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442 Disorders of the Auditory System
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The exact time course and devel­opment of polymicrogyria insult is not known. Given that normal gyration of a smooth fetal brain occurs between 21 and 28 weeks gestation (Squier & Jansen,
2014), researchers speculate that the time course of insult can be inferred from the layering patterns of the polymicrogyria. Unlayered polymicrogyria is thought to be an “early” insult that occurs at 18 to 24 weeks gestation. This is characterized by a microscopic band that encompasses, but does not fuse, adjacent microgyria surfaces. This also results in clefts being formed between small microgyria (Barth, 1987; Squier & Jansen, 2014). Layered polymicrogyria occurs later in develop­ment, after 24 weeks gestation, and is characterized by a microscopic layer that fuses the small microgyria together and appears in conjunction with a “festooned” cortical surface (Judkins, Martinez, Fer­reira, Dobyns, & Golden, 2011; Squier & Jansen, 2014).
Agenesis of the Corpus Callosum
A discussion of malformations of the cen­tral auditory nervous system should not occur without mention of agenesis of the corpus callosum. Agenesis of the corpus callosum reportedly occurs in 1 in 4,000 live births (Paul et al., 2007). It is a rare congenital condition that can be inherited as an X-linked or autosomal recessive trait or as the result of an intrauterine infection or injury that occurs at or around the 12th gestational week (National Organiza­tion for Rare Disorders, 2007; Palmer & Mowat, 2014). This disorder is character­ized by partial or complete absence of the corpus callosum. The corpus callosum is responsible for connecting the left and right cerebral hemispheres and transfer­ring information from one side of the
brain to the other. Individuals with callo­sal agenesis do not show the same level of disconnection symptoms and test findings as do split-brain patients, who typically show severe left ear deficits on dichotic speech tests and bilateral deficits on pat­tern sequencing tasks if a verbal response is required. The degree of neurodevelop­mental problems that result from corpus callosum agenesis can be highly variable and depends on the amount of collateral involvement of other parts of the brain. In some cases, the developmental delays can result in marked sensory, cognitive, and/ or motor problems. However, in cases where only the corpus callosum is dis­connected or partially disconnected and there is no involvement of other parts of the brain, the neurologic and related defi­cits can be minimal. In these cases, the symptoms can be so subtle that they may go unnoticed and central auditory testing (if completed) may not yield the lateral­ity findings for dichotic tasks or the bilat­eral pattern processing deficits mentioned previously that are commonly observed in split-brain patients (Paul et al., 2007; Bryden & Zurif, 1970; Musiek & Baran, 2020; Sotiriadis & Makrydimas, 2012). These cases speak to the amazing ability of the brain to reorganize. Even in cases of severe congenital malformations, such as in the case of corpus callosum agen­esis, the brain has the ability to exploit its innate plasticity abilities.
New knowledge regarding the ge­netic basis for various congenital brain malformations is rapidly advancing. While there is limited information regard­ing the specific impact of such malforma­tions on “central auditory function,” there are likely significant implications given the sites of involvement for many of these malformations. As new knowledge is gained regarding congenital malforma-
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tions and their genetic basis, hopefully we will observe significant advances in our understanding of the impact of such disorders on auditory function.
genetic evaluation
and
fo
Genetic evaluation and counseling are critical components in the identification and management of individuals with hearing loss. According to the American College of Medical Genetics and Genom­ics (Alford et al., 2014), every individual identified with congenital hearing loss should undergo a genetic evaluation. It is important to delineate the difference between a genetic evaluation and genetic counseling, as they each have separate functions. A genetic evaluation is a medi­cal evaluation performed by a trained clinical geneticist, which may or may not result in a diagnosis of a genetic condition. The diagnosis would depend on the out­come of the evaluation conducted. Only a geneticist is qualified to make the clinical diagnosis of a genetic disorder.
The genetic counselor is a professional with specialized training in counseling individuals about genetic disorders, but these professionals do not make genetic diagnoses. The genetic counselor, like the geneticist, has many key roles in patient care. These professionals provide educa­tion, guide decision making, provide sup­port to the patient and/or the family, and make appropriate referrals when neces­sary. They are also often involved in coun­seling families with respect to the prob­ability that a genetic trait was inherited, as well as what the probability is that the individual may pass an inherited genetic
counseling
R heaRing loss
trait to any offspring (Alford et al., 2014; Ciarleglio, Bennett, Williamson, Mandell, & Marks, 2003).
Genetic Evaluation
The genetic evaluation requires a multi­tiered approach that typically includes obtaining the patient’s history, complet­ing a comprehensive diagnostic evalua­tion, counseling the patient (or his or her parents or legal guardians if the patient is a minor), and recommending interven­tions and/or referrals to other specialists when necessary. The initial genetic evalu­ation begins with a detailed history that has a special focus on the occurrence of genetic conditions in the patient’s fam­ily, the patient’s risk factors for a genetic condition, and a comprehensive physi­cal examination (Alford et al., 2014). This is particularly important because early detection can decrease the chance of morbidities and mortalities that may be associated with some genetic conditions (Cooke-Hubley & Maddalena, 2011).
A detailed medical history is the foundation for all genetic evaluations. The evaluation should specifically include a review of the patient’s pedigree to deter­mine the likelihood of an inherited syn­dromic or nonsyndromic condition, a consideration of the patient’s ethnicity and country of origin, and a review of any audiometric evidence of hearing loss, as well as of any evidence or documen­tation of vestibular involvement and/or other associated syndromic features. Also, medical evaluation for comorbid condi­tions such as cardiac, vision, and renal impairments should be pursued (Alford et al., 2014). The pedigree is a component of the evaluation that deserves special attention. The pedigree can be defined as
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a chart or diagram which demonstrates the occurrence of the particular trait of interest (i.e., hearing loss). The geneticist or the genetic counselor will draw a fam­ily pedigree that covers three or more gen­erations of the family, showing relatives with hearing loss along the lineage. In addition, they will also note any history or other significant findings that may sug­gest disorders, traits, or conditions that are associated with a syndromic disor­der (e.g., the presence of heart conditions along with hearing loss, which may sug­gest CHARGE syndrome). The pedigree is carefully examined to find evidence that suggests the presence of an inherited trait and the probable inheritance pattern if a family pedigree is consistent with a genetic etiology.
In addition to careful analysis of the patient’s pedigree, the geneticist will eval­uate the patient in order to determine if the hearing loss may be associated with a specific syndrome. This is accomplished through either physical examination and/ or a detailed history of the various systems (visual, endocrine, cardiac, renal). Patients are examined for visual involvement such as retinitis pigmentosa, which is associ­ated with Usher syndrome. Additionally, the patient and family members may be examined for dysmorphic features as well as anomalies, such as preauricular pits or aural atresia. Patients are also examined for signs and symptoms that may include the endocrine, cardiac, and renal systems. Finally, careful attention should be paid to other integumentary changes (e.g., abnormal pigmentation, white forelocks, etc.), as such findings during the physi­cal examination of the patient could point to certain syndromes or diseases (e.g., a white forelock in Waardenburg syndrome or preauricular pits in branchiootorenal syndrome).
There are several important elements that should be taken into consideration with respect to the physical examination of the patient. Patients should undergo audiologic and neurologic examinations. In addition, they should have an otologic examination with emphasis on the evalu­ation of the airway and documentation of any dysmorphic features. Additional risk factors for hearing loss should be consid­ered, including meningitis, hypoxia, oto­toxic exposure, prenatal alcohol exposure, extracorporeal membrane oxygenation (use of an artificial lung machine), and intrauterine infections (cytomegalovirus, rubella, etc.). Such findings in the medi­cal history and/or evaluation may help to establish a nongenetic basis for the hear­ing loss (e.g., meningitis or cytomegalovi­rus infection, injury, or prenatal maternal infection).
As outlined in the American College of Medical Genetics and Genomics Guide­line for the Clinical Evaluation and Etio­logic Diagnosis of Hearing Loss (Alford et al., 2014), the following triage/testing paradigm is recommended when evaluat­ing a patient who is at risk for a genetic hearing loss (the following is a brief sum­mary of the information presented in this guideline and additional details for each of the following steps can, and should, be accessed from the original publication):
I. All newborns with confirmed
hearing loss should undergo a comprehensive evaluation including the following
Medical and birth history A three-generation pedigree
and family history analysis and evaluation
Physical examination focusing on
dysmorphic and other physical findings
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II. If syndromic hearing loss is
suspected
Pretest genetic counseling, and
with informed consent, genetic testing
Ordering of appropriate studies
to determine if other organs are involved
Appropriate near-term and
far-term screenings and manage­ment, including referrals to specialists as indicated
III. If physical findings of a syndromic
hearing loss are lacking and birth and medical records do not suggest an environmental or nongenetic cause of the hearing loss, a tiered testing approach is indicated
Pretest genetic counseling, and
with informed consent, genetic testing
Temporal bone imaging CMV testing
IV. Referral to multidisciplinary center,
if available, is recommended for optimal ongoing management of the patient
V. Regardless of genetic test results,
findings of the evaluation(s) should be communicated through genetic counseling
The guideline additionally indicates that the evaluation of children and young adults with hearing loss should follow a similar approach, and that evaluation of older adults with hearing loss be cus­tomized based on the age of onset and the characteristics of the hearing loss (see Alford et al., 2014).
Whenever there is the possibility of a genetic etiology of hearing loss, a clinical genetic evaluation is beneficial to deter­mine the cause of hearing loss regardless of the age of the patient (Alford et al.,
2014). The geneticist will determine if the hearing loss is genetic or whether it is a result of other causes like infections, head trauma, and so forth. If the hearing loss is found to be genetic, the geneticist will also be able to identify whether it is due to a syndromic or nonsyndromic etiology. Once that is determined, then the mode of inheritance (autosomal dominant, auto­somal recessive, X-linked, mitochondrial, or multifactorial) is studied. Depending on the findings, the patient’s spouse, par­ents, and siblings are frequently encour­aged to have an audiologic evaluation and may also be asked to undergo genetic testing. The geneticist will often work in conjunction with the genetic counselor to provide a multitiered approach to evalu­ation and management of these patients. The current standard of care in genetic testing for hearing loss now also includes multigene hearing loss panel testing. Multigene panel testing has been a sig­nificant advance in genetic testing due to its ability to simultaneously test multiple genes rather than routinely using single­gene tests, which are typically ordered and completed sequentially and can be expensive and delay identification of the basis for a hearing loss (Wallace & Bean,
2018). There are two types of multigene panels available: (1) off-the-shelf panels and (2) custom-designed panels. Off-the­shelf panels are designed to test for genes that are found to be commonly associated with broad phenotypes (e.g., ataxia, hear­ing loss, etc.). Custom-designed panels allow the clinician to select specific genes for analysis. Of utmost importance is for the professional who is not a geneticist to refer to a genetics specialist who will have a comprehensive knowledge of what tests are appropriate, efficient, and available to aid in the diagnostic process. For additional information on gene sequencing options
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and evaluation strategies, the reader is referred to Shearer et al. (2017).
Genetic Counseling
Genetic counselors are health profes­sionals with degrees in medical genetics and counseling. As outlined by the 2006 National Society of Genetic Counselors’ Task Force (Resta et al., 2006), these pro­fessionals are trained to assist families in understanding the “medical, psychologi­cal, and familial implications of genetic contributions of a disease.” Genetic coun­seling is an important resource for patients and their families throughout the genetic evaluation process. Once reserved for high-risk patients, genetic counseling has become a routine part of many aspects of medicine. The role of genetic counselors is to assist with interpretation of family medical histories and assess the likelihood of disease occurrence (or recurrence). In addition, they provide the framework for education regarding inheritance, testing, prevention, and management of genetic disorders (Arnos, Welch, & Pandya, 2013; Resta et al., 2006).
At the outset, it must be stressed that genetic counseling should be “nondirec­tive.” In other words, it is recommended that it be supportive and informative, but it should not prescribe the steps that the individual and/or the family should take. The purpose of genetic evaluation and counseling is to answer the various ques­tions that may arise about how genetic factors could cause hearing loss and other conditions (e.g., in the case of syndromic hearing losses) and the risk of the hearing loss (and other conditions, if they exist) to worsen or progress with time. It is also to ensure that the family understands the results of the genetic evaluation. A com-
mon question addressed during genetic counseling is, “What is the probability that the genetic condition could be passed down to offspring if a couple mates?”
After completion of the genetic eval­uation, a meeting is held with the pro­band and other family members (at the proband’s request) to explain the find­ings. The findings may reveal whether the hearing loss is genetic in nature and, if so, its mode of inheritance. If a syndrome is detected, then the physical and medi­cal features are described. In other cases, the cause of the hearing loss may not be found; however, the possibility exists that it may still be genetic.
The most common genetic cause in such a case is an autosomal recessive eti­ology where each normally hearing par­ent has an unknown mutation in one of the two alleles of a gene, and the affected person has inherited these two mutations, which results in hearing loss. The prob­ability of this occurring is 25% with each pregnancy. The chance for the affected person to have children with hearing loss is small (i.e., unless they marry someone with the same recessive gene for hearing loss or who has a dominant form of hear­ing loss).
Another possible pattern that may be observed is that the person with hear­ing loss may have a dominant gene that is new to him or her (or modified by a new mutation). In this case, the chance that this person will have a child with the same hearing loss is 50%. If the hearing loss is in a male, then it is possible that this hearing loss is due to a recessive X-linked mode of inheritance. In this case, the son would have inherited this gene from his mother. If the cause of hearing loss remains unknown, an estimated risk is calculated based on studies involving families with similar histories. Therefore,
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if a couple presents with normal hearing and has one child with profound deaf­ness, then their chance of having another deaf child is 10%. If both parents are deaf (and have unknown genetic histories/ information), then their chance of having a deaf first child is 10%.
The previously outlined analysis of inheritance patterns are only a few exam­ples of the counseling issues that genetic counselors encounter and about which they educate patients and their families on a daily basis. The information and support they provide to patients with hearing loss and their families are critical to the care and well-being of the patient. As a result, they play a critical role in the overall man­agement of patients with hearing loss, making them an integral part of the health care team. (For additional information on genetic counseling, see Alford et al., 2014, and Arnos et al., 2013.)
summaRy
Genetics, heredity, and congenital hear­ing loss are complex topics that are dif­ficult to overview. This chapter has pro­vided the reader with an overview of the more common genetic manifestations of hearing loss, however, an exhaustive dis­cussion of all the genes associated with hearing loss are beyond the scope of this chapter. Resources for additional infor­mation have been provided that we hope will the reader will find useful. While significant strides have been made in the identification of deafness/hearing loss­related genes, it is inevitable that there are many more genes to be uncovered and much more knowledge to be gained regarding the role these genes play in hearing. The future is likely to hold many
exciting new revelations and discoveries in not only identifying additional genes associated with hearing loss, but also in the development of effective gene thera­pies as well.
Genetic evaluation and counsel­ing have become an important part of the identification, treatment, and man­agement of individuals with hearing impairment. As genetic testing becomes even more highly integrated into audio­logic and otologic practices, so will the need for the support of geneticists and genetic counselors. The role of genetics in the identification, treatment, and man­agement of hearing loss is one that has become highly important to patients and their families, as well as to audiologists and other health care professionals.
Acknowledgments. The authors grate-
fully acknowledge the contributions of Kathleen Arnos, PhD, Retired Professor of Biology, Department of Science, Technol­ogy, and Mathematics, Gallaudet Univer­sity, Washington, D.C. and Abbas Younes, MD, Otolaryngologist, for their contribu­tions to this chapter.
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