Objective. This update of the 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation cerumen impaction clinical practice guideline provides evidencebased recommendations on managing cerumen impaction. Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. Changes from the prior guideline include• a consumer added to the development group;• new evidence (3 guidelines, 5 systematic reviews, and 6 randomized controlled trials); • enhanced information on patient education and counseling; • a new algorithm to clarify action statement relationships;• expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion; • an enhanced external review process to include public comment and journal peer review; and • 3 new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care.Purpose. The primary purpose of this guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention and to promote evidence-based management. Another purpose of the guideline is to highlight needs and management options in special populations or in patients who have modifying factors. The guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, and it applies to any setting in which cerumen impaction would be identified, monitored, or managed. The guideline does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal; recurrent otitis externa; keratosis obturans; prior radiation therapy affecting the ear; previous tympanoplasty/myringoplasty, canal wall down mastoidectomy, or other surgery affecting the ear canal.Key Action Statements. The panel made a strong recommendation that clinicians should treat, or refer to a clinician who can treat, cerumen impaction, defined as an accumulation of cerumen that is associated with symptoms, prevents needed assessment of the ear, or both.The panel made the following recommendations: (1) Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen. (2) Clinicians should diagnose cerumen impaction when an accumulation of cerumen, as seen on otoscopy, is associated with symptoms, prevents needed assessment of the ear, or both. (3) Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as ≥1 of the following: anticoagulant therapy, immunocompromised state, diabetes mellitus, prior radiation therapy to the head and neck, ear canal stenosis, exostoses, and nonintact tympanic membrane. (4) Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined. (5) Clinicians s...

The Hybrid S or “short-electrode” cochlear implant was developed to treat patients with a severe-profound hearing loss limited to the high frequencies. The short-electrode is implanted into just the base or high-frequency region of the cochlea, with the goal of preserving residual low-frequency hearing. As a result, electric stimulation can be combined with acoustic stimulation in the same ear (and the opposite ear); this is one instance of “acoustic plus electric” (A+E) stimulation. In this paper, we will review the latest findings from the first two stages of the clinical trial for the Hybrid concept in the United States. Generally, we will review surgical techniques, clinical trial criteria, residual hearing preservation, improvements in speech perception in quiet, and predictive factors for patient benefit. We will also discuss the significant benefit of A+E stimulation for speech perception in noise and musical measures of melody and instrument recognition, as well as valuable insights into central auditory nervous system plasticity gained from the use of a very short electrode array.

The effect of membrane electrical activity on spiral ganglion neuron (SGN) neurite growth remains unknown despite its relevance to cochlear implant technology. We demonstrate that membrane depolarization delays the initial formation and inhibits the subsequent extension of cultured SGN neurites. This inhibition depends directly on the level of depolarization with higher levels of depolarization causing retraction of existing neurites. Cultured SGNs express subunits for L-type, N-type, and P/Q type voltage-gated calcium channels (VGCCs) and removal of extracellular Ca 2+ or treatment with a combination of L-type, N-type, P/Q-type VGCC antagonists rescues SGN neurite growth under depolarizing conditions. By measuring the fluorescence intensity of SGNs loaded with the fluorogenic calpain substrate t-butoxy carbonyl-Leu-Met-chloromethylaminocoumarin (20 μM), we demonstrate that depolarization activates calpains. Calpeptin (15 μM), a calpain inhibitor, prevents calpain activation by depolarization and rescues neurite growth in depolarized SGNs suggesting that calpain activation contributes to the inhibition of neurite growth by depolarization. Keywords auditory neuron; axon growth; Ca 2+ /calmodulin dependent kinase II

Objective To examine long-term hearing outcomes after microsurgical excision of vestibular schwannoma (VS). Study Design Retrospective case review. Setting Tertiary referral center. Patients Forty-nine subjects at a single institution who had undergone microsurgical excision of a VS via middle cranial fossa (MCF) approach between 1994 and 2007 with immediate postoperative (PO) hearing preservation and for whom long-term audiograms were available. Intervention Diagnostic. Main Outcome Measures Word Recognition Score (WRS) is defined by speech discrimination scores (SDS) greater than 70% (grade I), 50% to 70% (grade II), less than 50% (grade III), and 0% (grade IV). Results For subjects with more than 2 years of follow-up, WRS I hearing was present PO in 42 of 49 patients and was preserved at the latest follow-up in 38 (90%) of 42 patients. No subjects fell beyond WRS II. WRS I hearing was maintained in 23 (88%) of 26 patients with more than 5 years of follow-up. Postoperative WRS I to II hearing was maintained in 28 (96%) of 29 patients with more than 5 years of follow-up. The patient who lost significant hearing in the ear operated on had sensorineural hearing loss that paralleled deterioration in her ear that was not operated on. Conclusion Most subjects maintain their initial PO SDS after microsurgical VS removal, and therefore, the initial PO WRS is predictive of long-term hearing. Postsurgical changes do not alter the natural rate or pattern of progressive bilateral sensorineural hearing loss in individual subjects.

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Upper airway manifestations, particularly sinonasal manifestations, are encountered frequently in granulomatosis with polyangiitis (GPA). Nasal endoscopy often reveals crusting, friable erythematous mucosa, and granulation. Up to 25% of patients may have a "saddle-nose" deformity as cartilage destruction worsens. Treatment is often complicated by loss of mucociliary function and necrosis, leading to refractory symptoms. Culture-directed antibiotics, topical antibiotic and saline irrigations, and occasional debridement of adherent crusts can reduce the frequency of sinonasal exacerbations and improve obstructive symptoms. Surgery should be reserved for patients unresponsive to maximal medical therapy. Saddle-nose reconstruction is possible in highly selected patients and can improve nasal breathing and resolve anosmia. Up to 20% of patients with GPA have subglottic stenosis; patients with respiratory symptoms should undergo laryngoscopy to assess the presence of subglottic narrowing. Although systemic manifestations of GPA are managed by immunosuppressive therapy, most patients with subglottic stenosis of GPA require surgical management (ie, endoscopic dilation, endoscopic or laser excision, surgical resection followed by reconstruction).

Vestibular schwannomas (VSs) arise from Schwann cells (SCs) and result from the loss of function of merlin, the protein product of the NF2 tumor suppressor gene. In contrast to non-neoplastic SCs, VS cells survive long-term in the absence of axons. We find that p75NTR is over-expressed in VSs compared with normal nerves, both at the transcript and protein level, similar to the response of non-neoplastic SCs following axotomy. Despite elevated p75NTR expression, VS cells are resistant to apoptosis due to treatment with pro-NGF, a high affinity ligand for p75NTR. Furthermore, treatment with proNGF protects VS cells from apoptosis due to c-Jun N-terminal kinase (JNK) inhibition indicating that p75NTR promotes VS cell survival. Treatment of VS cells with proNGF activated NF-κB while inhibition of JNK with SP600125 or siRNA-mediated knockdown reduced NF-κB activity. Significantly, proNGF also activated NF-κB in cultures treated with JNK inhibitors. Thus, JNK activity appears to be required for basal levels of NF-κB activity, but not for proNGF-induced NF-κB activity. To confirm that the increase in NF-κB activity contributes to the prosurvival effect of proNGF, we infected VS cultures with Ad.IκB.SerS32/36A virus, which inhibits NF-κB activation. Compared to control virus, Ad.IκB.SerS32/36A significantly increased apoptosis including in VS cells treated with proNGF. Thus, in contrast to non-neoplastic SCs, p75NTR signaling provides a prosurvival response in VS cells by activating NF-κB independent of JNK. Such differences may contribute to the ability of VS cells to survive long-term in the absence of axons.

Weconducted a retrospective outcomes review ofthe charts of 22 patients with Meniere s disease who were treated with intratympanicperf usion ofmethylprednisolone and/or dexamethasone. Outcomes were determined by subjective assessment ofvertigo control and by objective changes in audiometricpure-tone average (PTA) and speech discrim ination sco re (SDS). These evaluations were made at the jirstp ostperfusion visit (short term) andat least 12 months later (long term). In the short term, 12 patients (54.5%) achievedvertigo control, 4 pa tients (18.2 %) demonstrated a greater than 10-dB improvement in PTA, and 1patient (4.5%) experienced an increase in SDS of at least 15%. In the long term, the correspo nding numbers ofpatients were 4 (18.2%) , 2 (9.1%), and 1 (4.5%) . The level of hearing ultimately deteriorated in 9 patients (40.9%). These fi ndings sugges t that intratympanic stero id pe rfus ion does not result in any long-t erm alleviation of vertigo or hearing loss. However; the short-term alleviation of vertigo seen in approximately half ofthese pa tients suggests that this treatment may be useful f or the temp orary reliefofsymptoms ofMeniere s disease.