Cochlear implants without external hardware? New chip looks promising

 

Cochlear implants – devices that help people who would otherwise be deaf have some limited hearing – currently require hardware mounted on the outside of the skull to accommodate a recharger and microphone. Now, researchers in the US have developed a new low-powered chip that offers the prospect of eliminating these bulky, visible externals.

The new chip is the work of engineers in the Microsystems Technology Laboratory at Massachusetts Institute of Technology (MIT) together with team members from Harvard Medical School and the Massachusetts Eye and Ear Infirmary.

They are presenting a paper about their work at the 2014 IEEE international Solid-State Circuits Conference being held in San Francisco, CA, this week.

Cochlear implants are used by hundreds of thousands of people worldwide whose hearing is impaired because sensory hair cells in their cochleas, within the inner ear, do not pass on sound vibrations to the brain.

In the US, around 70,000 people have them, many of them children. The device works by electrically stimulating the auditory nerve to receive sound signals that pass from an external microphone into the ear.

Current designs mean that users have to wear a 1-inch diameter disk-shaped transmitter on the skull, attached by a wire to a microphone and power source inside what looks like a large hearing aid around the ear.

But the new low-powered signal-processing chip could lead to a new implant design that eliminates the need for any external hardware, say the researchers. The implant could be wirelessly charged – it could run for about 8 hours between charges – and instead of an external microphone, it could pick up sound using the natural microphone chamber of the inner ear, which is often intact in implant users.

One of the researchers, Anantha Chandrakasan, a professor of electrical engineering at MIT, says:

“The idea with this design is that you could use a phone, with an adaptor, to charge the cochlear implant, so you don’t have to be plugged in. Or you could imagine a smart pillow, so you charge overnight, and the next day, it just functions.”

Lawrence Lustig, director of the Cochlear Implant Center at the University of California at San Francisco (UCSF), who describes the device as “very cool,” says people often experience more stigma with hearing loss than vision loss, so “people would be very keen on losing the externals for that reason alone.”

And, he says, there would also be practical benefits, such as “not having to take it off when you’re near water or worrying about components getting lost or broken or stolen.”

Design is based on middle-ear implant mechanism

The researchers based their new design on the mechanism of a middle-ear implant. The idea is to pick up the sound vibrations in the delicate bones of the middle ear and instead of conveying them to the cochlea, send them to a microchip implanted in the ear that converts them to electrical signals passed to an electrode in the cochlea.

Lowering the power requirements of the chip was the key to eliminating the need for the external skull-mounted hardware, say the researchers.

The device has been tested on patients already with cochlear implants to check it does not affect ability to hear. And the researchers showed the chip can pick up and process speech played into the middle ear.

Lustig says such a device would require more complex surgery to implant than existing designs. A current operation takes about an hour – the new design would probably need about 3 to 4 hours of surgery but would still be a relatively straightforward procedure.

“I don’t anticipate putting a lot of extra risk into the procedure,” he adds.

Medical News Today recently reported a study that showed short stays in darkness can boost hearing. Another US team working with mice found that preventing sight for as little as a week was enough to help the brain process sound more effectively.

http://www.medicalnewstoday.com/articles/272439.php

Picture courtesy to wikipedia

 

After rhinoplasty, patients perceive differences in voice quality, but not in function

Patients who have undergone plastic surgery to change the appearance of their nose may also notice changes in the sound of their voice, reports a study in the February issue ofPlastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Changes in voice after rhinoplasty are perceptible to patients as well as to experts, but generally don’t cause problems with speech function, according to the new research by Dr. Kamran Khazaeni and colleagues of Mashhad University of Medical Sciences, Iran. However, they believe that patients considering rhinoplasty – especially those who use their voice professionally – should be aware of “potential voice alterations.”

Patients Perceive Voice Changes after Rhinoplasty

The researchers analyzed changes in voice quality in 27 patients undergoing rhinoplasty at two hospitals in Iran, where rhinoplasty is one of the most popular cosmetic procedures. The patients were 22 women and five men, average age 24 years. Twenty-two percent of the patients used their voice professionally.

After rhinoplasty, patients completed a standard questionnaire to rate perceived problems with their voice. In addition, recordings of the patients’ voices made before and after rhinoplasty were compared by trained listeners, who were unaware of whether they were hearing the “before or after” recordings.

The questionnaire responses showed worsening in some areas of voice quality: particularly in the physical and emotional subscales, reflecting patients’ perceptions of their voice and their emotional responses to it. There was no change on the functional subscale, reflecting the effects of voice on daily activities.

The trained listeners also perceived changes in voice quality, including an increase in “hyponasality” following rhinoplasty. Hyponasal speech reflects the sound of the voice when not enough air is moving through the nasal cavity – for example, in a person with a stuffy nose. “This observed increase in hyponasality perception demonstrates that the change in the patients’ voices is perceptible to trained listeners, but does not address whether this change is apparent in everyday life and in routine conversations,” according to Dr. Khazaeni and colleagues.

Changes May Reflect Narrowing of Nasal Cavity

An acoustic analysis suggested changes in the frequency and amplitude of certain sounds, which may be related to narrowing of the nasal cavity after rhinoplasty. “The changes in surface area of nasal cavity may increase airflow resistance and cause an increase in sound absorption and a decrease in passing sound amplitude,” according to the researchers.

With recent advances in surgical technique and long-term outcomes, rhinoplasty has become an increasingly popular procedure in Iran, as in other countries. The growing number of patients undergoing this cosmetic surgery raises concerns about how it might affect various functions and quality of life. “Recently we have noticed patients who use their voice professionally asking if rhinoplasty changes their voice,” Dr. Khazaeni and coauthors write.

Based on the new results, the answer seems to be that changes in voice quality do occur after rhinoplasty. Subtle but significant changes are apparent to trained listeners. Patients themselves may also perceive changes to some extent, although they don’t seem to cause interference in the patient’s lives. “However, for individuals who rely on their voice for professional reasons, the surgeon should discuss these changes with the patient preoperatively and consider more conservative types of surgery,” the researchers conclude.

http://www.medicalnewstoday.com/releases/271894.php

Photo courtesy to Mayo Foundation

 

Pediatric ear infections cost health care system nearly $3 billion a year

Acute otitis media, or ear infection, is the most common ailment among kids of preschool age and younger in the U.S., primarily because these children have immature middle-ear drainage systems, higher exposure to respiratory illnesses and undeveloped immune systems.

And because it’s also the most common reason for antibiotic use among all children, the costs associated with acute otitis media (AOM) are under more scrutiny than ever by health care and government administrators, especially given today’s political and economic climate, strained health-care resources and cost-containment efforts.

While estimates of the economic impact of AOM have been formulated in the past, a new study by UCLA and Harvard University researchers is the first to use a national population database that gives a direct, head-to-head comparison of expenditures for pediatric patients diagnosed with ear infections and similar patients without ear infections.

The findings show that AOM is associated with significant increases in direct costs incurred by consumers and the health care system. With its high prevalence across the U.S., pediatric AOM accounts for approximately $2.88 billion in added health care expenses annually and is a significant health-care utilization concern.

The research is published in the current edition of the journal The Laryngoscope.

“Although the annual incidence of ear infection may be declining in the U.S., the number of kids affected remains high, and the public health implications of AOM are substantial,” said study co-author Dr. Nina Shapiro, director of pediatric otolaryngology at Mattel Children’s Hospital UCLA and a professor of head and neck surgery at the David Geffen School of Medicine at UCLA. “As our health care system continues to be vigorously discussed around the nation, efforts to control costs and allocate resources appropriately are of prime importance.”

For the study, the researchers examined records of pediatric patients under the age of 18 culled from the 2009 Medical Expenditure Panel Survey, a national survey conducted by the Agency for Health Research and Quality which serves a benchmark data-set specifically designed for the assessment of health care costs.

Of the 81.5 million children the researchers sampled, 8.7 million had received care for ear infections. The rates of visits to the doctor’s office, refills of prescription medications and health care costs associated with doctor visits were then compared between those with diagnosed ear infections and those without. The rates were adjusted for age, sex, region, race, ethnicity, insurance status and co-morbidities.

The researchers found that children with ear infections had an average of two additional outpatient visits, 0.2 emergency visits and 1.6 prescriptions filled, compared with those without ear infections.

Ear infections were associated with an incremental increase of $314 per child annually for outpatient health care and an average of $17 in additional costs for medications. This resulted in an overall $2.88 billion annual cost for ear infections.

“Although certain immunizations that target infection-causing bacteria may play a role in slightly reducing the overall rate of ear infections, millions of young kids will still have them,” Shapiro said. “The take-home message is that the common ear infection is an extremely costly entity with significant financial burdens on the health care system.”

Future studies on the health care cost associated with AOM may include analyzing the indirect costs, such as work and school days missed, gasoline costs and parking charges for outpatient visits, the researchers said.

http://www.medicalnewstoday.com/releases/271084.php

Picture courtesy of www.healthofchildren.com 

Ear Infections: Treat All Kids

All children younger than 2 with acute otitis media diagnosed according to current American Academy of Pediatrics guidelines should receive antibiotics, researchers said.

Among children age 6 months to 2 years with unilateral, nonsevere acute otitis media given amoxicillin-clavulanate, treatment failures were seen in 14% compared with failure rates of 40% in those given placebo, for an adjusted relative risk of 0.27 (95% CI 0.13-0.41), according to Alejandro Hoberman, MD, of the University of Pittsburgh, and colleagues.

In contrast, children with bilateral, severe otitis media — those for whom treatment currently is recommended — had failure rates of 25% with antimicrobial treatment and 59% with placebo, giving an adjusted relative risk of 0.34 (95% CI 0.18-0.48), Hoberman and colleagues wrote online in a research letter in JAMA Pediatrics.

“A recent American Academy of Pediatrics guideline recommends prompt antimicrobial treatment for children ages 6 months to 2 years with acute otitis media, with one exception: for children in whom the disease is unilateral and also unaccompanied by severe signs or symptoms, the guideline recommends, as an option, observation without initial antimicrobial therapy,” they observed.

However, that recommendation was based on studies that used diagnostic criteria that were less strict than the current requirements, opening the possibility that some treated children didn’t actually have acute otitis media.

To clarify this, the researchers pooled data from two previously published trials, one conducted in Pittsburgh and the other in Turku, Finland, both of which had stringent requirements for enrollment that came close to guaranteeing valid diagnoses.

The Pittsburgh trial defined treatment failure as inadequate symptomatic or otoscopic improvement by day four or five and incomplete resolution by days 10 to 12.

The Turku study defined treatment failure as a lack of overall improvement by day three, no improvement in otoscopic findings by day eight, and the occurrence at any time of overall clinical deterioration, perforation of the tympanic membrane, or treatment discontinuation.

The otitis media was classified as severe if the parents described the ear pain as moderate or severe or if the child had had a temperature of 39 degrees C.

In general, treatment failure rates were similar for severe and nonsevere disease and for unilateral and bilateral involvement.

For those with unilateral severe disease, treatment failure rates were 14% for the treated group and 47% for the placebo group, with an adjusted relative risk of 0.34 (95% CI 0.18-0.50), while the rates for bilateral nonsevere disease were 22% and 53%, respectively, for an adjusted relative risk of 0.31 (95% CI 0.14-0.48).

The numbers needed to treat were:

• Unilateral nonsevere, 4
• Unilateral severe, 3
• Bilateral nonsevere, 4
• Bilateral severe, 3

“These findings make a case for a uniform approach to antimicrobial treatment in children younger than 2 years with stringently diagnosed [acute otitis media], irrespective of laterality or apparent severity of their illness,” Hoberman and colleagues stated.

Primary source: JAMA Pediatrics
Source reference: Hoberman A, et al “Acute otitis media in children younger than 2 years”JAMA Pediatr 2013; DOI: 10.1001/jamapediatrics.2013.3068.

http://www.medpagetoday.com/Surgery/Otolaryngology/41319

Start Swallowing, Eating ASAP in Oral Cancer Tx

Patients with oral cancers had significantly better long-term diet if they received oral feeding and practiced swallowing exercises during radiation therapy, data from a large retrospective cohort showed.

In adjusted models, both swallowing goals had independent associations with long-term diet (P<0.05), according to Katherine A. Hutcheson, PhD, of the University of Texas MD Anderson Cancer Center in Houston, and co-authors.

Patients who maintained full oral intake were twice as likely to eat a regular diet during long-term follow-up (OR 2.0, 95% CI 1.0-4.6) and patients adherent to swallowing exercises were four times as likely to return to a regular diet (OR 4.0, 95% C 1.9-6.4), they reported online in JAMA Otolaryngology Head and Neck Surgery.

Both oral intake and swallowing exercises also were associated with a reduced duration of gastrostomy dependence.

“Proactive swallowing therapy and swallowing exercise adherence should be considered an essential component of modern, multidisciplinary head and neck care,” they added. “Our findings, in concert with those of prior rigorous trials, offer support for early referral to the speech pathologist to begin proactive swallowing therapy before definitive radiation therapy or chemoradiation therapy.”

Modern therapy for pharyngeal and other types of oral cancer focuses on locoregional control and preserving function. As part of their treatment, most patients receive radiation therapy or chemoradiation, which leads to dysphagia in as many as two-thirds of cases, the authors said in their introduction.

In severe cases, dysphagia can result in dietary restriction and malnutrition that require long-term, if not life-long, dependence on feeding via gastrostomy.

The advent of modern radiation therapy protocols designed to spare normal tissue has reduced the frequency of long-term dependence on gastrostomy. Still, as many as 12% of patients cannot be weaned off gastrostomy feeding in a short period of time.

Proactive swallowing exercises have been standard treatment for patients with pharyngeal cancer, supported by both observational studies and randomized trials, the authors continued. However, toxic effects of radiation therapy and chemoradiation make eating difficult, and many patients require gastrostomy tubes and dietary restrictions that include avoidance of solid foods.

Limitations on oral intake lead to disuse of oral musculature and adverse remodeling of aerodigestive tract muscles that exacerbates the effects of radiation-induced edema and fibrosis.

“Thus, the central premise of proactive swallowing therapy is ‘use it or lose it’ to mitigate the muscular wasting and remodelling that occurs after even brief intervals of disuse,” the authors noted.

Proactive swallowing exercises aim to reduce prolonged periods of no oral feeding. The benefits of eating and exercise have been reported separately, but data are lacking on the independent effects. Hutcheson and colleagues examined data on almost 500 patients in an attempt to define the independent effects of eating and swallowing.

They reviewed records of 659 patients with oropharyngeal or hypopharyngeal cancer treated with definitive radiation therapy, with or without chemotherapy, from 2002 to 2008. After exclusions, 497 patients remained for the analysis.

The primary outcomes were oral feeding status at the end of radiation therapy (or chemoradiation) and self-reported adherence to swallowing exercises.

Most patients had oropharyngeal cancer, and most had nodal involvement (81% ≥N2). Intensity-modulated radiation therapy was used in 91% of cases, and 77% of patients received systemic therapy, which was administered concurrently in 234 of 497 (49%) patients.

The authors reported that 366 of 497 (74%) patients maintained oral intake throughout radiation therapy. The data showed that 131 (26%) patients had no oral intake at the end of radiotherapy or chemoradiation, 167 (34%) had partial oral intake, and 199 (40%) had complete oral intake. Complete oral intake consisted of pureed or liquid diets in 87 patients and solids in 112 patients.

Of 388 (76%) patients who had consultations with a speech pathologist, 286 (58% of the total patient population) reported adherence to swallowing exercises.

Overall, 13% of patients met neither goal of oral intake or adherence to swallowing exercises, 64% met some goals with at least partial oral intake and/or exercise adherence, and 24% of patients continued full oral intake throughout treatment and adherence to swallowing exercises.

After completing treatment, 402 (81%) patients resumed a regular diet. During a median follow-up of 22 months, significantly more patients who maintained full oral feeding or practiced swallowing exercises consumed a regular diet.

• 65% of patients who were NPO and did not practice swallowing exercises
• 77% to 84% of patients who met some of the eating/swallowing goals
• 92% of patients who met eating and swallowing goals

 

Subgroup analyses showed that full oral feeding led to better outcomes than did partial oral feeding among patients who were adherent to swallowing exercises (P=0.02), and patients who were adherent versus nonadherent to swallowing exercises did better among the subgroup of patients who maintained full oral feeding throughout radiation therapy (P=0.02).

Median duration of gastrostomy dependence was 222 days in patients who were NPO and did not adhere to swallowing exercises, 151 to 157 days in patients who were partly adherent, and 111 days in patients who continued oral intake and remained adherent to the exercises (P=0.03 for trend).

“Long-term swallowing outcomes were best in patients who both maintained full [oral intake] throughout radiation therapy or chemoradiation therapy and reported adherence to swallowing exercises and uniformly worst in those who were [nothing by mouth, NPO] at the end of treatment and nonadherent to the exercise regimen,” Hutcheson and co-authors concluded.

The study was supported by the University of Texas School of Public Health and the Research Institute of Texas.

The authors reported no relevant disclosures.

http://www.medpagetoday.com/HematologyOncology/OtherCancers/41758

 

Numbing No Help for Kids Having Nasendoscopy

Adding a topical local anesthetic to a decongestant did not reduce discomfort among children undergoing flexible endoscopy of the upper airway and was similar to placebo, a randomized trial found.

Mean pain scores rated by the children were statistically similar in all three randomized groups: 2.4 for placebo, 2.2 for a decongestant with topical local anesthetic, and 1.8 for a decongestant without topical local anesthetic, according to Neil K. Chadha, MBChB, MPHe, of the British Columbia Children’s Hospital in Vancouver, and colleagues.

Numerically, the decongestant without a topical local anesthetic was associated with the lowest discomfort as rated by the child, caregiver, and an observer — all of whom were blinded, researchers reported online Oct. 24 in JAMA Otolaryngology-Head & Neck Surgery.

“I found the results surprising,” Binoy Chandy, MD, a pediatric otolaryngologist at Texas Children’s Hospital in Houston, toldMedPage Today.

Chandy said he prefers to use a decongestant with a topical local anesthetic. He mainly performs nasendoscopy in children who have cleft palate disorders.

With a speech pathologist present, the children must talk so the movement of their palate can be evaluated. “It’s very important they cooperate because if they have an unpleasant experience, the whole study can be ruined and many times we can’t get them to do it again,” Chandy said.

The use of a decongestant before flexible nasendoscopy is meant to ease the passage of the endoscope and therefore reduce pain. However, the actual benefits of these sprays are unclear, according to the study background.

Researchers noted that an uncontrolled study of 23 children who were sprayed with a decongestant plus topical local anesthetic (phenylephrine and lidocaine) found a similar child-rated discomfort score (2.7) as the current study.

In the only other randomized clinical trial on this topic, there were no differences among the 53 children treated with the decongestant with a topical local anesthetic (oxymetazoline and lignocaine) or a decongestant alone (oxymetazoline). However, there was no placebo group and pain scores were given by observers only. The recognized standard is to use a child self-report, Chadha and colleagues said.

They therefore conducted a randomized trial with 69 children (71% boys) to compare pain from the procedure after using one of three nasal sprays: placebo (saline), a decongestant with a topical local anesthetic (xylometazoline and lidocaine), or a decongestant without a topical local anesthetic (xylometazoline). The main outcome measure was child-reported pain using a standardized scale.

Each arm comprised 23 children. They were recruited between June 1, 2011, and April 30, 2012. All children completed the study.

The children, ages 3 to 12 (median 6), were treated by a pediatric otolaryngologist at theBritish Columbia Children’s Hospital in the presence of an independent caregiver. The procedure was performed with a 2.4-mm flexible fiberoptic nasendoscope. The child could follow the image on a video monitor.

The scoring measures used in the study were:

• Child self-reported Wong-Baker Faces Pain (WBFP) scale — ranging from 0 to 5 — higher number signifying more pain
• A caregiver-proxy WBFP scale
• The Face, Legs, Activity, Cry, and Consolability (FLACC scale) — observer assigns rating from 0 to 2 for each of five domains for a total ranging from 0 to 10
• The Difficulty of Procedure Visual Analog Scale (DPVAS) — visual analog scale based on a 100-mm line ranging from easiest to most difficult

 

The primary outcome, child-rated WBFP, was not statistically different among the three arms. The decongestant group, however, had the lowest child-rated pain score (1.8 versus 2.2 for decongestant with topical local anesthetic and 2.4 for placebo), as well as the lowest caregiver rating (1.6 versus 1.8 and 2.0, respectively, although not statistically significant).

The decongestant also had the lowest score, albeit not statistically significant, in the observer-rated FLACC scale (3.3 versus 3.6 for decongestant with topical local anesthetic and 4.2 for placebo) and in the DPVAS (2.3 versus 3.2 and 3.0, respectively).

“With these findings, the study suggests that there is no significant benefit of topical decongestant with or without topical local anesthetic compared with placebo in reducing pain associated with pediatric flexible nasendoscopy,” the authors concluded.

“We recognize that if offered a choice, some children or caregivers would still elect to have a nasal spray before nasendoscopy in the hope that this might reduce the associated discomfort,” researchers wrote. Based on these results, they suggested the use of a decongestant alone.

The study has some limitations, including the use of only one size flexible endoscope and the use of saline as placebo, instead of nothing.

http://www.medpagetoday.com/Surgery/Otolaryngology/42467