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keynote lecture delivered at ORLSON’s Oluyole
2014
Advanced Rehabilitation in Otology
Olusesi A.D (FWACS, FMCORL)
Lecture Format
❖ Concept and models of rehabilitation
❖ Evolution of otological rehabilitation
❖ Advances in Otological Rehabilitation
❖ Global
❖ Africa
❖ Nigeria
❖ Round up
Rehabilitation concept
Definition:
"A set of measures that assist individuals who
experience, or are likely to experience, disability to
achieve and maintain optimal functioning in
interaction with their environment”
- WHO
Who is in need of rehabilitation?
❖ Impairment: loss/abnormality of function
❖ Disability: reduction/lack ability to perform within normal range
❖ Handicap: disadvantages from either limit fulfillment of normal role
❖ Functional limitation: loss of ability to perform tasks/obligations of
usual role/normal daily life
❖ Chronic illness: irreversible presence, accumulation or latency of
disease states/impairments that involve total human environment
Rehabilitation Issues
Quality
Quantity
Care
Cure
High
Cost
Long
Term
Rehab
Rehabilitation Team: Models
Rehab Team
Models
MultiDisciplinaryInterDisciplinary
TransDisciplinary
Rehabilitation Principles: Whatever Model
❖ Client centered therapy
❖ Team approach
❖ Evidence based care
❖ Equitable access
❖ Others
❖ care coordination / service integration / early
intervention / setting
Factors Influencing Effective Rehabilitation
❖ Acute / early intervention
❖ Early supported discharge
❖ Settings: home base with interface btw settings
❖ Therapy intensity associated with better outcomes
❖ Team care
❖ Goal setting
Rehabilitation in Otology: Evolution
❖ Prehistoric to XVI Century: Egypt / Greece / Rome /
❖ XVI Century: Italy
❖ XVII Century: France
❖ XVIII Century: France / Italy
❖ XIX Century: France / England / Germany/ Vienna
❖ XX Century: Scotland / England / Sweden / USA /
France /
Ref: Rev. Bras. Otorrinolaringol. vol.73 no.5 São Paulo Sept./Oct. 2007
Evolution of Otology By Geography
March of Otology Thro’ The Ages
❖ Hx of Otology followed Hx of Medicine
❖ Little know by ancient physicians
❖ Middle ages focused on readily accessible structured
(EAC, trauma, FBs)
❖ Magnification introduced 18th century
❖ Otology specialty started in France (1850s)
Otolaryngol Head Neck Surg. 1996 Feb;114(2):173-96
PreHistoric Otology
❖ 1,500 BC: Egyptian pharmacopedia > ‘Medication for the
hard of hearing ear’
❖ Alcmaeon of Croton (Greek): ‘air movement theory’ of
hearing
❖ Empedocles (Greek): 1st described cochlea
❖ Hippocrates: empirical Rx / relations of ear infection to
tonsils/brain infection
❖ Aristotle (Greek): ‘Pure air implantation theory’ of hearing
Otology in 1st to 16th Century AD
❖ Cornelius Celsius (Roman):
❖ first description of tonsillectomy (by finger dissection)
❖ New Rx options for tinnitus
❖ FBs in EAC
❖ Surgeries for EAC atresias
❖ Galerno (PP of Marcus Aurelius): animal dissection / creta
labyrinths
❖ Anatomical sculptures & paintings
Otology in the 16th Century
❖ Description of ossicles: Berengario de Capri / Ingrassia
❖ Description of tensor tympani, ET, and cord tympani as a nerve -
Eustachio
❖ Description of RW / OW - Versalius, 1543
❖ Fabrizi (student of Fallopius)-
❖ merged Aristotle theory with new concept of auditory stimulation
❖ proper methods of otological surgery lightning / devices to guide
light from sun or candles
Otology in the 17th Century
❖ Riolanus (1649): technique of simple mastoidectomy
❖ Perraut (Architect/Physician): Cochlear theory of
hearing/cochlear membranes vibration/degeneration in
aged
❖ Duverney: detail anatomical drawings / theory of cochlear
resonance predating Helmholtz/cholesteatomatous OM
Otology in 18th Century
❖ Jean Loius Petit: 1st description of tuberculous OM (b4
Kochs) / successful mastoidectomies
❖ Valsalva (of Bologna school): dissected over 1000
human heads / ‘ossicular chain discontinuity’ theory of
hearing loss
❖ Cotugna (from Naples): described perilymph/impressive
study of cochlea structures
❖ Scarpa (from modena) described endolymph
Otology in the 19th Century
❖ Astley Cooper: 1st myringotomy to cure ET occlusion (1801)
❖ Cruveilhier: pearl-like CNS tumor (cholesteatoma of petrous
apex) (1829)
❖ Toulemouche - 1st description of malignant otitis externa
❖ Johannes Muller - pioneer auditory physiology >> Helmholz
>> ME physiology (based on previous studies from
Duverney
❖ Dienffenbach (1845): 1st report of otoplasty for bulging ear
Otology in 19th Century contd.
❖ Huschke described brainstem / dissected birds ears /
erroneously thought he found end of auditor nerve fibers
❖ Albert Corti met Virchow (pathologist) >> to Schroeder van
der Kolk and Pieter Harting >> used innovative methods
with microscopes for anatomical dissection >> description
of Organ of Corti
❖ Evenberg (1860) 1st SHL from mumps
❖ Meniere (1861): MD, inner ear disease, not brain disorder /
deafness incurable
Rest of 19th Century Otology
Adam Politzer ViennaAtlas of Otoscopy/ ME Physiology /
Politzerization / Myringotomy for OME
Joseph Toynbee EnglandStapes footplate ankylosis main cause of
deafness
Mach GermanyPioneering rotatory stimulation for vestibular
assessment
Kessel First Surgery of stapes mobilization
Von Troltsch Germany Modified Schwartzes Mastoidectomy
Retzius Labyrinthine Microdissection
Emanuel Zaufal Radical Mastoidectomy
Ewald Labyrinthine origin of nystagmus
Otology in 20th Century
❖ Otology + Laryngology = Otolaryngology
❖ 1st electrical HA (Alt from Vienna) - micro telephone
❖ 1st VIII nerve neurectomy for MD (Perry, Scotland) - 1901
❖ Perforation of pars flaccid of apical cholesteatoma (Bondy, 1910)
❖ 1st trephination of PSCC without opening the antrum - Barany 1910)
❖ 1st description of tympanoplasty (Kisch, 1912)
❖ 1st trephination of horizontal SCC (Jenkins, 1913)
❖ Nobel Prize for work in vestibular research (Barany, 1914)
20th Century Otology Advances
❖ 1st use of cartilage in pinna reconstruction - Gilles, 1920
❖ Introduction of monocular microscope in ear surgeries - Carl
Nguyen, 1921)
❖ Audiometric exam in screening patients for HL - Fletcher &
Wegel, 1922)
❖ 1st analysis of nystagmus - Schutt & Meyer
❖ 1st MD Surgery - (Didier Portmann, 1926) >> House
❖ Description of ME acoustic muscle activity - Luscher, 1929
2oth Century Otology Advances contd.
❖ Facial nerve decompression technique introduced -
Balance & Duel, 1932
❖ 1st measure of ME impedance - Schuster, 1934
❖ Fenestration of LSCC for otosclerosis - Lempert
❖ 1st description of congenital cholesteatoma in petrous
temporal bone
Further 20th Century Otology
Boetcher, 1940Electrical burr introduced for mastoid
surgery
Glomus jugulare
described same year
Zeiss Optical, 1953Introduced modern binocular
microscope for ear surgery
Rosen, Wullstein
cashed in and improved
ear surgeries
William House,
1953
First case of Cong cholesteatoma of ME
cleft
Armstrong introduced
vent polyethylene tube a
year after
Better control and knowledge about use of microscope and the IAC area
(common btw ORL and Neurosurgery) with pioneering work of William House
contributing to successful removal of pontine cerebellar tumors with use of
microscope
Despite progress so far mentioned, 3 perplexing issues - Tinnitus, Vertigo, and Hypoacusis remain unsolvable.
Desire to conquer them form the basis of subsequent advances in ORL
Otology Advances - 1967 -Date
❖ 1st attempt at recording electrical activity of human
brainstem, evoked by acoustic stimuli - Sohmer &
Feinmesse, 1967
❖ Basis for electroCoch established - Aran & Le Bel, 1968
❖ Origin of brainstem potentials proved - Jewet, Romano &
Wilinston, 1970
❖ Many deafness related genes isolated - 2005
Otological Advances - Global
Global Otological Rehabilitation Advances
❖ Hearing Aids & Implantable Hearing (Aids) Solutions
❖ AudioVestibular implants
❖ CI / ABI / AMI
❖ Vestibular Implants
❖ Robotic Ear Surgeries
❖ Advances in Regeneration Medicine
❖ Stereotactic Ear / Skull Base Surgery
Advances in Hearing Aids
❖ Analog aids gradually giving way to digital HAs
❖ programmable
❖ equipped with more than one listening program
❖ directional microphone technology (better hearing in background
noise) 2 not 1 mic
❖ smart hearing aids - hearing aids that learn a user’s preference
recording them and - auto adjusting
❖ others: wireless connection to phone / waterproof & rustproof /
maskable / bluetooth compatible
Autoadjusting Hearing Aids
❖ Auto-focus on and amplify source of speech in a crowded room
❖ Siemens SpeechFocus / Phonak’s Zoom technology
❖ Auto-adjust to multiple listening environments
❖ e.g. Siemen’s Micon
❖ Learn user’s listening preference in up to 6 acoustic
environments
❖ Automatically detect and eliminate feedbacks (whistling) before
it begins
Bone Anchored Hearing Aids -Advances
❖ Abutment has given way to magnets
2nd BAHA Surgery in Nigeria
Cochlear / AB / AM Implants -Advances
❖ CI in the past 25 years:
❖ Speech feature extractor as coding strategy - 1986
❖ FDA approval for SPEAK strategy - 1994
❖ Implant integrated circuit - 1995
Oooh
Frequency Encoding: Signal-to-Noise Generation
Adult Male: 132 Hz; Adult Female: 223 Hz
Children: 264 Hz ; Most of Hearing: .3 - 3KHz
How Auditory System Encode Speech Sound: Cochlea
as Frequency Analyzer
Place Theory
❖ Bekesy discovered cochlear Traveling waves, 1927: Findings at variance with von
Helmholtz
❖ 1970s - 1980s: Vibration of basilar membrane non-linear
❖ 1985 - 1986: low frequency electromotility responses of OHC
❖ 1998: Mario Rugero et al: At near threshold stimulus level frequency tuning of
auditory nerves closely parallels that of basilar membrane displacement modified
by high-pass filtering
Frequency Theory
Advances in Hearing Theories till Today
Single-channel Implants Multichannel Implants
http://147.162.36.50/cochlea/cochleapages/overview/history.htm
Cochlear Implants Advances
❖ Electrode design: no. of electrodes / configuration /
placement (cochlear Vs extracochlear)
❖ Type of stimulation: analogue or pulsatile
❖ Transmission Link: transcutaneous Vs percutaneous
❖ Signal Processing: waveform Vs feature extraction
Cochlear Implants Electrode Design
❖ Single Vs Multiple Channel
Electrodes?
❖ frequency coding constrained by
❖ No. of surviving auditory
neuron at particular site in the
cochlea (Limited by etiology!!)
❖ Spread of excitation associated
with electrical stimulus
d
d
d
d
d
d
d
d
d
d
surviving neuron spread out
surviving neuron concentrated at a spot
Electrodes Design: Med El ‘Flex’ Electrodes for Different Indications
Electrodes Design: Med El ‘Form’ Electrodes for Deformed Cochlear
Commercially Available implant Devices
DeviceProcessor
Name
Electrodes
Stimulation
Number Spacing
Nucleus EsPrit/Freedom 22 0.7mm Sequential
Clarion Auria 16 1.1mmSequential/si
multaneous
Med El
Combi
40+/Tempo
40+/PULSARci100
12 2.4mmSequential/si
multaneous
Møller A (ed): Cochlear and Brainstem Implants. Loizou
Adv Otorhinolaryngol. Basel, Karger, 2006, vol 64, pp 109–143
Cochlear Implants in Last 25 Years
❖ Improvement in speech coding strategy: Nucleus 22 CI
speech feature extractor >> SPEAK strategy >> Nucleus
24M >> CIS / ACE strategy >> 1st ear level processor >>
dual microphone technology
❖ Functional improvement: Listening in background noise
(directional microphone technology)
❖ Broadening indications: Early implantation (<12
month+profound SNHL bilat), 12-24 month + severe-to-
profound SNHL+no benefit from amplification,
Last 25 years of CI - Broadening Adult Indications
❖ Moderate-to-Profound low-freq hearing loss & mid-to-
high-frequency hearing loss
❖ Aided speech recognition up to 50% in ear to be
implanted, up to 60% in bilateral aided conditions
❖ Pre- and post-lingually deafened adults - no upper limit
age restriction for adults
Last 25 Years of CI - Surgical Advances
❖ Minimally invasive cochlear implants
❖ Direct Cochlear Access (no mastoidectomy, no wide posterior
tympanotomy)
❖ Utilizes robotic drilling + image registration
❖ Residual hearing preservation in CI
❖ atraumatic RW insertion
❖ robotic micro-drill technique
❖ Electric Acoustic Stimulation (EAS)
Assadi et al, 2013; Williamson et al, 2014; Gurbani et al, 2014
‘Slim’ Versus ‘Hybrid’ Electrode CI from Cochlear
The AOS Electrode from Cochlear
Special Electrodes from Cochlear
Otological Rehabilitation Advances: The ABI Implant
❖ 1st implanted 1979 at HEI, for
NF2 cases
❖ Original implantation near
surface of cochlear nucleus
❖ From 2 >> 8 >> 21 electrodes
of Cochlear ABI
❖ 12 electrodes Med El ABI
❖ 16 Electrodes Clarion-1.2
(Advanced Bionics)
❖ Only 1,500 implanted to date
❖ Indications for ABI
❖ Acoustic Neuroma
❖ Cochlear Nerve
Avulsion
❖ Completely ossified
cochlear
Cochlear Vs Med El Auditory Brainstem Implants
Auditory Midbrain Implants
❖ Electrodes inserted to stimulate central nucleus of
inferior colliculus
❖ for those with
❖ little benefit from CI or ABI
❖ after surgery for bilateral acoustic neuroma
❖ Variable outcomes
Advances in Rehabilitation in Otology in Africa Over Past 25 Years - Published Otological Surgeries
0
4.5
9
13.5
18
Nigeria S/Africa Egypt Rest
Tympanoplasty Surgeries in Africa
0
0.25
0.5
0.75
1
1.25
Nigeria Egypt S/Africa Rest
Tympanomastoidectomy in Africa
Otological Rehabilitation in Africa - Published Minor Otological Surgries
0
0.75
1.5
2.25
3
3.75
Nigerian S/Africa
Myringotomy
0
1.75
3.5
5.25
7
8.75
Nigeria Egypt S/Africa Rest
Myringoplasty
Published Studies: Otological Flaps in Otological Rehabilitation in Africa
0
1
2
3
4
5
Nigeria S/Africa Egypt Rest
Hearing Aids Technological Advances in Africa
❖ HA distribution system
❖ Good in Egypt
❖ fair in S/Africa - 25% discount
❖ Non-existent in Nigeria, elsewhere
❖ No personalization of choice & fitting
❖ Personalized assembly still being discussed
Source: WHO
Advances in Rehabilitation in Otology - Vestibular Rehabilitation
❖ Normally functioning vestibular system ensures
❖ upright stance and locomotion
❖ head & eye stabilization
❖ internal spatial representation
❖ Practical advances in rehab of vestibular defective patients targets
❖ rehabilitation at early stage
❖ active retraining
❖ adaptive exercises over stereotyped rehab programs
❖ standardized environment examination
❖ both static & dynamic tests used
❖ avoids/limits use of drugs with sedative effects
Lacour M, 2006 - Curr Med Res Opin. 2006 Sep;22(9):1651-9.
Current Rehabilitation Algorithm
❖ Is it Vertigo?
❖ If yes is it for a peripheral or central vestibular disease?
❖ If peripheral vestibular disease, which one? - Common
thing occur commonly
❖ Is it treatable by medical or surgical means, or is
rehabilitation needed?
❖ Which rehabilitation method should be employed and
how often?
Current Vestibular Assessment
• Balance Test: (vestibulospinal
tract)• Romberg, Tandem Romberg
• Tandem gait (Acute or Chronic?)
• Evaluation of Basic Eye
Movement:• Nystagmus (saccadic, vestibular, pendular,
congenital, alternating)
• Saccades, pursuit, vergence, gaze
• Fixation Suppression
• Vestibulo-Ocular Reflex (VOR)
• Head Shake Test / Rapid Doll
Eye Movt Test
• Fistula Test (labyrinthine fistula)
• Vibration of SCM with Video
Frenzel(Unilateral vest. Lesion)
• Dynamic & Static Positional
Tests: Dix-HallPike Test
Tests carried out in clinician’s office
• ENG/VNG Test battery
(composed of saccadic,
gaze, pursuit, optokinetic-
eye movement, head-shake
nystagmus, positional
nystagmus, positioning
nystagmus, and bithermal
caloric tests)
• Rotational Tests
• Posturography
• CT Scan
• MRI Scan
• Audiometry
• Blood Tests
Additional Tests
Advances in Vestibular Assessment
❖ 3D fluid-attenuated inversion recovery MRI in diagnosis of
Endolymphatic hydrops
❖ potentials of intravenous contrast MRI in imaging of ear
began 2010 with visualization of post gentamicin injection
❖ Since expanded to ELH visualization / comparison of IV
and IT contrast MRI
❖ Vestibular Evoked Myogenic Potential (VEMP)
❖ Cochlear Hydrops Analysis Masking Procedure (CHAMP)
Vestibular Evoked Myogenic Response (VEMP)
❖ neurophysiological means of assessing otolith organs
function, especially saccule (slight sound sensitivity)
❖ Sound-evoked VEMP recorded from the neck usu
unilateral
❖ CHL obliterates VEMP, SNHL does nothing to VEMP
82 YO Male suspected MD: T2W 3D-FLAIR MRI
Courtesy of Naganawa S et al, 2012: Magn Reson Med Sci, Vol 9, No4, pp 237-242, 2010
46 YO Male with Bilateral MD: T2W 3D-FLAIR Compared to Other Protocols
Courtesy of Naganawa S et al, 2012: Magn Reson Med Sci, Vol 9, No4, pp 237-242, 2010
Cochlear Hydrops Analysis Masking Procedure (CHAMP)
❖ Modified standard ABR with click stimulus mixed with increasing
high-pass masking noise
❖ Cut off frequency of the masking successively lowered from one
runs to another, progressively masking lower frequency freq.
regions of cochlea
❖ Interpretation:
❖ Normal: latency of wave V prolonged with increasing masking
❖ Cochlear Hydrops: Little or no shift in latency of Wave V
Advances in Vestibular Rehabilitation
❖ Vestibular Rehabilitation Therapy (VRT)
❖ stable lesion, incomplete recovery
❖ Surgery / Vestibular Implants
❖ Unstable lesion, episodic, spontaneous
Vestibular RT - Basis
❖ Physical Therapy
❖ uses specialized
individualized exercises that
>> gaze/gait stabilization
❖ Use existing neural mechanisms
in human brain for adaptation,
plasticity and compensation
❖ Exercises: habituation, CRP,
VOR, static/dynamic balance
exercises
Ankle Stabilization Strategy
Goals of VRT
• Improve balance
• Minimize falls
• Decrease subjective sensations of
dizziness
• Improve stability during
locomotion
• Reduce overdependency on visual
and somatosensory inputs
• Improve neuromuscular
coordination
• Decrease anxiety and
somatization due to vestibular
disorientation Head Stabilization Strategy
VRT - What is New?
❖ Use of Virtual Reality in VRT
❖ Customized VRT programs can be provided
❖ Situations that cause difficulty in everyday living can
be artificially recreated to help >> vestibular
compensation
❖ Exercises can also be admitted remotely
Virtual Reality Vs Vest. Rehab Protocol
❖ Virtual reality-augumented rehabilitation
❖ Conventional exercises based on VR equipment at
office clinic/home + regime of simulated virtual rehab
exercises
❖ Virtual reality-based therapy
❖ No conventional exercises / New virtual rehab
approaches >> recovery
Virtual Reality Screen Interfaces
❖ Feedback-centered interaction
❖ e.g. threadmill training in front of a screen
❖ Gesture-based interaction
❖ e.g. specialized camera to capture point of reference of a target
during several motions/captured image projected in real time to
facilitate interaction btw target/virtual environment (like Wii)
❖ Haptic stimuli-based interaction
❖ enables user to perceive mechanical stimuli inside a virtual
environment (like sensory gloves)
Coutesy Valeska Gatica-Rojas et al, Neural Regen Res. Apr 15, 2014; 9(8): 888–896.
Virtual Reality Devices Used In Vestibular Rehabilitation
Over 33 publications to date
on Virtual Reality in
Vestibular Rehabilitation!!!
Vestibular Implants
❖ Fairly new approach to bilateral vestibular
failure
❖ Implants device similar to CI / can be hybrid
for SNHL coexisting with bilat vestibular failure
❖ Implanted component either connected
extravestibular or intravestibular (within the
SCC)
❖ External component has gyroscopes and
accelerometers that register and process head
movements.
❖ VI research over a decade old, first successful
human implants 2012
Image courtesy medgadget.com
Regeneration Medicine & Otology
❖ Stem cells research attempts to reconcile ‘Why HCs
regenerate in birds but not in mammals’ was driving force
❖ Several centers in USA / Japan at forefront of
groundbreaking research that could provide ‘cure’ for
hearing loss
❖ Autologous marrow cells / cord blood stem cells have been
implanted into inner ear of lab animals*
❖ Challenges have been getting regenerated stem cells to link
up with auditory nerve
First FDA-approved autologous cord-blood stem cells transplant given 2012
Summary
❖ Otology has advanced, and will continue to advance
based on available medical technology at each age
❖ Our ability to key in and keep abreast of advances in
otology will rely on how much we interface otology with
advances in medical technology
❖ Otolaryngologists should get out of their secluded
pedestal and team up with basic scientists /
technologists to help advance Otology