EAONO 2014: Bringing the otology world together

Hundreds of specialists in otology and neuro-otology and members of the European Academy of Otology and Neuro-otology (EAONO) met in Tuscany, Italy, in mid-September for the 7th scientific and technical Instructional Workshop. A highly successful event organized by the current President of the Academy, Franco Trabalzini. Here is our report.

No doubt a truly exciting moment for the members of the European Academy of Otology and Neuro-otology from a wide range of countries to find themselves at the medieval heart of one of Italy’s most culturally and historically rich cities for the 7th edition of the Instructional Workshop of the EAONO, held from September 13 to 16, 2014 in Siena. The President and organizers of the event, Franco Trabalzini, offered a very special moment to the participants showcasing some of Siena’s marvels: starting from the majestic Piazza del Campo with its famous tower, the Torre del Mangia, on a warm and colorful late summer afternoon, with the official opening and the concert by the band of the Carabinieri corps in the historical Teatro dei Rinnovati, and ending with a welcome cocktail in the studding setting of the courtyard of the Palazzo Pubblico. No details were missed either, with a special gift given to each participant: a print of the historic Il Palio horse race held each year in the city, depicting Our Lady in a gold robe and showing the grand squares and architecture of the city, the rights to which were granted by the Siena district of Contrada Capitana dell’Onda for the occasion.

The 7th Instructional Workshop of the European Academy of Otology and Neuro-Otology officially got underway in the lecture halls of the Medical School of Siena University, at the Santa Maria alle Scotte Polytechnic located on a hill just outside the city walls. This was the setting for high-level international experts to discuss the areas of implants, audiovestibular medicine, diagnostics and therapeutics, covering hearing and rehabilitation, hearing loss and neuroplasticity at various ages, and talking in detail about field research, clinical trials, and future directions. New technologies were also given prime position thanks to the presence of the most important manufacturers and distributors of medical equipment and devices, leading hearing solutions, and providers of services for specialist physicians and patients. Also as part of the meeting, the members of the EAONO discussed final recommendations on auditory implants and middle ear surgery, agreed upon at the European level, and that now constitute the current official guidelines of the organization in the area of otology and neuro-otology.

A highly successful interactive event

In terms of scientific content, the numbers speak for themselves: EAONO 2014 included over 500 specialists from all over the world with a rich training program made up of 118 training sessions, 23 round tables, and about 60 communications and posters. For the first time in the history of the European Academy of Otology and Neuro-otology, five guest countries from outside Europe were represented in Siena and shared their scientific and medical experience with the participants: Brazil, Canada, China, Japan, and Russia. The training congress obtained 15 European Union ECMEC credits for professional certification.

“The theme of our workshop is based on the European Guidelines which evaluate the highest quality evidence and most current data about a diagnosis, prognosis, and treatment modality”, explained Franco Trabalzini, current President of the Academy, to the group of colleagues. “Why do we need these guidelines? The first and most important reason is to ensure we continue to improve the care for every patient, placing the patient at the core of everything we do. This then allows us make recommendations through the risk/benefit based evidence and ultimately standardize our clinical practice. Finally but just as importantly, they provide a professional and uniform approach to any consequent medico-legal issues.” he added. Franco Trabalzini is director of the Otology and Skull-Base Surgery unit at the Santa Maria alle Scotte General Hospital. He passed leadership of the organization for the next two-year period to his successor Osman Nuri Özgirgin from Ankara, Turkey at the end of the congress.

The congress participants were able to enjoy a fully interactive event through a specifically dedicated website that included the real-time scientific program. A quick look at the website gives a good idea of the vast range of workshop content on offer, organized as didactic courses, round tables, lectures, free papers, focus groups, and study and working group sessions. The online program gave participants an easy-to-use tool to create their own list of favorites to fully personalize the experience over the congress days. The official EAONO 2014 website also gave access to ePosters and course and round table abstracts that had been sent to the secretary and that can be consulted at any time.

From a hands-on anatomy cadaver workshop, to courses on vertigo, and the future of cochlear implants

Two courses were proposed on the first day of the congress. The first was a hands-on cadaver workshop for otology and the skull base at the San Francesco di Sales ICLO - Anatomy Course Centre in the City of Arezzo, coordinated by Jacques Magnan from France and run by instructors with solid experience such as Daniel Kaplan, Sergey Kosyakov, Dirk Kunst, Jacques Magnan himself, Prepageran Narayanan, Nuri Özgirgin, Ronen Perez, Vlad Ruzovkov, Marcin Szymanski, Franco Trabalzini and Andrzej Zarowski. The second focused on the management of vertigo, and was presented by David Zee, Herman Kingma, Daniele Nuti, Bela Buki, Jose Antonio Lopez Escamez, Augusto Casani, Mans Magnusson, Marco Mandala, Paolo Vannucchi and Rudi Pecci, and chaired by Nuri Özgirgin.

During the opening ceremony at the Teatro dei Rinnovati, lectures were given from the European panel under the title “Standing on the shoulders of Giants” (see picture above), by the President of the Congress, Franco Trabalzini and Honorary President, Gregorio Babighian. A memorial address for Prof. Edoardo Arslan was given by Ettore Cassandro and introduced the speech on auditory neuropathy by Rosamaria Santarelli, a close collaborator of the late Prof. Arslan. The specialist highlighted the existence of three types of lesions, i.e. lesions of auditory or neural nerve fibers, of synapses, and of internal hair cells or receptors. During her presentation, she mentioned that infants admitted to neonatal intensive care units are at a higher risk of hearing loss, referring to incidence data between +1.5% and +3.2%, since a percentage of about 5.6% of those who do not pass hearing screening in this department present abnormal ABR results and otoacoustic emissions consistent with an electrophysiological profile of auditory neuropathy, and that post-mortem examination of the temporal bone of neonates who died shows extensive damage to hair cells, with a higher frequency of selective loss of internal ciliated cells in premature infants versus those born at term.

Later, an interesting study was presented by Bruce Gantz from the USA on the future of cochlear implants. It examined the area of acoustic and electric signal processing and trying to understand how much has been learned in the last 15 years about the auditory system. More than 1500 adults with postlingual deafness have been studied at the University of Iowa, USA, since the 1980s in the area of speech recognition. Results showed a constant increase in performance over time thanks to hybrid electric acoustic stimulation. According to Gantz, the benefits of cochlear implants are found in restoration of significant hearing in quiet environments, while in noise there are the same problems as with hearing aids. In addition, they do not provide good quality of sound or music, and the implant may entail the loss of residual hearing. It is also important to remember that low frequency residual hearing maintains better spectral resolution of vocal processing by the cochlear implant. So, what is the future of cochlear implants? How can we guarantee better performance? The answer Bruce Gantz gave was the hypothesis of speech processing to provide temporal fine structure, regeneration of the auditory neural environment and/or hair cells, and other novel electrodes and strategies. He considered that the next change will consist in extending the indications of for electric acoustic stimulation processing with electrodes that better preserve hearing.

In this area, Gantz was referring to functional hearing, i.e. above 85-90 dB in low frequencies that can be amplified with hearing aids, otherwise this would not be useful. Moreover, a number of cited studies have demonstrated that preservation of minimal acoustic hearing does not enhance electric-only speech processing. Gantz presented the results of clinical trials conducted in the United States pointing to the benefits of preserving residual hearing. In conclusion, in his opinion, the future of cochlear implants will require a few adjustments. First, the need for a more robust internal part than what has been used previously, improved preservation of residual hearing in order to improve speech recognition in noise, recognition of music and melody, sound quality, and the ability to locate sound. Second, there is also a need to remember that the central auditory system can reorganize peripheral place pitch if sufficient residual neural environment present to accommodate to shorter electrodes. Third, the need to understand hearing loss following activation of the device (excitotoxicity, trauma, fibrosis) and long-term stability of residual acoustic hearing with a hybrid device. Fourth, selection of electrode lengths; in the future, they may depend on the duration of deafness, patient age, level of preoperation hearing with sufficient neural substrate, and benefit/risk evaluation. Lastly, in the future, selection criteria will include subjects with substantial hearing, and the length of the device will depend on residual hearing, possibly 1.500 Hz and the duration of deafness.

The speech thus outlined the future direction of cochlear implant medicine, at least from the perspective of specialists from across the Atlantic. A fundamental concept is the fact that functional acoustic hearing can be maintained in most subjects with electrodes to preserve hearing in the initial activation phase, up to 93%. A percentage between 16% and 51% of patients lose functional hearing over time, most after activation. Therefore, we should remember that shorter electrodes involve higher rates of preservation over time and that as a result it is particularly important to evaluate the benefit/risk ratio and the choice of the custom-made implant. In addition, it should be emphasized that functional acoustic hearing and high perception points in speech can be maintained for more than a decade using electric acoustic stimulation. Also, it is important to note that selecting the length of the electrode must depend on the duration of deafness at high frequencies, on thresholds at middle frequencies and the benefit/risk of functional hearing. If in the future, it is possible to preserve functional hearing equal to 95%, Gantz concluded, electric acoustic stimulation could be extended to patients with presbycusis.

Innovations at EAONO 2014

The EAONO 2014 event will be remembered as an edition with major technical and scientific innovations. Here’s a short review of some of them.

The most significant and remarkable innovation that is likely to change the lives of cochlear implant wearers is a hearing device enabling the user to undergo magnetic resonance imaging, a diagnostic technique that is more and more widely used to detect a growing number of disorder and that was until now contraindicated in patients with implants, unless the aid was removed. A cochlear implant is indicated for severe to profound cochlear deafness. New much smaller devices compared to a few years ago and that have an external part that is now a small disk of two centimeters in diameter applied to the skin, provide stimulation that is increasingly close to normal levels. And the surgery required has become less and less invasive over the years, now requiring hospitalization of just one day.

One of the topics that most interested otology and neuro-otology specialists was brain plasticity, i.e. the ability of the brain to change its own structure, to adapt to stimuli from the environment or to compensate for damage to certain areas. According to the Franco Trabalzini, “thanks to this, it is possible to recover the sense of hearing with application of a device or cochlear implant. When sensory input is restored early through an artificial organ of sense, central sensory pathways are once again stimulated and trained, and both connections within the sensory area and connections with other associated areas are newly reactivated. For people with profound hearing loss that occurred congenitally, this could mean rehabilitation to a life of nearly normal communication”.

In school without a special teacher: a dream or a possible reality? This is the aim that otology science has given itself to improve the lives of children with hearing loss. In pediatric patients in particular, auditory defects that are not diagnosed and treated early irreversibly alter processes of language acquisition and development, significantly hindering verbal communication with serious consequences on cognitive, mental, motor and social development. If hypoacusis is persistent, even when it is mild to moderate or unilateral, can result in difficulty hearing in noise, for instance in a classroom setting, and in localizing the source of sounds. Just think about how important this ability is simply to cross the street safely. Often, diagnosis of this less obvious form of hearing loss is delayed and a sign may be reduced performance at school. “Thanks to rehabilitation based on hearing aids and cochlear implants,” says Trabalzini “our current objective is to enable development of hearing and language abilities in order to allow entry of children with hearing impairment into primary education along with normal-hearing children, and without support.”

During the 7th Instructional Workshop of EAONO, the experts also looked into the latest research that has not yet been applied clinically regarding use of stem cells for neurosensory disturbances and possible use in receptors that stimulate nerve cells.

Lastly, intratympanic drugs that are always administered by physicians are the new frontier to treat some types of cochlear hypoacusis and also certain vertigo syndromes. They are administered directly into the middle ear to reduce systemic adverse effects and to increase local therapeutic efficacy.

Claudia Patrone, editor in chief of Audiology Infos Italy

Photos: C.P.