%14,9). Four of these mutations were determined as homozygot mutant (~%8,5) and of three were determined as heterozygot mutant (~%6,4). 167delT and del(GJB6-D13S1830) mutations were not detected in these cases. Conclusion: 35delG mutation was determined as the most frequently mutation which lead to congenital hearing loss in this study.Key words: Congenital, genetic, hearing loss, Cx26 gene, Cx30 gene, 35delG, mutations.

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OP 107 The effects of 2-cyano-butyl-acrylate in guinea pig ear Fatma Tu¨lin Kayhan1, Mustafa Paksoy 2, Sevinc¸ Keser Hallac¸3, Arif S¸anlı2 Department of Otorhinolaryngology1 Bakırko¨y Dr.Sadi Konuk Research and Training Hospital, Bakırko¨y, Istanbul, Turkey, Department of Otorhinolaryngology and Department of Pathology2; Kartal Research and Training Hospital, Istanbul, Turkey Objective: This study investigated the effects of 2-cyano-butylacrylate in the Guinea pig ear. Study Design: Experimental study Methods: A small amount of adhesive had been inserted in the 16 guinea pigs right bulla as the study group. For the control group, saline had been applied to 8 guinea pigs right bulla. The removed animal temporal bones were investigated under the light microscope in the 2nd, 4th, 8th, and 12th weeks. Results: While normal histopathological details were examined in all subjects in the control group, active chronic inﬂammation, granulation tissue, foreign body reaction were found in the bullas of the majority of the animals and bone destruction in fewer animals in the study group. Active inﬂammation, granulation tissue and bone destruction was observed in the cochleas of one third of the ears. Conclusion: The ﬁndings of this study showed that, 2-cyano-butylacrylate results in serious inﬂammatory reaction in the middle and inner ear of the Guinea pig. For this reason, we do not recommend utilization of butyl-2-cyano-acrylate in middle ear.Keywords: Tissue adhesive, middle ear, guinea pig, experimental study.

OP 108 EGB761 extract prevents RAT’S cochlear age-related apoptosis 1

Ricardo Sanz, 2Julia´n Nevado, 1Alejandra Ayala, Carolina Sa´nchez-Rodrı´ guez, 3Jose´ R. Garcı´ a-Berrocal, 3 Rafael Ramirez-Camacho 1 Servicio de ORL, Hospital Universitario de Getafe, Getafe (Madrid). Spain; 2Unidad de Investigacio´n Hospital Universitario de Getafe, Getafe (Madrid). Spain, and 3Servicio de ORL, Hospital Universitario Puerta de Hierro Madrid. Spain. 2

Objectives: Recently, we demonstrated the existence of age-related caspase activation at the rat’s cochlea, which evokes the mitochondrion-initiated cell death pathway of apoptosis. Age-Related Hearing Loss (ARHL) or presbyacusis is the most common form of hearing loss, affecting approximately 40% of people by age 65. The main aim of this study is to explore the putative effects of Ginkgo biloba´s extract (EGb761) on age-related apoptosis in rats´ cochlea. Methods: Sprague-Dawley rats were grouped in two different ages (4 and 12 months-old) and treated with EGb761 extract dissolved in the tap water for either 4 or 12 months and then, compared with two similar untreated groups. Results: We measured different pro-apoptotic markers by well deﬁned molecular biology and luminescent assays, superoxide

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 dismutase (SOD) by means of ELISA, as well as evoked potentials. EGb761 treatment for 4 and 12 months prevents age-related caspase activation (e.g. caspase-3, caspase-9, Bax) within the rat’s cochleae in both, young-adults (4 months-old) and mature-older (12 months-old) rats. As a consequence of the treatment, auditory brain stem threshold levels seem to be reduced at both ages and at both time points studied and levels of SOD were increased. Conclusions: EGb761 impairs age-associated apoptosis in the rat’s cochlea, supporting the hypothesis of a signiﬁcant beneﬁcial effect in the integrity of the cochlea with an early and preventive treatment with antioxidants

OP 109 Effects of Cinnarizine on isolated vestibular hair cells of guinea pigs T. A. Duong Dinh1, M. Westhofen1 Department of Oto-Laryngology and Plastic Head and Neck Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen Objectives: The pathogenesis of the Menie`re´s disease and its histopathological correlate, the endolymphatic hydrops, is not well understood. There is no convincing answer which explains the cellular pathomechanisms on vestibular hair cells in case of the Menie`re´s disease. Therapeutic effects of various pharmaceutics on these cells are also unclear. Cinnarizine is a calcium antagonist, which is used in the treatment of the Menie`re´s disease. In our studies we analysed the effects of cinnarizine on ion currents in guinea pig vestibular hair cells. Methods: Membrane currents were measured with patch-clamp technique in conventional whole-cell mode. Vestibular hair cells were isolated by mechanical and enzymatical dissection. Results: We found out, that cinnarizine, beside its quality as a calcium antagonist, also has an effect on the calcium dependent K+ outward currents, which are responsible for the repolarisation of the vestibular hair cells. Cinnarizine abrogated increases of K+ currents induced by increases in the hydrostatic pressure. The pressure dependent K+ currents may play an important role according to the endolymphatic hydrops. Besides cinnarizine reduces the transmitter release and suppresses the signal transduction of the vestibular hair cells. Other experiments showed also an effect of cinnarizne on the TRPA1 channel of vestibular hair cells. TRPA1 channel is member of the transient receptor potential channel family of ion channels, which are of paramount importance for different physiological processes. Conclusions: Electrophysiological experiments on vestibular hair cell are essential for an all over understanding of the pathophysiology of the Menie`re´s disease. The inﬂuence of cinnarizine on the ion currents on guinea pig vestibular hair cells we showed attests the positive effects of this drug in the treatment of the Menie`re´s disease. It also enables new therapeutic option of local application of this and other drugs in the treatment of Menie`re´s disease.

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OP 110 Evaluating the apoptotic process in the organ of Corti at 6 h after neomycin treatment Roxana Vintila, Hubert Lowenheim, Karina Gultig, Marioara Poenaru, Stan Cotulbea ENT Department Timisoara Romania, Tuebingen Hearing Research Center Objectives: To detect on experimental way in what measure neomycin determines apoptotic hair cell death in the organ of Corti at 6 hours after their contact with the antibiotic. To determine the sensitivity gradient between the different hair cell types in the organ of Corti. To evaluate the order of cytoplasmatic caspase 3, 8 and 9 activation Methods: The study took place in Tuebingen Hearing Research Center. Cochleas harvested from 7 days old mice were incubated for 6 hours in rotatory bioreactors in the presence or absence of neomycin and were afterwards treated with ﬂuorochrominhibitors for caspase 3, 8 and 9. Results: The average number of cells in which caspase 3, 8 and 9 are active is signiﬁcantly increased in neomycin treated cohcleas compared to the controls. The ﬁrst row of outer hair cells is ﬁrst affected by neomycin. There are signiﬁcant differences between the neomycin sensitivity for cells in the medial and basal segment of the Corti Organ and the apical segment. The apoptotic process starts with activation of caspase 8 which determines activation of caspase 9 followed by caspase 3. Conclusions: Neomycin induces apoptotic hair cell death characterized by caspase 8 activation followed by caspazes 9 activation and ﬁnally by caspase 3 activations.

OP 111 Metallothioneins contribution to protection from noise-induced hearing loss A. Eleftheriadou1,3, J. Garcia1, M. A. Gratton2, S. P. Tinling1, T. J. Patel2, A. E. Va´zquez1 1 Department of Otolaryngology, and Center for Neurosciences, University of California, Davis, Davis, CA 95616, USA; 2 Department of Otolaryngology, University of Pennsylvania, Philadelphia PA 19104, USA; 3Department of Otolaryngology, G. Gennimatas Hospital, Athens, Greece Objectives: Metallothioneins (MTs) have protective roles against various types of cellular injury. The aim of this study was to enhance our understanding of the role of MTs as related to the molecular basis of susceptibility to noise-induced hearing loss (NIHL). Methods: We detected the expression of MTs in the membranous labyrinth of mice using gene arrays. Taking advantage of the availability of genetically altered mice that do not express MTI or II (MTKO) isoforms, we evaluated their contribution to hearing function. Results: MTKO mice had comparable baseline ABR thresholds to mice of their parental strain (129 SvImJ). ABR measures obtained after exposure to a 1-h, 105-dBSPL, octave band of noise centered at 10-kHz revealed that MTKO mice exhibited a greater threshold shift (TS) than the parental strain. A large variability in the TS of the MTKO mice was also apparent. TS analysis suggested that at least two populations of MTKO mice

S235 exist with respect to their susceptibility to NIHL. A greater susceptibility to NIHL was apparent in a subpopulation of the MTKO mice, when compared to the parental strain. In the second subpopulation of MTKO mice, the high resistance to NIHL exhibited by the parental strain was not compromised. Additionally, hearing thresholds at 6 and 11 months of age in this MTKO subpopulation were similar to the parental strain. Conclusions: The data indicated that MTs interact with yet other modiﬁer(s) conferring resistance to NIHL and that the inbred SvImJ mice are heterogeneous with respect to the expression of these modiﬁer(s).

OP 112 TNFa modulates spiral modiolar artery tone via regulation of the endogenous sphingosine kinase 1 Elias Q. Scherer1,2, Darcy Lidington4, Bernhard Friedrich Peter2, Stuart M Pitson3, Wolfgang Arnold1, Ulrich Pohl2, Steffen-Sebastian Bolz4 1 ENT-Department, Technical University of Munich, Germany; 2 Institute of Physiology, Ludwig-Maximilians University, Munich, Germany; 3Institute of Medical and Veterinary Science, Adelaide, Australia; 4Department of Phyiology, University of Toronto, Canada Objectives: Blood supply to the inner ear is entirely dependent on adequate blood ﬂow through the spiral modiolar artery (SMA). Consequently, even minor constriction of this artery can cause inner ear ischemia. Despite its potential clinical importance, our knowledge regarding the endogenous tone- and resistance-regulating mechanisms of the SMA is limited. We have previously shown that sphingosine-1-phosphate (S1P) induces strong vasoconstriction of the SMA. We proposed (i) that endogenous S1P (generated by sphingosine kinase 1; Sk1) is a key regulator of SMA tone; and (ii) that TNFa, an inﬂammatory cytokine associated with several inner ear pathologies, potently activates Sk1 in the SMA. Methods: Gerbil SMA were isolated, cannulated (25 mmHg transmural pressure) and cultured for 19–21 h with plasmids encoding green ﬂuorescent protein (GFP), GFP-tagged Sk1 (hSk1-GFP) or a catalytically inactive mutant of Sk1 (hSk1G82D). Results: Compared to non-transfected vessels, GFP expression did not alter vasoconstriction induced by exogenously applied S1P (n = 5) or the diameter-Ca2+i relationship (Ca2+-sensitivity). Expression of hSk1G82D (n = 7) signiﬁcantly shifted the diameter/Ca2+i relationship to the right. In contrast, treatment of the SMA with 1 nM TNFa (2 h, n = 6) left-shifted this relationship, an effect that could be prevented by the expression of hSk1G82D (n = 7) or by treatment with the TNFa receptor antagonist Ethanercept (1 lg/ml, n = 4). TNFa was also observed to stimulate the translocation of Sk1-GFP to the plasma membrane, indicative of Sk1 activation. Conclusions: We conclude that Sk1/S1P contributes to the physiological tone regulation of the SMA, primarily by a mechanism involving the modulation of Ca2+ sensitivity. TNFa activates Sk1 in the SMA, leading to enhanced Ca2+ sensitivity. Thus, TNFa could be a primary mediator of several inner ear pathologies (e.g., sudden hearing loss) via S1P-mediated augmentation of SMA contractile apparatus Ca2+ sensitivity and hence, vessel tone.

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OP 113 Polymorphism of gene CC16 as predisposing marker of OME development I. Tikhomirova, Y. Yanov, V. Chastnyk, V. Larionova St. Petersburg ENT Research Institute, Bronnitskay 9, St. Petersburg, Russia Purpose: We’ve tried to study the role of genetic predisposing to the forming of chronicle OME Methods: The ﬁrst checked group was consisted of 31 children with OME. The second group of 24 children went for adenotomy without ears pathology. All children were checked up according to system, including: audiometry, thympanometry, 3 generations genealogy analysis, gene polymorphism Il-4, Il-4R, CC16. DNA isolation was made from blood leucocytes. Polymorphism alleys identiﬁcation was made by restriction analysis. Il-4 (-590 C>T), Il-4R (Gln551Arg), CC16 (38 G > A) polymorphism was determined. The results were saved and processed in Exel database. Results: Gene Il-4 and Il-4R polymorphism does not differ signiﬁcantly in ﬁrst and second group. It cames up to Il4-0,29 and 0,25 correspondingly and for Il-4R-0,29 and 0,33 correspondingly. Frequency detection of polymorphism alley A of gene CC16 (38 G>A) in OME group was 0,5, while in comparison group it was 0,25. The data are reliable. Conclusions: Supposingly are certain groups gene, which polymorphism is risk factor in OME development. To this group we can also refer gene CC16, responsible for bronchus secret regulation.

OP 114 Strategies to limit host responses against adenovector mediated inner ear gene transfer Mark Praetorius, Chi Hsu, Douglas Brough, Peter K. Plinkert, Hinrich Staecker University of Heidelberg Medical, Department of Otolaryngology; Genvec Inc., Gaithersburg, MD, USA; University of Kansas Medical, Department of Otolaryngology Adenovector mediated gene delivery has been used to alter the phenotype of the inner ear in a variety of animal models of hearing loss. Adenovectors are versatile, easy to manufacture and modify and have a high payload capacity. We studied the immunogenicity properties of these vectors and resulting impact on gene delivery. Studies in other systems (eye and skeletal muscle) have demonstrated that immune response to adenovectors is dependent on the total dose of vector delivered. Consistent with these ﬁndings we have shown in a mouse model that we can transfect a broad range of inner ear tissues in mice pre-immunized with Ad5 without damaging hearing by limiting the total dose delivered and route/

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 site of administration. Further reﬁnement of enhanced delivery was gained by using a tropism enhanced Ad5 based vector with heparin binding, which allows efﬁcient delivery of an even lower dose of vector. Vectors that preferentially bind alpha V integrin were less effective. We are also testing an additional strategy to avoid pre-existing host responses by evaluating the transfection of inner ear tissues with adenovectors constructed from different adenovirus serotypes. We demonstrated that transfection of inner ear tissue can also be accomplished by using alternative serotypes of adenovectors. Our conclusions are that development of adenovector based molecular therapeutics in the inner ear will be improved by limiting the dose of total particles delivered, by enhancing binding to target cells, by using vectors from alternative adenovirus serotypes which are not immuno-recognized and by carefully controlling the entry point to the inner ear.

OP 115 Toxicological evaluation of sustained-release vehicle-Poloxamer 407 on the inner ear morphology and hearing function after perfusing in round window niche Feng Hong-yun, Sun Jian-jun, Jiang Wei, Jiang Ping Center of Otolaryngology of People’s Liberation Army, Naval General Hospital, Fucheng Road 6, Beijing 10037, China Objective: To observe the biodegradation and absorption of Poloxamer 407 in vivo, and the effect on the function and morphology of the inner ear after perfusing in round window niche. Methods: The right ears of 16 guinea pigs as experimental group were perfused with 20% Poloxamer 407 solusion 100ll in round window niche, the left ears as control group with normal saline. Another 4 animals without treatment were in negative control group. Auditory function was investigated before and immediate, 7, 14, 28, 49 days after perfusion, Then the histology of 2 animals’ bulleas were examined by means of serial section after parafﬁn imbedding and the cochlear basilar membranes of other 2 animals were stained with silver nitrate after ABR examinations at every time interval. Results: The ABR threshold to ﬁltered clicks were elevated after perfusion, and were recovered to normal at 49 days after perfusion. The morphology of inner ear was not signiﬁcantly damaged after perfusion. Conclusions: Poloxamer 407 can be biodigraded in vivo or discharged via eustachian tube, and cause temporary changes on auditory function of inner ear after perfusion in the round window niche, but no inreversible and persistent damage on function and morphology of inner ear. Therefore, Polomamer 407 can be used as sustained-release vehicle in middle and inner ear diseases. Key words: Sustained-release vehicle; Poloxamer 407; round window niche; inner ear; hearing function

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OP 116 Genetic and functional analysis of human mutation (R150Q) in pres gene Levente Dea´k1,4, Tı´ mea To´th2,, Ferenc Fazakas3, Jing Zheng4, La´szlo´ Muszbek3, Istva´n Sziklai2 1 St. Imre Hospital, Department of Otolaryngology (Hungary); 2 Medical and Health Science Center University of Debrecen, Department of Otolaryngology (Hungary); 3Medical and Health Science Center University of Debrecen, Clinical Research Center (Hungary); 4Auditory Physiology Laboratory, Departments of Communication Sciences and Disorders, The Neuroscience Institute, Northwestern University, Evanston (USA) Outer hair cells in the mammalian organ of Corti display electromotility, which is thought to provide the local active mechanical ampliﬁcation of the cochlear response. Prestin is the key molecule responsible for OHC electromotility. Hearing sensitivity is degraded by 40–60 dB in the absence of the motor molecule. The motor molecule is a modiﬁed transporter molecule, which belongs to the SLC26A anion-transport family. SLC26A5 (pres) gene contains 21 exons and localized on the long arm of chromosome 7 (7q22.1). In the present study we describe the results of a direct sequencing mutation in pres gene that was performed in 47 patients characterized with nonsyndromic, mild to moderate hearing impairment (30–70 dB) and in 50 control subjects without HI. The possible role of Connexin 26 and Connexin 30 mutations in the background had been excluded previously.One young 4 years old-male patient with moderate hearing impairment had a heterozygous misssense mutation (R150Q/WT) on the 6. coding exon of pres gene. His father had a same type of mutation, however he showed a normal hearing. None of the 50 control subject and 46 patients showed similar mutation.To monitoring the R150Q mutant electrophysiological properties, we transiently transfected this mutation into TSA201 cell line. Both homo-, and heterozygous form of the R150Q mutation showed signiﬁcant differences in their peak voltage of the capacitance function compared to wild type. Although, there were no statistically signiﬁcant differenece of average charge density and slope factors of the nonlinear capacitance curves between the R150Q mutant and wild type.This is the ﬁrst human mutation in coding exon of pres gene, where both in vivo and in vitro analyzis had been performed.

OP 117 Tympanic membrane perforations: video-otoscopy versus interobserver estimation Titus S. Ibekwe, Onyekwere G. Nwaorgu, Aderemi A. Adeosun, Daniel D. Kokong, Hakeem O. Lawal, Patrick O. Okundia Department of Otorhinolaryngology, University College Hospital, Ibadan, Nigeria The accurate estimation of the size of tympanic membrane(TM) perforations is necessary for its management. In the past, Otologists relied mainly on the visual estimation of the size of TM

S237 perforations. Currently, some computer based programmes such as video otoscopy had been designed for such estimations to promote accuracy. The question still remains, how reliable is visual method of estimation? Objectives: To compare the inter-observer estimates of the tympanic membrane perforations by the different cadres of the ENT specialists with video-otoscopy calculations. Methods: A hundred TM perforations were visually estimated independently by two randomly drawn ENT Registrars, Senior Registrars and Consultants with conﬁrmed good vision. The Video-otoscope [Welch-Allyn Compac System Model 23120 (NTSC) and 23120P (PAL)] images of the TM perforations were adapted through Cute TV USB [Model no-03020701] on the computer. Image J [version1.35j) geometrical package was used to calculate the percentage area. Comparative analysis and stastiscal signiﬁcance were tested with SPSS 11 package. Results: The TM perforation sizes (%) from video otoscopy, Consultants, Senior Registrars and registrars ranged as 0.9 to 98%, 1.5–96.5%, 1.5 to 97.5% and 3 to 96%; with means of 44.08%, 51.62%, 52.91% and 56.09% respectively. The difference between the results of the visual estimates by ENT specialists compared with the video-otoscope were signiﬁcant (P = 0.000). Conclusion: The error of visual estimation of TM perforation is highly signiﬁcant even among the most experienced Otorhinolaryngologists. Therefore video-otoscopy /computer-based estimation is recommended.

OP 118 Telemedicine in clinical and educational activity H. Skarzynski, R. Podskarbi-Fayette, P. H. Skarzynski, Ł. Bruski, P. Kochanowicz International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Mokra 17 st, Kajetany, 05– 830 Nadarzyn, Poland. Objectives: Development of the teleinformative technologies allows us for the immediate access to the whole recources and activities of the Clinic on site at the hospital, supervision of a patient at home, and participation of the large audience in events without necessity to move. Methods: Material consists of experience gained during: constant teleconsultations-observation of about 30–35 operations performed everyday by doctors specializing in otolaryngology, audiology and phoniatrics; Participance of foreign and national experts; Planning and supervising remote rehabilitation of hearing and speech, in patien’s home within ‘‘Home Clinic of Rehabilitation’’ Results: our experience in application and use of more advanced technologies allows us to disseminate the newest knowledge clearly among physicians. It helps to reduce costs, reduce the distance. Patient does not need to travel around the country. Conclusions: These circumstances signiﬁcantly change efﬁcacy of treatment and rehabilitation.

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OP 119 3D and MPR CT reconstructions in post-traumatic otologic complications Michal Kotowski, Ewa Dybiec*, Artur Niedzielski, Grazyna Niedzielska Departament of Pediatric Otolaryngology, Phoniatrics and Audiology, Medical University of Lublin; *Department of Pediatric Radiology, Medical University of Lublin ul.Chodzki 2, 20– 093 Lublin, Poland Objectives: As a result of facial skeleton trauma in children, early complications may occur in the form of nasopharyngeal obstruction, epistaxis, bloody discharge or otorrhoea. Hearing loss and balance disorders as well as inﬂammatory processes in paranasal sinuses are some distant post-traumatic disturbances. The aim of our study was to assess the usefulness of 3D and MPR CT reconstructions in the diagnostics of otologic complications after facial skeleton trauma in children. Material & Methods: The research covered 23 children with facial skeleton trauma who were radiologically examined with the use of computed tomography in the year 2006. Laryngologic examinations were conducted in all the patients directly after the incident and after the completed treatment. Nasopharynx patency, hearing level and status of balance organ were assessed on the basis of clinical examination and audiometry. Control CT with 3D and MPR CT reconstructions were performed in all complicated cases. Results: CT scans revealed post-traumatic lesions in 15 cases. Clinical complications were observed in 46.6% of children with facial trauma and they included post-traumatic hearing loss (2 cases), tinnitus (1 case), vertigo (1 patient), chronic nasal discharge (3 children). Control computed tomography examinations with 3D and MPR CT reconstructions enabled for visualization of the causes of complications in 5 cases. Conclusions: Control CT examinations with 3D and MPR CT reconstructions are useful in evaluation of causes of complications in children after facial skeleton trauma.

OP 120 A scanner noise impact on functional magnetic resonance imaging studies P. Bogorodzki1,2, E. Piatkowska-Janko 2, T. Wolak2, L. Sliwa1, K. Kochanek1, M. Orzechowski2, R. Kurjata 2, M. Golebiowski3, H. Skarzynski 1 1 Institute of Physiology and Pathology of Hearing in Warsaw; 2 Institute of Radioelectronics, Warsaw University of Technology; 3 1st Department of Clinical Radiology, Medical University of Warsaw

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 The aim of the study was to measure the level of impact of the Echo Planar Imaging (EPI) sequence noise on BOLD response in auditory cortex area. For each of the 20 healthy subjects at age 23.6 ± 0.7 four functional ‘runs’ were acquired with variable TR and block type acoustic stimuli with (/ka/, /ta/, /pa/, /ga/, /da/, /ba/) syllables in 30s length ‘on’ periods. In order to detect linear dependence of activation volume in dependence of TR a linear model was applied giving two regression parameters for each hemisphere. Activation was detected in both hemispheres for all functional runs. The mean activation size averaged across the runs was 32 and 25 cm3 for left and right hemisphere respectively. Pair-wise comparisons between groups TR2-TR3, TR2-TR4, TR2-TR6 did not show any differences on the a = 0.05 level. The presented work revealed a single percent range dependence of activation size in dependence from varying amount of noise in stimulating paradigm. The linear relation was rejected suggesting nonlinear relation between mentioned variables. A region of interest based approach may allow more quantitative or semiquantitative analysis of functional activations.

OP 121 MRI as a useful tool in diagnosis of cholesteatoma? Gerhard Moser1, Ursula Unterberger1, Ernst Doringer2, Klaus Albegger1 1 ENT-Clinic, Salzburger Landeskliniken and Paracelsus Private Medical University, Salzburg, Austria; 2Institute of CT and MRI, Innsbrucker Bundesstr. 83a, 5020 Salzburg, Austria Objectives: To evaluate if MR-imaging is able to detect primary and residual/recurrent cholesteatomas in patients who have undergone middle ear surgery in order to prevent second look surgery. Methods: Fifteenpatients (11 male, 4 female) with clinically suspected cholesteatoma had both high resolution CT scanning and MRI of the middle ear. Of these were 8 patients with primary cholesteatoma and 7 who were scheduled for second look surgery. MRI (1,5 T) was performed with a Siemens Magnetom Symphony using diffusion-weighted (DW) single shot coronal sections T1 SE native and with Gadolinum axial 3 mm and T2 TSE coronal 3 mm slices as well. Results: Diffusion weighted MRI combined with conventional MR imaging depicted 13 out of 15 (sensitivity 86,6 %). One was false negative—surgically conﬁrmed cholesteatoma, but only containing matrix without signiﬁcant proliferation, the other was false positive—only inﬂammatory material in the mastoid cavity. Conclusions: The presented MRI protocol is able to depict middle ear cholesteatoma in a high percentage. The problem however is the false negative statement (with potential fatal consequences). Therefore to date second look surgery cannot be replaced by MRimaging of the middle ear.

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OP 122 Immunohistochemistry of otosclerosis Tama´s Karosi, Istva´n Jo´kay, Jo´zsef Ko´nya*; Istva´n Sziklai University of Debrecen, Department of Otorhinolaryngology Head and Neck Surgery; *University of Debrecen, Department of Medical Microbiology Objectives: Stapes ankylosis is a disease with variable histopathology caused by otosclerosis or pseudo-otosclerosis. Persistent measles virus infection of the otic capsule could induce reactivation of embryonic osteoclasts and increase the expression of measles virus receptors (CD46) in otosclerotic foci. Methods: Nucleic acid was extracted from ankylotic stapes footplates removed during stapedectomy (n = 261). Measles virus RNA was ampliﬁed by RT-PCR. Results were correlated to histologic- and both CD46 and CD51/61 speciﬁc immunohistologic ﬁndings. Alcalic phosphatase activity assessment was performed to evaluate metabolic activity of osteoclasts. Results: One hundred and seventy-ﬁve otosclerotic stapes contained measles virus RNA. Histology for virus negative stapes (n = 86) represented nonotosclerotic disorders. Otosclerosis was featured by increased numbers of osteoclasts showing strong CD46 expression and by the presence of osteoclasts with embryonic phenotype. In virus negative stapes ﬁxation and in normal stapes footplates weak CD46 and missing CD51/61 immunoreaction was demonstrated on the osteocytes and ﬁbroblasts. In otosclerosis, alcalic phosphatase activity was higher compared with nonotosclerotic stapes ankylosis. Conclusions: The presence of CD51/61 positive osteoclasts in otosclerotic bone containing viral sequences provides the basis for an inﬂammatory bone remodeling disorder. In otosclerosis, it is reasonable to assume that measles virus increases the expression level of its own cellular receptor. Furthermore, intensive CD46 reaction could relate to active virus replication and continuous receptor internalization. Otosclerosis is a disease caused by persistent measles virus infection and reactivation of resting embryonic osteoclasts with special CD46 receptor pattern in the otic capsule.

S239 ference between two groups for preoperative and postoperative mean air-bone gap (P = 0,491 and P = 0.116). Besides, preoperative-postoperative mean air conduction difference in tinnitus ceased group was 33 ± 2 dB and it was 28 ± 3 dB in no change group. Conclusions: In patients with hearing loss and tinnitus due to otosclerosis, tinnitus was ceased among half of the patients after stapedotomy operation and there is a relation between tinnitus course and hearing levels of the patients.

OP 124 Economic viability and results of stapes surgery Eleftherios Savvas, Jan Maurer Katholisches Klinikum Marienhof, Koblenz, Germany We report on 164 consecutive cases of primary stapedotomies performed on patients with otosclerosis. The postoperative airbone gap average at the frequencies 500, 1,000, 2,000, and 4,000 Herz was under 10 dB for 62% of the patients, and under 20 dB for 92% of the patients. There was a postoperative sensorineural hearing loss in 1.2% of the patients. In order to determine the economic viability of the procedure, we compared the cost of the operation to the retail value and average cost of a lifelong supply of hearing aids. Results of the calculations show that even by an elderly patient at the age of 65 with a life expectancy of 15 years, the cost for lifelong hearing aids is higher than a stapedotomy procedure. Based on our group of patients the stapedotomy procedure proved to be 1 million Euros cheaper than the treatment with an averagely priced hearing aid. The economic beneﬁt is not only present when taking into account a possible revision surgery in 5–10% of cases, but also if in addition to the surgery a post-operative hearing aid is required in for example 20% of cases. In conclusion, stapes surgery is economically beneﬁcial for the individual patient as well as for the cohort irrelevant of age. The stapedotomy procedure also prevents the known disadvantages of conventional hearing aids improving the quality of life of the patient.

OP 123 Effect of otosclerosis surgery on tinnitus

OP 125 Inner ear malformation mimicking otosclerosis: a case report

Fatma Caylakli, Haluk Yavuz, Levent N. Ozluoglu Baskent University Faculty of Medicine, Otorhinolaryngology Head and Neck Surgery, Ankara, Turkey

C. Bellini, B. Fabiano, R. Teggi, F. Lira Luce, L. O. Piccioni Department of Otorhinolayngology S.Raffaele Hospital Vita-Salute University, Milano, Italy

Objectives: The aim of this study is to investigate the possible correlation between tinnitus and hearing level and the effect of surgery on tinnitus in otosclerosis patients with tinnitus. Methods: In this study, 55 patients (59 ears) operated for otosclerosis with tinnitus were retrospectively reviewed. Preoperative and postoperative mean air and bone conduction, mean air bone gap and speech discrimination scores in postoperative tinnitus ceased and tinnitus no change groups were evaluated. Results: It was detected that tinnitus was ceased in 30 ears and no change in 29 ears on postoperative 3rd month control. Preoperative and postoperative mean bone conduction, mean air conduction, speech discrimination scores were better in tinnitus ceased group than no change group (P = 0.001, P = 0.001,P = 0.002 respectively). Whereas there was no dif-

In 1978, Vavassori and Clemis described a radiologically identiﬁed large vestibular aqueduct in patients with a progressive hearing loss. Hearing loss is sensorineural with a conductive component in 15–27% of the cases. In literature we have found a report about a case with unilateral large vestibular aqueduct syndrome and stapes ﬁxation mimicking clinically otosclerosis. We report a case of a woman with a right mixed hearing loss with an important conductive component on low frequencies, absence of stapedial reﬂex and a sensorineural hearing loss on the left side. Otosclerosis was the ﬁrst diagnosis. CT scan and MRI showed a bilateral large vestibular aqueduct and an intradiploic dermoid in the right temporal bone.

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OP 126 Inferior displacement of the utricle: a practical problem for the stapes surgeon I. J. Keogh, R. Haeusler Department of Otorhinolaryngology Head and Neck Surgery, Inselspital, University of Bern, 3010 Bern, Switzerland Objectives: The utricle is located between 1.7 and 2.4 mm from the under surface of the stapes footplate and is usually not encountered during stapedotomy. This study describes the intraoperative ﬁndings of nine stapedotomies, where an inferiorly displaced utricle was identiﬁed. Our technique to avoid injury to the utricle is described. Methods: Retrospective case review of stapedotomies performed for otosclerotic stapes ﬁxation between 2003 and 2006. Stapedotomies were performed under local anaesthetic by a transcanal approach through a ﬁxed aural speculum. Argon laser-skeeter drill were used to perform stapedotomies in the inferior mid third of the stapes footplate. Results: Three hundred stapedotomies were performed. Nine patients, 6 female, 3 male, age range 40–55 years were identiﬁed. All were medically ﬁt with no history of vertigo. All had primary stapes surgery. In each case a cream coloured membranous structure was noted to be bulging from superior to inferior deep to the fenestration. Findings were consistent with inferior displacement of the utricle. A short Richards–Piston was inserted to avoid injury to the utricle, piston diameter 0.4–0.5 mm, piston lengths: 4.0 mm one patient, 4.25 mm seven patients, and 4.5 mm one patient. All had temporary postoperative vertiginous symptoms, recovery otherwise uneventful with long term hearing gain in all. Conclusions: The stapes surgeon must have the knowledge and skill to deal with a variety of anatomical anomalies. Inferior displacement of the utricle is uncommon (3%). Recognition is the key and simple modiﬁcations to surgical technique, such as using a shorter piston will help avoid complications.

OP 127 Surgical management of congenital malformations of the middle ear H. Skar_zyn´ski1, M. Porowski1, B. Skarzynska2, R. Podskarbi-Fayette1 1 International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Mokra 17, Kajetany, Warsaw, Poland; 2Department of Anatomy, Medical University in Warsaw, Poland Objectives: The aim of the study was to develop a standard for diagnostics and surgical management of congenital malformations of the middle ear.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Methods: Congenital malformations were found in 637 ears in the material of over 30 000 surgically treated ears. For the purpose of this study, 429 ears were considered, for which the postoperative follow-up period was minimum 3 years. The primary diagnosis of the middle ear malformation was based upon radiological examination, and then veriﬁed intraoperatively. In 369 of cases exploratory tympanotomy was performed applying the approach through the meatus. In some ears it was widened. In the remaining cases, total reconstruction of the canal was necessary. Results: In 394 ears remnants of the middle ear elements were used for reconstruction of the malformed or immobile ossicular chain. In 33 ears application of different kinds of allogenic materials was necessary. Improvement of hearing sensitivity was obtained in 89,7% of operated patients. Conclusions: the results conﬁrm great progress in surgical treatment of ear malformations. Allogenic materials proved to be very useful in the middle ear reconstruction. Final effects, however, depend on complexity of the malformation within the middle ear and in other parts of the facial skeleton.

OP 128 Osteopetrosis—case reports Emilia Katska, Robert Kaczmarczyk, Katarzyna Drabko, Gra_zyna Niedzielska, Magorzata Kostrzewa, Agnieszka Trojanowska, Danuta Skomra Depatrment of Paediatric Otorhinolaryngology, Phoniatry and Audiology, Medical University, Lublin, Poland; Depatrment of Paediatric Oncology and Haematology, Medical University, Lublin, Poland; Depatrment of Paediatric Radiology, Medical University, Lublin, Poland; Depatrment of Neurosurgery and Paediatric Neurosurgery, Medical University, Lublin, Poland; Depatrment of Pathomarphology, Medical University, Lublin, Poland Osteopetrosis is an extremely rare inherited disorder whereby the bones becoming denser. We distingnish 2 forms of this syndrome:with early symptoms and Albers–Schonberg disease. There are intermediate forms as well. In our report we present 2 girls with early and late form of this syndrome. KS´-3-year old girl with form with premature symptoms: congenital blindness, disturbances in sceletal system and in hematopoesis. She underwent bone marrow transplantation in age of 3 months. This procedure stopped obliteration of the bone marrow. ML-8-years old girl with benign form who was prevented against blidness by neurosurgery. Both girls are in audiological,neurosurgical, ophtalmological and haematological suirvailance. We present these cases because they are very rare. At the moment children haven’t got eitherolfactory nor acoustic nerve disturbances.

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OP 129 Auditory Neuropathy: Clinical Picture and Auditory Tests Results as a New Syndrome

of etiology (equivalent terms are secretory otitis media and serous otitis media). When MEP is below –200 cm H2O, the likelihood of MEE increases. Several schemes for classifying and interpreting tympanograms have been suggested, but regardless of the classiﬁcation system used, the amount and character of MEE do not ﬁt well-deﬁned criteria and are difﬁcult to interpret. Methods: In vitro measurements of the middle ear input immittance were performed in three temporal bones extracted from human cadavers, ﬁlling the middle ears via the Eustachian tube from the pharyngeal oriﬁce with 1,2,3 and 4 ml of water. Different patterns of tympanograms (widths and peak pressure difference) were registered depending on the amount of the ﬂuid. We also measured the total middle ear volumes. Results: All bones were succesfully ﬁlled through the Eustachian tube. The average middle ear volume was 4.1 ml. One ml of water in the middle ear did not cause change in shape of the tympanogram registered. The minimum detectable amount of MEE was 1.33 ml in average. Conclusions: Small amount of MEE can be undetectable by tympanometry. Cadaver middle ears are useful models.

Susan Abdi Tehran University of Medical Sciences, Tehran, Iran Objectives: To describe the clinical picture of the patients with the key clinical feature of hearing loss for pure tones and reduction in speech discrimination out of proportion to the pure tone loss, having some of the criteria of auditory neuropathy (i.e. normal otoacoustic emissions, OAE, and abnormal auditory brainstem evoked potentials, ABR) and lacking others (e.g. present auditory reﬂexes). Methods: During 1997–2005, in a retrospective study, patients’ records were reviewed and the results of OAE and ABR and pure tone audiometry (PTA) were tabulated as well as speech discrimination scores (SDS), measured in all patients using a standardized list of 25 monosyllabic Farsi words at MCL in quiet. Results: Both ears of 9 patients (5 males and 4 females) comprised the study population. Mean age at the onset was 15.2 ± 3.5. Hearing thresholds were measured at 250–8,000 Hz at octave intervals. SDS had a mean ± SD of 29.2 ± 30.7. A strong signiﬁcant correlation was noted between SDS and hearing threshold. Six samples (33%) had auditory reﬂexes. All of the patients were suffering from different degrees of tinnitus. Four patients were able to hear music, without understanding the words of the singer, although the SDS in all of them was no more than 10. Conclusions: Reviewing the medical records revealed deterioration of hearing and speech discrimination over time. Although in most of the cases the hearing loss had been more apparent in the lower frequencies, a stronger correlation was found between SDS and hearing threshold at higher frequencies. These patients may not beneﬁt from hearing aids, as the outer hair cells are functional and ampliﬁcation doesn’t seem to help; though, it was tried for all.

OP 130 Possibilities and limitations of the use of tympanometry in diagnosing middle ear effusion: a human temporal bone study Zolta´n Papp;* Csongor Gyo¨rgy Lengyel; Istva´n Sziklai Department of Otolaryngology Head & Neck Surgery, University Medical School of Debrecen, Debrecen, Hungary, H-4012, Nagyerdei Krt. 98., Debrecen, Hungary; *Department of Otolaryngology Head & Neck Surgery, Jo´sa Andra´s County Hospital, Nyı´ regyha´za, H-4400, Szent. I. u. 68., Nyı´ regyha´za, Hungary Objectives: Tympanometry has become a valuable and widely spread diagnostic tool, a standard of care for evaluating middle ear pressure (MEP) in cases of middle ear effusion. Middle ear effusion (MEE) denotes a liquid in the middle ear cleft regardless

OP 131 The inﬂuence of the pathology of the lymphatic pharyngeal ring on functional condition of Eustachian tube in children E. Merkulova, J. Kolajdiz, A. Levaj Belorussian State Medical University, ORL – Department The inﬂuence of the different pathology of pharyngeal lymphatic ring to the ventilation of the middle ear in children was studied with the method of the acoustic impedansometry. Children were divided into three groups: with adenoids (N = 206); with hypertrophy of palatal tonsils +adenoids (N = 66); with the chronic tonsillitis (N = 36) where N—number of the examined ears. The age of the children 2 to 15 years were treated. Incorrect ventilation function of the middle ear in children with adenoids was revealed in 75.2% (N = 155/206), severe dysfunction of Eustachian tube with registration tympanograms type ‘‘B’’ were observed in 57, 7% examinations. Obstruction of Eustachian tube was more frequent in second age group: in 87.9% examinations (N = 58/66).At the same time, chronic tonsillitis without hypertrophy is seldom a cause of dysfunction of Eustachian tube: only 2 of 36 tympanograms being analysed, marked negative pressure in the tympanic cavity. While comparing the age-groups by the X-test there was statistically authentic difference P = 0, 0463 (comparison of 1–2 groups, P = 0, 0044; 1–3 groups, P < 0, 0001; 2–3 groups, P < 0, 0001). Conclusion: Children with hypertrophy of palatal tonsils in combination with adenoids make a group of risk of the dysfunction of Eustachian tube.

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OP 132 Newborn hearing screening using ABR and OAE Virgilius Draganescu, Delia Trales, Gheorghe Iovanescu, Nicolae Balica, Roxana Vintila ENT Department Timisoara Objective: According to the recommendations of the Joint Committee of Infant Hearing, neonatal hearing screening programs are now implemented in ENT Department Timisoara, Romania, since February 2006. We intended to assess the importance of ABR and OAE as objective testing of hearing in newborn infants with the goal to identify all hearing impaired infants at an early age, thereby increasing these children‘s chance at healthy lives. Methods: All 2,674 neonates from maternity hospital were assessed using evoked otoacoustic emissions and brainstem evoked response audiometry, between February and December 2006. All of them were tested shortly after birth. Results: From the 2,674 neonates, 2,669 passed the tests and 5 failed (1.87%). From those who failed, 4 (80%) had a risk factor for hearing impairment. Infants who do not pass the screening are referred for follow up audiological and medical evaluation that should occur no later than 3 months of age. These evaluations conﬁrm the presence of hearing loss, determine the type, nature and (whenever possible) the cause of hearing loss, and help identify options for treatment. Conclusions: The percentage of infants with hearing loss accords to that from international literature (1–3&). Infant hearing loss occurs more often than any other problem screened for at birth. Finding such impairment helps to prevent early developmental delays that can hinder a child‘s physical, mental and emotional growth. ABR and OAE are non-invasive, objective physiologic measures, and the screening is necessary to be done in all newborn babies, because hearing loss does not occur only in high risk factors groups.

OP 133 Hearing loss into Albanian children, the risc factors and the prevalence Suela Sallavaci, Ylli Sallavaci, Alban Ylli, Pjerin Radovani* Objectives: Prevalence of hearing loss in some age cathegories, the dissemination of hearing loss into the albanian children, the evalutation of risc factors which might inﬂuence the hearing loss. Methods: Intersectional study which valutate the prevalence and the risc factors of hearing loss in one group of 400 children 4– 6 years old. Prevalence study: screening programme for the hearing loss in all children of the ﬁrst classes of elementary schools of Tirana (30% of population lives in Tirana) for the period 2003– 2006. (15112 children were included in this study). Results: Hearing loss consists 20% of all other physical and mental handicap. 40% of the children with hearing loss has passed OM at least once. More than 50% of hearing loss causes are prenatal one. Conclusions: In Albania three children in 1,000 born with sensorineural hearing loss. The Otitis Media results to be the factor which affect the hearing into albanian children. There is no difference in the prevalence of hearing loss between males and females. Children who lives in rural zones have high prevalence of hearing loss.

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OP 134 Reasons for late diagnosis of congenital hearing loss despite UNHS Doris Nekahm-Heis, Almut Hirst-Stadlmann, Viktor Weichbold, Kurt Stephan Department of Hearing, Speech and Voice Disorders, Innsbruck Medical University, A-6020, Anichstrasse 35, Austria Objectives: Although Universal Newborn Hearing Screening (UNHS) was introduced in Austria already in the mid nineties, current data on age of identifaction of congenital hearing loss still show a delayed diagnosis in about 30% of children. Reasons for this shortcoming were studied in children born in the Tyrol. Methods: In a retrospective analysis, data of children with bilateral, at least moderate hearing loss, born after implementation of UNHS were examined. Age at identiﬁcation of hearing loss as well as former assessment were evaluated based on clinical charts and interviews with parents and professionals previously involved. Results: Fifteen out of totally 42 children with congenital hearing loss who had been screened according to the UNHS protocol were diagnosed after the age of 12 months. In three children, a progressive or late-onset hearing impairment was likely. In two children, UNHS was not completely ﬁnished and follow-up not performed. In four children, results of hearing testing were misinterpreted mainly because of concomitant otitis media with effusion. In two cases, parents refused consent to the investigation of hearing loss for a long period of time. Conclusions: The success of UNHS strongly depends on an effective follow-up concept including activities to improve parents’ compliance.

OP 135 Preliminary study: newborn hearıng screenıng with TEOAEs and ABR ın the Neonatal Intensıve Care Unıt B. Keles, K. Ozturk, Z. Cenik Objectives: The aim of the present study is to investigate frequencies of hearing loss and associated risk factors in infants at the Neonatal Intensive Care Unit (NICU) Methods: Two hundred and twenty-one newborns admitted to NICU were screened for hearing loss using transient evoked otoacoustic emissions (TEOAEs) and auditory brainstem response (ABR). The protocol which is the ﬁrst and second TEOAEs screening followed by ABR test was used. Risk factors such as prematurity, low birth weight, hyperbilirubinemia, congenital abnormalities, ototoxical drug, anoxia during delivery, respiratory distress syndrome and use of mechanical ventilation were recorded. Results:196 (88.7%) of 221 newborns were passed the TEOAEs testing bilaterally. The positive rates in the ﬁrst screening and second screening by the TEOAEs were 164 (74.2%) and 32 (14.5%) newborns, respectively. The remaining 25 (11.3%) newborns were evaluated by ABR test. The incidence of bilateral and unilateral congenital hearing loss were found 7 (3.2%) and 18 (8.1%) newborns, respectively. Conclusions: Our results showed that newborns in NICU have a high risk for hearing loss. Therefore, newborn hearing screening must be applied to newborns in NICU for early hearing loss identiﬁcation and hearing aid ﬁtting.

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OP 136 Morphological link between SOM and mastoiditis in children Ljiljana Vlasˇ ki, Dragan Dankuc, Slobodanka Lemajic´-Komazec, Zoran Komazec, Danijela Dragicˇevic´ ENT Clinic Clinical center -Novi Sad, University of Novi Sad, Faculty of Medicine, Serbia Objectives: Noncholesteatomatous otitis media is a very common pathology in children. This disease is often recurrent or chronic and followed by transitional or prolonged hearing damages. Methods: The investigation included 100 operated children with secretory otitis media or otomastoiditis. The samples consisted of 50 children of both sexes, aged under fourteen. According to protocol, both clinical entities investigated risk factors, clinical course, preoperative, intraoperative and postoperative morphological ﬁndings, as well as preoperative and postoperative functional ﬁndings. Results: The link between two clinical entities was proved predisposing factors with statistical importance level of P < 0.05. The statistical association was established between successive development of otomastoiditis and the middle ear disease developed earlier, with implied that the time when symptoms were recognized was no the onset of otomastoiditis. The intraoperative morphological ﬁndings of the tympanomastoid complex proved that the middle ear disease started earlier that it could be concluded from heteroanamnestic data on the symptomatic phase of both entities. Intraoperative morphological ﬁndings have proven parallelism between tympanic and tympanomastoid hyperpasia and mucoid effusion occurrences in both clinical entities, witch implies that not-cured or inadequately cured secretory otitis leads to otomastoiditis. Conclusions: Secretory otitis media and otomastoiditis are part of continuous pathological tympanomastoid process. Considering to the ﬁndings, the basic therapy should be artiﬁcial aeration made by ventilation tube insertion in proper time.

OP 137 Multi-year experience in application of multimedia hearing screening programs ‘‘I can hear’’ and ‘‘I can speak’’ H. Skar_zyn´ski1, A. Czy_zewski2, A. Senderski11, Ł. Bruski1, P. H. Skar_zyn´ski 1 1 International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Warsaw, Poland; 2Multimedia Systems Department, Technical University of Gdansk Objectives: The aim of the study is to present the results of local and country-wide implementation of multimedia hearing screening programs ‘‘I can hear’’ and ‘‘I can speak’’. It is also intended to show that these programs contributed to developing, on a large scale, early diagnosis and treatment of hearing and speech impairments. Methods: During last 8 years, over 1.5 million of children in the age of 7–13 years have been tested at schools all over the country. The

S243 examinations were carried out through the Internet or by means of dedicated diagnostic multimedia software installed on local computers at schools. Results: The realization of nation-wide hearing screening program, carried out owing to the application of the programs ‘‘I can hear’’ and ‘‘I can speak’’, made it possible to test a large number of children, while keeping the costs of the program at a very low level. The obtained results, stored in databases, were consequently used in early treatment of communication disorders. Conclusions: Implementation of the multimedia hearing screening programs gave beneﬁcial effects for the whole population of Polish schoolchildren. The important social effect is the development of prophylactics. For clinical medicine, it gave the possibility of early surgical intervention or rehabilitation, which currently pertains to over 2 thousand children each year.

OP 138 Hearing disturbances in audiological tests in children after hematopoetic stem cell transplantation Emilia Katska, Katarzyna Drabko, Gra_zyna Niedzielska, Agnieszka Zaucha-Pra_zmo, Marta Choma Dept. of Paediatric Otorhinolaryngology,Phoniatry and Audiology, Medical University, Lublin, Poland; Dept. of Paediatric Oncology and Haematology, Medical University, Lublin, Poland Objectives: Hematopoetic stem cell transplantation (HSCT) is the life saving procedure in children with malignancy and severe hematological disorders, however late effects may occur. Most common late effects are: chronic graft versus host disease (GvHD), endocrinological impairment, secondary malignancy and neuropsychological complication. In addition those patients in peritransplant period often are treated with several ototoxic drugs: aminoglicosydes, diuretics. Some data suggest that hearing loss is possible complication after HSCT procedure, especially when cyclosporine is introduced into the treatment. The aim of the study was to evaluate audiological test (pure-tone audiometry, impedance audiometry, otoacoustic emission and brain stem responses) in children 6 or more months after HSCT. Methods: Children (5–18 years old) were included into this preliminary study. There were allogenic and autologus HSCT recipients. Patients after allo HSCT were treated with CsA.Audiological tests were performed according to standards in audiological standards in our hospital. Results: High frequency hearing loss was found in six children (2 of them were treated with CsA). In another girl after CsA low frequency hearing loss was observed. Impedance audiometry was normal in all examined patients. There was a trend to longer latency of waves I, III, V of brain. This may suggest impairment of hearing pathway in the stem brain. Conclusion: In this preliminary study we found a hearing disturbances in children after HSCT. The audiological study will be continued in the future.

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OP 139 Distortion product otoacoustic emission in newborns treated to ototoxic Marisa Ruggieri-Marone1,2, Osmar Clayton Person2,3, Eliane Schochat1 1 Faculty of Medicine - University of Sa˜o Paulo; 2Faculty of Medicine of ABC; 3Centro Universita´rio Sa˜o Camilo (Sa˜o Paulo, Brazil). Dr Henrique Calderazzo, 321- Bairro Paraı´ so, Santo Andre´ 09190–610 /SP, Brazil Objectives: To research the amplitude of distortion product otoacoustic emissions (DPOE) caused by the ototoxic drugs use, between the end of the administration and from 15 to 40 days after its use. Method: Three groups were evaluated: control group with 33 term and healthy newborns; term study group with 19 term newborns with more than 37 weeks exposed to amicacin and/or vancomycin; and preterm study group with 15 preterm newborns from 32 to 37 weeks exposed to the same ototoxic. All newborns were evaluated at a corrected gestational age greater than 37 weeks. The otoacoustic emissions amplitudes (OEA) obtained at the hospital discharge were compared to the ones obtained from 15 to 40 days after the discharge. Results: The OEA of the preterm study group were smaller than the amplitudes of the control group and the term study group in both moments of the test. The amplitude of the newborns’ otoacoustic emissions increased in the second moment of the test. The amplitudes were higher in the frequency of 6.000 Hz and, in the right ear in the frequency f2 3.000 Hz. The OEA of the control group in the second moment of the test were similar to the term study group in the ﬁrst moment of the research. Conclusion: There was an increase of DPOE amplitude from the discharge moment until 15 to 40 days after. The exposure to amicacin and vancomycin on the recommended dose did not alter the OEA in the newborns with neonatal infection without risk indicators.

OP 140 Results of hearing screening in NICU babies A. Aspris1, C. Thodi2, I. Kyamides1, G. Thrasyvoulou1, D. Aristodemou1, M. Ioannou1, M. Kallimachou1, A. Iakovou1, Th. Papadouri3, Chr. Komodikis1. 1 ENT Department, Nicosia General Hospital, 1450, Cyprus; 2 Cyprus Audiology Center,P.O.Box 20739, Nicosia, Cyprus; 3 Neonatal Intensive Care Unit, Arch. Makarios III Hospital, 1474, Nicosia, Cyprus Objectives: to report the results of a newborn hearing screening program in the Neonatal Intensive Care Unit in Cyprus between 2003 and 2005.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Methods: A hearing screening program including automatic Transient Evoked Otoacoustic Emissions and Auditory Brainstem Response was implemented in the Neonatal Intensive Care Unit (NICU) population. Results: A total of 1369 infants were screened: of these children, 551 (40%) had additional risk factors for hearing loss as deﬁned by the Joint Committee on Infant Hearing. Six percent (76 infants) were referred for diagnostic hearing evaluation. Of the referred children, 25 had normal hearing, 18 were lost to follow up, and 33 (2%) were diagnosed with a hearing loss. Eleven of these children had unilateral hearing loss, and 22 had bilateral hearing loss of various degrees: two children had a profound hearing loss, one severe, and 19 had a bilateral moderate hearing loss. Risk factors in the population of conﬁrmed hearing loss included low birth weight, perinatal anoxia, and craniofacial anomalies. Conclusions: Hearing screening in our NICU population revealed hearing loss in 2% of the population, within the range of published data.

OP 141 Complications of acute mastoiditis in children Jerzy Kuczkowski, Czesaw Stankiewicz, Bo_zena Kowalska, Wojciech Brzoznowski ENT Department, Med. University Gdan´sk, ul. De˛binki 7, 80–211 Gdan´sk, Poland Objectives: A retrospective study of 70 children with extracranial, intratemporal and intracranial complications of acute mastoiditis, 1968 to 2005. Method: Medical documentation and operation protocols analysis. Results: In 70 patients 76 complications were diagnosed (in 6 children two complications were observed). Extracranial complications occurred in 41 cases (50% of all complications). Intracranial complications were diagnosed in 17 cases (22,3%) and intracranial—in 18 cases (23,7%). Persistent otorrhea, otalgia and headache, high fever, neurological symptoms were signs associated with the intracranial complications of acute mastoiditis. The most frequently isolated bacteria were Staphyl. Aur., Strept. sp., Pseud. Aer. All patients were treated surgically with broad spectrum antibiotic therapy. In patients with epidural abscess, perisinusal abscess or sigmoid sinus thrombophlebitis (SST), the adjacent bone was removed and abscess was drained. In four patients with SST sigmoid sinus was exposed, punctured and clot was then removed. Conclusions: Superiosteal abscess is most frequent extracranial complication of acute mastoiditis. Among intracranial complications most common are sigmoid sinus thrombophlebitis and perisinusal abscess. Facial nerve paralysis is most frequent complication occurring in temporal bone. These complications need surgical treatment and aggressive antibiotic therapy.

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OP 142 Application of newborn hearing screening program at ‘‘Zvezdara’’ Hospital in Belgrade S. Babac1, D. eric´2, Z. Ivankovic´1 1 Department of Oto-Rino-Laringology, Zvezdara Hospital and Clinical Centre, Belgrade; 2Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade Objectives: The importance of early detection of hearing loss is well known. Newborn hearing screening programs are becoming more common around the world. In Zvezdara hospital in Belgrade universal newborn hearing screening is being conducted since January 2005.The aim of this study was to present the results of newborn hearing screening and to give contribution to the implementation of universal newborn hearing screening in our surroundings. Methods: Between January 2005 and December 2006, 4685 babies were tested, before discharge, on both ears with transient evoked otoacoustic emissions, using Echo-Screen Fischer-Zoth. If the results were ‘‘ refer’’ second phase with TEOAE and /or AABR was performed after 15–30 days. Also we were examining with AABR all babies that had risk factors for hearing loss. Audiologic examination was performed up to third month of life. Results: First screening pass 91.5% of the newborns. Out of 8.5% babies scheduled for follow-up only 33% returned for second screening. For additional audiologic tests 0.8% of babies were refered. Hearing loss was conﬁrmed in ﬁve cases. In one, profound bilateral sensorineural hearing loss, in two unilateral sensorineural, and in two unilateral conductive hearing loss. Conclusions: Early identiﬁcation of the cochlea pathology gives possibility of supplying with hearing aid and early rehabilitation. The question that remains is to ﬁnd the appropriate way to improve the quality indicators of the program.

OP 143 Quality of life of children with otitis media with effusion Lejla Rovcanin, Ognjen Jovicevic, Mirko Popovic, Marija Djuric ENT Department, Institute for children’s diseases, Podgorica, Montenegro Objective: To investigate if otitis media with effusion (OME) that lasts for three months and longer negatively effects the quality of life of children. This effect may be observed through speech delay, behavioral symptoms like poor attention and more frequent episodes of otitis media acuta (OMA). Methods: Children, who were not surgically treated for OME, were followed up during 18 months period. All children went

S245 through the same diagnostic protocol that included anamnesis about behavioral symptoms, routine audiological examinations and determination of speech status done by logoped. Number of episodes of acute otitis media was recorded for every child. Results: 30 children, aged 2–5 years were examined during this period. Behavioral symptoms were observed in 22 cases (73.3%). Speech disturbance was detected in 21 cases (70%). In 24 cases (80%) more than three episodes of OMA were registered during this period. Conclusion: Otitis media with effusion strongly negatively effects the quality of life of young children.

OP 144 Implementation of an universal newborn hearing screening program at hospital La Inmaculada: our ﬁrst year experience C. M. Del Aguila*, J. L. Castillo** Paediatric* and Otorhinolaryngology** Services, Hospital La Inmaculada, Huercal-Overa (Almeria), Spain Introduction: In 2004, Andalousian Health Service agree to introduce a newborn hearing screening program, but this program is not yet implanted in all public hospital of autonomous communitie. Since 2006, universal newborn hearing screening (NHS) program has been implemented in the Hospital ‘‘La Inmaculada ‘‘, Almeria, Spain. The program is based on otoacoustic emission (OAE) and auditory brainstem response (ABR). The objective of the communication is to evaluate the implementation program percentage in the ﬁrst year. Method: All babies born in our Hospital, included those in the neonatal unit care are tested before discharge. Our protocol consists of three stages. In the ﬁrst stage newborn are tested with transient evoked otoacoustic emission. The babies who did not respond to testing procedure were re-tested within a month (second stage) and those who failed received follow-up hearing diagnose with conventional ABR if necessary (third stage) Results: Infants born in the Hospital La Inmaculada during 2006 were screened. At the end of the year, participation over 75% was achieved. OAE pass rates were 92%. Second stage coverage was 82%, but 18% of the families declined or were uncontactable. Failure of second test was 12%, and the babies were referred to additional evaluation. Conclusion: In 2006 NHS program has been introduced at Hospital La Inmaculada. The effectiveness of the program in our Hospital has increased as a function of the month and mean coverage amounted to 75%. The OEA pass rates in ﬁrst stage were consistent with similars NHS programs.

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OP 145 Auditory middle latency response (AMLRs): study on health children Ana Claudia Figueiredo Frizzo; Carolina Arau´jo Rodrigues Funayama; Jose´ Fernando Colafeˆmina; Myriam de Lima Isaac; Ricardo Cassiano Demarco Department of Neurology, Psychiatry and Medical Psychology, and Department of Ophthalmology, Otorhinolaryngology Head and Neck Surgery- Faculty of Medicine of Ribeira˜o Preto- USPSP- Brazil Objective:To examine the components of AMLRs in a sample of healthy children to determine their properties. Methods: Thirty-two children of both genders aged 10 to 13 years, with no neurological disorders, participated in the study. Data were analyzed statistically by descriptive statistics (mean + SD) and by analysis of variance using the F test. AMLRs were investigated with tone-burst stimuli at 50, 60 and 70 dB HL. Results and conclusions: The mean latencies of the components were Na = 20.79 ms, Pa = 35.34 ms, Nb = 43.27 ms, and Pb = 53.36 ms, in 70 db HL. The mean values for Na-Pa amplitude ranged from 0.2 to 1.9 lV (M = 1.0 lV). The amplitude increased and latency decreased with increasing sound intensity. The inclination of the Na-Pa complex was present in some cases, what deserves attention in similar studies on still in children with speech, language and auditory processing difﬁculties. The present study provided additional information about AMLRs and it can be a reference to others clinical and experimental studies in children.

Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 Department of Otorhinolaryngology, University of Mainz Hospitals, Mainz, Germany Objective: test whether the vestibular nerve branch of tumor origin and/or an extra-canalicular, up to 1 cm, extension of the VS has an inﬂuence on hearing outcome after middlecranial fossa (MCF) surgery for vestibular schwannoma (VS). Methods: retrospective case review. Fifty patients with postoperative pure-tone audiogram (PTA) later than 90 days (median: 285. 5 days) after surgery were evaluated. Twenty patients had a VS arising from the superior vestibular nerve (SVN) and in 27 patients the VS was arising from the inferior vestibular nerve (IVN). In three patients the nerve branch of origin of the VS could not be unequivocally determined. Thirty four patients had a purely intracanalicular (IC) tumor and 16 patients had an extracanalicular extension in the cerebello-pontine angle (CPA). The differences between the pre-operative and the post-operative air-conduction pure-tone hearing thresholds at 500, 1,000, 2,000, 3,000 and 4,000 Hz were compared between groups using the Mann–Whitney–Wilcoxon-test. Results: Neither vestibular nerve branch of origin nor extracanalicular tumor extension (up to 1 cm) did cause any signiﬁcant difference in the degree of postoperative hearing change at any of the ﬁve tested PTA-frequencies. Conclusions: Nerve branch of origin of a VS does not inﬂuence the postoperative hearing outcome in patients operated via a MCF approach. Postoperative hearing outcome does not differ signiﬁcantly between patients with purely intracanalicular VS and patients with VS with a CPA—component with a largest diameter of less than 1 cm.

OP 146 Auditory brainstem responses in children with recurrent otitis media in the ﬁrst two years of life

OP 148 Conservative management of 386 patients with unilateral vestibular schwannoma. Pattern, occurrence and consequences of tumour growth

Milton Malheiros da Silva; Myriam de Lima Isaac; Ricardo Cassiano Demarco Department of Ophthalmology, Otorhinolaryngology Head and Neck Surgery Faculty of Medicine of Ribeira˜o Preto- USP-SP Brazil

El Bakkouri, R. Kania, J. P. Guichard, P. Herman, P. Tran Ba Huy Department of ORL, Hoˆpital Lariboisie`re, Paris, France

Auditory Brainstem Responses (ABR) were recorded from an group of eleven children with early history of recurrent otitis media in the ﬁrst and second year of life, and a control group of thirteen children without history of otitis media. The children had normal hearing at the time of this testing and had the ages in the intervals of 4–6 years and eleven months. The ABR were registered using rarefaction clicks following investigation of the medical records obtained at the Hospital das Clı´ nicas da Faculdade de Medicina de Ribeira˜o Preto da Universidade de Sa˜o Paulo which included clinical history, otoscopy, tympanometry, and audiometry. The absolute latency of waves and the interpeaks latencies were analyzed. The main goal of this study was to compare ABR between these two groups. The results showed that the group of children having a history of otitis media had signiﬁcantly greater absolute latencies for wave I. The results indicate that the group differences were due to more caudal alterations in auditives tracts, probably caused by otitis in their critical period of development.

OP 147 Inﬂuence of origin and extension of VS on hearing in middle fossa removal Fabio Fiscina, Haralampos Gouveris, Wolf Mann

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Objective:Evaluate natural history and pattern of tumour growth in small-sized vestibular schwannoma (VS). Methods: From 1990 to 2005, 386 patients with isolated VS were managed conservatively. Tumour size was measured yearly by MRI according to the guidelines of the Committee on Hearing and Equilibrium. Results: The mean tumour growth rate for the overall group was 1.15 ± 2.4 mm/year. 58.6% of patients did not show any growth; 29.2% had an annual growth rate inferior to 3 mm/year and 12.2% an annual tumour growth superior to 3 mm/year. At each serial imaging, these proportions were roughly similar and 10 to 20 % had to be treated. The tumour growth rate was not linear throughout the follow-up period. The 1-, 3-, 5- and 10-year Kaplan-Meier was 91.7%, 70.8%, 51.1% and 37.4% for VS which annual growth rate was superior to 3 mm and 56.3%, 15.9%, 8.8%, and 2.9% for VS with annual growth rate inferior to 3 mm. No signiﬁcant association was found between tumour growth and sex, age, initial hearing status and initial tumour grade. The delay of diagnosis was the only positive factor of tumour growth. Conclusion: Most of VS did not show any progression during the observed period; at each observation period, 10 to 20 % displayed a signiﬁcant growth >3 mm/year and had to be treated. A long term radiological control is needed even if the tumour don’t exhibit initially a growth.

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OP 149 Screening patients with sensorineural hearing loss for vestibular Schwannoma using a Bayesian Classiﬁer Reza Nouraei1, Quentin Huys2, P Chatrath1, James Powles1, Jonny Harcourt1 1 Charing Cross Hospital; 2Gatsby Computational Neuroscience Unit Objectives: Selecting patients with asymmetrical sensorineural hearing loss for further investigation continues to pose clinical and medicolegal challenges, given the disparity between the number of symptomatic patients, and the low incidence of Vestibular Schwannoma (VS) as the underlying cause. We developed and validated a diagnostic model using Gaussian Process Ordinal Regression, a generalization of neural networks, for detecting vestibular schwannomas from clinical and audiological data, and compared its performance with six previouslypublished clinical and audiological decision-support screening protocols. Methods: Clinical and audiometric data from 129 MR-proven VS+, and as many VS– patients were obtained. A Gaussian Process Ordinal Regression Classiﬁer (GPORC) was trained and cross-validated to classify cases as VS+ or VS–, and its diagnostic performance was assessed using Receiver Operator Characteristic plots. Results: It proved possible with GPORC to pre-select sensitivity and speciﬁcity, with an area under the curve of 0.8025. At 95% sensitivity, GPORC had a speciﬁcity of 56%, 30% better than audiological protocols with closest sensitivities. The sensitivities of previously-published audiological protocols ranged between 82 and 97%, and their speciﬁcities ranged between 15–61%. Conclusion: GPORC increased the ﬂexibility and speciﬁcity of the screening process for VS when applied to a sample of matched patients with and without vestibular schwannoma. If applied prospectively and clinically, for instance via an Internetbased application, it could reduce the number of ‘normal’ MR scans by as much as 30% without reducing the sensitivity of detecting true cases Performance of the system can be further improved through incorporating additional data domains into the decision-making process.

OP 150 Electronystagmography and dynamic posturography in vestibular schwannoma. Haralampos Gouveris1, Kai Helling 1, Anja Victor 2, Wolf Mann1 1 Department of Otorhinolaryngology – Head and Neck Surgery, The University of Mainz Hospitals and 2Institute for Medical Biometry, Epidemiology and Informatics, University of Mainz, Mainz, Germany Objectives: To test whether computerized dynamic platform posturography (CDPP) ﬁndings differ between vestibular schwannoma (VS) patients with and without asymmetry on caloric and/ or rotational electronystagmographic (ENG) studies. Methods: Retrospective chart review of 216 (103 female, 113 male, median age: 54 years) consecutive patients with a histological diagnosis of a VS. Condition-5-scores (C5S) and condition-6scores (C6S) of the sensory organization test of CDPP (Equitest)

S247 were compared among patients with normal both caloric and rotational ENG-studies, patients with asymmetry on caloric studies and normal rotational studies and patients with asymmetric both caloric and rotational ENG-studies using the Wilcoxon-Mann-Whitney test. Results: Condition-5-score and C6S of VS patients with normal ﬁndings on both caloric and rotational testing were signiﬁcantly higher from the respective scores in VS patients with either asymmetry on both rotational and caloric test results (P < 0.001 for C5S and P < 0.001 for C6S respectively) or normal rotational studies and asymmetry on caloric testing (P < 0.001 for C5S and p < 0.001 for C6S respectively). Neither C5S (P = 0.311) nor C6S (P = 0.284) were signiﬁcantly different between the group of VS patients with asymmetry on caloric testing and normal rotational studies and the group of VS patients with asymmetry on both rotational and caloric testing. Conclusions: Asymmetry on rotational ENG—studies does not inﬂuence C5S and C6S of CDPP in VS patients. Condition-5Score and C6S can detect the presence of a functional deﬁcit of the lateral semicircular canal (and the superior vestibular nerve), irrespective of the central vestibular compensatory status, in VS patients. Key words: Caloric test, Posturography, Rotational test, Vestibular schwannoma

OP 151 The prevalence of the audiologic risk factors in the Albanian NICU population Brikena Qirjazi1, Stavros Hatzopoulos2 1 ENT department, Faculty of Medicine, University of Tirana, Albania; 2Audiology, University of Ferrara, Italy Objectives: The objective of the project was to analyze the prevalence of the audiologic risk factors in the infants of the Neonatal Intensive Care Unit (NICU) who failed the ﬁrst TEOAE hearing screening test. Methods: 296 NICU infants screened during April–December 2006 were considered. Information on the ‘audiologic’ risk factors for hearing loss of each subject was collected from the corresponding clinical ﬁles. The prevalence of risk factors in the whole population in study and in the NICU subjects who failed the ﬁrst TEOAE screening test were analyzed and compared. Statistical analyses was applied to determine which of the risk factors found was more likely inﬂuencing the negative result of the screening test. Results: 146 (49%) of the NICU subjects failed the ﬁrst screening test. Among this population the most prevalent risk factors were (expressed in percentage of the affected population and in descending order) (1) the length of stay in NICU (>3 days, (65%); (2) prematurity (64.4%); (3) the use of aminoglycosides (32.9%) and (4) hyperbilirubinemia (25.3%). Conclusions: The most common conditions found in the NICU subjects who failed the screening test was the length of stay in NICU and prematurity. The statistical analyses showed that prematurity appeared to have the strongest impact on the result of the ﬁrst stage of screening. In addition to that, the analyses showed that the use of aminoglycosides, the length of stay in NICU and hyperbilirubinemia had also a negative inﬂuence on the REFER outcome of screening test.

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OP 152 Rhabdoid Meningioma of Internal Auditory Meatus

*Department of Neurosurgery, University of Regensburg, Germany; **Department of ENT, University of Regensburg, Germany

Ricardo Bento, Iulo Barauna, Rubens Brito University of Sa˜o Paulo – 255 Dr. Ene´as de Carvalho Aguiar Avenue, 6o Floor, room 6167. Sa˜o Paulo, Brazil

Objective: Dizziness is a common pre- and postoperative symptom in patients with acoustic neurinomas. Patients suffering from severe postoperative vertigo usually have a prolonged recovery. The purpose of this study was to analyze the rate, duration and severity of vertigo in patients with acoustic neurinomas before and after surgery. Methods: In a retrospective study data of 145 consecutive patients, 76 males and 69 females with unilateral acoustic neurinomas was analyzed. All patients underwent a microsurgical tumor resection either by an ENT- or neurosurgeon. Results: The mean age of treated patients was 50.8 years. A total tumor resection was achieved in 95.2%. A total of 79 patients (54.5%) suffered from dizziness before and 49 patients (33.7%) after surgery. Symptoms persisted for a mean time of 14 months before surgery and 18 months after surgery. Severe symptoms with nausea and vomiting requiring antiemetic treatment were observed in 51 patients (35.1%) before and 17 patients (11.7%) after surgery. Analysis according to gender showed a faster recovery and also a higher rate of postoperative recovery from vertigo symptoms in females. Males with small tumors (Samii grade T1 and T2) had the highest rate of severe postoperative vertigo requiring antiemetic treatment. Conclusion: Based on these results it is possible to identify patients with a higher risk of developing severe postoperative vertigo symptoms which allows the treating physician to start an appropriate therapy before symptoms become severe.

Objective: Present a case of a thirty 2-year old man referred to our institute with a intrameatal rhabdoid meningeoma. Methods: A 32-year old man referred to our Institute with complaints of left progressive facial palsy for 8 months and hearing loss in the same side for the last 2 months. MRI showed an intrameatal tumor arising in the left internal acoustic meatus with minimal extension to cerebelopontine angle. In December of 2004 the patient was submitted to a translabirinthine approach and a bleeding tumor was found in close contact with the facial nerve. We decided to resect the entire tumor. In order to achieve this purpose we sacriﬁed the facial nerve that was rerouted with a sural nerve graft to the distal portion. Results: Postoperative histological evaluation revealed cells with abundant eosinophilic cytoplasm, eccentric nuclei and intracytoplasmatic hyaline inclusions. Immunohistochemistry revealed tumors cells immunoreactive for EMA, vimentin and focally CD34. The cells did not react for CD56 and CD57, S100 protein, GFPA.These ﬁndings were consistent with the diagnosis of malignant rhabdoid tumor (WHO for meningeomas grade III). In the ﬁrst year of follow-up, clinical conditions deteriorated and the patient evolved to death within 9 months. Conclusions: The rhabdoid morphology, in our case and in most of the series described in literature, has been implicated with recurrences and poor prognosis when compared to classical meningeomas histology. These lesions request a constant surveillance in postoperative follow-up and aggressive therapy in cases of recurrences.

OP 153 Megadolichobasilar anomaly and trigeminal neuralgia Apostolos Papadopoulos, Anna Papadopoulou, Ilias Kantas, Nikolaos Marangos Center of Otorhinolaryngology, Head & Neck and Skull Base Surgery, Athens/Greece Objective: Differential diagnosis of trigeminal neuralgia include tumors and vascular malformations, thus imaging of the hole course of the nerve is mandatory. Method: All cases of trigeminal neuralgia presented in our center have been evaluated with MRI. If any vascular anomaly has been found, an additional angio-MRI has been peformed. Results: In two cases of young subjects an anomaly of the vertebrobasilar system was found. Magnetic resonance angiography revealed a long and oblique course of the vertebral arteries and a very cranially situated basilar artery. In both cases there was a wide arterial contact to the trigeminal nerve close to the brainstem. Conclusion: Megadolichobasilar anomaly can be a cause of trigeminal neuralgia due to vascular variation and next to the more frequent AICA loop.

OP 155 Analysis of pre- and postoperative dizziness in patients with acoustic neurinomas G. C. Feigl*, S. Schmidt*, M. Schneider**, J. Strutz**, A. Brawanski*

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OP 156 Assessment of quality of life after management of isolated vestibular schwannoma Romain Kania, Pierre Sagnet-Vidal, Elisabeth Sauvagnet, Wissame Elbakkourri, Emmanuel Bayonne, Philippe Herman, Patrice Tran Ba Huy Lariboisie`re Hospital Objective: To compare quality of life (QOL) for patients with isolated vestibular schwannoma according to the three management possibilities: follow-up, surgery, and radiosurgery. Methods: Based on an inception cohort of 760 patients with a previously isolated and untreated VS managed between 1990 and 2005, treatment modalities were follow-up in 50.8%, surgery in 45.9% and radiosurgery in 0.3%. A postal questionnaire surgery was done using the Glasgow Beneﬁt Inventory (GBI) and the acoustic neuroma association questionnaire was used for patient perception of comorbid conditions. Results: Response rate was 68%. Whatever the treatment modality, QOL was deteriorated with a signiﬁcant deterioration after microsurgery even for smaller tumors. No signiﬁcant difference was found in QOL between follow-up and radiosurgery. Selfassessment of comorbid conditions by patients showed a signiﬁcant deterioration when surgery was undertook in comparison with other management modalities for hearing loss, tinnitus, balance problems, eye and facial weakness, headache, depression and memory problems. When surgery was performed, the retrosigmoid approach was signiﬁcantly associated with more intense headache. Conclusions: This study suggests that a conservative management approach may be more appropriate for small VS. When treatment by either surgery or radiosurgery has to be undertaken, patients may beneﬁt from counselling about the potential impact of treatment on QOL in order to adapt the management strategy.

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OP 157 Hyperacusis in tinnitus patients comparing to patients without tinnitus Author Lubica Suchova Phoniatric Department University Hospital Antolska 11 Bratislava Slovak Republic Since May 1999, 300 patients with tinnitus and 100 patients without tinnitus have been tested in out department. Pure Tone Threshold Audiometry PTA and Loudness Discomfort Level LDL have been done in all patients. In tinnitus patients LDL was done in 295 right and 298 left ears. The average LDL diameter was 85–90dB. Hyperacusis was present in 60% of right ears, and in 53% of left ears. In patients without tinnitus LDL was examined in 100 right and 100 left ears, the average LDL diameter was 95–100dB. Hyperacusis was present in 18% of right ears and in 19% of left ears. Statistically signiﬁcant difference in hyperacusis occurrence in the series of patients with tinnitus comparing to the series of patients without tinnitus was conﬁrmed by nonparametric statistic analysis We could not conﬁrm whether hyperacusis is the cause or the consequence of the tinnitus but more than 50% of the patients suffering from tinnitus have hyperacusis comparing to only 20% of the patients without tinnitus.

OP 158 Extended high frequencies in idiopathic subjective tinnitus Jamal Jawad*; Hesham Abdel Kader A. Mansour**; Mohamed M Abdel Tawwab*** *ENT Department, Doctor Soliman Fakeeh Hospital, Jeddah, KSA; ** ENT Department, Faculty of Medicine, Cairo University, Egypt; *** ENT Department, Faculty of medicine, Mansoura University, Egypt; ASHA (American Speech, Language And Hearing Association) member. Objective: The purpose of this study was to measure the extended high frequencies in idiopathic subjective tinnitus patients. Methods: Prospective randomized study. 65 patients with idiopathic subjective tinnitus, 36 males and 29 females were included in this study. Extended high frequencies thresholds in dBHL were recorded from both ears at frequencies range from 9 to 16 KHz. Participants of this study were selected from attendances of out patient ENT and Audiology clinic, they were studied between July, 05 and December, 06. There age ranged from 22 to 57 with mean of 38 + 10 years. Results: Extended high frequencies (EHF) were affected in 40 patients (61.5%) of the study group. The patients with unilateral subjective tinnitus were 33 patients (16 females and 17 males), 21

S249 patients (32.3 %) have affected extended high frequencies 6 patients of them have no affection of the other side (4 females and 2 males). The patients with bilateral tinnitus were 32 patients (13 females and 19 males) with 19 patients (29.2 %) have extended high frequencies affection (8 females, 11 males) 3 patients of them have no affection of the other side (2 females and one male). Conclusions: The extended high frequencies were affected in large proportion of patients suffering from unilateral and bilateral idiopathic subjective tinnitus with normal peripheral hearing thresholds at frequencies range 250 to 8000 Hz. EHF can be used as a part of test battery for evaluation of patients with idiopathic tinnitus and for its follow up.

OP 159 Tinnitus due to anatomical alterations of basilar artery Osmar Clayton Person1,2, Raul Vı´ tor Rossi Zanini1, Marja Michelin Guerra1, Caio Barbosa Campanholo1, Marcos Luiz Antunes1, Priscila Bogar Rapoport1 1 Faculty of Medicine of ABC, Sa˜o Paulo, Brazil; 2Centro Universita´rio Sa˜o Camilo, Sa˜o Paulo, Brazil; R. Dr Henrique Calderazzo, 321- Bairro Paraı´ so, Santo Andre´ 09190–610 /SP, Brazil Introduction: Tinnitus is an otoneurological symptom that affects a considerable part of the population. Although pathophysiological mechanisms associated to this symptom are not completely disclosed, it is very common the association with hearing loss. Some kinds of tinnitus, however, can have speciﬁc characteristics, as a pulsatile tinnitus. It can be caused by vascular alterations, neoplasms or traumas, besides other pathologies. Objectives: This paper reports two cases of patients with pulsatile tinnitus due to anatomical alterations of basilar artery. Methods: This is a report of two uncommon cases in the literature. We looked for cases of pulsatile tinnitus, as this, especially in Medline (1996–2006) and found only six cases. Results: We found some anatomical alterations in the imaging exams (MRI): the ﬁrst one due to an arterial deviousness and the second with a dolichomegabasilar, a condition rarely reported in literature. Due to the causal characteristics of this cases and the difﬁculties of surgical treatment, we prescribed clonazepam and propranolol. The symptom did not disappear, but it was reduced during the sleep, and the patients were satisﬁed with the results. The patients are being followed-up in our outpatient care unit nowdays. Conclusion:7 Tinnitus is a frequent symptom, but objective tinnitus due to anatomical alterations of basilar artery (dolichomegabasilar) frequently is not reported in the literature, but must be considered as a cause of tinnitus.

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OP 160 Zinc supplement alters ABR in patients with tinnitus Osmar Clayton Person1,2, Jose´ Carlos Nardi3, Maria Cristina Lancia Cury Fe´res4 1 Faculty of Medicine of ABC; 2Centro Universita´rio Sa˜o Camilo; 3 Faculty of Medicine of Marilia; 4Faculty of Medicine of Ribeira˜o Preto – University of Sa˜o Paulo, Brazil; R. Dr Henrique Calderazzo, 321- Bairro Paraı´ so, Santo Andre´ 09190–610/SP, Brazil Introduction: Zinc is an oligoelement involved in several organic reactions and it has been recognized as an essential component in the synthesis of proteins and as a probable factor in the stabilization of cell membranes. Its participation in synapses in the auditory system and in the treatment of tinnitus has been largely studied in the past few years. Objectives: To evaluate the auditory brainstem responses (ABR) of patients who suffer from chronic idiophatic tinnitus, before and after being treated with zinc, and to compare both situations concerning to the neural transmission of the auditory structures of the brainstem. Method: Forty-one patients were included (22 with tinnitus and 19 controls, groups I and II, respectively). They were submitted to anamnesis, otorhinolaryngologic examination, boochemical evaluations and audiologic tests. Group I patients received zinc for 90 days, following a speciﬁc formulation. ABR tests were performed at the beginning of the study and 90 days after, at the end of the treatment with zinc. Results: The ﬁrst test showed no differences between both groups, but the second evaluation showed signifﬁcative enlargement of the latency and amplitude of wave V of group I. Conclusion: The treatment with systemic zinc could modify some aspects of auditory neurotransmission in the brainstem.

OP 161 Tinnitus due to palatal myoclonus successfully treated with trihexyphenidyl Osmar Clayton Person1,2, Renata Ribeiro de Mendonc¸a Pilan1, Eli Onivaldo Martinelli1, Marcos Luiz Antunes1, Renata Dutra de Moricz1, Priscila Bogar Rapoport1 1 Faculty of Medicine of ABC, Sa˜o Paulo, Brazil; 2Centro Universita´rio Sa˜o Camilo, Sa˜o Paulo, Brazil; R. Dr Henrique Calderazzo, 321- Bairro Paraı´ so, Santo Andre´ 09190–610 /SP, Brazil Introduction: Palatal myoclonus is a rare disorder presenting as unilateral or bilateral rhythmic involuntary movements of the soft palate. Patients with palatal myoclonus may complain of hearing an annoying rhythmic click, which is related to the opening and closing of the Eustachian tube due to pharyngeal contractions. This click may be perceived by the examiner by placing a stethoscope over the patient’s ear. Objectives: To report a case of a male child (4 years-old) with a unilateral tinnitus due to palatal myoclonus. His tinnitus (click) could be listened 50 cm away from the doctor. Method: This

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 paper reports a rare case of a child with tinnitus due to palatal myoclonus and we did not ﬁnd cases in children with this age in Medline (1996–2006). This patient was successfully treated with an anticholinergic drug. Results: The results of audiometric assessment revealed no evidence of hearing loss. This child was submitted to MRI that did not show alterations. He was treated with trihexyphenidyl- Artane (0,5 mg/day) and the symptoms were controlled and palatal myoclonus was virtually stopped with this treatment 8 months later. Trihexyphenidyl is an anticholinergic antiparkinsonian agent and it produces an atropine-like blocking action of parasympathetic-innervated peripheral structures, including smooth muscle. Conclusion: We report a rare case of objective tinnitus caused by palatal myoclonus in a child successfully treated with trihexyphenidyl. We believe that this drug can be used in some cases of tinnitus caused by palatal myoclonus, but it is important a control due to its potential risks of adverse effects.

OP 162 Application of Aktovegen in treatment of tinnitus Kh. E. Shaykhova, A. M. Khakimov, G. S.Haydarova Tashkent medical academy, Uzbekistan, Department of Otorhinolaryngology One of the actual problems of otorhinolaryngology at present is treatment of ear noise. We have decided to use in treatment of patients with noise in ears preparation Actovegin. The group included 51 patients with chronic sensonevral relative deafness, combined subjective ear noise. The age of patients was within the limits of from 18 till 60 years. Course of treatment by Actovegin included intravenous jet introduction of a preparation in quantity of 5 ml (200 mg) on 200.0 ml 0.9% solution of NaCl within 10 days. The control over efﬁciency of treatment was carried out by means of periodically spent acumetry, voice-frequency audiometer, noise meter, transcranial dopplerography vessels of a brain and on the basis of dynamics of complaints of patients. The positive effect from treatment by a preparation was observed at 46 patients. Signiﬁcant improvement of acoustical function was marked: the threshold sound perception has decreased on 5–10 dB. Decrease in intensity of ear noise was marked: if before treatment intensity of noise changed within the limits of 70–90dB, after the lead course of treatment intensity After the lead course of treatment intensity of noise has decreased on 10–15 dB. At deﬁnition the spectrum of ear noise before treatment settled down on frequencies 6,000–8,000 Hz. At control realization of noise meter deﬁned, that after treatments at 76 % of patients the spectrum of ear noise settles down only on one frequency 8,000 Hz. It speciﬁes positive effect of Actovegin conﬁrming its neurotropic and neuroprotective effect. The results received by us allow speaking about efﬁciency of Actovegen in treating patients with sensoneural hard of hearing combined with subjective ear noise.

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OP 163 Usefulness of tone-pip evoked ABRs in diagnosis of retrochochlear hearing loss in tinnitus patients L. Karpiesz, K. Kochanek, A. Karpiesz, B. Borawska, H. Skarzynski Institute of Physiology and Pathology of Hearing, Warsaw, Poland The aim of the study was to examine usefulness of the ABRs elicited by short tone-pip stimuli for the diagnosis of retrocochlear hearing impairments in tinnitus patients. In the measurements of the auditory brainstem responses, we applied short tone-pip stimuli of Gaussian envelope (the ABR PIP method). The responses were recorded at three frequencies, 1000, 2000 and 4000 Hz. The analyzed response parameters were wave V latency and the intra-aural latency difference, IT5. A magnetic resonance imaging (MRI) examination was performed in each patient. The examination by ABR PIP method revealed more cases of retrocochlear impairments than the standard ABR method using click stimuli. In some of these cases, MRI examination detected VIII nerve tumours and nervous-vascular conﬂicts. In one of the patients, a congenital malformation of the internal auditory canal was discovered. The ABRs elicited by tone-pips of relatively long rise times offer greater sensitivity in detecting small changes in the cochlear nerve and the brainstem than the sensitivity of standard ABR in group of patients with tinnitus.

OP 164 ABR in patients with tinnitus treated with betahistine Osmar Clayton Person1,2, Raul Vı´ tor Rossi Zanini1, Caio Barbosa Campanholo1, Eli Onivaldo Martinelli1, Alessandra Felippe Ribeiro2, Priscila Bogar Rapoport1 1 Faculty of Medicine of ABC, Sa˜o Paulo, Brazil; 2Centro Universita´rio Sa˜o Camilo, Sa˜o Paulo, Brazil; R. Dr Henrique Calderazzo, 321- Bairro Paraı´ so, Santo Andre´ 09190–610 /SP, Brazil. Objectives: To evaluate the auditory brainstem responses (ABR) of patients who suffer from chronic idiophatic tinnitus, before and after being treated with betahistine (Betaserc), and to compare both situations concerning to the neural transmission of the auditory structures of the brainstem. Method: Forty-four patients were included (23 with tinnitus and 21 controls, groups I and II, respectively). They were submitted to anamnesis, otorhinolaryngologic examination and audiologic tests. Group I patients received betahistine (Betaserc)—(32 mg/day) for 30 days. ABR tests were performed at the beginning of the study and 30 days after, at the end of the treatment with betahistine. Results: The statistic test showed some differences between both groups. The waves III and V of ABR showed signifﬁcative reduction of latency in group I, and the amplitude of wave V was bigger in group I (treated with betahistine). Conclusion: In this study, the treatment with betahistine modiﬁed some aspects of auditory neurotransmission in the brainstem in patients with tinnitus.

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OP 165 Unusual case of tinnitus due to arteriovenous sunt. M.-F. Graikou1, S. Mavroidakos2, K. Papakostas1, Ch. Lira1, D. Pantazis2, G. Mireas1, J. Vathilakis1 1 Department of audiology-neurootology, Red Cross Hospital; 2 Department of ENT, General Hospital of Elefsina ‘‘Thriasio’’ Athens, Greece. Objective: Objective tinnitus is an uncommon otological symptom, in contrast to the more common subjective non-pulsatile tinnitus Method: A 56 years old woman presented with unilateral, roaring, very disturbing pulsatile tinnitus that appeared two years before. She felt numbness round her left ear and pulsatile tinnitus synchronous with her heartbeat. The history of the patient was negative. Tinnitus was heard from the examiner during the otoscopy, even without a stethoscope. There was no hearing loss, vertigo, otorrhoea or otalgia. Otoscopy revealed a normal tympanic membrane with a characteristic pulsatile movement. The Tympanogram revealed the pulsation of tympanic membrane, the Audiogram was rather within the normal limits, CT was negative but MRI revealed the presence of soft tissue or ﬂuid in the mastoid cells. Finally, elective digital angiography revealed the presence of an arteriovenous shunt of the Occipital, Auricular and Petrous artery with the venous plexus that leads to the Straight sinus. Results: The patient was referred for selective embolism of this extraordinary shunt. Conclusion: early diagnosis and appropriate intervention may save patients from serious complications

OP 166 Treatment of Mass Blast Injury of Ear in war conditions: our experience Hr. Zlatanov, V. Tzvetcov, D. Donchev Department ENT, Military Medical Academia Soﬁa, Bulgaria Blast injury of auditory system is a primary trauma and includes rupture of eardrum, destroying of oscicular system, damages of cochlea, foreign body in the ear. Investigation includes 26 patients military man with blast injury of auditory system in the average age 26.15 ± 2.7. This is mass group blast injury after terrorist attack outside, in December 2003 in military base or Bulgarian army. Investigation is done on the base of data in the ﬁles of the patients, from examination and audiometry. Analysis revealed all victims had got immediate medical care from ENT specialist after explosion. Examination after explosion found this pathological changes: Perforation of eardrum in 9 (34.6%) patients; Trauma of external auditory canal 1 (3.8%); Otorragie 2 (7.7%); Trauma of the middle ear ossicles 1 (3.8%); Foreign body 2 (7.7%); Others –6 (23.07%). The blast injury has got a big medial importance for the modern society, where the risk from terrorist attacks has grown, and the readiness of medical teams in this direction put the requirement from achievement of new information.

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OP 167 Traumatic Perforation of Eardrum V. Haas, P. Cˇelakovsky´, L. Sˇkoloudı´ k, J. Drsˇ ata, J. Vokurka Department of Otorinolaryngology, Head and Neck Surgery, Charles University Faculty of Medicine in Hradec Kra´love´, Czech Republic The method of retrospective analysis was used for processing the data of patients observed at least 6 months after the injury of eardrum. The patients were examined by otoscopy, otomicroscopy or otoendoscopy and audiogram was made. Antibiotics were used for systemic treatment in all cases. The objective of the study was to demonstrate the effect of perforation coverage by prosthesis for healing. We have investigated the following parameters: etiology, side dependence, time from the injury until healing, dependence of healing of the perforation on the coverage with prosthesis and age of the patients. We failed to demonstrate a statistically signiﬁcant relationship of healing upon age of the patients. The coverage of the perforation with the small prosthesis did not signiﬁcantly improve healing of the eardrum. In spite of that we consider the coverage of traumatic perforation with prosthesis as a favorable contribution.

OP 168 SerenoCemTM - glass ionomeric granules: effectiveness in mastoid obliteration Matthew Clark, Ian Bottrill Department of Otolaryngology Head and Neck Surgery, Radcliffe Inﬁrmary, Oxford Objectives: To assess SerenocemTM granules (Corinthian Medical Ltd, UK), comprised of a glass ionomeric cement, as a synthetic material effective in mastoid obliteration. Methods: A retrospective case study of 16 patients who had undergone previous open cavity mastoid operations and subsequently suffered from repeated cavity discharge and the need for regular aural care. Each underwent mastoid obliteration using SerenoCem granules, with follow-up achieved in all cases for 3 years. The main outcome measures were the number of outpatient visits required after obliterative surgery for aural care, compared with those required preoperatively and patient satisfaction as assessed with the validated Glasgow Beneﬁt Inventory (GBI). A pre- and post-operative comparison of the pure tone

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 average was calculated as a secondary outcome. The setting was an ENT department of a Regional teaching hospital. Results: There was a signiﬁcant reduction in post-operative aural care visits (down 9.2 visits [95% CI 4.7–13.8, P < 0.001] over a 2 year period). There was also a signiﬁcant positive beneﬁt in quality of life (total post-operative GBI score 21.8 [95% CI 10.1– 33.6, P = 0.001]). There were no cases of signiﬁcant hearing loss as a result of the procedure. Conclusions: Serenocem would appear to be a satisfactory synthetic material which can be employed as part of a mastoid cavity obliteration procedure, successfully resolving the problems of an open discharging cavity whilst free of detrimental side-effects. Post-operative infection can prevent osseointegration.

OP 169 A pitfall In middle ear surgery Suha Ozbilgen, Cagatay Ruhi, Fikri Can Aribal, Aytug Altundag, Emre Kaytanci, Muhammet Tekin Goztepe Education and Research Hospital, Istanbul, Turkey Objectives: The aim of the study is to attract attention of the head and neck surgent about dehiscent juguler bulb which may cause serious bleeding problems during the middle ear surgery. Method: This is a retrospective study. Surgical intervention was performed to 116 patients between October 2004 and October 2006. Otoscopic radiographic examinations and intraoperative ﬁndings were compared. Results: Middle ear surgery was performed to 116 patients and in 10 of them (8.62%) exist high riding jugular bulb (HJB). Five on the right (4.31%), two on the left (1.72%) and three bilateral (2.6%) HJB were detected. Two had dehiscent high jugular bulb (1.72%), one of them had central perforation and tympanoplasty was performed; the other had chronic otitis media with cholesteatoma and underwent canal wall down tympanoplasty. In otoscopic ﬁndings a blue mass was seen in one; whereas in the other no blue mass was visible because of the cholesteatoma. On the contrary, a juguler bulb ﬁlling the whole hyphotympanium from posterior to anterior margin, hiding the round window niche was found in the operation of the one with cholesteatoma. Conclusion: In the middle ear surgery, the otoscopic ﬁndings, high resolution CT and the awareness of the head and neck surgent will prevent any complications. Dehiscent jugular bulb is not contraindication for middle ear surgery; although it complicates the surgical procedure.

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OP 170 The reconstruction of the lost anatomical structures with the help of different materials in otorinolaryngology is an actual problem Rita Blotsky, Alexsandr Blotsky, Maksim Tseplyaev, Elena Elanskaya Amur State Medical Academy, Russia For the reconstruction of facial walls of nasal sinuses after their extranasal dissection, the closing of thorough defects of the nasal septum and plastics of defects of the eardrum we used the tissues of the human embryo of 3–5 moon months (fetal tissues). This method was used in the treatment of 131 patients. In 43 patients the defect in facial walls of frontal and maxillary sinuses was closing with the transplantant from the ﬂat bone of the vault skull of the human embryo. With this, the transplantant exceeded the diameter of defect of the wall of the sinus by 0.2–0.3 cm, and was ﬁxed to bone walls of sinus using the method of laser «biological» welding. In 47 patients during one-moment plastics of the nasal septum and closing of thorough defects of the nasal septum we used the transplantant, consisting of the ﬂat bone or cartilage and the scrap of the hard cerebral membrane. The transplantant was put between leafs of the mucous membrane of the nasal septum and it was ﬁxed to the remained bone-cartilage framework and the mucous membrane of the nasal septum with the using the method of laser «biological» welding. In 41 patients the plastics of defects of the eardrum were used to scrap the hard cerebral membrane of the human embryo. The transplantant was the ﬁxed to the remains of the eardrum in 6–8 points using laser «biological» welding. All transplantant were ﬁxed using the utilized semi-guide laser «ATKUS - 15» in a constant and impulse regime with the help of the contact method (power of radiation 6–8 Wt). Magnetic-resonance tomography was fulﬁled in different terms after the transplantation of fetal tissues and allowed to discover different stages of reconstruction of transplantants. Thus, laser «biological» welding allowed to attain the reconstruction of integrity of anatomical structures, the compact ﬁxation of transplantant to motherly tissues, exclusded the displacement of transplantant and promoted quick reconstruction of transplantant.

OP 171 Kurz titanium prosthesis ossiculoplasty-medium term results Philip Michael, Jim Fong, Vivek Raut New Cross Hospital, Wolverhampton, United Kingdom Objectives: While many materials exist as reconstructive options to improve hearing in cases of chronic otitis media (COM), titanium has been shown to be highly biocompatible. Due to its relatively recent introduction for ossicular reconstruction, we wished to assess its efﬁcacy in hearing improvement. Methods: A prospective analysis of hearing results following ossicular reconstruction using Kurz titanium prostheses was conducted. Results: Pure-tone audiometrical data at 12 month follow-up was obtained for 50 consecutive cases. 34 cases (68%) demonstrated an air bone gap (ABG) £20 dB using a four-frequency average (0.5–4 Khz) while 36 cases (76 percent) achieved an air-bone gap (ABG) £20 dB using AAO-HNS (0.5–3 Khz) criteria. The average post-operative air conduction (AC) improvement was 12.3dB using a four-frequency average and 12.5 dB using AAO-HNS

S253 criteria. There were no cases with post-operative sensori-neural hearing loss or cases of prosthesis extrusion at 1 year follow-up. Conclusions: The results demonstrate that titanium prostheses may afford a safe and efﬁcacious management option for ossicular reconstruction in cases of COM and have sustainable improvements in hearing in our hands. Long-term results are awaited.

OP 172 Malformations of the ﬁrst branchial cleft: a case report Dejan Radaljac1, Aleksandra Simic1, Mladen Lazic2, Tatjana Radaljac3 1 Departement of Otorhinolaryngology; 2Departement of Pathology; 3Departement of Internal Desease; Hospital ‘‘Dr M. Marin’’, Loznica, Serbia Objectives: First branchial cleft anomalies are extremely rare and account for less than 8% of all branchial anomalies. In 1972 Work classiﬁed ﬁrst branchial cleft anomalies into two types: Type I, ectodermal cysts, is a duplication of the external auditory duct; Type II, originate in both ectodermal and endodermal components and contain cartilage. Their presentation may be similar to other conditions. Methods and results: A healthy 16-year-old girl presented with cystic swelling, localized to the left postauricular area. Since,CT and otological examination were negative, surgery was performed to completely excise the cystic mass. Histological examination conﬁrmed the diagnosis of the ﬁrst cleft cyst. Conclusions: There are potential difﬁculties in the diagnosis and menagement of ﬁrst cleft anomalies. Incorrect diagnosis and mismenagement lead to persistence or recurrence lesion and secondary infection.

OP 173 Long term histological results of ossiculoplasty with bioceramics implants H. Mocanu, Oana Alexandra Iosif, M. Radulescu, Iulia Tirziu, V. Postelnicu, Gabriela Ciorbea Institute of Phono-Audiology and Functional ENT Surgery ‘‘ Prof. Dr. D. Hociota’’ – Bucharest, Str. Mihai Cioranu, nr. 21, sect.5, Bucuresti Objectives: Explaining the long term expectations regarding ossicular implants and rejection probability in patients with radical or partial mastoidectomy. Deﬁning the most likely factors to inﬂuence the rejection or histological integration of a synthetic implant. Deﬁning indications and counter indications of implantation in such cases (pre, intra and postoperative situations). To outline an expectation horizon regarding evolution and results. Material and methods: 108 patients with both radical or partial mastoidectomy and ossicular implants during a 3 year period (1993–1996). Synthetic prosthetics PAW1 of autochthonous origin were used. Data analysis began in 2004 giving a mean followup period of 9, 12 years. Follow-up by clinical means (otoscopy). Results: Rejection rate 21% (23 patients). Integration rate 79% (85 patients). Over 50% of all rejections during the ﬁrst month. Most of the rejections (74%) during the ﬁrst year. Conclusions: Contrary to common opinion that rejections do not occur after 2 years time, we found them even after a 7 year period (insufﬁcient follow-up may explain this). The rejection rate is mathematically deﬁned by an exponentially decreasing function. The rate of success for mastoid dicing in is congruent to the rate of the successful implants.

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OP 174 Ossicular chain reconstruction with ionomer cement and cortical bone La´szlo´ Lujber University Pe´cs, Medical School, Hungary Objectives: Partial or total necrosis of the long process of the incus or the superstructure of the stapes leads to conductive hearing loss. Most frequently used techniques bridge the stapes head and the malleus handle with arteﬁcial prostesis. Our objective was to demonstrate a different, but reliable and versatile reconstructional method that restores the anatomical integrity and the function of the ossicular chain. Methods: Glass-ionomer cement alone or in combination with cortical bone was used to reconstruct different forms of ossicular chain discontinuities. Short necrotized portion of the long process of the incus was rebuilt with glass-ionomer cement identical to the original anatomy. If the entire long process was missing, a piece of cortical bone was shaped and cemented between the body of the incus and the head of the stapes. In case the stapes supersturcture was also missing, a cortical bone columella was fashioned to connect the stapes footplate to the previously rebuilt incudal long process. Results: Almost anatomical restoration of the ossicular chain could be achieved by this surgical technique. Mobility of the ossicles was satisfactory by visulal control during surgery. Functional results are also promissing. Mean air-bone gap is less than 10dB in the follow-up of 6 months. Conclusion: The described surgical technique gives an exellent anatomical and functional result and can be a good alternative to other reconstructional methods.

OP 175 Tympanic portion of the facial nerve: anatomical study V. Nikolaidis, A. Hatziavramidis M. Nalbadian, G. Kekes ENT Dpt, Aristotle University of Thessaloniki Objectives: The purpose of this study was to measure the length of the tympanic portion of the facial nerve in normal temporal bones. Methods: 52 human temporal bones obtained from 46 individuals, were studied by microsurgical dissection. Results: The mean length of the facial nerve between the geniculate fossa and the pyramidal eminence was 10.93 mm and the median value was 11.2 mm (std dev. 1.26 mm). The greatest length was 13.3 mm and the least was 8.3 mm. The mean length of the facial nerve between the geniculate fossa and the cochleariform process was 5.22 mm and the median value was 5.24 mm (std dev. 0.98 mm). The greatest length was 7.3 mm and the least was 3.5 mm. The mean length of the facial nerve between the cochleariform process and the pyramidal eminence was 5.77 mm and the median value was 5.7 mm (std dev. 0.55 mm). The greatest length was 7.3 mm and the least was 4.3 mm. Using the t-Test method for independent samples, no statistically signiﬁcant differences were determined according to gender and localization of the temporal bone, for a conﬁdence interval of 95%. Conclusions: Half of the length of the tympanic portion of the facial canal lies into the anterior epitympanic space.

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OP 176 The second turn of the facial canal: anatomical relations V. Nikolaidis, A. Hatziavramidis, I. Konstantinidis, A. Kouloulas ENT Dpt, Aristotle University of Thessaloniki Objectives: The purpose of the study is to deﬁne the anatomical characteristics of this part of the facial nerve and its relations with the horizontal semicircular canal and the sinus incudis. Methods: 52 human temporal bones obtained from 46 individuals, were studied by microsurgical dissection. Results: The mean distance between the horizontal semicircular canal and the facial nerve was found to be 2,22 mm, with the highest value of 3,4 mm and the lowest value of 1,1 mm. Using independent sample t-Test for the statistical analysis of our results there was no statistically signiﬁcant difference when we test the viable of sex P = 0.713 or side P = 0.731 of the excised temporal bone. The mean distance between the sinus incudis and the facial nerve was 2,27 mm, with the highest value of 3,6 mm and the lowest 1,2 mm. Once again we did not ﬁnd signiﬁcant differences according to sex P = 0.600 and side of the temporal bone P = 0.761. The mean angle of mastoid turn was 105o with highest value 130o and lowest value 89 (std. dev. 9.71). We identify abnormalities of the course of the facial nerve in the second turn in 4 (7.7%) excised specimens. Conclusions: The knowledge of the distances between the facial nerve and neighboring anatomical structures can lead to a safer surgical approach.

OP 177 Long term assessment of the results of operations improving hearing based on the material of over 15,000 ears H. Skarzynski, M. Mrowka, P. Mlotkowska-Klimek International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Mokra 17 st, Kajetany, 05– 830 Nadarzyn, Poland. Objectives: Thirty thousand of operations that have been performed for 11 years makes up an extensive material allowing us to assess various reconstructive solutions in the area of the middle ear as well as allows to assess epidemiological tendencies of numerous diseases in Poland. The aim of the study was to assess various reconstructions of the ear applying autogenic and alloplastic material. Methods: The material consisted of 15237 ears, observed for minimum 3 years in the follow-up period. There were two groups: children and adults. The whole material was divided into subgroups that were taking into account::cause of the ear disease, prior therapeutic procedure, level of damages or ﬁxation of the conductive apparatus of the middle ear, type of auto and allogenic materials. Results: Results were assessed 1, 2and 3 years according to EAONO rules. Conclusions: (1) Earlier detection of middle ear damages, resulting from hearing screening examination that have been performed for 10 years, improved remote hearing results. (2) Better paediatric, otolaryngology and audiology care effects in signiﬁcantly increasing problem—obliterative changes, such as tympanoﬁbrosis and tympanosclerosis. (3) Appropriate application and elaboration of the autogenic and alloplastic materials for the reconstruction of auditory ossicle chain gives remote comparable hearing results.

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OP 178 Morphological examination of facial nerve H. Skar_zyn´ski1, J. Wysocki2, M. Porowski1, K. Krasucki1, P. H. Skar_zyn´ski 1 1 International Center of Hearing and Speech of the Institute of Physiology and Pathology of Hearing, Warsaw, Poland; 2 Department of Otolaryngology, Medical University of Warsaw, Poland Aims: The aim of the study was the assessment of condition of the facial nerve bone canal and detection of its possible defects. Methods: The examinations were carried out on a material of 100 specimens of temporal bone. The preparation method consisted in exposing, under a microscope, the nerve within the temporal bone. The tympanic segment of the nerve was subject to detailed assessment. This was possible because no preliminary preparation was needed in this nerve segment, which eliminated the possibility of intraoperative damage. Consequently, the nerve trunk was exposed in proximal and distal direction; the results were plotted on previously prepared map and then used in statistical analysis. Results: The elaborated results have shown that nearly 97% of all defects in the nerve canal wall appear in its tympanic segment. It is particularly important, because this part of the nerve is in direct contact with the tympanic cavity, thus it is susceptible to irritation or damage. This fact is an important hint for clinicians, especially young doctors specializing in otosurgery. Conclusions: The presented results of morphological examination provide a valuable material for teaching young doctors topographic anatomy of the temporal bone. The results have proven that frequency of appearance of defects in nerve canal walls is much greater than that reported in literature. One can assume that the discovered defects could explain unclear, temporary pareses observed by clinicians during conservative and/or surgical treatment. 17 ears after 1 year on the 3.2 dB. There was no improvement in 12 ears. The next control showed deterioration of hearing with airbone gap in the next 13 ears. Patients were provided hearing aids. Conclusions: Obtained results allow us to extend previous indications to apply stapedotomy in various pathologies of the middle ear but it will always require extraordinary caution for the beneﬁt of the patients and their ears.

OP 179 Extrusion rates and hearing results of plastipore prostheses in reconstruction of middle ear ossicular chain T. Chalastras1, A. Elefteriadou1, I. Lambrou1, S. Korres1, J. Yiotakis1, L. Manolopoulos1, D. Kandiloros1, G. Georgopoulos2 1 Department of Otolaryngology, Medical School, University of Athens, ‘‘Hippokration’’ Hospital, Athens, Greece; 2Department of Otolaryngology, General Hospital, ‘‘Elpis’’, Athens, Greece Objectives: To exanimate the acoustic results in a 10 years period of time, the percentage of extrusion of prostheses, the factors which are related with the prognosis, in patients who tried ossiculoplasty with plastipore. Methods: Forty-two patients who tried ossiculoplasty with plastipore at ENT department (Hippokration hospital, university of Athens, Greece) were studied over a 4 year period from 1991 to 1994. Patients were followed for the next 10 years. The surgical procedures were classiﬁed in: tympanoplasty, tympanoplasty with mastoidectomy with canal wall up, and tympanoplasty with mastoidectomy with canal wall down. An air–bone gap closure to

S255 within 20 dB was considered successful. Results: Signiﬁcant postoperative improvement of pure-tone air conduction threshold averages and air-bone gap averages were reported in 3 studied groups. Successful results presented 65% of our patients. For the PORP was 68.8%, and for the TORP was 62.5%, while the mean value for air bone gap improvement was 25.5 db. The percentage of prostheses rejected was 4.7%. Conclusions: Signiﬁcant hearing improvement is recorded in each pathologic group, with low percentage of extrusion implants in a variety of ear diseases and ossicular chain deformity.

OP 180 Total fasial nerve decompression of a patient with Melkersson–Rosenthal syndrome via middle fossa and retroauricular approaches: a case report Ahmet Kutluhan, Sami Berc¸in, Veysel Yurttas Ataturk Education and Research Hospital ENT Department Ankara, Turkey A 27 year-old male patient with recurrent facial nerve paralysis of Melkersson-Rosenthal Syndrome treated with total fasial nerve decompression was presented in this study.

OP 181 Classiﬁcation in evaluation of treatment of congenital defects of the external ear with our own grading scale H. Skarzynski, R. Podskarbi-Fayette, M. Mrowka, P. Mlotkowska-Klimek, B. Skarzynska International Center of Hearing and Speech of The Institute of Physiology and Pathology of Hearing, Warsaw, Poland Objectives: Treatment of congenital defects of the external ear may be considered quite a difﬁcult problem in otosurgery. According to our Institute’s standards it consists of reconstruction of the auricle and/or the external auditory canal. Methods: There are several grading systems describing the degree and type of malformation of the external ear. However, so far there were no reports describing a uniﬁed system of classiﬁcation of the results after the surgical procedure. We present our own grading system, proposed by the senior author, that best describes post operative aesthetic and functional results. Results: The study material consisted of 112 patients—children and adults—with different degree of unilateral malformation of the external ear. According to our standard protocol the primary task was to reconstruct the auricle. This was done in accordance to the two step procedure described by Brent and Nagata. The ﬁrst step was the preparation of a full cartilagenous frame of the auricle and its placement underneath the skin of the patient’s head. The graft was later moved to create the right angle with the surface of skin. The second step was to reconstruct the external auditory canal if there was proof of existence of the middle ear on X-rays. In cases of poor development of the middle ear Bone Anchored Hearing Aids were implanted. Conclusions: Variety of types of malformations of the external ear and several modiﬁcations of reconstruction procedures impose a need for a uniﬁed system of evaluation of post operative results. The 10 point grading system, proposed by the authors seems to help to classify such results.

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OP 182 Cartilage tympanoplasty for tympanic membrane perforation Chiraz M’barek, Sarra Zribi, Ines Hariga, Khaled Charrada, Olfa Ben Gamra, Abdelkader El Khedim ENT Department Habib Thameur Hospital Tunis Tunisia Objective: The aim of this study is to evaluate anatomical and audiological results of cartilage tympanoplasty compared to fascia tympanoplasty in the reconstruction of tympanic membrane perforations.Materials and methods:We carry a retrospective study about 380 patients operated in our department between 1998 and 2005. Patients were classiﬁed into 2 groups: 90 (23.6%) undergo cartilage tympanoplasty and 290 (76.4%) undergo fascia tympanoplasty. In each group, we calculated the average of pre, postoperative air-bone gap (ABG) and the average air-conduction gain (ACG) at 250–4,000 Hz. Results: We detail and analyze the audiological and anatomical results in each group. Successful closure of the tympanic membrane perforation was achieved in 97% of the cartilage group as compared to 94% of the fascia group. The average ACG was 14 ± 11 dB in cartilage group and 13.6 ± 11dB in fascia group. With an average follow-up of 2 years, residual perforation was observed in 2.2% in cartilage group. Reperforation of fascia graft and retraction were noted in 2.7 and 1%, respectively. Conclusion: We recommend using cartilage as a ﬁrst choice, especially in stable or evolutive chronic otitis media, and in recurrent perforations of the tympanic membrane.

OP 183 Surgical treatment of posttraumatic impairments of the middle ear conductive apparatus H. Skar_zyn´ski, M. Mrowka, P. Mlotkowska-Klimek, M. Porowski, R. Podskarbi-Fayette Clinical Center of Oto-Rhino–Laryngosurgery, International Center of Hearing and Speech of Institute of Physiology and Pathology of Hearing, Warsaw Objectives: The aim of the study was to assess results of posttraumatic treatment of conductive apparatus of the middle ear in children and adults. Methods: In the 1999–2004 there were 214 ears operated at our Clinic. All of them had posttraumatic changes within the middle ear. Most of them followed head injuries and pyramid fracture of the temporal bone. The tympanoplasty was delayed and performed only after condition of patients was stabilized. In most cases injuries were concerning broken ossicular chain in the incudo-stapedial joint, accompanied by a dislocation of the

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OP 184 About myringoplasty by under-lay method A. Antohi, S. Vetricean, I. Antohi Department of otorhinolaryngology, University of medicine and pharmacy ‘‘Nicolae Testemitanu’’, 2025, Testemitanu str., Chisinau, Republic of Moldova Objectives: The work is based on study of anatomical and functional results after myringoplasty, performed by ‘‘under lay’’ technic—the placement of autofascial graft under meato-tympanal ﬂap. Methods: The study was done on 137 patients with age between 7 and 60 years old.The operations were performed at Central Hospital and Central Hospital for children of Republic of Moldova. Results: The closure of tympanal perforations was obtained in 76.92% of cases.In 13.85% of cases were observed a small perforation of ear drum.Necrosis of fascial graft was in 9.23%.In the pacients with age between 7 and 15 years old the closure of tympanal perforations was in 89.6% of cases.Air-bone gap was reduced in 90.8% of cases. Conclusions: The performing of myringoplasty by a ‘‘under-lay’’ method assures better placement of fascial graft in a reception zone of ear drum,increases the contact surface of graft with tympanic membrane,in most of cases avoids phenomenon of lateralization.Anatomical and functional results were better in children that in adults.

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OP 185 T.O.R.P. after radical trepanation of temporal bone

to hard during surgical excision. Tympanosclerotic plaques can be classiﬁed histologically. Methods: Thirty-three surgically excised tympanosclerotic tissues were examined otomicroscopically and light microscopically. Otomicroscopically; plaques were classiﬁed as type I; soft (7 cases), type II; moderately hard (11 cases) and type III; too hard (15 cases) according to their consistency and facility of surgical separation. Sections prepared from tympanosclerotic tissues were stained with hematoxylin and eosin, Mallory-Azan and von Kossa stains for light microscopic evaluation. Results: In the ﬁrst group (type I), ﬁbroblasts and collagen ﬁbers were equally abundant in typical loose connective tissue. A few small calcium crystals were seen. In the second group (type II), large bundles of collagen ﬁbers, proliferation of ﬁbroblasts and focal calciﬁcation points were seen. In the third group (type III), round shaped condroblast-like cells located in lacunae and diffuse calciﬁcation points are evident. Conclusions: Histological classiﬁcation of tympanosclerotic tissue may inform us about the maturation of the tissue, so the grade of the disease. In type I tympanosclerotic disease, even if complete resection of sclerotic tissue is performed, process may go on and new sclerotic tissue formation may be expected. A type III sclerotic tissue can contribute to a limited, inactive disease. Progress of the disease and patient’s beneﬁt from the operation can be interpreted according to this classiﬁcation.

Dejan S. Rancic ENT Clinic, Clinical center Nis 48. Dr Zorana Djindjica street, 18000 Nis, Serbia The work shows a usage the T.O.R.Prosthesis in patient after radical trepanation of temporal bone. Radical trepanation of temporal bone was indicated, caused by large cholesteatoma. During this operation mastodectomy, antrotomy, removing of ossicles (except a base of stapes) and closure of tube were performed. Few months after, audiogram shows very good bone conduction and poor air conduction. For this reason, for returning a hearing, T.O.R. prosthesis was used. On ﬁrst stage, whole epithelization was removed from cavum and closured tube was released. On the end of this operation a ‘‘cavum parvum ‘‘ was performed. It was closed with cartilage–perichondral membrane. One cartilage pin was positioned as guide from surface to base of stapes because preventing a collapsing of membrane. Tree months after, second stage operation was performed. After timpanomeatal ﬂap preparing, cartilage pin was removed and T.O.R. prosthesis was positioned. Upper part was curved and anchored in cartilage. Lower part positioned on base of stapes. One month after last operation, audiogram shows an excellent result.

OP 186 Case report: hemangioma of the tympanic membrane Hakki Uzunkulaoglu, Erdal Samim, Ilhan Unlu, Kursat Ceylan, Hakan Gocmen, Unal Bayiz, Ahmet Yavanoglu, Veli Gunduz, Arzu Alanya Ministry of Health Ankara Research and Training Hospital Ear Nose and Throat Department, Ulucanlar Cad. No:1 Mamak Ankara, Turkey Objective: We report an extremely rare case of hemangioma of the tympanic membrane Method: Case report and world literature concerning hemangioma of the tympanic membrane are presented. Results: Hemangiomas are frequently seen benign vascular tumours although their existence on the tympanic membrane is very rare. By now only ﬁve cases of tympanic membrane hemangiomas were reported consisting of both cavernous and capillary forms. In this paper we report case of hemangioma on the right tympanic membrane in a 40-year-old male with the review of the literature. Conclusion: Hemangiomas should be kept in mind in the differential diagnosis of the lesions visible on the tympanic membrane.

OP 187 Histopathological classiﬁcation of tympanosclerotic plaques Adin Selcuk, Serdar Ensari, Ayse Kose Sargin*, Belgin Can*, Huseyin Dere Ankara Numune Educational and Research Hospital, 4th ENT Clinic, Ankara, Turkey; *Ankara University Faculty of Medicine, Histology and Embriology Department, Ankara, Turkey

OP 188 Long term follow up of tympanoplasties in childhood Jo´zsef Pytel, Ga´bor Ra´th, Pe´ter Bako´, Imre Gerlinger Department of Otorhinolaryngology, Head and Neck Surgery, Medical School, Pe´cs University, Hungary Objective: A retrospective analysis of the audiograms, surgery reports and drawings, video records, postoperative notes relating to the sequential cases of patients who, at the time of their ﬁrst tympanoplasty, had been under 18 years of age, is presented. Study design: The data processing software was developed and all the surgeries were performed by one author (J.P.). Children underwent intact canal-wall procedure and in case of cholesteatoma a planned second look at 1 year. Autograft temporal fascia is used to reconstruct the eardrum, autogenous cortical temporal bone columella (ACBC), harvested with chisel, fashioned to appropriate size and shaped with scalpel according to the type of tympanoplasty, is used to the reconstruction of the chain. Setting: otorhinolaryngological university department. Participants: During 31 years between 1st September 1975 and the 11th July 2006 tympanoplasties were performed on 222 ears of 195 children. The documents of a total of 366 surgeries have been processed. The results of patients who were operated on in their childhood and adolescence and followed up later on in their adulthood were also integrated in the database. Twenty-two second or third operations were performed over the age of 18. Results: Hearing results are considered acceptable if postoperative ABG is below 20 dB and good if it is less than 10 dB. 86% of the type I, 69% of type II, 43% of type III and 70% of type V operations were classiﬁed under acceptable category. Conclusion: The computer-based procession conﬁrmed us in the belief that we achieved good results in tympanoplasty in childhood applying the same technique for more than 30 years.

Objectives: Tympanosclerotic plaques seen in the middle ear and tympanic membrane as a sequela of otitis media have different characteristics. Plaque consistency shows a wide range from soft

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OP 189 Vestibular evoked myogenic potentials in vestibular neuritis patients

system prevalence due to a central nervous system (CNS) modiﬁcation and highlights a CNS disease. These data highlight the importance of our test.

Shawky Elmorsy,* Mohamed M. Abdel Tawwab** *ENT Department, Mansoura University, Egypt; **ENT Department, Mansoura University, Egypt. ASHA (American Speech, Language and Hearing Association) Member

OP 191 Stabilometric ﬁndings in agoraphobic patients

Objectives: To study the effect of vestibular neuritis on the inferior vestibular nerve by its assessment through vestibular evoked myogenic potential measurements. Methods: Prospective randomized study. The participants were selected from patients attending mansoura university hospitals outpatient ENT clinics. A total of (35) subjects age range from (16) to (60) years were enrolled in this study (15) control subjects and (20) vestibular neuritis patients after there consent. They were subjected to the vestibular-evoked myogenic potential (VEMPs) measurement, audiometric and caloric test measurements. Results: There were no signiﬁcant statistical difference between vestibular-evoked myogenic potential measurements in vestibular neuritis patients side of lesion and the contalateral healthy side as will as with the control normal subjects group with clear detectable N13-P23 waveform of vestibular-evoked myogenic potential in patients with vestibular neuritis. Conclusions: Vestibular neuritis spare the inferior vestibular nerve and could affect other parts of the vestibular nerve. The vestibular-evoked myogenic potential can be used as an effective tool in the evaluation of the vestibular neuritis patient as a part of its test battery evaluation.

OP 190 Visual-vestibular-interaction test in the diagnosis of vertigo Massimo Dellepiane, Renzo Mora, Francesco Mora, Angelo Salami ENT Department, University of Genoa, Italy Objectives: The aim of this investigation was to determine the diagnostic value of our visual-vestibular test in the diagnosis of vertigo. Methods: A total of 106 patients (group A), affected by central vertigo were submitted to electronystagmography (ENG) recording. As a control group 100 healthy adults were identiﬁed. All the patients head blocked, sat on a ‘‘Tonnies rotatory chair Pro model’’ which was placed in the middle of a rotatory cylindrical chamber (2 m in diameter and 1.9 m in height). The rotatory chamber was driven by a direct current engine, which turned it clockwise and counterclockwise, and its internal area was covered with 32 black vertical contrast. All the subjects underwent to rotatory vestibular stimulation by Stop test (VOR), to optokinetic stimulation (OKN) and to contemporary rotatory vestibular and optokinetic stimulation (VVOR). Results: In the control group, all the patients presented no VOR and OKN mean gain modiﬁcations; all the patients showed a VVOR nystagmus homodirectional to OKN. In group A, all the patients presented VOR and OKN mean gain modiﬁcations, 46 patients (43%) showed a VVOR nystagmus with quantitative modiﬁcations, 60 patients (57%) had a VVOR nystagmus homodirectional to VOR. Discussion: In the healthy patients, VVOR nystagmus is always homodirectional to OKN and indicates the optokinetic system prevalence on VOR. The presence of a VVOR nystagmus homodirectional to VOR indicates the absence of the optokinetic

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R. Teggi, D. Caldirola, G. P. Perna, S. Bondi, L. Bellodi, M. Bussi San Raffaele Hospital- Vita e Salute University- via Olgettina 60–20132 Milano Objectives: In order to assess if an overweight of visual cues in postural control may contribute to the onrise of of agoraphobic disorders Methods: 25 agoraphobic patients performed a static stabilometry in 4 conditions: open eyes, closed eyes, open and closed eyes on a 10 cm. rubber foam, performing a 30 sec exam for each condition. Results have been compared with those of 25 healthy patients matching for age and sex. The following stabilometric parameters were used for the analysis: locus Length (L), Surface (S) and Velocity of oscillation (V). Moreover Romberg Index (RI) between conditions has been calculated. Results: Agoraphobic patients obtained higher values of all parameters above all in the two closed eyes conditions. Visual Romberg is signiﬁcantly lower in agoraphobic patients (0.55 vs 0.73, p = 0.001) Conclusions: Postural control in agoraphobic patient seems to be more visual related than in control group. Visual dependance in our opinion may contribute to the manteinance of agoraphobic symptoms in reason of major instability in all conditions in which Central Nervous System has too many visual information to manage. Moreover our results support the idea that vestibular system may be involved in the patophysiology of agoraphobia.

OP 192 Does sinus disease cause dizziness Tristram Lesser et al Consultant ENT/Skull Base Surgeon, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL Objectives: The Objectives are to analyse the symptoms that patients attribute to sinusitis including dizziness, headaches, pain in the nape of the neck, pressure in the head, heavy feeling between the eyes, temporal pains and visual disturbances and compare them with a control group of patients who have the same symptoms as tertiary symptoms from vestibular problems. Methods: The questionnaire was undertaken on the two groups of patients using the SNOT scoring, the vestibular handicap inventory and dizziness symptom scale between the two groups. The materials were patients attending the rhinology clinic with conﬁrmed rhinosinusitis and the dizziness clinic with vestibular disorders. Results: The ﬁndings were that the majority of patients who had symptoms from sinus disease were indistinguishable from the patients who had symptoms from uncompensated vestibular disorders and the dizziness attributed by patients to sinus disease was more likely to be due to a vestibular disorder than the sinus disease. Conclusions: More awareness needs to be undertaken in rhinology clinics of the possible vestibular causes of the symptoms that patients attribute to sinus disease.

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OP 193 Betahistine 16 mg tid or 24 mg bid in Me´nie`re’s disease Maurı´ cio Gananc¸a, Heloisa Caovilla, Fernando Gananc¸a Federal University of Sa˜o Paulo – Rua Periquito, 210 Ap. 32 A – Moema – Sa˜o Paulo – Brazil Objectives: To compare the efﬁcacy and tolerability of betahistine 16 mg tid and 24 mg bid in the treatment of vertigo in Me´nie`re’s disease patients. Methods: Randomised, open study in which 120 consecutive definite Me´nie`re’s disease patients were included, diagnosed according to their medical history and audiological and computerised nistagmography evaluation. Patients (n = 60 per dose group) were treated for 24 weeks. Treatment efﬁcacy was assessed at Weeks 4, 12 and 24, according to the intensity, frequency and duration of vertigo spells. Results were evaluated by means of Wilcoxon test and the comparison between groups was performed by Mann-Whitney test (a = 0.05). The incidence of adverse events was investigated during each visit. Results: Patients treated with betahistine 16 mg tid or 24 mg bid showed statistically signiﬁcant improvement of vertigo, compared with the initial and ﬁnal visits (16 mg: Z = 6.42, P < 0.01; 24 mg: Z = 6.57, P < 0.01). There was no statistically signiﬁcant difference between groups in relation to vertigo evaluation at Weeks 4 (U = 0.100, P = 0.752), 12 (U = 1.361, P = 0.243) and 24 (U = 0.150, P = 0.699). Each group presented a low incidence of adverse events with no need for treatment interruption. Conclusions: Betahistine 24 mg bid and 16 mg tid presented similar efﬁcacy and tolerability in the vertigo therapy of Me´nie`re’s disease patients.

OP 194 Common aetiologies of ‘dizziness’ in patients referred to the Balance Clinic Jiun Thong, Christopher Woods*, Stephen Lo, Jeffrey Knight Department of Otorhinolaryngology-Head and Neck surgery, St George’s Hospital, Blackshaw Road, London; *Audiology Department, Mayday Hospital, Croydon, UK Objectives: To determine common aetiologies of ‘dizziness’ in patients referred to the Balance Clinic. Method: Data was collected prospectively over 4 months on all patients referred to the Balance Clinic with a major complaint of dizziness, vertigo or disequilibrium. Diagnosis was made based on history, clinical examination and relevant audiovestibular testing, with radiological imaging when indicated. Results: During the time period, 62 patients attended the Balance clinic. Of these, 43 were female and 19 were male. The mean age was 57 years and the age range was from 22 to 87 years. The duration of symptoms varied from 2 months to over 5 years. 56%

S259 had associated symptoms of neck stiffness, 23% had associated headaches, 19% had associated hearing loss, 16% had associated nausea, 11% had associated tinnitus and 8% had associated visual disturbance. The commonest aetiology of ‘dizziness’ was neckrelated positional vertigo (31%). Other aetiologies included benign paroxysmal positional vertigo (27%), post-viral (13%), vascular (8%), whiplash injury (5%) and migraine (3%). 2% of the patients each had ‘dizziness’ related to Meniere’s disease, peripheral vestibular failure, post-stapedectomy, previous head injury, Ramsay-Hunt syndrome and menopausal symptoms. Anxiety and stress were sole causes of ‘dizziness’ in 3% of patients, and contributing factors in 16 % of patients. Conclusion: Dizziness is a non-speciﬁc and common complaint with a wide range of aetiologies, the commonest 3 being neckrelated positional vertigo, benign paroxysmal positional vertigo (BPPV) and post-viral dizziness. Anxiety and stress appear to be signiﬁcant causes and contributing factors in dizzy patients.

OP 195 Type A behaviour pattern and dizziness Jiun Thong, Christopher Woods*, Stephen Lo, Jeffrey Knight Department of Otorhinolaryngology- Head and Neck Surgery, St George’s Hospital, Blackshaw Road, UK; *Audiology Department, Mayday Hospital, Croydon, UK Objectives: Type A behaviour pattern is a complex of personality traits, the most signiﬁcant of which being the constant sense of time-urgency which may manifest as impatience and irritability. Its association with dizziness has not been examined in the past. The aim of our study was to determine the prevalence of Type A behaviour amongst dizzy patients attending the Balance Clinic. Method: Patients attending the Balance Clinic between August and November 2005 were examined. All patients had ‘dizziness’ as the main complaint. A self-administered validated questionnaire adapted from the Bortner Self-Rating Scale, was used to measure Type A behaviour pattern amongst these patients. The 4 categories of behaviour pattern were: strongly Type A, moderately Type A, moderately Type B and strongly Type B. Results: Sixty two patients attended the Balance clinic but only 54 patients (38 female, 16 male) were included in the study (8 questionnaires incorrectly-ﬁlled). Mean age was 56 years. Age range was from 22 to 86 years. 20% of patients were strongly Type A, 61% moderately Type A and 19% moderately Type B. Conclusion: The majority of patients with dizziness attending the Balance Clinic appear to be of moderately or strongly Type A behavioural pattern type. An explanation may be that Type A patients, being more time-urgent and keen to get back to routine, are more likely to seek help with their symptoms. A study is currently in progress to determine if possession of Type A behaviour pattern in these patients would predict response to balance retraining exercises.

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OP 196 VEMP: an objective tool for saccular function Alexandru Pascu, Madalina Georgescu Institute of Phono-Audiology and E.N.T. Functional Surgery, 21 Mihail Cioranu str., 050751 Bucharest, Romania Objective: To examine the properties and potential clinical uses of vestibular evoked myogenic potentials. Methods: Vestibular evoked myogenic potentials were recorded from normals (to observe variations depending on SCM muscle contraction and intensity of acoustical stimulus) and in different otoneurological conditions in an attempt to ﬁnd correlations between results of VEMP and these pathologies. Recording conditions were standard: click or 500 Hz tone burst at maximum intensity on Bio-logic or ICS equipment (100 and 97dB nHL, respectively), 200 sweeps; electrodes were positioned on upper third of ipsilateral SCM muscle and ground electrode on the sternum. Contraction of the SCM muscle was obtained with subjects in supine position and head elevated. Results: VEMP were: absent or decreased ipsilaterally in patients with peripheral (vestibular schwannoma, after gamma-knife surgery for vestibular schwannoma, vestibular neuritis, Menie`re’s disease, bilateral ototoxic vestibular failure) or central vestibular lesions (multiple sclerosis, neuroﬁbromatosis type III); preserved in those with severe/profound cochlear hearing loss; augmented (with lower threshold) in perilymphatic ﬁstula and superior semicircular canal dehiscence. Conclusions: In our experience, VEMP is a very useful objective vestibular test, mainly for diagnostic purpose and also for monitoring evolution of some transitory vestibular pathologic conditions whenever saccula or inferior vestibular nerve is involved.

OP 197 Benign paroxsysmal positional vertigo (BPPV) of the CSA: on purpose of a clinical case N. Taurozzi, M. Truzzi, R. Gaudelli, C. Sivelli ENT Department Hospital ‘‘C.Poma’’ Mantova Italy The BPPV constitutes the vestibular diagnostic entity of greater reply in the practical clinical. Draft of an entity to otolitic separation characterized clinical from the insorgence of transitory crises breathtaking by means of expresses changes of position of the head, with the elicitation of the peculiar paroxsysmal nystagmus (ny) and with tendency to the spontaneous remission and by means of liberatory or riabilitativy terapy. Beyond to the classic involvement of the CSP and CSO, it is possible, very rarely, a otolitic migration also to cargo of the front semicrcolari channels (advanced), evidencing therefore the entity of BPPV of the CSA (inibitoria or eccitatoria shape), on which in the last biennium a lot difference of opinions has been debated in literature. Pathology is revealed from manoeuvre of Dix-Hallpike executed on the side of the maze

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S153–S264 not the affection. Appear a paroxsysmal ny of positioning, nearly exclusively rotatory, with inverse clinical characteristics to those waits for the CSP of the explored side; it is possible also that the ny it has the same direction of the tested side, with but the appearance of greater intensity in the phase of rebound. It comes brought back the clinical case of a female patient, years 67, reached our observation for intense positional breathtaking crises with neurovegetatives symptoms, tied to the laterorotation of the head to left and dealt in other center for BPPV of the CSP left without beneﬁt. The Authors have identiﬁed a shape of BPPV of the CSA right that it has shown a complete remission after suitable treatment.

OP 198 Analysis of symptomathology and concomitant diseases with balance disturbances in epidemiological aspect Jarosaw Wysocki1,2, Henryk Skar_zyn´ski2, Wojciech Chrza˛stowski2, Ireneusz Szyman´ski3, Piotr Orszulak1 1 Clinic of Otolaryngology and Rehabilitation II Medical Faculty University Medical School in Warsaw, Poland, Kajetany, 05–830 Nadarzyn, Mokra 17 Str.; 2Institute of Physiology and Pathology of Hearing, Warsaw, Poland, 01–943 Warsaw, Pstrowskiego 1 Str.; 3Department of Otolaryngology, Bro´dno Hospital, Warsaw, Poland, 03–242 Warsaw, Poland, Kondratowicza 8 Str. Objectives: In available literature there are scarce data dealing with epidemiology of vertigo and balance disorders. Aim of the study was to obtain information about population of patients suffering from hearing and balance disorders, especially about concomitant diseases and their relations with observed symptomathology. Methods: Six thousand eight hundred and thirty seven of patients treated on outpatient wards, suffering from vertigo and balance disorders. An author’s original questionnaire was used. In statistical analysis Student’st test, analysis of variance, v2 test and Pearson’s coefﬁcient of correlation were calculated. Results: Patients with central balance damages were older, poorly educated and presented modest professional activity, and more frequent lied up on hypertension, diabetes and degeneration of neck spine than patients with peripheral damages. Patients with labyrinth damages more frequent worked in noise, suffered form chronic otitis media, and were being exposed on ototoxic medicines. In all patients some factors signiﬁcantly correlated with particular symptoms were observed. It concerned in particular hypertension which was correlated with headache and hearing impairment/tinnitus which were correlated with neck spine degenerative changes. Conclusions: Groups of patients distinguished by character of vertigo and balance disorders presents several signiﬁcant differences in demographic features, symptomathology and accompanying diseases, which conﬁrms that there are two different diseases.

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OP 199 Analysis of agents carrying weight on therapeutic success in balance disturbances treated ambulatory by Betahistine application Jarosaw Wysocki1,2, Henryk Skar_zyn´ski2, Wojciech Chrza˛stowski2, Ireneusz Szyman´ski3, Piotr Orszulak1 1 Clinic of Otolaryngology and Rehabilitation University Medical School in Warsaw, Poland; 2Institute Of Physiology and Pathology of Hearing, Warsaw, Poland; 3Department of Otolaryngology, Bro´dno Hospital, Warsaw, Poland, 03–242 Warsaw, Poland; 4 University Medical School in Warsaw, Poland Objectives: Find and assess possible factors inﬂuencing on ﬁnal therapeutic success in therapy of vertigo and balance disorders. Methods: Prospective, questionnaire study, 4648 of patients, adults and adolescents, both gender, suffering from vertigo or other balance disturbances treated in primary care system by neurologists and otolaryngologists, by Betahistine (Histimerck) application during a 30–60 days period in doses 24 or 48 mg/day. Therapeutic success was evaluated as withdrawal of vertigo or dizziness and in physical examination. Results: Generally results were better in patients with diagnosis of vertigo labyrhintica and in younger than in older patients. Statistically signiﬁcant positive inﬂuence on therapeutic success was proved not for summaric dose of Betahistine but for summaric time of therapy and therapy according to alternative model: the different dose in the following 30 days. Head injury in the past, cervical spine degenerative changes and VIII nerve diseases deteriorated chances of headache, waving and visual disorders release but only for patients with diagnose of vertigo centralis. In patients with vertigo labyrhintica hypertension signiﬁcantly deteriorated ﬁnal result in headache release. It was also proved negative inﬂuence of acoustic injury on vertigo release in all the patients. Conclusions: To the group which is anticipated as having worse therapeutic effects belong older patients and patients burdened with cervical spine degenerative changes, acoustic injury and head or cervical spine injuries in the past.Extending of time of therapy until 60 days provides considerable positive effect.

OP 200 Posturography study in irradiation-induced carotid angiopathy patients with head and neck malignancies L. To´th, A´. To´th, A´. Sz} ucs, I. Sziklai University Of Debrecen Medical And Healthscience Center Objective: Therapeutic cervical radiation for head and neck cancer has been associated with an increased incidence of carotid arterial stenosis. The neck irradiation may accelerate atherosclerosis, increasing the risk of vascular stenosis, increasing risk of vestibular symptoms. The purpose of this study was to determine the value of posturography in the estimation of the risk of vestibular symptoms, including a comparison with ultrasound examination. Method: Fifty-seven irradiation induced carotid angiopathy patients and 25 healthly subjects as control were evaluated.

S261 All patients were screened with bilateral carotid arterial duplex ultrasonography.. Previously unrecognized vestibular dysfunction were detected by clinical examination and conﬁrmed by quantitative vestibular testing. Static posturography were carried out using platform system.The Romberg quotiens, the long of way of vertigo, the ﬁel of vertigo, the mean direction of vertigo were examined. Results: Irradiated carotid arteries had a more frequently stenosis, intimal thickness, narrower lumen than the controls. After irradiation some symptoms were more frequently vertigo, orthostatic collapse, headache.Posturography is helpful in the management of patients with suspected vestibular disorders.The clinical balance tests, the static posturography test revealed signiﬁcant differences between the groups.This study demonstrates that computerized posturography can accurately identify and document vestibular symptoms in head and neck malignancies. Conclusion: Posturography might serve as one method to evaluate the functional consequences of a vestibular deﬁcit in patients with irradiation-induced carotid angiopathy patients with head and neck malignancies.

OP 201 Electronystagmographic ﬁndings in children Dimitrios G. Balatsouras1, Georgios Kloutsos1, Panayotis Ganelis1, Constantinos Balas1, Nicolas C. Economou1, Sotiris Papouliakos2, Stavros Korres3, Antonis Kaberos1 1 ENT Department, Tzanion General Hospital of Piraeus, Zani & Afentouli, 18536 Piraeus, Greece; 2ENT Department, Gennimatas Hospital, Athens, Greece; 3ENT Department of Athens National University, Hippokration Hospital, Athens, Greece Objectives: To evaluate the electronystagmographic (ENG) ﬁndings in children presenting with vertigo of peripheral origin. Methods: Twenty-six consecutive children (11 boys and 15 girls) aged 5–16 years who presented with vertigo attacks during the past year were studied. A detailed medical history was obtained from our patients or their parents. All patients underwent otolaryngologic and neurologic clinical examination. Detailed laboratory examinations and a complete audiological and neurotologic evaluation, including electronystagmography, were performed as well. ENG testing was carried out using standard adult techniques, slightly modiﬁed to accommodate for children. Imaging studies were obtained in selected cases. Patients with central ﬁndings were excluded from the study. Results: Diagnoses included viral infections, otitis media, benign paroxysmal positional vertigo, head trauma and Meniere’s disease. The main ENG ﬁndings were peripheral type spontaneous nystagmus (62%), directional preponderance (50%), and canal paresis (42%). Conclusions: Diagnostic approach in vertigo in children should include a detailed history and clinical examination in conjunction with a test battery of audiological and neurotologic tests. Electronystagmography is feasible and may afford valuable information for the disease.

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OP 202 Inferior versus superior vestibular nerve involvement in Meniere´s disease surgery Bloedow A, Jovanovic N, Westhofen M ENT-Department, University Hospital RWTH Aachen Objective: The aim of this study was to evaluate the sacculus versus utriculus and lateral semicircular canal dysfunction in patients with Meniere’s disease treated with endolymphatic sac surgery. Methods: The study includes 23 patients suffering from persistent unilateral or bilateral Meniere’s disease according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) criteria and incapacitating vertigo. In these patients, the vestibular evoked myogenic potentials (VEMPs) and vestibulo-ocular reﬂexes (VORs) in bithermal caloric testing in prone and supine position were monitored before and after endolymphatic shunt surgery. Results: Before surgery, on the affected side dysfunction of lateral semicircular canal was found in 85%, utricular response was absent in 50% of the patients with Meniere’s disease. Comparison of VEMP responses revealed saccular deﬁcits in 90% on the affected side and 50% on the unaffected side. After therapeutic intervention there was no additional macula or semicircular canal dysfunction. Conclusions: Endolymphatic shunt surgery is a safe and effective treatment method in severe cases of Meniere’s disease. Patients with Meniere´s disease often have saccular dysfunction prior to canal dysfunction. Abnormal VEMPs even on the previously unaffected side, demonstrates a saccular impairment which is indicative for persistent vertigo after surgery. Therefore, VEMP testing is useful for detecting patients at risk.

OP 203 Menie`re’s disease refracting to saccotomy: application of intratympanic gentamicin Gert Lange, Haralampos Gouveris, Wolf Mann Roemerwall Clinic Mainz (G.L.), Department of ORL-HNS, The University of Mainz Hospitals (H.G. and W.M.), Langenbeckstrasse 1, Mainz 55131, Germany Objectives: Recurrent incapacitating vertigo attacks sometimes persist after saccotomy for Menie`re’s disease (MD). In these cases we advocate the once weekly application of intratympanic gentamicin (12 mg, maximum 3 doses). Methods: Five patients (age range 39–65 years) suffering from deﬁnite MD according to AAO-HNS criteria, underwent intratympanic gentamicin treatment (IGT) after unsuccessful saccotomy. Follow-up period after IGT ranged from 26 to 59 months. Results: Complete control of vertigo attacks (Class A, AAO-HNS) was achieved in all ﬁve cases as well as preservation of hearing at 0.5, 1, 2 and 3 kHz. Conclusions: Intratympanic gentamicin therapy is a successful therapeutic option in MD refracting to saccotomy.

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OP 204 Prospective analysis of ofﬁce vestibular exam and ENG Mohamed Hamid The Cleveland Hearing & Balance Center, Cleveland, OH, USA Ofﬁce vestibular examination is an important element of the neurotologic evaluation of patients with dizziness. Electronystagmography (ENG) is the traditional test for dizziness. Recent use of video based systems (VNG) has made it easier to conduct a more comprehensive ofﬁce examination. The purpose of this presentation is to compare ofﬁce vestibular examination with VNG to the results of laboratory based ENG testing. Prospective results showed >90% correlation between the two methods in detecting abnormal eye movements and caloric asymmetries. Ofﬁce vestibular examination with VNG is both time and cost effective. Physicians can reliably use ofﬁce VNG when laboratory based ENG is not available.

OP 205 Correlation of vestibular evoked myogenic potentials and electronystagmic ﬁndings in patients with sudden hearing loss Stavros Korres2, Sotirios Papouliakos1, Georgios Stamatiou2, Dimitrios Balatsouras3, Dimitrios Kandiloros2, Antonios Tzagaroulakis2, Eleftherios Ferekydis2 1 ENT Department, General Hospital of Athens ‘‘G.Gennimatas’’; 2 ENT Department, National University of Athens, Hippokration Hospital, Greece; 3ENT Department, Tzanion General Hospital, Piraeus Objectives: Vestibular Evoked Myogenic Potentials (VEMPs) are electric potentials, used as a parameter for the assessment of the otolith function. They can be recorded after sound stimulation with surface electrodes over each sternocleidomastoid muscle. The purpose of the study is to investigate VEMPs and correlate them with the electronystagmic ﬁndings in cases of Sudden Hearing Loss (SHL). Methods: Pure tone audiometry, acoustic immittance testing, caloric testing, Auditory Brainstem Responses and VEMP testing was performed on 34 patients with unilateral idiopathic SHL. Same testing was performed on a control group of healthy volunteers. VEMP responses were measured and compared to caloric responses. Results: VEMPs were present in all normal subjects of the control group and ipsilaterally normal on the unaffected side in all patients with SHL. Twenty ﬁve out of 34 patients (73,53%) showed normal VEMP responses. In 13 patients both electronystagmographic ﬁndings and VEMPs were normal, but in 12 patients VEMPs were normal but there were abnormal caloric responses (canal paresis in 7 patients, spontaneous nystagmus in 5 patients). Nine patients displayed abnormal VEMPs (26,47%) on the affected side (in eight cases absent, in one case delayed) and eight of them demonstrated decreased caloric responses, while one patient had normal caloric responses. Conclusions: In a considerable number of cases VEMPs were abnormal. However, most of the patients displayed normal VEMPs. Also, in the majority of patients, VEMPs correlated to the caloric responses, although in a certain number of cases either the superior or the inferior vestibular nerve was involved.

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OP 206 Vestibular evoked myogenic potentials and eElectronystagmographic ﬁndings in patients with benign paroxysmal positional vertigo Stavros Korres2, Sotirios Papouliakos1, Dimitra Giannakakou2, Dimitrios Balatsouras3, Ioannis Xenelis2, Georgios Korres2, Eleftherios Ferekydis2 1 ENT Department, General Hospital of Athens ‘‘G.Gennimatas’’; 2 ENT Department, National University of Athens, Hippokration Hospital; 3ENT Department, Tzanion General Hospital, Piraeus Objectives: Vestibular Evoked Myogenic Potentials (VEMPs) are short-latency potentials recorded from the ipsilateral tonically contracting sternocleidomastoid muscle in response to loud clicks or tone-bursts. Benign Paroxysmal Positional Vertigo (BPPV) is believed to be caused by free-ﬂoating in the endolymph degenerative debris that gravitates into one of the semicircular canals. The aim of this study was to record and analyze VEMP responses in patients with BPPV and compare them with the results of their caloric responses. Methods: Twenty nine patients with posterior semicircular canal BPPV were subjected to pure tone audiometry, acoustic immittance testing, Auditory Brainstem Responses, Electronystagmography and VEMP testing. A control group of healthy volunteers was also enrolled. BPPV diagnosis was based on history and positive Dix–Hallpike test. Results: VEMPs were present in all normal subjects, while there was no abnormality regarding the caloric tests in the control group. Twelve out of 29 patients (41.38%) displayed canal paresis on the caloric testing. VEMP test revealed abnormal responses in 10 patients (34.48%), 6 of them displaying prolonged latency ipsilaterally and 4 of them with absence of the wave ipsilaterally. Three patients showed both abnormal electronystagmic and VEMP ﬁndings. Considering both investigations, 19 out of the 29 patients (65,5%) revealed abnormal vestibular ﬁndings. Conclusions: Although each test revealed vestibular abnormalities in a considerable number of cases, it appears that none of them individually can be used for the assessment of the vestibular system in patients with BPPV. However, when the two tests are combined, they reveal a vestibular abnormality of 65.5%.

OP 207 Videonystagmographical analysis of the Halmagyi–Curthoy’s test Henryk Kaz´mierczak, Katarzyna Pawlak-Osin˜ska DPT. of Otolaryngology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland Objectives: The usefulness of the Halmagyi–Curthoy’s test (H-C) in unilateral labyrinthine weakness was examined.

S263 Methods: In 23 patients with canal paresis of II and III stages by Dix–Hallpike classiﬁcation, VNG registration of active and passive H-C test was performed. In the control group we tested 10 healthy. Results: VNG recoding in the forms of the smooth or distorted lines was recieved in both gruops. In 4 persons from control group distorted line was observed, but direct observation was ‘‘normal’’. In 7 patients in which direct examination was ‘‘normal’’ too, VNG regstration showed distorted line. In the past 16 patients registration was the same as direct test i.m. ‘‘pathological’’. In passive and active examination the results were the same. Conclusions: Our analysis pointed the limitation of the H-C test and its rough application.

OP 208 The estimation of vestibular and audiological function in patients with ﬁnal kidney insufﬁciency Katarzyna Pawlak-Osin˜ska1, Henryk Kaz´mierczak2, Zbigniew Wlodarczyk2, Andrzej Adamowicz2 1 Department of Otolaryngology, 2Department of Transplantation, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland Objectives: The purpose of the study was to estimate the vestibular ad audiological function in patients with ﬁnal kidney insufﬁciency. The examination was done just before kidney transplantation Methods: Fifty patients aged 26–65 were tested. The examination of audiological function and vestibular testing were performed Tonal audiometry, otoacoustic emisssions, evoked audiological potentials of short latency, vestibular myogenic evoked potentials and video(electro)nystagmography were done in every case. Each patients had been treated with steroids for a long period of time before transplantation of the kidney. Results: On the base of tonal audiometry 60% of patients demonstrated normal hearing. The rest suffered from sensorineural hearing loss, mostly bilateral. Otoacoustic emissions were abnormal in majority of cases, despite of the normal subjectve hearing in tonal audiometry. Evoked audiological potentials of short latency were absolutely normal in all patients apart from four. Vestibular myogenic evoked potentials testing revealed typical morphology and normal latencies of P13N23P30 complex- in a few patients the prolonged latency of the wave P13was noted. Video(electro)nystagmography was rarely pathological- if yes- positional, cervical, gaze nystagmus were present. In 2 patients spontaneous nystagmus with eyes closed was registered. Conclusions: In patients with ﬁnal kiney insufﬁciency treated with steroids for the years the audiological function was more frequent distroyed than vestibular one. Despite of steroids pharmacotherapy-inner ear cochlear part was predominantly damaged. Even if the subjective hearing was normal, the objective examination (OAE) showed subclinical cochlear deffect.

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OP 209 Comparison of two methods of vestibular rehabilitation Traditional vestibular rehabilitation as compared to vestibular substitution via the BrainPortTM balance device. Olin Ce´cile1,2, Imbaud Sylvie3, Rougier Patrice2, Sampaı¨ o Eliana1 Cnam; 2Univesite´ de Savoie; 3Centre d’exploration fonctionelle oto-neurologique 1

Objectives: To compare classic and BrainPortTM method of rehabilitation in areﬂexic patients. To determine the impact of each treatment on balance and on quality of life (QL), and to deﬁne most effective treatment option, or combination of treatments. Methods: BrainPortTM is a medical device developed for vestibular rehabilitation. Training with the BrainPortTM leads to improvements of postural control, not only when using the system, but also for increasing periods of time after training sessions (Danilov et al. 2004).The BrainPortTM consists of an intra-oral device (IOD) and a controller. IOD contains a miniature accelerometer and a 10*10 electrode array. Information about the head-position and motion is translated to the electrode array, which is held against the subject’s tongue. Subject learns to use the stimulus on the array to make posture corrections.

TM

Experimental plan

Classic rehabilitation

BrainPort

First week Second week

Patients 1, 2, 3, 4 Patients 5, 6, 7, 8

Patients 5, 6, 7, 8 Patients 1, 2, 3, 4

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Our patients trained over ﬁve sessions with each technique. Patients were evaluated by the means of posturography; a double force platform (Equi+) and two clinical tests : the European Evaluation of Vertigo (EEV) and a QL test: the Diziness Handicap Inventory (D.H.I.). Results: On the way: Conclusions - PerspectivesImprovements from the two rehabilitation methods can naturally be expected. Comparison will show if one treatment, or a combination of both, is more effective to achieve balance or QL improvements.

OP 210 The biomechaninical model of the inner ear/vestibular part A. Shukuryan, M. Nazaryan, M. Harutyuyan, R. Topcian Yerevan State Medical University, ‘‘Erebouni’’ Medical Center ENT Department Objectives: The biomechanical model of the inner ear and charecterise of vestibular disorders was studied. Methods and results: Characterise of vestibular disorders mas studied in 120 patients with conductive and sensorineural hearing loss. At the ENT department of ‘‘ Erebuni ‘‘ Medical Center all patients grouped by age, gender and type of diseases. The biomechanical model of the inner ear shows that in parallel with endolimpha ‘s density, growths her oscillations amplitude, but when growths endolimpha ‘s viscosity there is amplitude contraction in 35% and redaction damping time of 70 till 55 s. There is same regularity under the angle deﬂection of cupula. Conclusions: Therefore, the modiﬁcations of endolimpha’s physicochemical properties under some pathologic processes have a same type inﬂuence on her angle shift, angle deﬂection of cupula, and on redaction damping time.

O – Otology: Neurootology

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