Improve Hearing Outcomes Research Articles

Cell-based neurotrophin treatment supports long-term auditory neuron survival in the deaf guinea pig

The cochlear implant provides auditory cues to profoundly deaf patients by electrically stimulating the primary auditory neurons (ANs) of the cochlea. However, ANs degenerate in deafness; the preservation of a robust AN target population, in combination with advances in cochlear implant technology, may provide improved hearing outcomes for cochlear implant patients. The exogenous delivery of neurotrophins such as brain-derived neurotrophic factor (BDNF) and neurotrophin-3 is well known to support AN survival in deafness, and cell-based therapies provide a potential clinically viable option for delivering neurotrophins into the deaf cochlea. This study utilized cells that were genetically modified to express BDNF and encapsulated in alginate microspheres, and investigated AN survival in the deaf guinea pig following (a) cell-based neurotrophin treatment in conjunction with chronic electrical stimulation from a cochlear implant, and (b) long-term cell-based neurotrophin delivery. In comparison to deafened controls, there was significantly greater AN survival following the cell-based neurotrophin treatment, and there were ongoing survival effects for at least six months. In addition, functional benefits were observed following cell-based neurotrophin treatment and chronic electrical stimulation, with a statistically significant decrease in electrically evoked auditory brainstem response thresholds observed during the experimental period. This study demonstrates that cell-based therapies, in conjunction with a cochlear implant, shows potential as a clinically transferable means of providing neurotrophin treatment to support AN survival in deafness. This technology also has the potential to deliver other therapeutic agents, and to be used in conjunction with other biomedical devices for the treatment of a variety of neurodegenerative conditions.

The Role of Tympanostomy Tubes in Surgery for Acquired Retraction Pocket Cholesteatoma

Objectives: (1) Determine whether intraoperative tympanostomy tubes (TT) during surgery for acquired retraction pocket cholesteatoma (ARPC) results in improved hearing outcomes or decreased recurrence of ARPC. (2) Determine the need for subsequent TT in children that did not receive TT at initial surgery. Methods: Institutional review board–approved retrospective review of children 4 to 18 years, who underwent primary surgery (tympanoplasty or tympanomastoidectomy) for ARPC at a tertiary care children’s hospital from January 1, 2000, to December 31, 2012. Audiometry, operative reports, office findings, TT, and recurrence data for ARPC were analyzed. The chi-square test was used for statistical analysis. Results: Preoperative Mills staging for extent of cholesteatoma was similar for both groups. A total of 24 patients had TT at initial surgery (TT Group) and 34 patients did not (no TT Group). The average preoperative and postoperative SRT were 23dB and 25dB, respectively, for the TT Group, and 31 dB and 31 dB for the no TT Group. The recurrence rate for ARPC was 29% for the TT Group versus 41% for the no TT Group ( P = .35). Thirty-five percent of patients in the no TT Group required TT at a subsequent surgery. Conclusions: There was no statistical difference in recurrence or audiometric outcomes between patients who underwent TT insertion versus those who did not during initial surgery for ARPC. However, since the incidence of recurrent ARPC was 12% lower when TT were placed, and since the rate of subsequent TT was 35% in the no TT Group, a larger, prospective study of TT at initial surgery for ARPC is needed.

Surgical outcomes with subperiosteal pocket technique for cochlear implantation in very young children

ObjectivesAs data continue to emerge demonstrating improved hearing outcomes associated with younger age at time of cochlear implantation, more children aged 12 months or younger are undergoing this procedure. Drilling a well to house the cochlear implant receiver/stimulator (R/S) may carry an increased risk in this group of patients as the calvarium is thin and drilling an adequate well may require exposure of the underlying dura. Our group has employed a technique in this age group which involves securing the R/S in a subperiosteal pocket without creating a bony well. We report our experience with six infants 12 months of age or younger undergoing cochlear implantation with the subperiosteal pocket technique. MethodsCases were identified by searching an IRB approved research registry. Charts were reviewed for demographics, surgical technique, and clinical outcomes. Descriptive statistics were calculated. ResultsSix patients 12 months of age or younger underwent cochlear implantation over a one year period. Simultaneous bilateral implantation was performed in all cases, for a total of 12 implanted ears. The average age at time of implantation was 9.8 months (SD 2.1 months). There were no postoperative wound complications. No evidence of device migration was noted in any patient as of the most recent follow-up appointment. There was one device hard failure at 32 months. Average length of follow-up was 28.4 months (SD 13.8 months). ConclusionsNo wound complications or device migrations occurred in 12 cochlear implantations in six children aged 12 months or younger. Advantages of this technique include no risk to the dura in this location, smaller incisions, and shorter surgical time. A potential disadvantage is the increased device profile from the lack of a well. New thinner implant designs may minimize this concern. Further prospective study is justified to confirm our initial experience in this small group.

Automatic localization of cochlear implant electrodes in CT.

Cochlear Implants (CI) are surgically implanted neural prosthetic devices used to treat severe-to-profound hearing loss. Recent studies have suggested that hearing outcomes with CIs are correlated with the location where individual electrodes in the implanted electrode array are placed, but techniques proposed for determining electrode location have been too coarse and labor intensive to permit detailed analysis on large numbers of datasets. In this paper, we present a fully automatic snake-based method for accurately localizing CI electrodes in clinical post-implantation CTs. Our results show that average electrode localization errors with the method are 0.21 millimeters. These results indicate that our method could be used in future large scale studies to analyze the relationship between electrode position and hearing outcome, which potentially could lead to technological advances that improve hearing outcomes with CIs.

Some considerations in congenital cholesteatoma

A review of recent publications is combined with our clinical experience to provide salient tips for optimizing the care of children with congenital cholesteatoma. Increasing utilization of surgical adjuncts such as endoscopy and KTP laser provides the opportunity to improve postoperative outcomes by reducing residual cholesteatoma rates and improving hearing outcomes. Nevertheless, the best prospect of leaving the child with a normal ear is achieved by prompt removal after early detection when the lesion is still small. Education of primary care providers to promote early identification and referral of congenital cholesteatoma remains an important objective and responsibility for otolaryngologists in order to obtain optimal outcome.

Efficacy of the active middle-ear implant in patients with sensorineural hearing loss

This systematic review aims to advise on the effectiveness of the active middle-ear implant in patients with sensorineural hearing loss, compared with external hearing aids. A systematic search of several electronic databases, including PubMed and Embase, was used to identify relevant studies for inclusion. Fourteen comparative studies were included. Nine studies reported on the primary outcome of functional gain: one found that the middle-ear implant was significantly better than external hearing aids (p < 0.001), while another found that external hearing aids were generally significantly better than middle-ear implants (p < 0.05). Six of the seven remaining studies found that middle-ear implants were better than external hearing aids, although generally no clinically significant difference (i.e. ≥ 10 dB) was seen. Generally, the active middle-ear implant appears to be as effective as the external hearing aid in improving hearing outcomes in patients with sensorineural hearing loss.

Image-Guidance Enables New Methods for Customizing Cochlear Implant Stimulation Strategies

Over the last 20 years, cochlear implants (CIs) have become what is arguably the most successful neural prosthesis to date. Despite this success, a significant number of CI recipients experience marginal hearing restoration, and, even among the best performers, restoration to normal fidelity is rare. In this paper, we present image processing techniques that can be used to detect, for the first time, the positions of implanted CI electrodes and the nerves they stimulate for individual CI users. These techniques permit development of new, customized CI stimulation strategies. We present one such strategy and show that it leads to significant hearing improvement in an experiment conducted with 11 CI recipients. These results indicate that image-guidance can be used to improve hearing outcomes for many existing CI recipients without requiring additional surgical procedures.

The use of bone cement for ossicular chain defects

Bone cement is a good and cheap option for some ossicular chain problems such as incudostapedial re-bridging. The purpose of this retrospective study is to evaluate the audiologic results after reconstruction of three different types of ossicular chain defects, using bone cement. Group 1 consists of 42 patients who underwent an ossiculoplasty using bone cement between the damaged long process of the incus and an intact stapes superstructure. Group 2 consists of 46 patients in which incus interposition between malleus and stapes superstructure was performed, using bone cement to fix the interposed incus. For group 3, consisting of 32 patients who had a present malleus, a defective long process of the incus and a missing stapes superstructure, a re-shaped incus was placed between the stapes footplate and the malleus and bone cement was again used as a fixator. Preoperative and postoperative pure-tone audiometric findings were obtained and hearing differences were assessed. The mean preoperative and postoperative air-bone gaps were 34.8 and 15.6, 35 and 18.4, and 43.4 and 19.8 for groups 1, 2, and 3, respectively. There was a significant improvement in hearing outcomes in all the groups when comparing preoperative and postoperative mean air-bone gaps (p<0.001). The postoperative air-bone gap was ≤20dB in 76% of patients in group 1, 64% of patients in group 2, and 46% of patients in group 3. Bone cement is an effective and cheap option for some ossicular chain problems such as incudostapedial re-bridging. It may also be used to fix the interposed incus to the stapes superstructure and/or malleus to avert displacement.

Position of TORP on the Stapes Footplate Assessed With Cone Beam Computed Tomography

To improve hearing outcomes of ossiculoplasty with a total ossicular replacement prosthesis (TORP) in ears lacking a footplate superstructure, 3-dimensional computed tomography (3D CT) images were reconstructed to verify the position of the TORP on the footplate and contact between the TORP and the stapes footplate. Retrospective study. University-affiliated tertiary referral center. Six ears of 6 patients who underwent ossiculoplasty with TORP and were followed for greater than 3 years postoperatively. Cone beam CT (CBCT) images. An en face view of the stapes footplate and a volume-rendered 3D image were reconstructed. The en face view of the stapes footplate showed whether the TORP was centered on the stapes footplate. Volume-rendered 3D CBCT images revealed TORP malpositioning or migration, which were not detected on 2-dimensional CBCT images. In such cases, the TORP shaft was in contact with the wall of the oval window niche or the TORP had moved from the stapes footplate. Accurate visualization of TORP location on the footplate is important. Images that accurately show the position of the TORP on the stapes footplate will help improve hearing outcomes.

Targeted salivary screening for congenital CMV in the UK is feasible, acceptable and may improve hearing outcomes

<h3>Background</h3> Congenital CMV (cCMV) causes up to 15% sensorineural hearing loss (SNHL) in the UK, however hearing outcomes may improve with ganciclovir treatment commencing in the first month of life. Targeted screening of infants who are ‘referred’ for further audiological testing after ‘no clear responses’ are found on their newborn hearing screen for CMV might identify these babies early enough to offer treatment. <h3>Aims</h3> We present initial feasibility and acceptability data of targeted cCMV screening. <h3>Methods</h3> Eligible infants from Northumbria and South-West London, (those9 referred9 for further hearing testing after their newborn hearing screening and &lt;22 days old) had cCMV screening by PCR on urine and salivary samples. Infants screening positive had confirmatory CMV testing. Feasibility was measured by the number of infants correctly identified with cCMV and assessed for treatment by 28 days; acceptability was measured by parental anxiety (Spielberger STAI anxiety score). <h3>Results</h3> Of 14,373 newborns 351 were9 referred9 for further hearing testing after their initial hearing screening and 248 families were approached with 152 (62%) agreeing to cCMV screening. Three newborns were found positive, all detected in time to allow assessment for treatment within 28 days. Salivary samples were easier to acquire with 95% (145) returning salivary samples and 41% (63) urine samples. Anxiety scores in study mothers were not significantly different to reference mothers. <h3>Conclusions</h3> Targeted cCMV screening using saliva is feasible and acceptable to parents. Extending the National screening programme to include cCMV testing in all infants without clear early hearing responses may improve hearing outcomes. Economic analysis and mechanistic processes require further evaluation.

New cochlear implant technologies improve performance in post-meningitic deaf patients

The objective of the study was to compare the performance of cochlear implantation between post-meningitic and non-meningitic patients, and to evaluate the impact on hearing outcome of technical advances in cochlear implant technology. Retrospective chart review was used as the study design. Twenty adults with post-meningitic profound hearing loss receiving unilateral or bilateral cochlear implants between 1990 and 2008 were tested. Results were compared to a control group of 46 adults implanted for a non-meningitic hearing loss, with the same pre-operative speech scores. Speech scores were poorer in post-meningitic patients compared to those of control group, whatever the duration after implantation (p < 0.0001). Speech scores of subjects implanted and fitted before 2001 were compared to those of subjects implanted after 2001, with the same duration of hearing loss. Performance improved with implants and processors available after 2001, with a magnitude of improvement higher in post-meningitic patients (p < 0.0001 and p < 0.05 in post-meningitic and control groups, respectively, two-way ANOVA). Consequently, speech scores of post-meningitic patients implanted after 2001 achieved those of control subjects (two-way ANOVA). Advances in cochlear implant technology and coding strategy improve hearing outcome in post-meningitic adult patients, who now achieve similar performance as those of non-meningitic patients.

Effects of Early Surgical Exploration on Hearing Outcomes in Suspected Traumatic Perilymph Fistulas

Objective: Analyze the outcomes of early surgical exploration in suspected traumatic perilymph fistulas (PLF). Method: Study Design: Retrospective case review. Setting: Tertiary otology referral center. Patients and Intervention: Nine patients (10 cases) that developed sudden sensorineural hearing loss and dizziness following head trauma underwent exploratory tympanotomy and PLF repair with the clinical impression of traumatic PLF. Outcome Measure: Postoperative hearing changes and control of dizziness. Results: All patients had sudden or progressive hearing loss and dizziness following head trauma; a car accident, slap injury, and barotraumas. Surgical exploration was performed 2 to 47 days after the trauma. Possible evidence of PLF was found in 9 cases and included: fibrous web around the oval window (OW) (n = 3), perilymph collection around the round window (RW) (n = 5), and bulging of the RW membrane (n = 1). After surgical repair, the mean hearing gain was 28dB (10~55dB); the hearing improved to serviceable levels in 6 out of 10 cases (60%). All patients had resolution of the vestibular symptoms after the surgery. Conclusion: Sudden or progressive sensorineural hearing loss accompanied by dizziness following head trauma should prompt the consideration of a traumatic PLF. Early surgical exploration is recommended to control dizziness and improve hearing outcomes.

Future technology in cochlear implants: assessing the benefit

It has been over 50 years since Djourno and Eyries first attempted electric stimulation in a patient with deafness. Over this time, the Cochlear Implant (CI) has become not only remarkably successful, but increasingly complex. Although the basic components of the system still comprise an implanted receiver stimulator and electrode, externally worn speech processor, microphone, control system, and power source, there are now several alternative designs of these components with different attributes that can be variably combined to meet the needs of specific patient groups. Development by the manufacturers has been driven both by these various patient needs, and also by the desire to achieve technological superiority, or at least differentiation, ultimately in pursuit of market share. Assessment of benefit is the responsibility of clinicians. It is incumbent on both industry and clinicians to ensure appropriate, safe, and affordable introduction of new technology. For example, experience with the totally implanted cochlear implant (TIKI) has demonstrated that quality of hearing is the over-riding consideration for CI users. To date, improved hearing outcomes have been achieved by improvements in: speech processing strategies; microphone technology; pre-processing strategies; electrode placement; bilateral implantation; use of a hearing aid in the opposite ear (bimodal stimulation); and the combination of electric and acoustic stimulation in the same ear. The resulting expansion of CI candidacy, with more residual hearing, further improves the outcomes achieved. Largely facilitated by advances in electronic capability and computerization, it can be expected that these improvements will continue. However, marked variability of results still occurs and we cannot assure any individual patient of their outcome. Realistic goals for implementation of new technology include: improved hearing in noise and music perception; effective invisible hearing (no external apparatus); automated fitting; and reduction in outcome variability. This paper provides examples of relevant potential future technologies that can be applied to reach these goals. In the quest for better outcomes, future technology must deliver improved reliability and usability for both clinicians and recipients that does not compromise safety and is affordable. One of the challenges related to the introduction of new technologies is the ‘classification’ of CI systems and the framework under which sufficient change and increased benefit can be demonstrated to establish a claim of ‘new generation CI’ and hence increased reimbursement from third-party payers. Significant improvements in hearing outcomes and quality of life associated with CI design changes are difficult to measure, particularly when there is such dramatic benefit from the intervention of cochlear implantation from the individual's perspective. Manufacturers and clinicians need to be objective and undertake appropriate safety studies and long-term and multi-centre clinical trials to ensure that the introduction of new technology is both safe and effective and supported by health systems worldwide.

Reduced spiral ganglion neuronal loss by adjunctive neurotrophin-3 in experimental pneumococcal meningitis

BackgroundHearing loss is a frequent long-term complication of pneumococcal meningitis (PM). Its main pathological correlate is damage to the organ of Corti and loss of spiral ganglion neurons. The only current treatment option is cochlear implants which require surviving neurons. Here, we investigated the impact of systemically applied neurotrophin-3 (NT-3) on long-term hearing loss and the survival of neurons.MethodsEighteen hours after infection with S. pneumoniae, C57BL/6 mice were treated with a combination of ceftriaxone with NT-3 or dexamethasone or placebo. Hearing, cochlear damage, and brain damage were assessed by audiometry and histology.ResultsThe main findings from immunohistochemical visualization of neurotrophins (NT-3, BDNF) and their receptors (TrkB, TrkC, and p75) in the cochlea were (i) enhanced staining for the cell survival-promoting receptor TrkB and (ii) increased NT-3 staining in NT-3 treated mice, showing that systemically applied NT-3 reaches the cochlea. The major effects of adjunctive NT-3 treatment were (i) a reduction of meningitis-induced hearing impairment and (ii) a reduction of spiral ganglion neuronal loss. The efficacy of NT-3 therapy was comparable to that of dexamethasone.ConclusionSystemically applied NT-3 might be an interesting candidate to improve hearing outcome after pneumococcal meningitis.

Gamma Knife Surgery of Vestibular Schwannomas

Determine which variables are correlated with early hearing changes after gamma knife surgery of vestibular schwannomas (VSs). Prospective clinical study of hearing outcomes, radiation dosimetry, conformity, and tumor size of all sporadic unilateral VS patients treated between June 2000 and July 2009. Tertiary referral center. : Fifty-nine VS patients with at least 6 months of follow-up data were studied. Audiometry and imaging were performed to determine auditory thresholds, speech discrimination, and tumor size. Radiation doses to 5 volumes were measured. Pretreatment and posttreatment comparisons were performed with regard to change in tumor size; radiation dose to specific volumes including the internal auditory canal, cochlea, basal turn of the cochlea, and modiolus; and conformity of the treatment. The mean follow-up was 63.76 months (standard deviation, ±29.02 mo; range, 9-109 mo). The median follow-up was 65.5 months. A statistically significant association between maximum radiation dose to the cochlea volume and 3-frequency pure-tone average in patients starting with 50 dB or lesser PTA3 was demonstrated using linear regression analysis. Longitudinal changes in hearing occur over time, with the largest changes seen in the first 12 months after treatment. With our study outcomes as basis, limiting the dose of radiation to the cochlea to no more than 4 Gy would likely reduce vascular injury to the stria vascularis and improve hearing outcomes. Shielding the cochlea during the treatment planning process would be one mechanism to accomplish this goal.

Intratympanic dexamethasone as initial therapy for idiopathic sudden sensorineural hearing loss: Clinical evaluation and laboratory investigation

Objective To evaluate the effect of intratympanic dexamethasone (ITD) as initial therapy for idiopathic sudden sensorineural hearing loss (ISSHL) as well as to determine the concentration-dependent time course distribution of dexamethasone in the inner ear. Methods Sixty-six patients with profound ISSHL were included. Twenty-two were treated with ITD and the rest as control. Audiograms were performed before the treatment and one month afterwards. In the animal study, dexamethasone of different concentrations (5, 10 and 20 mg/ml) was injected into the tympanums of three groups of SD rats (Groups A, B and C), their inner ears dissected free at various postinjection survival intervals. Immunofluorescence was applied to detect the locations of dexamethasone. Results The overall rate of good prognosis was 77.27% in ITD group, which was not significantly different from 81.82% in the control group. In the animal study, the higher local concentration and longer lasting period was found in Groups B and C. Conclusions ITD at 5 mg/ml did not add effect to systemic steroids in improving hearing outcomes in patients with ISSHL. An increase in dexamethasone concentration led to large variations in pharmacokinetics in animal study, showing potential value in optimizing the drug delivery protocols and improving the therapeutic results.

Hearing rehabilitation in congenital aural atresia using the bone-anchored hearing aid: audiological and satisfaction results

Conclusion: The BAHA (bone-anchored hearing aid) remains the most reliable method of auditory rehabilitation for patients with congenital aural atresia and improves hearing outcome and quality of life in these patients who are otherwise unable to benefit from traditional hearing aids. New techniques are being developed, such as fully implantable hearing devices, and will have to prove their efficacy and safety in this indication. Objective: To evaluate the audiological results and patient satisfaction after rehabilitation of congenital aural atresia using the BAHA. Methods: Sixteen patients suffering from bilateral congenital aural atresia were implanted with unilateral BAHA. Preoperative air- and bone-conduction thresholds and air–bone gap (ABG), preoperative sound reception threshold (SRT), postoperative aided thresholds, implantation complications, patient satisfaction, and the APHAB questionnaire were collected. Results: After a mean follow-up period of 6.5 years, 15 patients were still using their device. Each patient had an average improvement of 33 ± 7 dB. Closure of the ABG within 15 dB of the preoperative bone-conduction thresholds occurred in 10 patients. Adverse skin reactions appeared in 50% of patients over 6.5 years of follow-up. Eleven of the 12 patients used their BAHA for more than 8 h per day.

L-NAC Treatment Improves Hearing Outcome in Sudden Deafness

L-NAC Treatment Improves Hearing Outcome in Sudden Deafness

Screening Newborns for Congenital Cytomegalovirus Infection

IN THIS ISSUE OF JAMA, BOPPANA AND COLLEAGUES 1 DEscribe their attempts to validate universal screening methods for congenital cytomegalovirus (CMV) infection, the most common congenital viral infection in the United States and many other regions, by using polymerase chain reaction (PCR) analysis of newborn dried blood spots. Congenital CMV infection remains an important public health problem not only because it has accounted for as much or more disability over the past 50 years than was associated with congenital rubella syndrome, but also because CMV infection, whether symptomatic or silent at birth, represents the most common nongenetic cause of permanent hearing loss among children in the United States. Congenital CMV infection causes a substantial proportion of sensorineural hearing loss even in regions with a low prevalence. Culture surveillance of nearly 4000 newborns in Utah revealed a congenital infection rate of 0.29%, corresponding to approximately 3 infected infants for every 1000 newborns or 165 infected newborns annually statewide, given the state’s current birth rate. Because as many as 10% of these infants will have CMV disease, a condition associated with a 30% to 50% prevalence of sensorineural hearing loss, and the remainder will have silent CMV infection, a condition conservatively associated with a 6% to 8% rate of sensorineural hearing loss, CMV accounts for hearing loss in 15 to 20 children each year in Utah, or approximately 20% of the 90 to 120 Utah children identified with permanent hearing loss annually (J. C. Carey, University of Utah School of Medicine, written communication, March 2010). Worldwide, thousands of infants have CMV-induced hearing loss annually. Universal newborn screening for many disorders has immense public health benefits. The history of phenylketonuria (PKU) illustrates the enormous benefit of such strategies. Universal screening of newborn hearing has led to improvement in language outcomes, with greater improvements when deaf infants are identified earlier and interventions are begun sooner. Thus, it seems logical to infer that if CMV-infected infants can be identified in the neonatal period, hearing could be tracked closely, interventions could begin early, and the hearing outcomes of congenital CMV infection might be improved. However, 2 challenges confront universal screening for congenital CMV infection. First, universal screening is only justified when an effective intervention exists that prevents adverse health outcomes, such as averting intellectual disability when infants who lack phenylalanine hydroxylase initiate a diet low in phenylalanine early in life. At present, no such solution exists for CMV. Although neonatal ganciclovir therapy improves hearing outcomes in some infants, the benefits are not universal and the risk/benefit ratio of ganciclovir therapy in infants with silent congenital CMV infection has not been sufficiently well-established to recommend such therapy for all CMV-infected infants. Nonetheless, knowing which infants are infected with CMV has benefit through early identification of infants at risk of CMVinduced hearing loss and may have additional benefits in the future when new and more effective antiviral strategies become available. The second challenge, the one addressed by Boppana et al, is the availability of a highly sensitive and specific screening method. Neonatal screening of hearing alone is insufficient to detect all CMV-infected infants because most infants with congenital CMV infection have normal hearing in the neonatal period. Fowler et al demonstrated that nearly 20% of the children with hearing loss due to silent congenital CMV infection have delayed onset of sensorineural hearing loss. In addition, most infants with congenital hearing loss do not have CMV infection. In 1996, when Barbi et al demonstrated that newborn dried blood spots and PCR assays could be used to detect CMV DNA in the blood of congenitally infected infants, there was optimism that the opportunity for universal screening for CMV had arrived. However, the study by Barbi et al was not population-based and did not have a sufficient sample size to establish convincingly the sensitivity and specificity of mass screening of newborn dried blood spots. In contrast, the large, prospective study by Boppana et al shows that even though real-time PCR has excellent specificity (approaching 100%), the sensitivity of the PCR

Can Intratympanic Dexamethasone Added to Systemic Steroids Improve Hearing Outcome in Patients With Sudden Deafness?

Can Intratympanic Dexamethasone Added to Systemic Steroids Improve Hearing Outcome in Patients With Sudden Deafness?