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BackgroundTension pneumothorax is one of the leading causes of preventable death on the battlefield. Current prehospital diagnosis relies on a subjective clinical impression complemented by a manual thoracic and respiratory examination. These techniques are not fully applicable in field conditions and on the battlefield, where situational and environmental factors may impair clinical capabilities. We aimed to assemble a device able to sample, analyze, and classify the unique acoustic signatures of pneumothorax and hemothorax.MethodsAcoustic data was obtained with simultaneous use of two sensitive digital stethoscopes from the chest wall of an ex-vivo porcine model. Twelve second samples of acoustic data were obtained from the in-house assembled digital stethoscope system during mechanical ventilation. The thoracic cavity was injected with increasing volumes of 200, 400, 600, 800, and 1000 ml of air or saline to simulate pneumothorax and hemothorax, respectively. The data was analyzed using a multi-objective genetic algorithm that was used to develop an optimal mathematical detector through the process of artificial evolution, a cutting-edge approach in the artificial intelligence discipline.ResultsThe in-house assembled dual digital stethoscope system and developed genetic algorithm achieved an accuracy, sensitivity and specificity ranging from 64 to 100%, 63 to 100%, and 63 to 100%, respectively, in classifying acoustic signal as associated with pneumothorax or hemothorax at fluid injection levels of 400 ml or more, and regardless of background noise.ConclusionsWe present a novel, objective device for rapid diagnosis of potentially lethal thoracic injuries. With further optimization, such a device could provide real-time detection and monitoring of pneumothorax and hemothorax in battlefield conditions.

OBJECTIVE Compare outcomes of middle cranial fossa approach (MCF) to vestibular schwannoma (VS) resection in patients 60 years of age and older to patients under 60. STUDY DESIGN Retrospective case series. SETTING Tertiary referral center. PATIENTS Charts of 216 consecutive VS patients over 18 years of age were reviewed to identify 67 patients who underwent MCF approach to VS resection between 2006 and 2017. INTERVENTION(S) Age at time of surgery. MAIN OUTCOME MEASURE(S) Measured outcomes included postoperative hearing results, facial nerve function, length of hospital stay, wound complications, cerebrospinal fluid leak, myocardial infarction, cerebrovascular accident, seizure, deep vein thrombosis, 30-day readmission, and return to operating room. RESULTS Sixty-seven patients underwent VS resection via MCF approach including 16 patients > = 60 years (mean 64.4 SD 3.3) and 51 patients

To compare speech perception (SP) in noise for normal-hearing (NH) individuals and individuals with hearing loss (IWHL) and to demonstrate improvements in SP with use of a visual speech recognition program (VSRP).Single-institution prospective study.Tertiary referral center.Eleven NH and 9 IWHL participants in a sound-isolated booth facing a speaker through a window. In non-VSRP conditions, SP was evaluated on 40 Bamford-Kowal-Bench speech-in-noise test (BKB-SIN) sentences presented by the speaker at 50 A-weighted decibels (dBA) with multiperson babble noise presented from 50 to 75 dBA. SP was defined as the percentage of words correctly identified. In VSRP conditions, an infrared camera was used to track 35 points around the speaker's lips during speech in real time. Lip movement data were translated into speech-text via an in-house developed neural network-based VSRP. SP was evaluated similarly in the non-VSRP condition on 42 BKB-SIN sentences, with the addition of the VSRP output presented on a screen to the listener.In high-noise conditions (70-75 dBA) without VSRP, NH listeners achieved significantly higher speech perception than IWHL listeners (38.7% vs 25.0%,The VSRP significantly increased speech perception in high-noise conditions for NH and IWHL participants and eliminated the difference in SP accuracy between NH and IWHL listeners.

Objective Determine whether elevated body mass index (BMI) is associated with postoperative complications after vestibular schwannoma (VS) surgery. Study design Retrospective case series. Setting Tertiary referral center. Patients Two hundred six patients undergoing surgery for VS between 2010 and 2017, grouped into obese and nonobese patients. Intervention Surgery for VS resection. Main outcome measures Postoperative facial nerve outcomes, length of hospital stay, presence of postoperative cerebrospinal fluid leak, 30-day readmission, return to the operating room, wound complications, cardiovascular and thromboembolic complications. Results After excluding 1 patient for missing BMI, our cohort included 205 patients. Seventy-nine patients (38.5%) were obese (mean BMI 36.2 kg/m, range 30-55.1) and the remaining 126 (61.5%) were nonobese (mean BMI 25.0, range 18.8-29.8 kg/m). Compared with nonobese patients, obesity was not associated with postoperative cerebrospinal fluid leak (OR 1.1, 95% CI 0.93-1.1), length of hospital stay (OR 0.98, 95% CI 0.65-1.47), 30-day readmission rates (1.04, 95% CI 0.95-1.14), return to operating room (OR 1.05, 95% CI 0.98-1.11), or other wound-related complications (OR 0.99, 95% CI 0.94-1.04). Conclusion In this cohort, elevated BMI was not associated with an increased risk for postoperative complications after VS surgery. Our findings may mitigate concerns associated with surgical management of VS in obese patients.

To explore socioeconomic disparities in pediatric single-sided deafness (SSD) treatment.Retrospective chart review.Tertiary referral academic center.The charts of 190 pediatric patients with SSD were reviewed for demographic and clinical characteristics. Socioeconomic variables included race and insurance status. ZIP codes were used to obtain additional socioeconomic data from the American Community Survey, including mean and median income, percentage of families below the poverty level, and employment status. Socioeconomic status (SES) was classified by insurance status and income. Treatment outcomes were analyzed by socioeconomic variables.There were 105 males and 85 females with a mean follow-up of 55.2 months and a mean age at diagnosis of 4.4 years. Sixty-three percent of children received treatment at last follow-up. Thirty-five percent of children had public insurance and 65% had private insurance. Treatment rates were similar in the private and public insurance groups (60.6% vs 66.7%,Insurance type and SES were not associated with SSD treatment outcomes in children, although device use may be higher in children with private insurance and higher SES. Further research should focus on strategies to reduce barriers to treatment and improve adherence.

Objectives: To report a rare case of idiopathic intracranial hypertension (IIH) presenting with hemifacial spasm (HFS) and review the current literature. Methods: Case report and literature review. The patient’s medical record was reviewed for demographic and clinical data. For literature review, all case reports or other publications published in English literature were identified using PUBMED. Results: A 43-year-old obese female presented with a 2-year history of left HFS. Electroencephalography and head computed tomography were unremarkable. Magnetic resonance imaging demonstrated bilateral anterior inferior cerebellar artery vascular loops involving the internal auditory canals as well as IIH-associated findings. A lumbar puncture was performed and revealed an elevated opening pressure of 26 cm H20 cerebrospinal fluid. Acetazolamide treatment was then initiated, resulting in complete resolution of the HFS. Conclusion: HFS may be a rare presenting manifestation of IIH, and treatment of IIH may result in improvement of HFS symptoms. This is the first report of IIH presenting with HFS in the absence of headache or visual change. As a result, this is the first report of HFS as a presenting manifestation of IIH in Otolaryngology literature.

Objective Evaluate the safety and efficacy of the ultrasonic bone aspirator (UBA) during middle cranial fossa (MCF) approach to vestibular schwannoma (VS). Study design Retrospective case series. Setting Tertiary referral center. Patients Charts of 192 consecutive VS patients over 18 years of age were reviewed to identify 65 patients who underwent MCF approach to VS resection between 2006 and 2017. A combination of UBA and high-speed drill (HSD) was used to decompress the internal auditory canal (IAC) in 25 patients and HSD alone was used in the other 40 patients. Intervention(s) Use of UBA during vestibular schwannoma surgery via MCF approach for decompression of the IAC. Main outcome measure(s) Postoperative facial nerve outcomes assessed by the House-Brackmann (HB) facial nerve grading scale. Rates of gross total resection (GTR) and cerebrospinal fluid (CSF) leak. Results There were no significant differences in postoperative facial nerve function, in rate of GTR of tumor, or in rate of CSF leak. In the UBA group 24/25 (96%) had postoperative HB grade I-II compared with 36/40 (90%) in the HSD group (p-value = 0.66). GTR was achieved in 25/25 (100%) in the UBA group compared with 38/40 (95%) in the HSD group (p-value = 1). In the UBA group, there were 0/25 (0%) cases of CSF leak compared with 1/40 (2.5%) in the HSD group (p-value = 1). Conclusions UBA use is a safe and effective alternative or adjunct to HSD during MCF approach to expose the IAC contents. This surgical tool allows for bone removal with low risk of injury to adjacent structures.

Objective Evaluate the cerebrospinal fluid (CSF) leak rate after the middle cranial fossa (MCF) approach to vestibular schwannoma (VS) resection. Design Retrospective case series. Setting Quaternary referral academic center. Participants Of 161 patients undergoing the MCF approach for a variety of skull base pathologies, 66 patients underwent this approach for VS resection between 2007 and 2017. Main Outcome Measure Postoperative CSF leak rate. Results There were two instances of postoperative CSF leak (3.0%). Age, gender, and BMI were not significantly associated with CSF leak. In the two cases with CSF leakage, tumors were isolated to the internal auditory canal (IAC) and both underwent gross total resection. Both CSF leaks were successfully treated with lumbar drain diversion. For the 64 cases that did not have a CSF leak, 51 were isolated to the IAC, 1 was located only in the cerebellopontine angle (CPA), and 12 were located in both the IAC and CPA. 62 patients underwent gross total resection and 2 underwent near-total resection. Mean maximal tumor diameter in the CSF leak group was 4.5 mm (range: 3–6 mm) versus 10.2 mm (range: 3–19 mm) in patients with no CSF leak (p = 0.03). Conclusions The MCF approach for VS resection is a valuable technique that allows for hearing preservation and total tumor resection and can be performed with a low CSF leakage rate. This rate of CSF leak is less than the reported rates in the literature in regard to both translabyrinthine and retrosigmoid approaches.

Objective Although speech perception tests are available to evaluate hearing, there is no standardized validated tool to quantify speech quality. The objective of this study is to develop a validated tool to measure quality of speech heard. Study design Prospective instrument validation study of 35 normal hearing adults recruited at a tertiary referral center. Methods Participants listened to 44 speech clips of male/female voices reciting the Rainbow Passage. Speech clips included original and manipulated excerpts capturing goal qualities such as mechanical and garbled. Listeners rated clips on a 10-point visual analog scale (VAS) of 18 characteristics (e.g. cartoonish, garbled). Results Skewed distribution analysis identified mean ratings in the upper and lower 2-point limits of the VAS (ratings of 8-10, 0-2, respectively); items with inconsistent responses were eliminated. The test was pruned to a final instrument of nine speech clips that clearly define qualities of interest: speech-like, male/female, cartoonish, echo-y, garbled, tinny, mechanical, rough, breathy, soothing, hoarse, like, pleasant, natural. Mean ratings were highest for original female clips (8.8) and lowest for not-speech manipulation (2.1). Factor analysis identified two subsets of characteristics: internal consistency demonstrated Cronbach's alpha of 0.95 and 0.82 per subset. Test-retest reliability of total scores was high, with an intraclass correlation coefficient of 0.76. Conclusion The Speech Quality Instrument (SQI) is a concise, valid tool for assessing speech quality as an indicator for hearing performance. SQI may be a valuable outcome measure for cochlear implant recipients who, despite achieving excellent speech perception, often experience poor speech quality. Level of evidence 2b. Laryngoscope, 128:1622-1627, 2018.

Objective Epistaxis is a common complaint, yet few studies have focused on the incidence and risk factors of recurrent epistaxis. Our objective was to determine the patterns of incidence and risk factors for recurrent epistaxis admission (REA). Study Design Case series with chart review. Settings Single academic center. Subjects and Methods The medical records of patients admitted for epistaxis between 1999 and 2015 were reviewed. The follow-up period was defined as 3 years following initial admission. REAs were categorized as early (30 days) and late (31 days to 3 years) following initial admission. Logistic regression was used to identify potential predictors of REAs. Results A total of 653 patients were included. Eighty-six patients (14%) had REAs: 48 (7.5%) early and 38 (6.5%) late. Nonlinear incidence curve was demonstrated for both early and late REAs. Based on logistic regression, prior nasal surgery and anemia were independent risk factors for early REAs. According to multivariate analysis, thrombocytopenia was significantly associated with late REAs. Conclusion Early and late REAs demonstrate different risk predictors. Knowledge of such risk factors may help in risk stratification for this selected group of patients. All patients at risk should be advised on possible preventive measures. Patients at risk for early REA may benefit from a more proactive approach.

OBJECTIVE To examine the association between operative duration and complications after vestibular schwannoma (VS) surgery. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS One hundred forty-eight patients undergoing vestibular schwannoma resection in a single institution. INTERVENTION Vestibular schwannoma resection. MAIN OUTCOME MEASURES Operative duration, surgical approach, tumor size, and postoperative complications. RESULTS Forty-one patients underwent middle cranial fossa (MCF) approach, 46 underwent translabyrinthine (TL) approach, and 61 underwent retrosigmoid (RS) approach. The mean operative duration overall was 407 minutes (MCF-339 min, TL-450 min, RS 420 min). When controlling for tumor size, there was no difference in procedure duration by approach (OR 0.92, CI 0.82-1.02, p=0.11).When controlling for approach, there was a significant increase in procedure duration by tumor size (OR 1.36, CI 1.23-1.50, p

The current literature on peripheral cranial nerve stimulation for the purpose of achieving therapeutic effects via altering brain activity is reviewed. Vagus nerve stimulation, which is approved for use in refractory epilepsy, is the most extensively studied cranial nerve stimulator that has direct impact on the central nervous system. Despite the recognized central effects of peripheral cranial nerve stimulation, the mechanism of action for all indications remains incompletely understood. Further research on both mechanisms and indications of central effects of cranial nerve stimulation has the potential to alleviate burden of disease in a large array of conditions.

To demonstrate the clinical utility, sensitivity, and specificity of standard magnetic resonance imaging (MRI) sequences in differentiating temporal bone cerebrospinal fluid leaks from all other middle ear effusions.Retrospective imaging review.Academic medical center.Patients with cerebrospinal fluid leaks or other middle ear effusions who also underwent MRI.Patients were assigned to cerebrospinal fluid leak and other effusion cohorts based on clinical course, findings at surgery/myringotomy, and beta-2 transferrin fluid analysis. Reviewers blinded to the clinical outcome examined T1-weighted, T2-weighted, diffusion-weighted, fluid-attenuated inversion recovery (FLAIR), and 3-dimensional (3D) acquired T2-weighted MRI sequences. For each sequence, fluid imaged in the temporal bone was graded as either similar or dissimilar in signal intensity to cerebrospinal fluid in the adjacent subarachnoid space. Signal similarity was interpreted as being diagnostic of a leak. Test characteristics in predicting the presence of a leak were calculated for each series.Eighty patients met criteria (41 leaks, 39 other effusions). The 3D T2 series was 76% sensitive and 100% specific in diagnosing a leak, and FLAIR was 44% sensitive and 100% specific. The T1-weighted (73% sensitive, 69% specific), T2-weighted (98% sensitive, 5.1% specific), and diffusion-weighted (63% sensitive, 66% specific) series were less useful.MRI, with attention to 3D T2 and FLAIR series, is a noninvasive and highly specific test for diagnosing cerebrospinal fluid leak in the setting of an indeterminate middle ear effusion.

Background Despite widespread calls for its use, there are challenges to the implementation of evidence-based medicine (EBM) in clinical practice. Methods In response to the challenges of finding timely, pertinent information on diagnostic test accuracy, we developed an online, crowd-sourced Wiki on diagnostic test accuracy called Get the Diagnosis (GTD, http://www.getthediagnosis.org). Results Since its launch in November 2008 till October 2015, GTD has accumulated information on 300 diagnoses, with 1617 total diagnostic entries. There are a total of 1097 unique diagnostic tests with a mean of 5.4 tests (range 0–38) per diagnosis. 73% of entries (1182 of 1617) have an associated sensitivity and specificity and 89% of entries (1432 of 1617) have associated peer-reviewed literature citations. Altogether, GTD contains 474 unique literature citations. For a sample of three diagnoses, the search precision (percentage of relevant results in the first 30 entries) in GTD was 100% as compared with a range of 13.3%–63.3% for PubMed and between 6.7% and 76.7% for Google Scholar. Conclusion GTD offers a fast, precise and efficient way to look up diagnostic test accuracy. On three selected examples, GTD had a greater precision rate compared with PubMed and Google Scholar in identifying diagnostic test information. GTD is a free resource that complements other currently available resources.

Noise reduction algorithm (NRA) in speech processing strategy has positive impact on speech perception among cochlear implant (CI) listeners. We sought to evaluate the effect of NRA on music enjoyment.Prospective analysis of music enjoyment.Academic medical center.Normal-hearing (NH) adults (N = 16) and CI listeners (N = 9).Subjective rating of music excerpts.NH and CI listeners evaluated country music piece on three enjoyment modalities: pleasantness, musicality, and naturalness. Participants listened to the original version and 20 modified, less complex versions created by including subsets of musical instruments from the original song. NH participants listened to the segments through CI simulation and CI listeners listened to the segments with their usual speech processing strategy, with and without NRA.Decreasing the number of instruments was significantly associated with increase in the pleasantness and naturalness in both NH and CI subjects (p 0.05). However, there was no difference in music enjoyment with or without NRA for either NH listeners with CI simulation or CI listeners across all three modalities of pleasantness, musicality, and naturalness (p 0.05): this was true for the original and the modified music segments with one to three instruments (p 0.05).NRA does not affect music enjoyment in CI listener or NH individual with CI simulation. This suggests that strategies to enhance speech processing will not necessarily have a positive impact on music enjoyment. However, reducing the complexity of music shows promise in enhancing music enjoyment and should be further explored.

Objective To examine the imaging findings on computer tomography (CT) and magnetic resonance imaging (MRI) in pediatric single-sided deafness (SSD) and asymmetric hearing loss (ASH). Methods The medical records of 189 pediatric patients with SSD and ASH were retrospectively reviewed, and imaging findings were compared. SSD was defined as unilateral profound hearing loss and contralateral normal hearing ear. In the ASH group, ASHw was defined as the worse hearing ear with profound hearing loss, while ASHb was defined as the better hearing ear with mild-moderate hearing loss. Results There were 170 patients with SSD and 19 patients with ASH. In the SSD group, 83 patients (48.8%) had imaging findings associated with hearing loss. In the ASH group, such imaging findings were found in six (31.6%) of the ASHw and in five (26.3%) of the ASHb ears. The most common finding in the SSD group was cochlear nerve deficiency (50.6%), followed by cochlear dysplasia (39.8%) and enlarged vestibular aqueduct (26.5%). In the ASH groups, cochlear dysplasia was seen in three (50%) of ASHw ears and in two (40%) of the ASHb ears, and enlarged vestibular aqueduct was seen in three (50%) of ASHw ears and in two (40%) of the ASHb ears. Conclusion Imaging studies identified the etiology in half of the cases of SSD and in one-third of ASH patients. Our findings strongly support the use of imaging studies in the evaluation of pediatric SSD and ASH. Level of evidence 4 Laryngoscope, 130:1007-1010, 2020.

OBJECTIVE We investigated the hypothesis that childhood obesity is a risk factor for sensorineural hearing loss (SNHL) independent of other metabolic risk factors. STUDY DESIGN A complex, multistage, stratified geographic area design for collecting representative data from noninstitutionalized US population. METHODS A total of 5,638 adolescents between age 12 and 19 from the NHANES database (2005-2010) were studied. Subjects with body mass index >= 95th percentile were classified as obese. SNHL was defined as average pure-tone greater than 15 dB HL for 0.5, 1, and 2 kHz or 3, 4, 6, and 8 kHz in at least 1 ear. Multivariable logistic regression models assessed incident hearing loss odds across obese patients in comparison with normal weight individuals (5th-85th percentile). Multivariable models included age, sex, socioeconomic status, race, smoke exposure, high density lipoprotein level, triglyceride level, elevated blood pressure measurement, hemoglobin A1C level, and C-reactive protein level. RESULTS The rate of SNHL was 21.5% in obese and 13.44% in normal weight adolescents (p

Purpose of review To review the current literature on the extended middle cranial fossa (xMCF) approach and to provide a comprehensive description of the relevant anatomy, indications, surgical technique, results, and complications. Recent findings The xMCF approach expands the surgical exposure provided by the sMCF approach, allowing access to the internal auditory canal, cerebellopontine angle, prepontine cistern, anterior petrous apex, petrous carotid artery, Meckel's cave, cavernous sinus, mid and upper clivus, and posterior lesions approaching the jugular foramen. Preservation of serviceable hearing is possible with success rates approximating 50% in vestibular schwannoma and meningioma resection, and facial nerve outcome is excellent. Summary The xMCF is an important approach for difficult to access lesions that additionally offers the possibility of hearing preservation. This approach is also useful for vascular lesions, auditory brainstem implantation, and lesions of mid-brainstem.

Although speech perception tests are available to evaluate hearing, there is no standardized validated tool to quantify speech quality. The objective of this study is to develop a validated tool to measure quality of speech heard.Prospective instrument validation study of 35 normal hearing adults recruited at a tertiary referral center.Participants listened to 44 speech clips of male/female voices reciting the Rainbow Passage. Speech clips included original and manipulated excerpts capturing goal qualities such as mechanical and garbled. Listeners rated clips on a 10-point visual analog scale (VAS) of 18 characteristics (e.g. cartoonish, garbled).Skewed distribution analysis identified mean ratings in the upper and lower 2-point limits of the VAS (ratings of 8-10, 0-2, respectively); items with inconsistent responses were eliminated. The test was pruned to a final instrument of nine speech clips that clearly define qualities of interest: speech-like, male/female, cartoonish, echo-y, garbled, tinny, mechanical, rough, breathy, soothing, hoarse, like, pleasant, natural. Mean ratings were highest for original female clips (8.8) and lowest for not-speech manipulation (2.1). Factor analysis identified two subsets of characteristics: internal consistency demonstrated Cronbach's alpha of 0.95 and 0.82 per subset. Test-retest reliability of total scores was high, with an intraclass correlation coefficient of 0.76.The Speech Quality Instrument (SQI) is a concise, valid tool for assessing speech quality as an indicator for hearing performance. SQI may be a valuable outcome measure for cochlear implant recipients who, despite achieving excellent speech perception, often experience poor speech quality.2b. Laryngoscope, 128:1622-1627, 2018.

OBJECTIVE Cochlear implantation is associated with poor music perception and enjoyment. Reducing music complexity has been shown to enhance music enjoyment in cochlear implant (CI) recipients. In this study, we assess the impact of harmonic series reduction on music enjoyment. STUDY DESIGN Prospective analysis of music enjoyment in normal-hearing (NH) individuals and CI recipients. SETTING Single tertiary academic medical center. PATIENTS NH adults (N = 20) and CI users (N = 8) rated the Happy Birthday song on three validated enjoyment modalities-musicality, pleasantness, and naturalness. INTERVENTION Subjective rating of music excerpts. MAIN OUTCOME MEASURES Participants listened to seven different instruments play the melody, each with five levels of harmonic reduction (Full, F3+F2+F1+F0, F2+F1+F0, F1+F0, F0). NH participants listened to the segments both with and without CI simulation. Linear mixed effect models (LME) and likelihood ratio tests were used to assess the impact of harmonic reduction on enjoyment. RESULTS NH listeners without simulation rated segments with the first four harmonics (F3+F2+F1+F0) most pleasant and natural (p

Background Inferior turbinate (IT) hypertrophy and adenoid hypertrophy are both causes of pediatric nasal obstruction. Objective The purpose of this survey was to study nasal obstruction evaluation and management among pediatric otolaryngologists with respect to IT and adenoid hypertrophy. Methods A questionnaire with embedded clinical videos was sent electronically to American Society of Pediatric Otolaryngology members. Results A total of 435 questionnaires were sent, and 75 were completed. Respondents were presented with scenarios that involved a 7-year-old child with nasal obstruction unresponsive to medical therapy, and the respondents were asked to choose a surgical plan, either IT reduction, adenoidectomy, or combined IT reduction and adenoidectomy. Three questions described the extent of IT and adenoid obstruction in text form, although three questions included a video of the child's nasal endoscopy. In questions with perceived or stated IT hypertrophy, the respondents chose to perform IT reduction significantly more frequently when the perceived or stated adenoid hypertrophy was less severe (p < 0.0001 for video and p = 0.039 for written questions). Conclusion The decision to perform IT reduction in children is inversely related to the extent of adenoid hypertrophy. Future studies on pediatric IT surgery should include objective descriptions of the IT and adenoid in study subjects.

Wegener's granulomatosis (WG) classically affects the upper and lower respiratory tracts as well as the renal system, while central nervous system (CNS) involvement is rare. We report a 17-year-old patient with WG who presented with a 2-month history of meningeal signs, left Horner's syndrome, multiple cranial neuropathies and a left middle ear effusion. MRI demonstrated left middle ear and mastoid effusions, pachymeningitis with diffuse left temporal dural enhancement, and right sinus destructive changes. In this report, we will review diagnostic and therapeutic approaches to Wegener's granulomatosis, with a particular emphasis on CNS manifestations and the adolescent population.

To prospectively compare the homogeneity, adequacy, and patient acceptance of nonionic iodine-based regimens with those of a barium-based regimen for computed tomographic (CT) colonography with electronic subtraction cleansing.After institutional review board approval and informed consent were obtained, 68 subjects (41 men (60%) men, 27 (40%) women; mean age, 60 years +/- 6 [standard deviation]) with average or moderate risk factors for development of colorectal carcinoma were recruited and placed into three study groups. Group 1 (n = 25) ingested 150-mL aliquots of 2% barium sulfate suspension with meals and snacks for 48 hours prior to imaging, without other diet modification or a cathartic. Group 2 (n = 21) ingested 10-mL aliquots of nonionic iodinated contrast material (iopromide) with a concentration of 300 mg per milliliter with meals and snacks for 2 days before imaging, without diet modification or a cathartic. Group 3 (n = 22) ingested nonionic iodinated contrast material (iohexol) with a concentration of 300 mg per milliliter with meals and snacks for 2 days before imaging and ingested 34 g of magnesium citrate the evening prior to imaging. CT colonography was also performed on 10 control subjects who ingested polyethylene glycol electrolyte solution prior to imaging. Subjective and numerical measures of bowel preparation quality, homogeneity, and patient comfort among the noncathartic and cathartic cohorts were compared with nonparametric analysis of variance, the Fisher exact test, and the F test, as appropriate. The study was HIPAA compliant.Study subjects who received tagging preparations reported significantly improved discomfort scores when compared with those of the control subjects (P.05, each comparison). There was no significant difference in discomfort scores among groups 1, 2, and 3. For each reader, scores of subtracted image readability were highest for group 3. Dichotomized rates of preparation "success" were also greatest for group 3.In this series, the patient discomfort scores were significantly improved with tagging preparations for CT colonography. Nonionic iodinated contrast material in conjunction with a hyperosmotic laxative (magnesium citrate) was associated with the best subjective and numerical indices of readability.

OBJECTIVE To identify factors that enhance the enjoyment of music in cochlear implant (CI) recipients. Specifically, we assessed the hypothesis that variations in reverberation time (RT60) may be linked to variations in the level of musical enjoyment in CI users. STUDY DESIGN Prospective analysis of music enjoyment in normal-hearing individuals. SETTING Single tertiary academic medical center. PATIENTS Normal-hearing adults (N = 20) were asked to rate a novel 20-second melody on three enjoyment modalities: musicality, pleasantness, and naturalness. INTERVENTION Subjective rating of music excerpts. MAIN OUTCOME MEASURES Participants listened to seven different instruments play the melody, each with five levels (0.2, 1.6, 3.0, 5.0, 10.0 s) of RT60, both with and without CI simulation processing. Linear regression analysis with analysis of variance was used to assess the impact of RT60 on music enjoyment. RESULTS Without CI simulation, music samples with RT60 = 3.0 seconds were ranked most pleasant and most musical, whereas those with RT60 = 1.6 seconds and RT60 = 3.0 seconds were ranked equally most natural (all p < 0.05). With CI simulation, music samples with RT60 = 0.2 seconds were ranked most pleasant, most musical, and most natural (all p < 0.05). Samples without CI simulation show a preference for middle-range RT60, whereas samples with CI simulation show a negative linear relationship between RT60 and musical enjoyment, with preference for minimal reverberation. CONCLUSION Minimization of RT60 may be a useful strategy for increasing musical enjoyment under CI conditions, both in altering existing music as well as in composition of new music.