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Hearing Disorders: HELP
Articles from Henry Ford Health System
Based on 27 articles published since 2009
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These are the 27 published articles about Hearing Disorders that originated from Henry Ford Health System during 2009-2019.
 
+ Citations + Abstracts
Pages: 1 · 2
1 Guideline Clinical practice guideline: sudden hearing loss. 2012

Stachler, Robert J / Chandrasekhar, Sujana S / Archer, Sanford M / Rosenfeld, Richard M / Schwartz, Seth R / Barrs, David M / Brown, Steven R / Fife, Terry D / Ford, Peg / Ganiats, Theodore G / Hollingsworth, Deena B / Lewandowski, Christopher A / Montano, Joseph J / Saunders, James E / Tucci, Debara L / Valente, Michael / Warren, Barbara E / Yaremchuk, Kathleen L / Robertson, Peter J / Anonymous4970719. ·Department of Otolaryngology, Henry Ford Hospital, Detroit, Michigan 48202, USA. rstachl1@hfhs.org ·Otolaryngol Head Neck Surg · Pubmed #22383545.

ABSTRACT: OBJECTIVE: Sudden hearing loss (SHL) is a frightening symptom that often prompts an urgent or emergent visit to a physician. This guideline provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with SHL. The guideline primarily focuses on sudden sensorineural hearing loss (SSNHL) in adult patients (aged 18 and older). Prompt recognition and management of SSNHL may improve hearing recovery and patient quality of life (QOL). Sudden sensorineural hearing loss affects 5 to 20 per 100,000 population, with about 4000 new cases per year in the United States. This guideline is intended for all clinicians who diagnose or manage adult patients who present with SHL. PURPOSE: The purpose of this guideline is to provide clinicians with evidence-based recommendations in evaluating patients with SHL, with particular emphasis on managing SSNHL. The panel recognized that patients enter the health care system with SHL as a nonspecific, primary complaint. Therefore, the initial recommendations of the guideline deal with efficiently distinguishing SSNHL from other causes of SHL at the time of presentation. By focusing on opportunities for quality improvement, the guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients. RESULTS: The panel made strong recommendations that clinicians should (1) distinguish sensorineural hearing loss from conductive hearing loss in a patient presenting with SHL; (2) educate patients with idiopathic sudden sensorineural hearing loss (ISSNHL) about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy; and (3) counsel patients with incomplete recovery of hearing about the possible benefits of amplification and hearing-assistive technology and other supportive measures. The panel made recommendations that clinicians should (1) assess patients with presumptive SSNHL for bilateral SHL, recurrent episodes of SHL, or focal neurologic findings; (2) diagnose presumptive ISSNHL if audiometry confirms a 30-dB hearing loss at 3 consecutive frequencies and an underlying condition cannot be identified by history and physical examination; (3) evaluate patients with ISSNHL for retrocochlear pathology by obtaining magnetic resonance imaging, auditory brainstem response, or audiometric follow-up; (4) offer intratympanic steroid perfusion when patients have incomplete recovery from ISSNHL after failure of initial management; and (5) obtain follow-up audiometric evaluation within 6 months of diagnosis for patients with ISSNHL. The panel offered as options that clinicians may offer (1) corticosteroids as initial therapy to patients with ISSNHL and (2) hyperbaric oxygen therapy within 3 months of diagnosis of ISSNHL. The panel made a recommendation against clinicians routinely prescribing antivirals, thrombolytics, vasodilators, vasoactive substances, or antioxidants to patients with ISSNHL. The panel made strong recommendations against clinicians (1) ordering computerized tomography of the head/brain in the initial evaluation of a patient with presumptive SSNHL and (2) obtaining routine laboratory tests in patients with ISSNHL.

2 Review Successful Placement of a BAHA Implant in a Patient With Epidermolysis Bullosa: A Case Report and Review of the Literature. 2017

Brown, Jason R / Milgraum, D Micah / Riyaz, Farhaad R / Jahnke, Marla N / Thottam, Prasad John. ·1 Department of Otolaryngology - Head and Neck Surgery, Detroit Medical Center, Detroit, MI, USA. · 2 Drexel University College of Medicine, Philadelphia, PA, USA. · 3 Department of Dermatology, Henry Ford Hospital, Detroit, MI, USA. · 4 Children's Hospital of Michigan, Detroit, MI, USA. · 5 Michigan Pediatric Ear, Nose, and Throat Associates, West Bloomfield, MI, USA. · 6 Pediatric Otolaryngology, Beaumont Children's Hospital, Royal Oak, MI, USA. ·Ann Otol Rhinol Laryngol · Pubmed #28895441.

ABSTRACT: INTRODUCTION: Epidermolysis bullosa (EB) is a spectrum of mechanobullous disorders characterized by blistering following minor trauma or traction to the skin. Hearing loss in this population is poorly described in the otolaryngology literature, and its treatment oftentimes results in external auditory canal skin irritation. CASE PRESENTATION: We present the case of a 26-year-old female with EB and mixed hearing loss unable to wear conventional hearing aids due to sequelae of the external auditory canals. An osseointegrated implant was used as other hearing aids were deemed to be too destructive of the external auditory canal skin. Management and Outcome: Our patient underwent placement of a right bone-anchored hearing aid with minimal disruption of the surrounding skin using a minimally invasive punch technique. Over 1 year of follow-up, her course was complicated by 1 simple cellulitic infection at the surgical site treated successfully with oral antibiotics. DISCUSSION: The literature regarding the otolaryngologic manifestations of EB is sparse. The otologic sequelae are particularly overlooked in the workup and management. Based on the results of this case study, it appears that an osseointegrated implant can be safely utilized to treat significant mixed or conductive hearing loss in patients with EB.

3 Review Current opinion: the management of tinnitus. 2015

Seidman, Michael D / Ahsan, Syed F. ·Division of Otology/Neurotology, Department of Otolaryngology, Henry Ford Medical Center, West Bloomfield, Michigan, USA. ·Curr Opin Otolaryngol Head Neck Surg · Pubmed #26204362.

ABSTRACT: PURPOSE OF REVIEW: The purpose of this review is to describe our experience with management of chronic tinnitus and to review the recent literature on the best treatment options available for treating patients who are troubled by their tinnitus. In addition, we want to highlight our experience and approach to this very common problem. RECENT FINDINGS: Treatment options for patients are based on the severity of the tinnitus and any associated problems. The use of nutritional supplements has a place in the treatment of mild-to-moderate tinnitus. Ginkgo biloba and B-complex vitamins may have an impact on selected patients. Treatment of underlying or accompanying anxiety disorders especially with cognitive behavior therapy can help to reduce the distress associated with tinnitus. Surgical treatment options, such as cochlear implant, have been shown to be very effective in reducing tinnitus in patients with sudden unilateral hearing loss as the cause of tinnitus. Other surgical approaches, such as repetitive transcranial magnetic stimulation and vagal stimulator, have had some limited benefits. SUMMARY: Treatment for subjective tinnitus can range from the conventional to the investigational modalities. Best treatment options take into account the possible cause of the tinnitus and other associated symptoms.

4 Review What is the best imaging modality in evaluating patients with unilateral pulsatile tinnitus? 2015

Ahsan, Syed F / Seidman, Michael / Yaremchuk, Kathleen. ·Department of Otolaryngolog-Head and Neck Surgery, Henry Ford Health Systems, Detroit, Michigan, U.S.A. ·Laryngoscope · Pubmed #25042105.

ABSTRACT: -- No abstract --

5 Review Bilateral hearing loss heralding sporadic Creutzfeldt-Jakob disease: a case report and literature review. 2014

Salazar, Richard / Cerghet, Mirela / Ramachandran, Virginia. ·*Department of Neurology, Parkview Neurology Services, Rocky Vista University, Parker, Colorado, U.S.A.; †Department of Neurology, ‡Division of Audiology, Henry Ford Hospital, Detroit, Michigan, U.S.A. ·Otol Neurotol · Pubmed #25122149.

ABSTRACT: OBJECTIVE: To report a case of sporadic Creutzfeldt-Jakob disease (CJD) with bilateral hearing loss at onset and literature review of the scarce cases of CJD with similar audiologic manifestations at presentation. CASE REPORT: A 67-yr-old man presented to the hospital for evaluation of rapid progression of behavioral decline, unsteady gait, and bilateral hearing loss. Three months before admission, he abruptly developed bilateral hypoacusis without associated tinnitus or vertigo. Shortly after, his family noted an ataxic gait and behavioral changes, for example, paranoid delusions. Initial workup, including a complete autoimmune panel and heavy metals, infectious, toxicology, and paraneoplastic panel (e.g., anti-Hu, anti-VGKC), was conducted. Electroencephalography revealed diffuse generalized slowing without periodic complexes. The presence of distortion product otoacoustic emissions bilaterally was consistent with normal cochlear function, suggesting a retrocochlear origin for symptoms of hearing loss. In the meantime, the patient developed startle myoclonus. The brain magnetic resonance imaging demonstrated asymmetric cortical ribbon along with T2 FLAIR signal hyperintensities of bilateral basal ganglia. Later on, the protein 14-3-3 in the cerebrospinal fluid came back positive, which supported the diagnosis of CJD. Only three cases of CJD with deafness at onset have been published: one sporadic, associated with symptoms suggestive of polyneuropathy; and the other two familial, with the E200K mutation. One presented with symptoms of polyneuropathy and the other with typical features. CONCLUSION: This case illustrates the phenotypic variability of presentation of CJD in a patient with hearing loss as the initial manifestation. In patients with subacute bilateral hypoacusis and signs of dementia, the differential diagnosis of CJD must be taken into consideration.

6 Review Sudden bilateral sensorineural hearing loss following polysubstance narcotic overdose. 2011

Schweitzer, Vanessa G / Darrat, Ilaaf / Stach, Brad A / Gray, Elizabeth. ·Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, MI 48202, USA. vschwei1@hfhs.org ·J Am Acad Audiol · Pubmed #21586255.

ABSTRACT: BACKGROUND: Auditory disorders associated with substance abuse are rare. Hearing loss secondary to heroin and hydrocodone abuse has been described variously as not always responsive to steroid management, as not always reversible, and in some cases, as nonresponsive profound sensorineural hearing loss requiring cochlear implantation. We present a case of a teenager with sudden-onset moderate to severe bilateral sensorineural hearing loss after documented polysubstance "binging." The hearing loss improved substantially after high-dose steroid and vasoactive therapy. PURPOSE: The purpose of this report is to describe the hearing disorder of a patient who had awakened with a bilateral severe hearing loss following a night of recreational drug abuse. RESEARCH DESIGN: Case report and review of the literature. DATA COLLECTION AND ANALYSIS: The subject of this report is an 18-yr-old patient with a history of substance abuse. Data collected were magnetic resonance /computed tomography brain imaging; metabolic, infectious disease, and autoimmune evaluation; and extensive audiologic evaluation, including pure-tone and speech audiometry, immittance measures, distortion-product otoacoustic emissions, and auditory brainstem response testing. Serial audiograms were collected for 10 mo following the onset of symptoms. RESULTS: Two days of polysubstance abuse (heroin, benzodiazepine, alcohol, and crack [smoked cocaine]) resulted in moderately severe sensorineural hearing loss bilaterally. The loss responded to a 1 mo course of high-dose prednisone and a 10 mo course of pentoxifylline. Hearing sensitivity subsequently improved, leaving only residual high-frequency sensorineural hearing loss. CONCLUSIONS: This case report highlights the importance of "recreational" drug abuse in the evaluation of sudden hearing loss. Potential etiologies include altered pharmacokinetics, vascular spasm/ischemia, encephalopathy, acute intralabyrinthine hemorrhage, and genetic polymorphisms of drug-metabolizing enzymes.

7 Review Tinnitus: current understanding and contemporary management. 2010

Seidman, Michael D / Standring, Robert T / Dornhoffer, John L. ·Henry Ford Health System, Director Division Otologic/Neurotologic Surgery, Medical Director Center for Integrative Medicine, Detroit, MI 48202, USA. mseidma1@hfhs.org ·Curr Opin Otolaryngol Head Neck Surg · Pubmed #20625292.

ABSTRACT: PURPOSE OF REVIEW: Tinnitus is a debilitating condition that affects a broad range of patients. Despite thorough and extensive research, the cause of tinnitus has yet to be determined. Also, there has never been a single intervention identified that can consistently eliminate the symptoms of tinnitus. However, despite our inability to 'cure' tinnitus, there are many medical and behavioral strategies that may result in symptomatic relief. The purpose of this article is to review some of the previous information on tinnitus and to examine the recent research on the etiology and management of this condition. RECENT FINDINGS: Recent research into the etiology of tinnitus has demonstrated that genetics plays less of a role than previously thought. Although many medications can cause some relief of tinnitus, a number of well designed studies have failed to identify a single cure. For patients with severe tinnitus who have failed other treatments, such as dietary modification, herbs and nutrients, sound therapies (tinnitus retraining, Neuromonics, masking, and others), or centrally acting medications, transcranial magnetic stimulation has emerged as a viable treatment option. SUMMARY: Tinnitus is a common medical complaint and debilitating problem for some patients. It has a broad range of etiologies and even more potential treatments. This review is meant to inform the reader on the current options available to treat this condition.

8 Review Clinical issues and frequent questions about biotinidase deficiency. 2010

Wolf, Barry. ·Department of Medical Genetics, Henry Ford Hospital, 3031 West Grand Blvd., Suite 700, Detroit, MI 48202, USA. bwolf1@hfhs.org ·Mol Genet Metab · Pubmed #20129807.

ABSTRACT: Biotinidase deficiency is a biotin-responsive, inherited neurocutaneous disorder. The disorder is readily treatable and is screened for in the newborn period. Over the years since the discovery of the disorder, many practical questions and issues have been raised as to the diagnosis, management, treatment, and newborn screening of the disorder. In this paper, many of these issues are addressed using evidence-based medicine and anecdotal experiences. If adequate answers are not known, the answers to these queries will require future investigations.

9 Article Impact of Stimulus Polarity on oVEMP Response Using the Belly-Tendon Electrode Montage. 2019

Romero, Daniel J / Kitner, Blythe H / Wilson, Matthew J / Smith, Kaylee J. ·Northern Illinois University, DeKalb, IL. · Henry Ford Health System, Detroit, MI. ·J Am Acad Audiol · Pubmed #31044695.

ABSTRACT: BACKGROUND: One stimulus parameter not well established with respect to the ocular vestibular evoked myogenic potential (oVEMP) is stimulus polarity. Many research studies traditionally record oVEMPs using alternating polarity primarily. PURPOSE: The purpose of this study was to evaluate the effects of stimulus polarity on the oVEMP response under three different conditions (condensation, rarefaction, and alternating) with updated but established recording procedures-the belly-tendon electrode montage. RESEARCH DESIGN: oVEMPs were assessed with changes in stimulus polarity in the seated upright position. STUDY SAMPLE: Thirty otologically normal participants (60 ears) with no history of hearing or balance disorders and normal middle ear function. DATA COLLECTION AND ANALYSIS: Five hundred-hertz air-conducted tone bursts at 95-dB nHL were used to evoke the oVEMP response while recordings were made from the contralateral eye to acoustical stimulation using the belly-tendon electrode montage. Measurements were made using three polarities: alternating, condensation, and rarefaction. Natus Bio-logic AEP hardware and software was used for all data collection and analysis. RESULTS: Condensation stimulus phase provided the largest response amplitude compared with alternating and/or rarefaction. Rarefaction provided the earliest latency among stimulus polarities. CONCLUSIONS: Condensation is a more effective stimulus polarity regarding response amplitude when recording the oVEMP. This study further supports the use of the belly-tendon electrode montage for recording the oVEMP response.

10 Article Clinical Characteristics and Neuroimaging Findings in Internal Jugular Venous Outflow Disturbance. 2019

Zhou, Da / Ding, Jiayue / Asmaro, Karam / Pan, Liqun / Ya, Jingyuan / Yang, Qi / Fan, Chunqiu / Ding, Yuchuan / Ji, Xunming / Meng, Ran. ·Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China. · Advanced Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China. · Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China. · Department of Neurosurgery, Wayne State University School of Medicine, Wayne State University, Detroit, Michigan, United States. · Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan, United States. · Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China. · Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China. ·Thromb Haemost · Pubmed #30605919.

ABSTRACT: Recently, internal jugular vein stenosis (IJVS) is gaining increasing attention from clinical researchers due to a series of confounding symptoms that impair the quality of life in affected individuals but cannot be explained by other well-established causes. In this study, we aimed to elucidate the clinical features, neuroimaging characteristics and pathogenesis of IJVS, and explore their possible correlations, in attempt to provide useful clues for clinical diagnosis and treatment. Forty-three eligible patients with unilateral or bilateral IJVS confirmed by contrast-enhanced magnetic resonance venography of the brain and neck were enrolled in this study. Magnetic resonance imaging along with magnetic resonance angiography or computed tomography angiography was applied to identify the radiological pattern of parenchymal or arterial lesions. Cerebral perfusion and metabolism were evaluated by single-photon emission computed tomography (SPECT). Of the 43 patients (46.0 ± 16.0 years old; 30 female), 14 (32.6%) had bilateral and 29 had unilateral IJVS. The common clinical symptoms at admission were tinnitus (60.5%), tinnitus cerebri (67.6%), headache (48.8%), dizziness (32.6%), visual disorders (39.5%), hearing impairment (39.5%), neck discomfort (39.5%), sleep disturbance (60.5%), anxiety or depression (37.5%) and subjective memory decline (30.2%). The presence of bilateral demyelination changes with cloudy-like appearance in the periventricular area and/or centrum semiovale was found in 95.3% (41/43) patients. SPECT findings showed that 92.3% (24/26) patients displayed cerebral perfusion and metabolism mismatch, depicted by bilaterally and symmetrically reduced cerebral perfusion and increased cerebral glucose consumption. IJVS may contribute to alterations in cerebral blood flow and metabolism, as well as white matter lesion formation, all of which may account for its clinical manifestations.

11 Article Johanson-Blizzard syndrome with associated urogenital anomalies. 2018

Sood, Akshay / Jamzadeh, Asha / Chowdhury, Mashrin / Lakshmanan, Yegappan. ·Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA. · VCORE | Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA. · Department of Urology, Children's Hospital of Michigan, Detroit, Michigan, USA. ·BMJ Case Rep · Pubmed #30097546.

ABSTRACT: We present a case of a child with pancreatic insufficiency and facial defects typical of Johanson-Blizzard syndrome (JBS), along with the more facultative anomalies of the JBS, such as those of the urogenital system including persistent urogenital sinus, urethral duplication and dysplastic kidneys. Fetal ultrasound in a 21-year-old G1P1 woman revealed ambiguous genitalia. Examination at birth revealed a phallic structure with urethral meatus, non-palpable gonads, two orifices in close proximity in the perineum, with the anterior being a common urogenital channel and the posterior, the rectum. A voiding cystourethrogram/genitogram showed bilateral high-grade vesicoureteral reflux and a common urogenital sinus extending 1.5 cm before dividing into three channels: the native urethra, an accessory urethra directed anteriorly towards the clitoris and a septate vagina with uterus didelphys. JBS was suspected by clinical presentation and confirmed by UBR1 molecular testing (46,XX). At 16 months of age, she underwent feminising genitoplasty and posterior sagittal anorectoplasty.

12 Article Evaluation of Noise Exposure Secondary to Wind Noise in Cyclists. 2017

Seidman, Michael D / Wertz, Anna G / Smith, Matthew M / Jacob, Steve / Ahsan, Syed F. ·1 Department of Otolaryngology Head and Neck Surgery, Florida Hospital Celebration Health, Celebration, Florida, USA. · 2 Department of Otolaryngology Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, USA. · 3 Department of Pediatric Otolaryngology Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA. · 4 Automotive Operations, Ford Motor Company, Allen Park, Michigan, USA. ·Otolaryngol Head Neck Surg · Pubmed #28742424.

ABSTRACT: Objective Determine if the noise levels of wind exposure experienced by cyclists reach levels that could contribute to noise-induced hearing loss. Study Design Industrial lab research. Setting Industrial wind tunnel. Subjects and Methods A commercial-grade electric wind tunnel was used to simulate different speeds encountered by a cyclist. A single cyclist was used during the simulation for audiometric measurements. Microphones attached near the ears of the cyclist were used to measure the sound (dB sound pressure level) experienced by the cyclist. Loudness levels were measured with the head positioned at 15-degree increments from 0 degrees to 180 degrees relative to the oncoming wind at different speeds (10-60 mph). Results Wind noise ranged from 84.9 dB at 10 mph and increased proportionally with speed to a maximum of 120.3 dB at 60 mph. The maximum of 120.3 dB was measured at the downwind ear when the ear was 90 degrees away from the wind. Conclusions Wind noise experienced by a cyclist is proportional to the speed and the directionality of the wind current. Turbulent air flow patterns are observed that contribute to increased sound exposure in the downwind ear. Consideration of ear deflection equipment without compromising sound awareness for cyclists during prolonged rides is advised to avoid potential noise trauma. Future research is warranted and can include long-term studies including dosimetry measures of the sound and yearly pre- and postexposure audiograms of cyclists to detect if any hearing loss occurs with long-term cycling.

13 Article Developmental window of sensorineural deafness in biotinidase-deficient mice. 2017

Maheras, Kathleen June / Pindolia, Kirit / Wolf, Barry / Gow, Alexander. ·Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, 3216 Scott Hall, 540 E Canfield Ave, Detroit, MI, 48201, USA. · Department of Research Administration, Henry Ford Hospital, Detroit, MI, 48202, USA. · Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, 3216 Scott Hall, 540 E Canfield Ave, Detroit, MI, 48201, USA. agow@med.wayne.edu. · Carman and Ann Adams Department of Pediatrics, Detroit, MI, 48201, USA. agow@med.wayne.edu. · Department of Neurology, Wayne State University School of Medicine, Detroit, MI, 48201, USA. agow@med.wayne.edu. ·J Inherit Metab Dis · Pubmed #28516283.

ABSTRACT: Biotinidase deficiency is an autosomal recessively inherited disorder that results in the inability to recycle the vitamin, biotin. If untreated, the disorder can result in a range of neurological and cutaneous symptoms, including sensorineural deficits and deafness. To understand early mechanistic abnormalities that may precede more generalized and nonspecific effects of metabolic deficits such as weight loss and acidosis, we have analyzed auditory brainstem responses (ABRs) in biotinidase-deficient knockout (Btd

14 Article The utility of early developmental assessments on understanding later nonverbal IQ in children who are deaf or hard of hearing. 2017

Meinzen-Derr, Jareen / Wiley, Susan / Phillips, Jannel / Altaye, Mekibib / Choo, Daniel I. ·Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Division of Pediatric Otolaryngology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States. Electronic address: jareen.meinzen-derr@cchmc.org. · Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States. · Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Henry Ford Health System, Detroit, MI, United States. · Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States. · Division of Pediatric Otolaryngology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States. ·Int J Pediatr Otorhinolaryngol · Pubmed #28012515.

ABSTRACT: OBJECTIVE: In children who are deaf or hard of hearing (DHH), it is helpful to have meaningful early measures of development in order to provide effective interventions and offer benchmarks that help recognize varied developmental trajectories. The main objective of this study was to compare results of an early developmental assessment prior to 3 years of age to later nonverbal IQ assessed between 3 and 6 years of age in children who are DHH. METHODS: This study included children 3-6 years of age with bilateral permanent hearing who were enrolled in a prospective cohort study on developmental outcomes. As part of the study, children received the Leiter International Performance Scale-Revised, which provided a nonverbal Brief IQ, as well as standardized language assessment and behavioral checklists. Children were included in this analysis if they had received an early developmental assessment with the Gesell Developmental Schedules-Revised as part of a clinical visit with a developmental pediatrician. Correlation coefficients and multiple regression analysis were used to associate the scores on the Gesell (using a developmental quotient) with scores on the Leiter-R Brief IQ. RESULTS: Forty-five participants who enrolled in the observational study had available evaluation results from the Gesell and complete Brief IQ results from the Leiter-R. The adaptive domain of the Gesell had good correlation (r = 0.61, p < 0.0001) with the Brief IQ on the Leiter-R. Children who had stable developmental or intelligence classifications based on scores (<70, 70 to <85, 85 to <100, ≥100) over time were older (>24 months) at the early Gesell assessment. Degree of hearing loss or maternal education did not appear to confound the relationship between the Gesell and the Leiter-R. CONCLUSIONS: The adaptive domain of the Gesell Developmental Schedules - Revised administered in early childhood (under 3 years of age) has good correlation with the nonverbal Brief IQ on the Leiter International Performance Scale-R. Because children who are DHH have a higher likelihood of having a developmental disability compared to the general population, early developmental assessments are often important. Although early developmental assessments have their limitations, our results indicate that they are fairly robust indicators of later development. Such early indicators can be extremely useful in the clinical and educational management of children who are DHH.

15 Article Evaluation of Compliance for Treatment of Sudden Hearing Loss: A CHEER Network Study. 2016

Witsell, David L / Khoury, Tawfiq / Schulz, Kristine A / Stachler, Robert / Tucci, Debara L / Wojdyla, Daniel. ·Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA David.witsell@duke.edu. · Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA. · Henry Ford Medical Group, Detroit, Michigan, USA. · Duke Clinical Research Institute, Durham, North Carolina, USA. ·Otolaryngol Head Neck Surg · Pubmed #27371626.

ABSTRACT: OBJECTIVE: The objective of this study is to describe the presentation and management of sudden sensorineural hearing loss for patients seen in academic and community-based practices within the context of the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline: Sudden Hearing Loss." The intention is to use these findings to guide implementation strategies and quality improvement initiatives and as pilot data for the development of clinical research initiatives. STUDY DESIGN: A cross-sectional study of patients with sudden hearing loss. SETTING: Patients were recruited from practices within the Creating Healthcare Excellence through Education and Research (CHEER) network. The CHEER network is an National Institutes of Health-funded network of 30 otolaryngology sites across the country, half of which are community based and half of which are academic practices. SUBJECTS AND METHODS: A total of 173 patients were recruited. Data were gathered via custom questionnaires collected by study site coordinators and entered into a secure online platform. Descriptive analyses and correlation statistics were run with SAS 9.3.1. RESULTS: Of the 13 guideline statements in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's clinical practice guideline on sudden hearing loss, 11 statements were evaluable through this study. Compliance for otolaryngologists was >95% for key action statements (KASs) 1, 3, and 6; 90% to 95% for KASs 5 and 10; and <90% for KASs 7 and 13. Compliance was <45% for nonotolaryngologists for KASs 3 and 5-7. CONCLUSIONS: There is opportunity for nonotolaryngologists to improve for statements 3 and 5-7. Otolaryngologists are compliant with many of the KASs overall, but there is significant room for improvement.

16 Article Bony cochlear nerve canal stenosis and speech discrimination in pediatric unilateral hearing loss. 2015

Purcell, Patricia L / Iwata, Ayaka J / Phillips, Grace S / Paladin, Angelisa M / Sie, Kathleen C Y / Horn, David L. ·Department of Otolaryngology, University Of Washington, Seattle, Washington. · Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan, U.S.A. · Department of Radiology, University Of Washington, Seattle, Washington. · Department of Otolaryngology, Seattle Children's Hospital, Seattle, Washington. · Department of Speech and Hearing Sciences, University Of Washington, Seattle, Washington. ·Laryngoscope · Pubmed #25878020.

ABSTRACT: OBJECTIVES/HYPOTHESIS: To examine the relationship between bony cochlear nerve canal (BCNC) width, degree of hearing loss, and speech discrimination in children with unilateral sensorineural hearing loss (USNHL). STUDY DESIGN: Retrospective chart review (case-control study). METHODS: Audiometric database was cross-referenced with radiologic database at pediatric tertiary care facility to identify children with USNHL and temporal bone computed tomography. BCNC widths were measured independently by two radiologists blinded to affected ear. Regression analyses investigated associations among variables. RESULTS: One hundred and sixty children with USNHL had temporal bone imaging. Mean BCNC width was significantly smaller in affected ears, P = 0.0001. Narrower width was associated with more severe hearing loss, P = 0.01. Among children who had narrower cochlear nerve canals in affected ears compared to unaffected ears, smaller width was associated with lower speech discrimination score, P = 0.03. Increasing asymmetry in BCNC width between affected and unaffected ears was associated with poorer discrimination scores, P = 0.02. Among ears with asymmetrically smaller cochlear nerve canals, a 1-mm reduction in cochlear canal width between the normal and affected ear was associated with 30.4% lower word recognition score percentage in the affected ear, P = < 0.001. CONCLUSION: There is a significant association between BCNC stenosis and impaired speech discrimination, independent of degree of hearing loss. Further investigation is needed to determine whether BCNC stenosis is a poor prognostic factor for auditory rehabilitation.

17 Article Clinical predictors of abnormal magnetic resonance imaging findings in patients with asymmetric sensorineural hearing loss. 2015

Ahsan, Syed F / Standring, Robert / Osborn, Daniel A / Peterson, Ed / Seidman, Michael / Jain, Rajan. ·Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan. · Department of Diagnostic Radiology, Henry Ford Health System, Detroit, Michigan. · Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan. · Department of Radiology, New York University School of Medicine, New York. ·JAMA Otolaryngol Head Neck Surg · Pubmed #25719460.

ABSTRACT: IMPORTANCE: Asymmetric sensorineural hearing loss (ASNHL) is commonly encountered in an otolaryngologic clinical practice. Determining what factors are associated with abnormal magnetic resonance imaging (MRI) findings will help with diagnostic workup. OBJECTIVE: To evaluate the association between clinical and audiometric factors and abnormal MRI findings in patients with ASNHL. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review from an urban, tertiary referral center of 451 patients with ASNHL who underwent MRI testing between January 2005 and December 2011. MAIN OUTCOMES AND MEASURES: Medical records were reviewed for audiometric parameters as well as clinical presentation and compared with MRI results, which were categorized as abnormal, normal, or incidental. Data analysis included χ2 tests, logistic regression analysis, and multivariate analysis. RESULTS: A total of 48 patients (10.6%) had abnormal MRI findings. Only 21 patients (4.7%) had a mass of the cerebellopontine angle/internal auditory canal on MRI, making up 40% of all abnormal MRI findings. The next most common MRI finding was labyrinthitis (n = 13; 25%). Vertigo/dizziness (n = 20; P = .01), tinnitus (n = 18; P = .02), sudden hearing loss (n = 15; P = .054), and 15-dB asymmetry at 3 kHz (n = 39; P = .01) were associated with abnormal MRI findings. Loud noise exposure was associated with normal MRI findings. Logistic regression analysis showed that vertigo/dizziness (odds ratio [OR], 2.14; 95% CI, 1.15-3.96; P = .02), unilateral tinnitus (OR, 2.15; 95% CI, 1.14-4.03; P = .02), and 15-dB asymmetry at 3 kHz (OR, 2.62; 95% CI, 1.24-5.57; P = .01) were significantly associated with abnormal MRI findings. Multivariate analysis showed that only 15-dB asymmetry at 3 kHz (OR, 2.42; 95% CI, 1.07-5.50; P = .03) was significantly associated with an abnormal MRI finding. CONCLUSIONS AND RELEVANCE: This study found that asymmetry of 15 dB at 3 kHz on audiometry was associated with higher positive yield on use of MRI in evaluating patients with ASNHL. We recommend that patients who present with ASNHL with this audiometric characteristic undergo MRI as part of their diagnostic workup.

18 Article Variations in the cochlear implant experience in children with enlarged vestibular aqueduct. 2015

Pritchett, Cedric / Zwolan, Teresa / Huq, Farhan / Phillips, Amanda / Parmar, Hemant / Ibrahim, Mohannad / Thorne, Marc / Telian, Steven. ·Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, Illinois. · Division of Otology-Neurotology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan. · Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan. · University of Michigan Medical School, Ann Arbor, Michigan. · Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan. · Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan, U.S.A. ·Laryngoscope · Pubmed #25647353.

ABSTRACT: OBJECTIVES/HYPOTHESIS: To describe the clinical experience and characterize the outcomes of cochlear implantation (CI) in children with isolated enlarged vestibular aqueduct (IEVA) as compared to children with enlarged vestibular aqueduct (EVA) associated with other bony labyrinth abnormalities. STUDY DESIGN: Single, tertiary care, institutional retrospective review over 2 decades. METHODS: The clinical course and outcomes of 55 children with EVA undergoing CI between 1991 and 2013 were reviewed. Test measures included open and closed set speech perception tests, and various speech and language measures. RESULTS: In 18 children (32.7%), IEVA was the only defect present. In 33 children (60%), EVA occurred concomitantly with incomplete partition type 2 (IP 2) bilaterally, and three children with incomplete partition type 1 bilaterally. Ninety-two percent (51 of 55) occurred bilaterally and had matching bony defects. Mean age of CI was 73.4 months. A statistically significant defect-related and linguistic-status pattern was noted, impacting the timing of implantation: IEVA = 112.8 months, IP 2 = 58.4 months (P < .001), prelingual deafness = 53.8 months, postlingual deafness = 110.8 months (P < .001). Controlling for implant age and hearing loss severity, IEVA children demonstrated superior performance on speech perception tests (8.2 to 20.3 point differences), though statistical significance was inconsistent (P = .01-.40. Performance was also superior in speech and language tests, though statistical significance was never reached (2.9-13.9 point differences; P = .14-.69). CONCLUSIONS: Children with hearing loss secondary to EVA respond meaningfully to cochlear implantation. However, the severity of temporal bone anomalies in these children has clinical relevance. LEVEL OF EVIDENCE: 4.

19 Article Cost of care for subjective tinnitus in relation to patient satisfaction. 2015

Goldstein, Eric / Ho, Chuan-Xing / Hanna, Rania / Elinger, Clara / Yaremchuk, Kathleen L / Seidman, Michael D / Jesse, Michelle T. ·Otolaryngology-Head & Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA ergoldst@med.wayne.edu. · Otolaryngology-Head & Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA. · Otolaryngology-Head & Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA Transplant Institute and Behavioral Health Services (dual appointments), Henry Ford Health System, Detroit, Michigan, USA. ·Otolaryngol Head Neck Surg · Pubmed #25632027.

ABSTRACT: OBJECTIVE: A consistent management algorithm for subjective tinnitus remains to be elucidated. Chronic tinnitus yields approximately US$2110 in annual health care costs per patient. However, it is unclear whether spending more in the management of tinnitus equates with greater patient satisfaction. Thus, the aim of this study is to correlate patient satisfaction with patient demographics, provider recommendations, and total health care-related expenditures. STUDY DESIGN: A retrospective chart review and a patient satisfaction questionnaire. SETTING: All data were collected from a large Midwestern hospital. SUBJECTS AND METHODS: Patients were included who presented to the tinnitus clinic during the year 2011 and were between the ages of 18 and 89 years. They were excluded with diagnoses of Ménière's disease, pulsatile tinnitus, acoustic neuromas, or autoimmune inner ear diseases. The retrospective data and satisfaction surveys were entered by 3 of the authors. Responses were based on Likert scales. RESULTS: Of the 692 patients included, 230 completed and returned the satisfaction questionnaire (33.2% response rate), yielding an overall mean of $662.60 charges. The frequency of intervention recommendations per patients ranged from 0 to 13, with a median of 4. Spearman's correlations did not result in significant correlations between patient satisfaction and number of clinic visits (P=.499) or associated charges (P=.453). CONCLUSION: Given that the variability among provider recommendations, the high overall mean of tinnitus-related charges, and patient satisfaction was not related to costs, further research is needed examining patient preference in the treatment of tinnitus.

20 Article Contralateral hearing loss after vestibular schwannoma excision: a rare complication of neurotologic surgery. 2015

Deeb, Robert H / Rock, Jack P / Seidman, Michael D. ·Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, 2799 West Grand Blvd., Detroit, MI 48202, USA. rdeeb1@hfhs.org. ·Ear Nose Throat J · Pubmed #25606833.

ABSTRACT: We report a rare case of contralateral hearing loss after vestibular schwannoma excision in a 48-year-old man who underwent surgery via a suboccipital approach for removal of a nearly 2-cm lesion involving the right cerebellopontine angle. Postoperatively, the patient awoke with bilateral deafness, confirmed by both audiometry and spontaneous otoacoustic emissions. The patient was treated aggressively with high-dose intravenous steroids, vitamins E and C, and oxygen. Over the next several months he had gradual recovery of most of the hearing in his left (unoperated) ear. Contralateral hearing loss may develop after vestibular schwannoma excision; multiple pathophysiologic mechanisms for this occurrence have been proposed.

21 Article An audiological analysis of stereotactic radiation strategies to preserve hearing in patients with vestibular schwannomas. 2014

Movsas, Shoshana / Hefferly, Michael / Movsas, Benjamin / Shafiro, Valeriy. ·Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, Illinois, USA. · Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan, USA. ·J Radiosurg SBRT · Pubmed #29296380.

ABSTRACT: The purpose of this systematic review was to compare, from an audiological perspective, hearing preservation rates after fractionated stereotactic radiotherapy (FSRT) and stereotactic radiosurgery (SRS) for patients with vestibular schwannomas (VS). A literature review was conducted via Pubmed with the following phrases: radiosurgery, fractionated radiotherapy, vestibular schwannoma and hearing. Of 57 studies identified, six were included in the analysis based on the inclusion and exclusion factors. Tumor control rates were excellent (>90%) for both treatment options. Regarding hearing preservation, three of the six articles reported a significant advantage of FSRT over SRS, while the other three did not find significant differences. The FSRT method may result in higher hearing preservation in selected clinical settings: larger tumors (>3cc), age >55 years, and/or when the SRS dose prescribed was >13 Gy. However, as limitations exist and these studies were not randomized, further studies are needed which incorporate hearing outcomes using enhanced tools. This systematic review can help physicians and patients make more informed decisions regarding radiation treatment options for VS.

22 Article The effect of insomnia on tinnitus. 2014

Miguel, George S / Yaremchuk, Kathleen / Roth, Thomas / Peterson, Ed. ·Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, USA gmiguel1@hfhs.org. · Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, USA. · Department of Pulmonary and Critical Care Medicine, Section of Sleep Medicine, Henry Ford Hospital, Detroit, Michigan, USA. · Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan, USA. ·Ann Otol Rhinol Laryngol · Pubmed #24816421.

ABSTRACT: OBJECTIVE: The objective is to see how chronic tinnitus sufferers who are unmanageable to maximized medical therapy can benefit by decreasing their subjective complaints from a sleep evaluation and treatment. However, the proper identification of these particular patients has not been described well in the literature when attempting to correlate these 2 diagnoses. Thus, tinnitus patients with and without insomnia, based on ICD-9 diagnosis, were evaluated using the Tinnitus Reaction Questionnaire and Insomnia Severity Index to determine correlations between insomnia and tinnitus. METHODS: Patients with a diagnosis of tinnitus and tinnitus along with insomnia who were treated at our institution from 2009 to 2011 were identified. Tinnitus Reaction Questionnaire and Insomnia Severity Index responses were obtained through written and telephone interviews. A Pearson product moment correlation was used to determine the effect of insomnia on tinnitus. Additional analyses identified whether Tinnitus Reaction Questionnaire scores were associated with a possible benefit from an evaluation for insomnia in tinnitus patients. RESULTS: A total of 117 patients met inclusion criteria. A significant correlation was found between the Insomnia Severity Index score and Tinnitus Reaction Questionnaire severity (r = 0.64; P = .001). Tinnitus Reaction Questionnaire severity was shown to be a good predictor of sleep disturbance and good in predicting group association, especially the "emotional" subscore component (sensitivity 96.9% and specificity 55.3% for identifying tinnitus patients with insomnia). The greater the insomnia disability as exhibited by an elevated Insomnia Severity Index score, the more severe the patient's complaints were regarding the tinnitus. CONCLUSION: Results suggest that if the emotional score on the Tinnitus Reaction Questionnaire is ≥ 15, the Insomnia Severity Index may be useful to identify patients who may benefit from further treatment and evaluation of insomnia. The robust correlation between the Tinnitus Reaction Questionnaire and Insomnia Severity Index objectively showed that patients with insomnia have an increased emotional distress associated with their tinnitus. Both questionnaires can be used together with a high degree of specificity and sensitivity in predicting tinnitus patients with an underlying sleep disturbance.

23 Article Hearing aid use among older U.S. adults; the national health and nutrition examination survey, 2005-2006 and 2009-2010. 2014

Bainbridge, Kathleen E / Ramachandran, Virginia. ·1National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland, USA; and 2Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, USA. ·Ear Hear · Pubmed #24521924.

ABSTRACT: OBJECTIVES: The authors estimated the proportion of older adults in the United States who report hearing aid use among those likely to benefit. To more fully understand what factors underlie the low proportion of hearing aid use, the authors examined a variety of socio-demographic correlates as well as measures of health care access and insurance status in relation to hearing aid use among potential hearing aid candidates. DESIGN: The study makes use of cross-sectional data collected during 2005-2006 and 2009-2010 as part of the National Health and Nutrition Examination Survey. The 1636 adults aged 70 years and older were selected by using a complex sampling design and comprise a nationally representative sample. In addition to self-reported hearing aid use, data on pure-tone thresholds, perceived hearing ability, place for routine health care, time since last hearing test, type of insurance coverage, and socio-demographic characteristics including age, sex, race/ethnicity, family size, and income-to-poverty ratio were collected. The analytical sample consisted of 601 adults who had a better-ear pure-tone average of ≥35 dB HL at 500, 1000, and 2000 Hz or who reported moderate or worse hearing ability. RESULTS: One third of the potential hearing aid candidates reported current use of hearing aids. The authors observed a 28 to 66% greater prevalence of hearing aid use among older adults in the upper four fifths of the income-to-poverty distribution compared with those in the bottom one fifth. Compared with people who had their hearing tested 5 to 9 years ago, those with more recent hearing tests were more than two to three times as likely to be a current hearing aid user. No differences were observed by age after adjusting for pure-tone average and no differences were observed by sex after adjusting for perceived hearing ability. No differences were observed by place of routine health care or by type of insurance coverage. CONCLUSIONS: Use of hearing aids is low among older adults who might benefit. Identifying and surmounting barriers to hearing aid use, especially among low-income adults, remains an important objective for hearing health care in the United States.

24 Article Normative data of incus and stapes displacement during middle ear surgery using laser Doppler vibrometry. 2013

Seidman, Michael D / Standring, Robert T / Ahsan, Syed / Marzo, Sam / Shohet, Jack / Lumley, Catherine / Verzal, Kevin. ·*Henry Ford Health System, Department of Otolaryngology-Head and Neck Surgery, Detroit, Michigan; †Loyola University Chicago, Department of Otolaryngology-Head and Neck Surgery, Maywood, Illinois; ‡Shohet Ear Associates, Newport Beach, California; §Wayne State University School of Medicine, Detroit, Michigan; and ∥Envoy Medical Corporation, Saint Paul, Minnesota, U.S.A. ·Otol Neurotol · Pubmed #23928515.

ABSTRACT: OBJECTIVES: To report normative data for incus and stapes motion using laser Doppler vibrometry (LDV) during middle ear surgery and to discuss possible limitations of the procedure. STUDY DESIGN: Institutional review board-approved, retrospective study of data from patients undergoing the Envoy Esteem implantable device at 3 institutions. SETTING: Quaternary referral health system. ELIGIBILITY CRITERIA: patients sucsessfully implanted with an Esteem device. METHODS: Data from 70 patients undergoing the Envoy Esteem procedure were reviewed. Sound at 100 dB and 50 frequencies ranging from 125 to 8,000 Hz were used during the procedure. LDV was performed to measure the displacment of the body of the incus and the posterior crus of the stapes to assess whether there was sufficient ossicular mobility to allow for implantation. RESULTS: The average displacement of the ossicles for all 70 patients was collected and analyzed. The trend was an average displacement around 100 nm from 125 to 500 Hz for both the incus and stapes with a linear decline starting at 1,000 Hz for the incus and 500 Hz for the stapes, with slightly greater displacement of the stapes at higher frequencies. CONCLUSION: This is the first article to report in vivo measures of ossicular mobility. These data help to understand the micromechanics of ossicular motion as well as the use and limitations of LDV. This information may lead to a prescreening process for implanted middle ear devices that function by overdriving the stapes.

25 Article Extensive intracranial calcifications in a patient with a novel polymerase γ-1 mutation. 2013

Sidiropoulos, Christos / Moro, Elena / Lang, Anthony E. ·Morton and Gloria Shulman Movement Disorders Clinic and Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Toronto, Canada. csidiro1@hfhs.org ·Neurology · Pubmed #23836942.

ABSTRACT: A 55-year-old woman presented to our center with an almost lifelong action tremor, associated with peripheral neuropathy, progressive sensorineural hearing loss, and a strong family history of tremor. CT of the brain was notable for extensive intracranial calcifications, much more prominent in the dentate nucleus, cerebellar hemispheres, and midpons, compared to the globus pallidus (figure 1). T1-weighted MRI demonstrated hypointense signal in the aforementioned areas (figure 2). Polymerase gamma-1 (POLG1) gene analysis revealed a novel heterozygous sequence variant at c3239G > c; p.Ser1080Thr. Similar diffuse intracranial calcification can be seen in a variety of disorders including idiopathic basal ganglia calcifications and spinocerebellar ataxia 20.(1) Mitochondrial disorders(2) are a well-recognized cause; however, to our knowledge this is the first time that such extensive intracranial calcium deposits have been described in a patient with a POLG1 mutation.

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