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ACTA OTOLARYNGOLOGICA

Head injury and prolonged bed rest, but not inner ear disease, predict poorer outcome after Epley manoeuvre in posterior semicircular canal benign paroxysmal positional vertgo (P-BPPV)
Reviewed by: Victoria Possamai
September/October 2014 (Vol 23 No 4)
 

This Japanese study included 197 patients with P-BPPV treated over a two and a half year period. The vast majority had idiopathic BPPV (n=157). The remaining 40 had secondary BPPV, eight following head trauma, 14 due to prolonged bed rest and 18 related to inner ear disease, including sudden sensorineural deafness, Ménière’s disease and vestibular neuritis. A single Epley manoeuvre was performed by the same therapist in all patients, and patients were followed up weekly with repeat Epley manoeuvre to assess response. Comparing response at seven days, there was 73% resolution in the idiopathic group, 56% in the inner ear group (no significant difference), 25% in the head trauma group and 36% in the bed rest group (both statistically significant). The study then assessed resolution over the longer term with helpful Kaplan Meier curves to demonstrate that again there was no significant difference in resolution rates between the idiopathic and inner ear groups at one and three months post Epley manoeuvre, but significantly lower rates of resolution at these intervals in the head trauma and bed rest groups. In all groups the majority of patients had resolution by three months. This was poorest in the head trauma group with 25% of patients still unresolved, whereas for the three other groups this was less than 10%. One must bear in mind the small numbers of patients in each of the secondary BPPV groups when considering the strength of the conclusions, however this study certainly adds weight to the notion that idiopathic P-BPPV has a better outcome than that secondary to a separate pathology. The authors hypothesise regarding the possible mechanism of deposition of otoconial debris to explain their observations.

Reference

Risk factors for poor outcome of a single Epley maneuver and residual positional vertigo in patients with benign paroxysmal positional vertigo.
Sato G, Sekine K, Matsuda K, Tadeka N.
ACTA OTOLARYNGOLOGICA
2013;133(11):1124-27.

ALLERGY

Is there a cause-and-effect relationship between allergic rhinitis and chronic rhinosinusitis?
Reviewed by: Evangelia Tsakiropoulou
September/October 2014 (Vol 23 No 4)
 

This review examines the possible causative relationship between allergic rhinitis (AR) and chronic rhinosinusitis (CRS) that has long been proposed. Many observational and experimental studies exist, however no clear and definitive connection has been established. This is mainly due to great diversity in study methodology. For this reason, the authors applied the revised Bradford-Hill guidelines to relevant studies, aiming to answer the question “is AR a predisposing factor for CRS?”. Despite the ‘unified airway’ concept, multiple pathophysiologic mechanisms seem to be involved that are not common in both clinical entities. This review identifies that there is a lack of consistency in the terms used to define AR and CRS, which undermines the strength of the association. The authors conclude that no clear and definitive causal relationship can be established, especially in children. It is also suggested that any CRS patient with uncontrolled symptoms should be evaluated for underlying allergies. The authors appropriately reinforce this principle, also supported by the Joint Task Force on Practice Parameters (JTFPP) document, Clinical Practice Guideline: Adult Sinusitis (CPG:AS), The British Society for Allergy & Clinical Immunology (BSACI) and European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) guidelines.

Reference

Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation.
Georgalas C, Vlastos I, Picavet V, et al.
ALLERGY
2014;69(7):828-33.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Evidence and nasal polyp treatments
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

The change in the routine management of nasal polyps in the past 2-3 decades has been fascinating and this review from Charleston covers the topics of systemic treatment, local treatment, perioperative treatment and immunotherapy and touches on the lower airway effects. Few would disagree with the statement ‘aggressive medical and surgical treatment of CRSwNPs (chronic rhinosinusitis with nasal polyps) improves asthma outcomes’, but it deserves repetition. Otolaryngologists would be particularly interested in topical steroid delivery methods such as bioresorbable materials and we are reminded that ‘topical antibiotic use for CRSwNPs is not currently supported by evidence. We are informed that ‘macrolides and doxycycline have anti-inflammatory effects and macrolides also have mucolytic and anti-biofilm properties. Thus it is difficult to attribute any benefit solely to antimicrobial characteristics.’ This is an article for all rhinologists to read. I would be surprised if something here is not new to a reader.

Reference

Evidence-based treatment of chronic rhinosinusitis with nasal polyps.
Schlosser RJ, Soler ZM.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(6):461-66.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Improving smell outcomes after sinus surgery: impregnated dressings?
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

There is much we can do to improve the airway of patients with chronic sinus disease, especially those with polyps. However, the olfactory outcomes are usually disappointing and patients miss this important sensory modality, which has an effect on their quality of life. These authors report a study in which a gelatin dressing was placed high in the nose, as close as possible to the olfactory epithelium, at the conclusion of sinus surgery. The gelatin had been impregnated with triamcinolone. The 60 patients were divided into two groups, one of which did not receive the triamcinolone. The outcome for smell was good in the treated group, but follow-up was only 8 weeks. While this is gratifying, it is the long-term effect that is demoralising for this group of patients and I would be surprised if this short-term gain was translated into a superior long-term gain.

Reference

The effect of an absorbable gelatin dressing impregnated with triamcinolone within the olfactory cleft on polypoid
rhinosinusitis smell disorders.
Bardaranfar MH, Ranjbar Z, Dadgarnia MH, et al.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;28(2):172-75.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

What do we put in our nasal douches? Anything?
Reviewed by: Edward W Fisher
September/October 2014 (Vol 23 No 4)
 

The rise of the popularity of saline nasal douches, with several commercial preparations available, may be a rediscovery of an age-old tradition, but it has been shown to benefit patients. The question then arises as to whether this can be improved by adding in various medications, especially in recalcitrant cases of chronic rhinosinusitis (CRS) in patients who perhaps have had several operations. This paper pulls together information on anti-infective additives (rather than corticosteroid or anti-inflammatory additives), which include topical antibiotics (e.g. mupirocin, gentamicin, tobramycin), topical antifungals and ‘additives’ which include surfactants, xylitol, manuka honey and N-Chlorotaurine (an antiseptic). The overall message is that such additives are not part of the routine management of standard CRS patients, but should be reserved for recalcitrant cases, but that research is weak on most of these categories (apart from antibiotics). The evidence on antifungals is particularly weak and these are not recommended. Clearly, there is a long way to go before we have enough evidence to recommend use of these categories of additives to douches with a good evidence base, except for antibiotics and, even in those cases, there are many unanswered questions (dose, risk-benefit balance, outcomes, case selection, etc).

Reference

Topical anti-infective sinonasal irrigations: update and
literature review.
Lee JT, Chiu AG.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;28(1):29-38.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Consequences of tonsillectomy rationing?
Reviewed by: Thomas Jacques
September/October 2014 (Vol 23 No 4)
 

This article examines Hospital Episode Statistics and Office for National Statistics data to investigate the change in rates of tonsillectomy and admissions for tonsillitis and its complications, over a 20-year period. Between 1991 and 2011, 44% fewer tonsillectomies were performed. This was accompanied by a 310% increase in admissions for tonsillitis. Admissions for retropharyngeal and parapharyngeal abscesses rose by 39% between 1996 and 2011. The trends were most pronounced in paediatric patients. It was identified that ‘Procedures of Limited Clinical Effectiveness’ guidance varies regionally by clinical commissioning group (CCG), with some adhering to Scottish Intercollegiate Guidelines Network (SIGN) guidelines, and others being more stringent. The authors rightly state that these data cannot imply causation, and are subject to some limitations in terms of accuracy. However it is likely that they represent sobering evidence of the erroneous economic and clinical logic behind surgical rationing. Whilst the authors caution that a return to historical rates of tonsillectomy is not desirable, they conclude that deliberate disregard of the evidence for the efficacy of tonsillectomy, in the pursuit of monetary savings alone, may be endangering patients.

Reference

The rising rate of admissions for tonsillitis and neck space abscesses in England, 1991-2011.
Lau AS, Upile NS, Wilkie MD, et al.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(4):307-10.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

Trends in parathyroidectomy
Reviewed by: Thomas Jacques
September/October 2014 (Vol 23 No 4)
 

he authors retrospectively analysed Hospital Episode Statistics data for parathyroidectomy between 2000 and 2010. Overall, parathyroidectomy rates nearly doubled from 3.3/100,000 population in 2000 to 5.8/100,000 in 2010, with particularly significant increases in elderly patients. The authors attribute this rise to the development of standardised endocrinological guidelines indicating surgery in asymptomatic hypercalcaemia, and an increasing life expectancy. Improvements in pre-operative localisation have also led to an increase in minimally-invasive parathyroidectomy, allowing shorter anaesthetic times, or even surgery under local anaesthesia. The data may not apply to surgery for secondary or tertiary hyperparathyroidism (HPT), but the authors point out that the most recent British Association of Endocrine and Thyroid Surgeons (BAETS) audit shows that around 90% of surgery is performed for primary HPT. The authors’ conclusions do rely on inference, but the reasoning is very plausible and an interesting insight. They reflect that the changes mirror a more general trend, whereby improvements in diagnostic and surgical technology tend to expand the indications for surgical procedures.

Reference

A decade of change in the uptake of parathyroidectomy in England and Wales.
Evans LM, Owens D, Scott-Coombes DM, Stechman MJ.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2014;96(5):339-42.

BMC EAR, NOSE AND THROAT DISORDERS

3D ultrasonography for evaluation of muscles following facial palsy
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Reconstructive surgery for facial nerve palsies is not recommended beyond two to three years after a degenerative facial nerve lesion. Since the time course of muscle atrophy is variable, this timeline is a rough guideline. The only assessment method currently used is needle electromyography (EMG). This paper describes a fast, non-invasive, and reliable method to evaluate the condition of the facial muscles and the degree of atrophy. The authors used a 3D ultrasonographic (US) acquisition system driven by a motorised linear mover combined with conventional US probe to acquire 3D data sets of several facial muscles on both sides of the face in a healthy subject and in seven patients with different types of unilateral degenerative facial nerve lesions. The US results were correlated to the duration of palsy and the EMG results. The facial muscles on the side of the paralysis, with the exception of the frontal muscle, were much smaller than on the healthy side in patients with severe facial nerve injuries. This new 3D ultrasonographic tool seems to be a promising innovation for the quantitative evaluation of facial muscles in patients considering reconstructive surgery or conservative treatment.

Reference

3D-Ultrasonography for evaluation of facial muscles in patients with chronic facial palsy or defective healing: a pilot study.
Volk GF, Pohlmann M, Finkensieper M, et al.
BMC EAR, NOSE AND THROAT DISORDERS
2014;14(4):2-8.

BMC NEUROLOGY

Head and neck radiation and the brain
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

An increasing number of patients with head and neck squamous cell carcinoma and other lesions are treated with high dose radiotherapy. An increase in survival rates is being reported along with a younger patient demographic. The long-term effects of treatment on the carotid arteries and hence cerebral function are not well recognised. The authors followed 103 patients undergoing head and neck irradiation for a variety of lesions for more than five years. Baseline protocol (before radiotherapy) included screening for cerebrovascular risk factors and intima media thickness measurement of carotid arteries by ultrasonography. Follow-up assessment after radiotherapy included screening for cerebrovascular risk factors, cerebrovascular events, neurological examination with gait and balance tests, extensive neuropsychological examination, self-reported questionnaires, ultrasonography of the carotid arteries with measurement of intima media thickness and elastography, magnetic resonance imaging of the brain and magnetic resonance angiography of the carotid arteries. The final results are not yet published but the mere amount of data is likely to improve our understanding of the causes and consequences of long-term cerebral and vascular changes after radiotherapy of the neck. These data will be helpful to develop a protocol for accurate diagnosis and aid preventive strategies to avoid long-term neurological complications in patients undergoing radiotherapy treatment

Reference

Long term cerebral and vascular complications after irradiation of the neck in head and neck cancer patients: a prospective cohort study: study rationale and protocol.
Wilbers J, Kappelle AC, Kessels PCR, et al.
BMC NEUROLOGY
2014;14:132.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Is it time for cone-beam CTs to replace the traditional orthopantomogram in the primary diagnosis of temporomandibular joint disorders?
Reviewed by: Sampath Chandra Prasad
September/October 2014 (Vol 23 No 4)
 

Cone-beam CT requires a lower dose of radiation compared to the multidetector CT and provides much more detailed information in 3D about the bony structures of the temporomandibular joint (TMJ) when compared to the traditional orthopantomogram (OPG). In this article the authors assess the value of cone-beam computed tomographic (CT) images in the primary diagnosis and management of 128 outpatients with disorders of the temporomandibular joint (TMJ). After clinical examination, an assessment of the cone-beam CT images was made and the oral and maxillofacial surgeon was allowed to revise the provisional primary diagnosis and management. The degree of certainty was rated by the clinician before and after the cone-beam CT had been assessed. The primary diagnosis was changed in 32 patients (25%), additional diagnostic procedures were changed in 57 (45%), and the treatment was changed in 15 (12%). In 4/15, the treatment was changed to a (minimally) invasive procedure. A total of 74 patients (58%) had their diagnosis and management changed after the cone-beam CT had been assessed. Changes in diagnosis and management were clinically relevant in 9/32 and 9/61 patients, respectively. The clinician’s certainty about the primary diagnosis increased after the cone-beam CT had been assessed in 57 patients. Logistic regression analysis showed that the odds in favour of changes in primary diagnosis and management increased when limited mandibular function was a primary symptom, the patient was taking medication for pain, and the articular eminence could not be assessed on OPG. Assessment of cone-beam CT led to changes in primary diagnosis and management in more than half the patients with disorders of the TMJ.

Reference

Value of cone-beam computed tomography in the process of diagnosis and management of disorders of the temporomandibular joint.
de Boer EW, Dijkstra PU, Stegenga B, et al.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2014;52(3):241-6.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Role of copper ions in drinking water in the pathogenesis of oral submucous fibrosis: the missing link in the aetiopathology?
Reviewed by: Sampath Chandra Prasad
September/October 2014 (Vol 23 No 4)
 

Often a breakthrough link in the understanding of the aetiopathogenesis of a hitherto common pathology that has been evading the medical community may not come from the hi-tech labs of the developed world, but from the intelligent investigations from a modest laboratory of a developing nation. Researchers from a far-flung district in Southern India have investigated the concentration of copper ions in drinking water and attempted to determine whether copper has a role in the pathogenesis of oral submucous fibrosis (OSMF). They studied 50 patients with clinically and histologically diagnosed OSMF from the Yadgir district of Karnataka in India. Fifty healthy people, matched for age and sex, were used as controls. In both groups concentrations of copper ions in serum, saliva, and home drinking water were measured using atomic absorption spectroscopy and intelligent nephelometry technology. Serum ceruloplasmin concentrations were also estimated in both groups. The studies showed that the mean (SD) concentration of copper in the home drinking water of patients with OSMF was significantly higher (764.3 (445.9)μmol/L) than in the controls (305.7 (318.5)μmol/L) (P<0.001). Patients with OSMF also had a significantly higher copper concentration in serum and saliva, and serum ceruloplasmin than controls (P<0.001). The authors claim that, for the first time, a positive association between copper concentrations in home drinking water and OSMF has been established. It raises the possibility that increased copper in drinking water contributes to the development of OSMF, and adds to that ingested when areca nut is chewed.

Reference

Evaluation of possible role of copper ions in drinking water in the pathogenesis of oral submucous fibrosis: a pilot study.
Arakeri G, Patil SG, Ramesh DN, et al.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2014;52(1):24-28.

CLINICAL OTOLARYNGOLOGY

Balloon dilatation of the eustachian tube: An evidence based review
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

Eustachian tube dysfunction has long provoked debate among otolaryngologists with wide-spread variation in management. Establishing a safe and effective surgical technique to bring about resolution would be of benefit to those affected, with an estimated incidence of 0.9% in the UK. This well-constructed article takes a pragmatic approach to evaluating the current evidence through a case series review of cartilaginous dilatation. Pre- and post-operative parameters of tympanometry, otoscopy findings, valsalva and subjective symptoms were used focusing on short term (<6 months) and long term (>6 months). The literature demonstrates balloon dilatation performed on 375 eustachian tubes from 235 patients with clear short-term benefits across the aforementioned outcome measures. A complication rate of 3% was observed, yet these were deemed minor and short-lived. Indeed, in the absence of bony dilatation the practice of a routine pre-operative CT scan is questioned by the authors. The stage appears set for the eventual evolution of its use in mainstream practice, although the authors sensibly emphasise the importance of formalised training and meticulous review of outcomes.

Reference

Balloon dilatation of the Eustachian tube: an evidence based review of case series for those considering its use.
Miller BJ, Elhassan HA.
CLINICAL OTOLARYNGOLOGY
2013;38(6):525-32.

CLINICAL OTOLARYNGOLOGY

Clinical coding: variability and error in otolaryngology
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

The ever topical spectre of coding in otolaryngology is comprehensively evaluated in this article. It attempts to debunk the mystique of current coding practices and the challenge of health informatics in the modern NHS. A total of 3131 randomly selected otolaryngology patients initially coded in the standard manner were evaluated by a clinician-auditor multi-disciplinary team. This was substantially larger than the sample size used to audit coding accuracy in the entire NHS by the audit commission! Overall this led to a 13% rate of change in both the primary procedure and underlying diagnosis. Coding data informs resource allocation and has an influence on clinical prioritisation within the NHS. Attempts to decrease variability and drive excellence in coding should remain a priority for clinicians as well as managers yet achieving this continues to present difficulties.

Reference

An audit of the nature and impact of clinical coding subjectivity variability and error in otolaryngology.
Nouraei S, Hudovsky A, Virk J, et al.
CLINICAL OTOLARYNGOLOGY
2013;38(6):512-24.

CLINICAL OTOLARYNGOLOGY

Cost effectiveness and vestibular schwannoma surgery
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

This is the first cost effectiveness modelling study looking at the three main treatment options for small to medium sized vestibular schwannomas. This study uses the widely accepted cost per quality adjusted life year (QALY) outcome measure to evaluate three hypothetical cohorts of adult patients receiving conservative, radiosurgery or surgical treatment. The model used finds initial conservative management to be the most cost effective treatment strategy available for small to medium sized vestibular schwannomas (extrameatal diameter less than 2cm). Slow growth allows two-thirds of these to never require aggressive treatment. Overall this strategy appears to offer more QALYs at a lower cost, yet overall quality of life data in this patient population continues to need evaluation.

Reference

Conservative management, surgery and radiosurgery for treatment of vestibular schwannomas: a model-based approach to cost-effectiveness.
Gait C, Frew EJ, Martin TPC, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(1):22-31.

CLINICAL OTOLARYNGOLOGY

Management of metastatic neck disease
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

This article publishes the findings of a recent expert-led evidence based management symposium in the UK with recommendations according to the SIGN level of evidence and grading. The article neatly summarises the key points, and its clarity despite the complexity of the topic should be recognised. Naturally any topic such as this will continue to involve areas in need of further research and discussion; one key point, however, is in the need for international agreement on the most appropriate neck dissection classification system. Consistency in terminology is vital in areas such as this. This article is a must for oncological surgeons looking for a neat review of the current understanding of the topic; anyone with examinations around the corner would also be wise to review.

Reference

Management of metastatic neck disease – summary of the 11th Evidence Based Management Day.
O'Hara J, Simo R, McQueen A, et al.
CLINICAL OTOLARYNGOLOGY
2014;39(1):3-5.

CLINICAL OTOLARYNGOLOGY

National analysis of outcome of head and neck cancer surgery
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

Patient outcomes continue to become ever more visible in the NHS with ongoing drives to demonstrate transparency in our delivery of healthcare. This article reviews unit-level data publication using Hospital Episode Statistics data in all units undertaking head and neck cancer surgery in England. This includes 10,589 patients who underwent major head and neck cancer surgery between 2006 and 2011. Interestingly the authors used an in-hospital mortality measure in contrast to the commonly accepted 30-day mortality used elsewhere. Data such as an overall in-hospital mortality rate of 3.05% and myocardial infarction rate of 4% is provided. The important issue of variability between units is explored and the demonstration of distinction between units performing ‘intermediate’ numbers of major surgeries (16-25 a year) as opposed to high volumes is not unexpected given work in other areas (cardiothoracics and vascular). Summarising this paper is no mean feat owing to the breadth of issues discussed and illustrated; I urge you to read and consider for yourself how the future of head and neck cancer care is likely to develop and be monitored.

Reference

A national analysis of the outcome of major head and neck cancer surgery: implications for surgeon-level data publication.
Nouraei S, Middleton SE, Hudovsky A, et al.
CLINICAL OTOLARYNGOLOGY
2013;38(6):502-11.

CLINICAL OTOLARYNGOLOGY

Sham controlled trial: BPPV
Reviewed by: Andy Hall
September/October 2014 (Vol 23 No 4)
 

I was drawn to this study and it proved an enlightening read; it also is a good example of where recommendations of a Cochrane review for long-term evidence of benefit have been acted upon! The study looked at the efficiency of the Epley manoeuvre as a long-term therapeutic procedure for posterior canal benign paroxysmal positional vertigo (BPPV). A randomised, double blind sham-controlled trial involving two groups of 22 patients ensued. Following identification of BPPV, participants were treated with either an Epley or sham procedure and followed up for a year post treatment. Outcome measures of both conversion of a positive Dix Hallpike test to a negative Dix Hallpike test and Dizziness Handicap Inventory were used. Treatment success was found in 91% of patients after 12 months of follow-up in the Epley group as opposed to 46% in the sham group.

Reference

A randomised sham-controlled trial to assess the long-term effect of the Epley manoeuvre for treatment of posterior canal benign paroxysmal positional vertigo.
Bruintjes TD, Companjen J, van der Zaag-Loonen HJ, van Benthem PP.
CLINICAL OTOLARYNGOLOGY
2014;39(1):39-44.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in elderly candidates and effect on quality of life
Reviewed by: Thomas Nikolopoulos
September/October 2014 (Vol 23 No 4)
 

The authors aimed to assess the improvement in quality of life (QoL) of cochlear implant patients over 60 and its relation to audiometric benefits. An observational retrospective study was conducted on 26 individuals older than 60. The outcome was compared to the respective outcome in 10 implanted patients aged between 40 and 60. A full postoperative audiological evaluation was completed and the Glasgow Benefit Inventory test was used to assess QoL. The patients in both groups had similar preoperative speech recognition levels. Preoperative audiometric thresholds were significantly worse in patients from 40 to 60 years of age, although they scored better in speech recognition after implantation. Patients experienced significant improvement in their QoL in all areas, especially in general health, while they experienced a smaller improvement in social interaction. Age, duration of deafness, and years wearing the processor were statistically related to QoL, regardless of audiometric benefit. The authors concluded that cochlear implantation improves QoL of patients over 60 by the mere fact of having been implanted, regardless of poorer audiological benefits. Older patients, with long-term deafness experience a greater improvement in QoL after implantation. An interesting study with interesting results. However, a better study design with a larger number of patients would help in identifying the small differences between the two groups.

Reference

Cochlear implants in adults over 60: A study of communicative benefits and the impact on quality of life.
Ramos Á, Guerra-Jiménez G, Rodriguez C, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):241-5.

COCHLEAR IMPLANTS INTERNATIONAL

How can we assess children with complex needs?
Reviewed by: Thomas Nikolopoulos
September/October 2014 (Vol 23 No 4)
 

In the early days of cochlear implantation, children with additional disorders were being excluded as poor candidates whereas today a large number of children with complex needs are being referred for cochlear implant assessment. However, the related problems include difficulties in the assessment to determine whether a particular child is suitable for cochlear implantation and post-implantation tuning of the device in order to obtain accurate threshold responses to acoustic or electrical stimuli. The behavioural and objective tests of hearing have weaknesses and this study outlines the pros and cons of these tests which should be taken into account when performing them on children with complex needs. The author reviewing all related problems concludes that just because a child has complex needs as well as deafness should not mean he / she is ruled out for consideration for cochlear implantation. However there are issues which need to be addressed with the family prior to a decision. The main problem is that there is a lack of preoperative candidature criteria and postoperative outcome measures specific to children with complex needs. A greater evidence base is needed to allow informed decisions to be made. It seems that cochlear implantation in children with additional disorders has made it more clear than ever that (re)habilitation of these children urgently needs appropriate and well designed outcome measures.

Reference

Audiological assessment of children with complex needs.
Midgley E.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s18-s19.

CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY

Sublingual immunotherapy
Reviewed by: Susan A Douglas
September/October 2014 (Vol 23 No 4)
 

This paper reviews the recent European studies on sublingual immunotherapy (SLIT). SLIT is currently widely used in Europe and is gaining popularity in the United States. It is known that longer treatment is needed with SLIT compared with subcutaneous immunotherapy (SCIT) to reduce the rhinitis symptoms in children with house dust mite (HDM) allergies. SLIT appears to be a well-tolerated and effective disease-modifying option for treating rhinitis and asthma in children and adults including the elderly. Studies on HDM, grass, and ragweed have demonstrated post-treatment efficacy in both monosensitised and polysensitised patients. The effects of treatment are lasting, providing clinical benefit even one year after SLIT is discontinued. With its roots in Europe, SLIT is now gaining attraction around the world as a viable alternative to SCIT. The advantages include an improved safety profile with no reported systemic effects, a more tolerable route of administration, and the potential to significantly improve compliance by allowing at-home self-administration. Recent studies shed light on the wider age range that may benefit from SLIT, the potential for treating a larger array of environmental allergies, and the sustained effects beyond the treatment period.

Reference

Sublingual immunotherapy: what we can learn from the European experience.
Linkov G, Toskala E.
CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY
2014;22(3):208-10.

EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY

Endoscopic myringoplasty: a promising alternative to microscopic surgery
Reviewed by: George Garas
September/October 2014 (Vol 23 No 4)
 

Endoscopes have revolutionised otitis media surgery in recent years and are increasingly used in the surgical management of cholesteatoma, sinus tympani pathology and facial nerve surgery. Despite this, the development of endoscopic myringoplasty and how this compares to its microscopic counterpart have received relatively little attention. This study aimed to assess exactly that, by directly comparing endoscopic with microscopic myringoplasty for similarly sized and positioned tympanic membrane perforations. Sixty patients were recruited and randomised between the two groups (30 endoscopic and 30 microscopic). Endoscopic myringoplasty was always performed transcanal with tympanomeatal flap elevation in all cases. On the other hand, microscopic myringoplasty was performed via a postaural approach. The use of an endoscope (0º or 30° 4mm rigid endoscope) proved to offer numerous advantages over microscope use. Firstly, no patient in the endoscopy group required canalplasty as adequate exposure of the margins of the perforation (even when very anterior) and visualisation of the incudostapedial joint complex were easily achieved with the endoscope and without the need for any posterosuperior canal wall curettage. This was despite four patients in the endoscopic group having significant canal overhangs. This was not the case in the microscopic myringoplasty group where all five patients with significant canal overhangs required canalplasty to obtain adequate exposure of the tympanic annulus and four also required curettage of the posterosuperior canal wall to obtain visualisation of the incudostapedial joint complex. Moreover, all patients in the endoscopy group (30/30) reported excellent cosmetic outcomes as the incision scar was well hidden in the hairline whereas the equivalent percentage in the microscopic group was 25/30 with the remaining five patients reporting it as only satisfactory due to the associated scar. No difference was observed in graft uptake rates which were 83.3% in both groups. The hearing outcomes were comparable between the two techniques and endoscopic myringoplasty was well received by the residents being trained in the technique. In summary, this study, albeit small, illustrates the promising role that endoscopic myringoplasty has to play as it achieved improved cosmesis, comparable tympanic membrane perforation and air-bone gap closure rates to microscopic surgery without the need for canalplasty and postaural incision even in the presence of major canal overhangs

Reference

Endoscopic vs microscopic myringoplasty: a different perspective.
Lade H, Choudhary SR, Vashishth A.
EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY
2014;271(7):1897-902.

EUROPEAN REVIEW OF ENT

The sentinel lymph nodes revisited
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

The concept of sentinel lymph node sampling has been around for some time. However, its acceptability in routine head and neck practice has yet to be established. This article presents the authors’ experience in 10 patients with Merkel cell carcinoma [eight T1N0Mo, one T2N0M and one T3N0M0], which is an aggressive cutaneous neuroendocrine tumour. Lymphoscinti-graphy was performed after infiltrating the tumour surround with Tc-99m labeled NANOCIS. Sampling of the sentinel node was performed during the excision of the primary tumour and stained by HPS and immunostains. Scintigraphy-positive nodes were detected in 7/10 patients. Three patients underwent neck dissection, either because of absent marker detection during scintigraphy or the absence of a surgically detected sentinel node. All these nodes were negative for malignancy. One patient had systemic metastases, but no lymph node recurrence 12 months later. The remaining nine patients were disease-free after two years’ follow-up. The conclusion of the authors is that sentinel node sampling in such patients is useful to determine the need for simultaneous neck dissection during excision or, instead, just follow-up.

Reference

Prognostic value of sentinel lymph node in Merkell cell carcinoma of the head and neck.
Penicaud M, Cammilleri S, Giorgi R, et al.
EUROPEAN REVIEW OF ENT
2013;134(2):75-9.

FACIAL PLASTIC SURGERY

Polydioxanone in septal reconstruction
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

Septal reconstruction is a challenging problem and is undertaken for functional or cosmetic reasons, or a combination of both. Either autologous cartilage, commonly auricular, or other alloplastic material can be used. The authors describe the use of a Polydioxanone (PDS) plate for this purpose. The authors discuss extracorporeal septoplasty, indications and technique. Similarly they next discuss endonasal and then partial extracorporeal endonasal septoplasty. A very useful discussion on the indications and technique is provided. It is clear and succinct with excellent accompanying photographs. Similar sections are then provided on columellar struts, extension grafts and septal perforation repair. The final discussion is mainly on the useful applications of the PDS plate. There is some good background on the animal experiments that confirm the histoconductive effects. The authors conclude that the PDS plate is a valuable addition in difficult septal surgery. The article is of value for the seasoned nasal surgeon as well as others. This is a very well written and lucid paper, most surgeons will be able to pick some ‘tips’ and add a valuable technique to the armamentarium in correcting a difficult problem.

Reference

Use of Polydioxanone Plate in Septal Reconstruction.
Rimmer J, Saleh H.
FACIAL PLASTIC SURGERY
2013;29(6):464-72.

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Techniques in Facial Plastic Surgery: Discussion and Debate part 2
Reviewed by: Mrinal Supriya
September/October 2014 (Vol 23 No 4)
 

This edition of this popular journal is dedicated to ‘panel discussion’ on some of the most common controversies associated with ‘bread and butter’ facial aesthetic procedures. The procedures included are relevant and the aspects discussed are of practical importance to anyone involved in facial aesthetic procedures. The panel members are authorities in their field and they bring their experience to the discussion. I found the chapters well written and informative. I found the chapter discussing rhinoplasty and revision rhinoplasty particularly interesting as they discussed topics such as division of tip lobule, use of alloplast or options for dorsal augmentation, when there is no septal or auricular cartilage; these are relevant to all surgeons performing this procedure. It is heartening to see that even experienced surgeons can have divergent philosophy in tackling these tricky aesthetic and functional problems. Similar questions have been discussed for procedures such as blepharoplasty, mid face lift and chemical peel. In summary I think this issue will be beneficial to any surgeon who has a practice in facial aesthetics.

Reference

Techniques in Facial Plastic Surgery: Discussion and Debate part 2.
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA
2014;22(1):1-160.

HEARING, BALANCE AND COMMUNICATION

Auditory processing in children with unilateral hearing los
Reviewed by: Claudia Nogueira
September/October 2014 (Vol 23 No 4)
 

t is a common assumption that unilateral hearing loss (UHL) in children is of little consequence because appropriate development of speech and language can still occur with one normal hearing ear. Recent studies, however, suggest that there are significant differences in the cortical processing of sound between children with severe to profound unilateral hearing loss and normal hearing children. Central auditory processing was evaluated in children with UHL using the P300 component of event related potentials. Three groups of listeners participated in this prospective clinical study, listeners with UHL in the right (n=15) or left ear (n=15) and listeners with bilateral normal hearing (BNH) (n=20). Children with right UHL showed a significant reduction in P300 amplitudes in response to speech when compared to a tone stimulus. Comparing speech-evoked P300 response in the three groups revealed a significant delayed latency in the groups with UHL compared with children with bilateral normal hearing. These findings suggest that speech processing is affected in children with UHL whichever its side. The authors also suggested that a right UHL may have a greater impact on the central perception of processing of sound than a left UHL.

Reference

Auditory processing in children with unilateral hearing loss
Gabr TA.
HEARING, BALANCE AND COMMUNICATION
2014;12(2):99-104.

HEARING, BALANCE AND COMMUNICATION

Tinnitus in patients on therapy with PPI and in PPI non–users
Reviewed by: Claudia Nogueira
September/October 2014 (Vol 23 No 4)
 

Tinnitus is a chronic and debilitating condition and approximately 10% of the population is afflicted. A myriad of pharmacological treatments for tinnitus are available but only a few controlled studies have shown positive results. The relationship between proton pump inhibitors (PPI) and tinnitus is contradictory. The difficulty of a strict follow-up, due to the variable pattern of presentation of tinnitus symptoms, and the different methods of PPI application have made it difficult to draw definitive conclusions. In order to investigate the effect of PPI on tinnitus sufferers, a cohort of 120 consecutive patients aged 50-69 years were recruited in this study. Subjects were subdivided into two groups: PPI users and non-users. Each patient was instructed to complete an anonymous validated questionnaire on hearing problems. The results showed that in the age class 60-69 years, there was a significantly lower prevalence of generic tinnitus symptoms in patients on PPI maintenance therapy compared to those who did not take these drugs. The mechanism of action of PPIs in the relief of tinnitus is still unclear. Current research indicates a direct regulatory effect on inner ear homoeostasis through an action of PPIs on gastric-type proton pumps in the inner ear. The authors suggest that further longitudinal studies are required before claims can be made as to the beneficial effect of PPIs on tinnitus.

Reference

Tinnitus in patients on therapy with proton pump inhibitors (PPI) and in PPI non–users.
Piroda A, Raimondi MA, Cicero AFG, et al.
HEARING, BALANCE AND COMMUNICATION
2014;12(3):84-7.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Objective versus subjective – again!
Reviewed by: Christos Georgalas
September/October 2014 (Vol 23 No 4)
 

The use of objective measurements of nasal airflow has a long history; however, its clinical application remains, at most, patchy. The main reason for that has been the lack of convincing studies showing a good correlation between the findings of, for example, anterior rhinomanometry and nasal obstruction, as experienced by the patient. Having said that, an equally patchy relationship exists between chronic rhinosinusitis (CRS) symptoms and sinus opacification (Lund-McKay score), however no one would suggest abolishing sinus CT for the diagnosis and assessment of CRS. The key is interpretation; while the results of rhinomanometry may be insufficient to separate patients with obstruction from those with no obstruction; they appear to be useful to monitor the symptoms of individual patients over time. In this prospective study, the authors followed up 53 patients undergoing radiofrequency ablation for inferior turbinate hypertrophy with anterior rhinomanometry as well as VAS at one, three and six months. They found that objective improvement at one month correlated well with subjective improvement; however, this correlation disappeared after three months. It is very likely that other factors were also at play – with allergy and patient expectations being but two of them.

Reference

Prediction of outcome of radiofrequency ablation of the inferior turbinates.
Sahin-Yilmaz A, Oysu C, Devecioglu I, et al.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2014;4(6):470-4.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Forward-going sound pressure wave with hearing thresholds
Reviewed by: Richard Navarro
September/October 2014 (Vol 23 No 4)
 

This article discusses an important and well-known point regarding the differences between coupler sound pressure measurements, used to calibrate earphones, and actual pressures delivered to the ear due to individual variances across patients. The study purports to suggest a new clinical tool; however, there is not sufficient definition of a number of key points, e.g. how is the ‘forward-going’ sound pressure wave defined? There are a number of methodological points that were not provided to help interpret the results in a meaningful way and the use of parametric statistical tests for non-parametric data raises some concern. While there may be some value to the use of a forward-going sound pressure wave, this article does not demonstrate the clinical utility with sufficient clarity to justify a wholesale change in the modus operandi for diagnostic or rehabilitative benefit. The article is worth reading as the introduction defines the issue well; however, the method needs considerable work before becoming a clinical tool.

Reference

The clinical utility of expressing hearing thresholds in terms of the forward-going sound pressure wave.
Withnell RH, Jeng PS, Parent P, Levitt H.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2014;53(8):522-30.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Inflammation associated with presbyacusis
Reviewed by: Richard Navarro
September/October 2014 (Vol 23 No 4)
 

Inflammaging and presbyacusis is a topic that few audiologists consider in their daily clinical routine due to lack of training in this area. Inflammaging is a chronic state of inflammation present throughout the body. The classic 1965 work by Rosen and Pikka laid the groundwork documenting the co-morbidity of hearing loss and cardio-vascular disease. The current work explores the relationship between a number of bio-markers, such as white blood count and homocysteine levels, and elevated hearing levels as measured by tonal audiometry in an aged population. They compared their results to a previous study. In both studies, they found a positive correlation with a number of biomarkers and concluded that both lifestyle and pharmacological treatment may provide prophylactic solutions to the development and progression of age-related hearing loss. This is an important paper for all audiologists because it clarifies that not all hearing loss is caused by intense noise, but that cochlear metabolism is one factor that should be considered in the treatment and prevention of hearing loss. The evolution of care provided by audiologists should be predicated on learning more about how metabolism affects hearing, balance, and tinnitus so that more effective prevention and treatment protocols may be developed. Similar studies might be improved if distortion product otoacoustic emissions were added to the research protocol as this may reveal cochlear hair cell inflammation prior to the development of permanent hearing loss.

Reference

Inflammation is associated with a worsening of presbyacusis: Evidence from the MRC national study of hearing.
Verschurr V, Agyemang-Prempeh A, Newman TA.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2014;53(7):469-475.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early habilitation for hearing impairment in children with Down syndrome
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Approximately 40-80% of children with Down syndrome have hearing impairment in addition to speech and language impairment. The commonest cause of hearing impairment in young children is otitis media with effusion. This paper investigated the impact of early hearing loss on language outcomes in children with Down syndrome. They found that early hearing loss has a significant impact on the speech and language development of children with Down syndrome. The authors suggest that speech and language therapy should be provided when children are found to have ongoing hearing difficulties. In addition, joint audiology and speech and language therapy clinics could be considered for preschool children.

Reference

Early hearing loss and language abilities in children with Down syndrome.
Laws G, Hall A.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS 2014:49(3):333-42.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early intensive aphasia therapy in stroke patients
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The impact of aphasia following stroke is devastating. Very early aphasia rehabilitation studies have been the subject of ongoing debate. This paper describes the comparison of a very early aphasia therapy regimen with a historical ‘usual care’ control group after therapy completion, at four to five weeks post stroke and again after six months. The authors found that an impairment-based aphasia therapy regimen, provided daily over 20 sessions (over four to five weeks) in very early stroke recovery, resulted in significantly greater communication gains in people with mild to severe aphasia. The study adds to the existing literature, suggesting that increased and intensive aphasia therapy in the very early recovery phases is important for improving the effects of spontaneous recovery.

Reference

A comparison of aphasia therapy outcomes before and after a very early rehabilitation programme following stroke.
Godecke E, Ciccone NA, Granger AS, et al.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS
2014;49(2):149-61.

INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS

Early intensive aphasia therapy in stroke patients
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The impact of aphasia following stroke is devastating. Very early aphasia rehabilitation studies have been the subject of ongoing debate. This paper describes the comparison of a very early aphasia therapy regimen with a historical ‘usual care’ control group after therapy completion, at four to five weeks post stroke and again after six months. The authors found that an impairment-based aphasia therapy regimen, provided daily over 20 sessions (over four to five weeks) in very early stroke recovery, resulted in significantly greater communication gains in people with mild to severe aphasia. The study adds to the existing literature, suggesting that increased and intensive aphasia therapy in the very early recovery phases is important for improving the effects of spontaneous recovery.

Reference

A comparison of aphasia therapy outcomes before and after a very early rehabilitation programme following stroke.
Godecke E, Ciccone NA, Granger AS, et al.
INTERNATIONAL JOURNAL OF LANGUAGE &
COMMUNICATION DISORDERS
2014;49(2):149-61.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Are biofilms present in deep neck abscesses?
Reviewed by: Patrick Spielmann
September/October 2014 (Vol 23 No 4)
 

Why are some cervical abscesses resistant to antibiotic treatment? The authors postulate that a biofilm develops to allow the bacteria to overcome normal host defences. They investigated the micro-environment of deep neck abscesses in a largely paediatric cohort. Biopsies of abscess walls were taken and processed for electron microscopy scanning. Twelve of 14 demonstrated cocci and rods embedded in a 3-dimensional matrix – all features of a biofilm. This may explain why so many abscesses, particularly large ones, are difficult to treat with antibiotics alone.

Reference

Potential role of biofilms in deep cervical abscess.
May JG, Shah P, Sachdeva L, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2014;78:10-13.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

BAHA stability measurement in children
Reviewed by: Patrick Spielmann
September/October 2014 (Vol 23 No 4)
 

This useful paper reports the experience of using resonance frequency analysis for single stage bone-conduction implants in a paediatric population. A smartpegTM is attached to the abutment and vibrated by a close quarters magnetic field. The amount of vibration is converted into an implant stability quotient (ISQ) score. The ISQ was produced for each implant at time of surgery and at follow-up intervals. The mean stability scores were good enough to accept loading on the day of surgery with marginal improvements thereafter (at four weeks and 16 weeks). This has encouraged the authors to accelerate the loading of paediatric patients to a median of six weeks (range 1-16 weeks). With improved implant design and better understanding of osseointegration the loading times are inevitably being reduced, which has to be a good thing…

Reference

Resonance frequency analysis of osseo-integrated implants for bone conduction in a pediatric population – a novel approach for assessing stability for early loading.
McLarnon C, Johnson I, Davison T, et al.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2014;78:641-44.

JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY

Extranodal natural killer / T-cell lymphoma in the head and neck
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a retrospective single institution review of patients with a very rare variant of non-Hodgkin lymphomas (NHL). They report on the occurrence, clinical course and outcomes of their patients with natural killer / T-cell lymphoma (NKTCL) nasal type. Sixty-three patients with NHL were treated between 2006 and 2011. Of these 11 had extranodal lymphoma with six in the head and neck; of these three had NKTCL nasal type group. They report three clinical cases leading to the diagnosis and treatment course of the disease and outcomes. Two of the three had aggressive disease resistant to chemotherapy. The authors discuss a tumour rarely found in Europeans, but highlight its aggressive nature, chemo resistance and poor clinical outcomes. Because this can present with features of upper respiratory tract infection, it could be seen by a maxillofacial or otolaryngology practitioner and authors do a good job of drawing attention to this disease.

Reference

Extranodal lymphomas of the head and neck with emphasis on NK/T-cell lymphoma, nasal type.
Coha B, Vucinic I,Mahovne I, Vukovic-Arar Z.
JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY
2014;42,149-52.

JOURNAL OF CRANIOFACIAL SURGERY

Cheek reconstruction following melanoma excision
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

Malignant melanoma occurs most commonly on the cheek and thus is usually diagnosed early, and rarely needs large reconstructions for advanced disease. This is a retrospective study looking at 26 patients that had undergone treatment for cheek melanomas between 1996 and February 2012. Reconstruction was with skin grafts (split in nine and full in three cases), seven with local flaps and seven with free flaps. The authors quantify the size of the defects and methods of reconstruction. On average the skin defect was 41.4cm2 with skin grafts, 24.9cm2 with local flaps and 76.7cm2 with free flaps. The authors discuss the range of the size of the defects and suggest the dividing line between local or free flaps as 40cm2. Skin grafts meanwhile being so much more versatile can be used for defects up to as large as 78cm2. The other considerations were exposed structures, such as bone, that cannot be grafted and tumour thickness and hence resultant defect. They suggest three factors are important in selecting a reconstruction procedure, size and aesthetic considerations. stage of the melanoma and age of the patient. The study is limited because of the patient numbers but it provides a good mental algorithm to use in assessment and planning of reconstruction.

Reference

An analysis of cheek reconstruction after tumour excision in patients with melanoma.
Hayashi T, Furukawa H, Oyama A, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25: e98-101.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

A diagnostic survey of dizziness
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The prevalence of self-reported dizziness and that requiring medical consultation is remarkably high. Cardiac and neuropathic comorbidities, often associated with these patients confuse the diagnosis. In this multicentre study, the prevalence and characteristics of various diagnostic groups, for example, Benign paroxysmal positional vertigo (BPPV), Ménière’s and likewise were studied in 1034 consecutive patients presenting with dizziness. Various diagnostic categories relating to vestibular causes were defined and patients were placed in them. The study took into account the recurrence of dizziness which was highest in patients with BPPV and migraine associated vertigo. Imaging was carried out in 151 of the 1034 patients and 24 (15.8%) had abnormalities. Of the 150 patients with vertigo of central origin, 12 had abnormal imaging results. Of the 551 with BPPV 64 were scanned and three of them had abnormal findings of which only one could be related to vertigo. Patients with vestibular neuronitis required most sick leave and night time awakening was most frequent in patients with BPPV. The diagnostic certainty was highest for patients with BPPV. Patients with BPPV provided the largest diagnostic group. A number of interesting attributes have been mentioned for BPPV. In various studies published in the literature, the percentage of patients referred for dizziness who have vestibular causes is 14-72.9%. In one study, 52.5% of patients were diagnosed with BPPV. In this study the incidence of BPPV was highest in patients between 60-79 years of age and the author emphasised that this diagnosis should not be overlooked in elderly patients because they have an increased risk of falling. Of these patients 49% are aware of their dizziness and 85% reported that symptoms were triggered by turning over in bed. There is also evidence that awareness of BPPV is insufficient in clinicians and necessary tests are not performed. The study therefore illustrates that BPPV is the underlying cause in the majority of patients presenting with dizziness, it is easily diagnosed and treated and therefore should not be missed.

Reference

Prevalence and characteristics of diagnostic groups amongst 1034 patients seen in ENT practices for dizziness.
Luscher M, Theilgaard S, Edholm B.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:128-33.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Assessment of viral aetiology in the formation of nasal polyps
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The exact aetiology of nasal polyposis is not yet established although it is believed that allergic, infectious, mechanical, immunological and biochemical factors may be involved. Using the technique of polymerase chain reaction, this study assesses the role of human adenovirus, metapneumovirus, coronavirus, parainfluenza virus types 1, 2 and 3, influenza A and B virus, respiratory syncytial virus A and B and rhinovirus A and B in the formation of nasal polyps. The authors used the method of polymerase chain reaction based on nucleic acid isolation, reverse transcription, polymerase chain reaction amplification of target DNA and DNA detection with agarose gel electrophoresis. There were 30 patients with nasal polyps, 22 men and eight women, and a control group of 20 healthy patients. Nasal polyposis was diagnosed histopathologically. Tissue examination by agarose gel electrophoresis identified human coronavirus and rhinovirus in one of the patients in the control group. Another patient in this group had human respiratory syncytial virus. Influenza B virus was identified in one of the nasal polyp patients along with human coronavirus in another in this group. There was no statistically significant relationship between nasal polyposis and respiratory viruses. The study therefore does not support viral aetiology in the formation of nasal polyps. References have been made to past studies which showed a high prevalence of EBV in normal nasal pharyngeal mucus but not in nasal polyps. Therefore its role in nasal polyposis is doubtful which agrees with this study. The aetiology of this common condition therefore still remains uncertain.

Reference

Investigation of the role of major respiratory viruses in the aetiology of nasal polyps using polymerase chain reaction technique.
Aksoy F, Yenigun A, Dogan R, et al.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(4):356-9.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Can smaller cancer centres deliver high quality care for patients with laryngeal cancer?
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

There is a continuing conflict between treating patients as close to their homes as possible and centralising specialised services, taking into consideration the critical mass and the multi-disciplinary expertise available. This is a report of outcomes in the treatment of laryngeal cancer in a small cancer centre serving a population of only 330,000, just about a third of what is recommended by IOG guidelines (2005). The authors looked at the survival rates of 209 consecutive patients, who presented with laryngeal cancer, over a 15 year period. These patients were prospectively entered into a standardised database. The distribution of these patients was as follows: 86 had stage one disease, 43 had stage two, 33 had stage three and 47 presented with stage four disease. A five year disease specific survival rate is reported as 100% for stage one, 76% for stage two, 87% for stage three and 46% for stage four. Of the 46 patients treated non-surgically 36 had recurrence of disease (79%). Most of these patients were treated surgically, before or after radiotherapy. The authors compare their five year tumour related survival rate of 82% and a five year overall survival rate of 59% with relative survival figures for laryngeal cancer across Europe ranging from 44% to 86%. This suggests excellent outcomes in a small cancer centre. An interesting review of the literature addresses the more recent trend for non-surgical treatment of laryngeal cancer, resulting in a non-significant decrease in the overall survival at five and 10 years. The authors attribute their 87% five year survival for Stage three disease to favouring surgical management of such advanced disease. The problems associated with radiotherapy and chemotherapy are mentioned and the role of surgery for advanced disease is supported. Less radical radiotherapy regimes are favoured. The article lends credence to the belief that laryngeal cancer can be managed reasonably well in a small, remote head and neck cancer centre, bringing care nearer to the patients’ homes.

Reference

Laryngeal cancer management in a small, rural, multi-
disciplinary team setting: 15 year review.
Hamilton DW, McMeekin PJ, Dyson P, Robson AK.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1203-7.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Clinical value of 3 T magnetic resonance imaging after intratympanic gadolinium injection in cases of delayed endolymphatic hydrops
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Recurrent vertigo can continue after severe unilateral or bilateral hearing loss. This is a condition similar to Ménière’s disease, the diagnosis of which can be difficult. In this study intratympanic injection of gadolinium-diethylenetriamine penta-acetic acid dimeglumine was done in 25 patients and followed by inner ear 3-D fluid-attenuated inversion recovery MRI 24 hours later. The distribution of Gadolinium in the labyrinth was quantitatively scored in the regions of cochlear base, middle and apex, vestibule and the three semi-circular canals. The presence of endolymphatic hydrops was evaluated with an established formula and the diagnosis was thought confirmed if the score of the function reached an accepted numerical value. The authors claim that this method diagnosed 84% (21/25 patients) of endolymphatic hydrops and thus has a higher sensitivity rate. No complications resulted with this technique. At the same time the authors performed pure tone audiometry, electrocochleography, bithermal caloric testing and VEMP potential testing. They found this MRI method to be the most sensitive. Electrocochleography is not useful in cases of severe hearing loss. Bithermal caloric testing has 72% sensitivity but is not a normal physiological vestibular stimulus and often evokes a vestibule-autonomic reflex. VEMP is limited in that it evaluates only the saccular function. The authors claim that accurate identification of the clinical type of delayed endolymphatic hydrops helps determine surgical strategy for treating these patients. If there is delayed endolymphatic hydrops in one ear and hearing loss in the other, endolymphatic sac surgery in the affected ear can maintain hearing and eliminate dizzy spells. Despite limited numbers the study does seem promising in the management of vertigo where symptoms persist years after hearing loss.

Reference

Diagnostic value of 3 dimensional magnetic resonance imaging of inner ear after intratympanic gadolinium Injection, and clinical application of magnetic resonance imaging scoring system in patients with delayed endolymphatic hydrops.
Gu X, Fang ZM, Liu Y, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:53-59.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Facial paralysis risk factors in benign parotid surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The literature shows that the risk of facial paralysis following benign parotid surgery can be as high as 57% for temporary weakness and 7% for permanent facial nerve damage. It is generally thought that the factors involved may be related to age, sex, types of benign tumours, indications for the procedure, histological diameter, tumour location and the extent of parotidectomy. In this retrospective study involving 150 patients over a 10 year period the authors have assessed these factors and compared their findings with other studies. Of these patients, 26.7% had temporary weakness and 2.6% had permanent weakness. The age of these patients ranged from 15-80 years but this factor did not influence this risk nor did their gender. Different types of benign tumours and their size did not add to the risk of facial paralysis and the same was the case with location of the tumour in the parotid gland. The study included 10 cases in whom parotidectomy was done for sialadenitis and this did not add to the risk of facial nerve paralysis. The grade of the surgeon performing the parotidectomies was also taken into account but this did not matter thus making the authors feel reassured of the training and supervision. The most interesting aspect of this study is that facial nerve monitoring was used in only 44% of cases and authors do not feel the lack of it affects the risk of facial nerve paralysis. This does appear reassuring but how it stands from the medico-legal point of view is another matter.

Reference

Stratifying the risk of facial nerve palsy after benign parotid surgery.
Sethi N, Tay PH, Scally A, Sood S.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:150-62.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Hearing loss in the contralateral ear after mastoid drilling
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

It is difficult to conceive that most of the noise generated by drilling the mastoid would not be conveyed to the contralateral cochlea, by direct transmission through the skull bone, where the attenuation factor is only 5-10 dB. Only a few studies have been conducted to ascertain this with minimal variables in terms of the duration of drilling, speed of the drill and the size and nature of the drills used – whether diamond or cutting. In this study the authors assessed 30 patients who underwent drilling of the mastoid for cholesteatoma and had normal hearing in the contralateral ear. The hearing was tested by DPOAE and TEOAE preoperatively, in the recovery and the first two consecutive days. Pure tone audiometry was used preoperatively and in the first and second consecutive postoperative days. The speeds of the drill were 60,000 and 35,000 rpm. There was no statistically significant difference observed in the pure tone audiometry assessed as average threshold for low and high frequencies in the pre and postoperative periods. However, there were statistically significant changes in the pre and postoperative TEOAEs over both low and high frequency ranges. The DPOAE changed only in the high frequencies. The follow-up period was only 72 hours, therefore it has not been established whether or not these changes were temporary or permanent. A few studies from the literature support these findings in contrast to one which does not, but the authors explain that in that particular study only a small diamond burr (1-4mm) was used. Diamond burrs produce less noise. There were also statistically significant correlations between the burr times and changes in DPOAEs at high frequencies and TEOAEs at both high and low frequencies for cutting burrs, and changes in high frequency DPOAE only for diamond burrs. The speed of drilling did not matter. Quite understandably, this study has used a number of variables but the sample size is rather small and the assessment is collective which excludes variables such as individual susceptibility. Studies with larger sample size and longer follow-ups are required.

Reference

The effect of mastoid drilling on hearing of the contralateral ear.
Goyal A, Singh PP, Vashishth A.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:952-56.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Medical information required with requests for CT scans of the temporal bones; a two cycle audit
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

It is a common experience that radiology reports on the CT scans of the temporal bones do not always reach a diagnosis. Various studies have produced differing results in that detailed information may not be necessary to help reach a diagnosis by the radiologist and there are no national guidelines to this effect. However, the general consensus is that comprehensive rather than scanty information is helpful. In this two cycle audit the authors assess the extent to which accurate diagnosis was made in relation to CT temporal bone requests, firstly with random clinical information and then in the second cycle of the audit, with regulated information which unfailingly included the site, the symptoms, past medical history, audiological results, specific clinical questions asked, any suspected complications and mention of differential diagnosis. It was noted that CT reports indicating a diagnosis or excluding an important complication increased from 52 to 94 and the need for further clinical information or repeat of the imaging dropped from 12 to two. The factors which played the most significant role in this were mention of a differential diagnosis in the request, the clinical questions, the audiological findings, duration of signs and symptoms and the patient’s history. The striking aspect of this audit is that the same three neuro-radiologists delivered the reports in both cycles of this audit and were not aware of the audit itself, thus removing the element of bias quite convincingly. The study therefore strongly illustrates that, regardless of some reports in the literature stating otherwise, detailed information including the factors mentioned helps arrive at a better diagnosis and save repeat imaging.

Reference

A two cycle prospective audit of temporal bones computed tomography scan request: improving the clinical applicability of radiology reports.
Qureishi A, Garas G, Shah J, Birchall J.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:49-52.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Noise induced hearing loss caused by nightclubs
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Legislation on hearing loss and tinnitus, occurring due to noise exposure at work, has been well established in terms of protection and compensation, but the same damage resulting from noise in nightclubs remains an open issue. This study, based on a questionnaire answered by 325 university students of ages ranging from 18 to 30, explores in a subjective manner the damage caused by noise exposure in nightclubs and their awareness of this possibility. Of these subjects, 46.2% attended a nightclub at least once a week. More than half the participants experienced muffled hearing and tinnitus after exposure to noise in a nightclub and in a quarter this persisted till the following morning. 86.6% had never received information about noise induced hearing loss, although awareness of this was more prevalent in medical students. Interestingly enough, there was no statistically significant difference in the level of concern between medical and non-medical students. Only 26.8% of these subjects said that knowing the link between noise in a nightclub subsequent and hearing loss would affect their attendance. The subjects however agreed that the level of noise in nightclubs should be reduced to avoid hearing damage, so they can continue to attend. The study is limited as it is based on questionnaires and is therefore purely subjective, but it opens an important issue which is presently not governed by legislation, nor is there any warning for visitors to nightclubs that their hearing may be damaged due to noise exposure.

Reference

British university students. Attitudes towards noise-induced hearing loss caused by nightclub attendance.
Johnson O, Andrew B, Walker D, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:29-34.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Post tonsillectomy recovery in thermal welding method compared with recovery in cold steel method
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Many different methods for tonsillectomy have emerged but whether they provide an improvement over the traditional cold steel tonsillectomy is another matter. Thermal welding is a recent method of tonsillectomy in which the tissues are simultaneously coagulated and divided. In this study the authors have made a direct comparison between the two methods of tonsillectomy in the same patient. The study comprises 40 children ranging from four to 14 years. Postoperative morbidity was measured in terms of a visual analogue scale for pain, the presence or absence and sidedness of otalgia during swallowing, drinking and speaking, bleeding and comparison of postoperative healing on the two sides. Patients were assessed on the first, third, seventh and fourteenth postoperative days. It was noted that it took less time to do the thermal welding tonsillectomy, which also had less bleeding. However in cases undergoing cold dissection, tissue healing proved to be better and the throat pain scores were significantly lower on the seventh postoperative day. There was no primary or secondary bleeding in any of the cases. The authors are aware of the pain scores being confused because of the highly subjective nature of pain. The study has its merits in that the two different methods were used on the same subject by the same surgeon and statistical analysis has been applied. The study is in agreement with many comparative studies between cold dissection tonsillectomy and newer methods and rightly makes one conscious of introducing more expensive methods in a cost effective scenario.

Reference

Post tonsillectomy morbidities: randomised, prospective controlled clinical trial of cold dissection versus thermal welding tonsillectomy.
Aydin S, Taskin U, Altas B, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:163-65.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Precautions to be taken in cosmetic facial surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

In this comprehensive write-up on precautionary measures to be taken when doing cosmetic surgery on our patients, the authors begin by emphasising that facial plastic surgery is no longer limited to celebrities and the privileged. It has extended into everyday life situations involving people who in recent years have better means to undertake this surgery. The patient selection should be done with careful emphasis on patient motivation for surgery and expectation. They should not expect to obtain dramatic results such as saving of a marriage or secure employment. These patients can have variable personalities, ranging from perfectionist and narcissistic, excessively demanding, through to passive and unfocused who remain indecisive on both the need and result of the surgery. In this scenario various psychological disorders should also be considered. Some patients simply do not like their appearance, which results in altered personality traits and in extreme cases proves a continuous obsession. A note should be made of possible eating disorders and the difference between an unhappy patient and the one who is clinically depressed should be registered and psychiatric help sought. The legal aspect of an informed consent is elaborated. One can deliver relevant information (prudent patient test) based on the patient’s values and beliefs about operations and complement this with the desired level of information. The patient’s understanding of the consenting process does remain a problem and many available solutions are difficult to implement in the NHS. Documentation of the consenting process is by no means fool proof in the present legal system. A note should be made of the author’s particular statement that ‘a well prepared lawyer will manage to circumnavigate their (surgeon’s) defence’. Medical photography helps in documentation, that should not be limited to the best results of the surgeon. With image manipulation software the patient may consider the portrayed and agreed image as a guaranteed surgical result. Revision operations should be considered very carefully and only after allowing time for the healing process to complete. The patient’s family doctor should be copied into the correspondence, but sometimes patients may desire that family doctors do not know and this has to be handled very carefully. The conclusion that can be derived from this scenario is that the patient should know what to expect and the surgeon be aware of what can be done.

Reference

Pre-operative considerations in aesthetic facial surgery.
Veer V, Jackson L, Kara N, Hawthorne M.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2014;128:22-28.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

The need for pre-operative overnight pulse oximetry in children undergoing surgery for obstructive sleep apnoea syndrome
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

Snoring is a common occurrence in children listed for adenotonsillectomy. This may be associated with obstructive sleep apnoea syndrome, in which case the post-operative recovery of these children needs to be closely monitored. This study undertakes to assess whether an overnight pre-operative pulse oximetry can determine the need for high dependency unit (HDU) observation of these children after their operation. It is a retrospective study identifying patients from the high dependency unit admissions register over a two-year period. It was noted in which of these patients a pre-operative pulse oximetry was actually done and how it related to the post-operative overnight pulse oximetry in terms of desaturation events. The study involved 82 patients who underwent elective adenotonsillectomy, adenoidectomy or tonsillectomy for obstructive sleep apnoea syndrome (OSAS). In 59% of these patients pre-operative overnight pulse oximetry was performed and 32 were considered high risk. Thirty patients showed oxygen desaturation events. It was observed that all children who showed desaturation events pre-operatively also exhibited this in the post-operative pulse oximetry monitoring. Other children, for whom HDU was arranged post-operatively on clinical grounds but who had not undergone pre-operative overnight pulse oximetry, also showed desaturation events in SaO2 monitoring in the post-operative phase. The authors therefore highly rate the value of pre-operative overnight pulse oximetry in predicting post-operative desaturation events and suggest that this simple investigation be carried out in all children in whom OSAS is suspected so that the need for HDU may be identified. This may be a useful predictor for HDU bed requirement allowing targeted referrals for an increased level of post of care.

Reference

Pre-operative overnight pulse oximetry to predict high dependency unit intervention in children undergoing adenotonsillectomy for obstructive sleep apnoea.
Lightbody KA, Kinshuck AJ, Donne AJ.
THE JOURNAL OF LARYNGOLOGY & OTOLOGY
2014;128(4):360-4.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

‘Dead ear’ after mastoid surgery
Reviewed by: Madhup K Chaurasia
September/October 2014 (Vol 23 No 4)
 

The primary aim of surgery in the management of cholesteatoma is eradication of the disease which can potentially result in serious complications such as intracranial extension, facial nerve weakness and further hearing loss. A profound hearing loss resulting postoperatively considerably compromises the outcome but is sometimes unpredicted. In this series the authors looked at 617 middle ear operations performed by a single consultant in which there were six cases of ‘dead ear’. None of these followed 83 operations for otosclerosis or 62 paediatric mastoid operations. However in 187 adults undergoing exploration of the mastoid for cholesteatoma, five (2.7% of cases) ended up with ‘dead ears’. The author has described these six cases in which the pathology ranged from fistulae of the lateral semicircular canal, granulations over the footplate, cholesteatoma covering the footplate, cholesteatoma surrounding the ossicular chain and unanticipated extensive cholesteatoma. In two of these cases surgery went satisfactorily and ‘dead ear’ was not at all predictable, but in the other four further hearing loss appeared likely in the course of surgery. It appears that in one of these cases ‘dead ear’ was definitely avoidable, in two it was probably avoidable and in the other three total hearing loss was inevitable in the process of clearance of disease. All the cases had CT scans which helped to some extent to decide on the surgical approach, but did not reliably predict hearing outcome after surgery. In this series 2% of patients had a ‘dead ear’ due to cholesteatoma itself. Therefore, the risks involved with surgery can be weighed against the disease itself causing a ‘dead ear’. This requires careful thought on whether or not to operate and its timing. The incidence of 2.7% ‘dead ear’ following cholesteatoma surgery is rather high and this calls for informed consent with very clear explanation of surgery and the possible adverse outcomes.

Reference

An audit of ‘dead ear’ after ear surgery.
Prinsley P.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1177-83.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Comparing gracilis free flap and pectoralis major after salvage laryngectomy
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

A pharyngocutaneous fistula (PCF) following total laryngectomy is the most common and challenging complication. Reported incidence varies widely 5-65% and there are multiple factors implicated, but their significance is still controversial. The current practice is of organ preservation with initial chemoradiation followed by salvage laryngectomy for recurrence. This practice increases the risk of a PCF by a factor of 2.6. Muscle flaps are often used in the prevention and treatment of PCF. Commonly pedicled flaps such as the pectoralis major or other free flaps are employed such as radial forearm free flap or the antero-lateral thigh free flap. The authors report their results with the gracilis muscle free flap, compared with the pedicled pectoralis major flap. They report 49 patients with post radiation recurrent laryngeal carcinoma over 10 years that underwent salvage laryngectomy, with 22 free gracilis free flaps and 27 patients with pectoralis major flaps. There were 12 complications in the pectoralis major group and eight in the gracilis group but fistula rates were similar. They discuss the advantages and disadvantages of both flaps and make a good case for immediate initial repair with a free flap and leaving the pectoralis major muscle for a future need. The authors present their experience clearly and suggest the gracilis free flap is a good alternative to the pedicled pectoralis major flap in the prophylaxis or treatment of PCF.

Reference

A comparison between the free gracilis muscle flap and pedicled pectorlis major flap reconstructions following salvage laryngectomy.
Jing SS, O’Neill O, Clibbon JJ.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014;67:17-22.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

The use of Integra™ to allow early cover wounds
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present the use of Integra™ in a unique cohort of patients. Seven patients ages 21-31 in a six month period treated in one hospital. These were a very fit group of patients that had injuries caused by improvised explosive devices and had limb and trunk injuries. With better medical evacuation and field services, more service personnel survive injuries that were fatal previously. Unfortunately, when first evacuated they have significant injuries apart from the massive soft tissue injuries. There is a relative lack of skin that can be used to close open wounds / amputation. These patients, whilst previously very fit, are now unable to undergo the complex surgery. This is in distinction to the more commonly encountered vascular patient with compromised physiology and motivation. The authors describe the use of Integra™ for early closure of the defects. Seven patients with 11 wounds were treated. Good take was noted in eight wounds and there was only one complete loss. Partial take was noted in two wounds. While this is a small number of patients, anything that helps in the treatment of this unique cohort of patients and these injuries in useful. There is also an introduction to this type of war injury and difficulty in treating it.

Reference

Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps.
Foong DPS, Evriviades D, Jeffery SLA.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1717-24.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Use of atenolol to treat infantile haemangiomas and comparison with propranolol group
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a prospective blinded series of 30 consecutive patients with infantile haemangioma (IH) treated with Atenolol, a selective beta-1 blocker. This is the first study comparing two different beta blockers. They achieved good results and they suggest this is because Atenolol is a more selective beta-1 blocker with fewer side-effects. All patients had significant IH. Prior to therapy all patients were screened for contraindications and an ECG was performed. Atenolol was administered to all patients with IH, orally. Patients were evaluated around two, eight and 20 weeks, weight, BP and heart rates as well as photographic records were noted. Side-effects were determined and documented. The data was compared with the propranolol group. The accepted treatment of IH is with beta-blockers. This study proposes fewer side-effects and significantly fewer serious side-effects, such as hypoglycaemia or bronchial hypersensitivity. While an interesting study, there still remains a number of questions. Although the authors do correct for age, the Atenolol group were treated at a younger age. It is a small group of patients with promising initial results and needs more investigation. This is echoed by the authors themselves.

Reference

Treatment of infantile haemangiomas with atenolol: comparison with a historical propranolol group.
de Graaf M, Raphael MF, Breugem CC, et al.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1732-40.

JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Wide local excisions for dermatofibrosarcoma protuberance
Reviewed by: Sunil Kumar Bhatia
September/October 2014 (Vol 23 No 4)
 

The authors present a viable alternative treatment for Dermatofibrosarcoma protuberance (DFSP). They show that wide local excision for DFSP can achieve a good result, saving the patient multiple visits to undergo Mohs surgery. The accepted method of treatment is surgery, be it Mohs or wide local excision (WLE). Mohs surgery has been suggested as the standard of care. The advantage of WLE is the single procedure. The authors present a retrospective analysis of 10 years of all cases of DFSP treated with WLE by a single operator. Twenty patients were identified; all patients had excision and reconstruction as one procedure. There were no incomplete excisions and no recurrences were recorded. They do not report any post complications or recurrences over 5.6 years of follow-up. Apart from the excisions none of the patients had any other treatment. It is a sound study with a good discussion. The authors accept it being a small group and a very diverse one, as the sites include head, torso and limbs. One can identify with their statement, ‘WLE with immediate reconstruction offers complete excision of DFSP and allows safe, reliable excision of the tumour without the need for a two staged operation without compromising the long-term outcome.’

Reference

To Mohs or not to Mohs.
Kokkinos C, Sorkin T, Powell B.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2014:67 23-6.

JOURNAL OF ULTRASOUND IN MEDICINE

Ultrasound and MRI for NPC
Reviewed by: Badr E. Mostafa
September/October 2014 (Vol 23 No 4)
 

The traditional radiological evaluation of patients with suspected nasopharyngeal carcinoma (NPC) is CT and MRI. The authors compared MRI and ultrasonography of the nasopharynx of patients with biopsy proven disease. Both sonography and MRI had good diagnostic performance for nasopharyngeal carcinoma. There was no significant difference in the rate of tumor detection between sonography and MRI (p= 0.12); the specificities of sonography and MRI were also similar (p= 0.22). However, sonography is less expensive and easier to perform. The results of this study also suggest that nasopharyngeal sonography could be used for the initial investigation of primary nasopharyngeal carcinoma. This is a very attractive alternative to MRI but the main disadvantage of ultrasound remains: it is highly operator dependant.

Reference

Diagnostic Accuracy of Sonography Versus Magnetic Resonance Imaging for Primary Nasopharyngeal Carcinoma.
Gao Y, Zhu SY, Dai Y, et al.
JOURNAL OF ULTRASOUND IN MEDECINE
2014;33(5):827-34.

JOURNAL OF VESTIBULAR RESEARCH

Discussion of the dizziness handicap inventory
Reviewed by: Fiona Barker
September/October 2014 (Vol 23 No 4)
 

This paper purported to be a review of the dizziness handicap inventory. The authors start (and finish) by stating that the DHI is the most widely used self-report scale used to assess handicap in context of vestibular dysfunction. While this is probably the case this statement was not referenced or justified and, as this paper did not compare studies which used the DHI versus other measures, this review failed to add to the evidence in this regard. It was not clear whether this was meant to be a review of the validity, reliability and consistency of the DHI or whether it was attempting to review its effectiveness as an outcome measure. I’m afraid it did neither. The paper begins by stating that 227 articles met the inclusion criteria but only 74 were reviewed. The inclusion criteria for the review were rather ‘woolly’. It was not clear on what basis this selection of 74 studies was made. Not a great start! The main body of the paper appeared to be a list of studies using the DHI. There was no narrative or meta-analysis and no assessment of study quality despite the fact that some of the individual studies contradicted each other. In short, there was an absence of critical appraisal which is an essential element of a review of any body of evidence. This was a summary of evidence at best rather than a review. As a clinician, what I would like to know from a paper like this is whether the DHI measures what we think it measures and whether it is any good as an outcome. I’m afraid this paper did not answer either question for me.

Reference

Discussion of the dizziness handicap inventory.
Matlu B, Serbetcioglu B.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:271-7.

JOURNAL OF VESTIBULAR RESEARCH

Using the international classification of functioning disability and health (ICF) in the context of vestibular rehabilitation
Reviewed by: Fiona Barker
September/October 2014 (Vol 23 No 4)
 

There should be something of interest in this paper for those interested in measuring outcome in vestibular rehabilitation. The paper introduces and describes the ICF and how it is being applied in this context. As the ICF is a global health classification system many of its categories do not apply in the context of vestibular work and the author describes how a relevant core set of classifications has been defined. This breaks the huge scope of the ICF into more manageable chunks that can be applied in clinical practice and to inform research. In particular the author suggests that this framework might be useful in the development of future outcome measures for vestibular rehabilitation that might more comprehensively capture the range of impairments, participation restrictions, activity limitations, barriers, facilitators and personal factors that impact on outcome. Using an agreed theoretical framework such as this to inform future research can only be a good thing and this paper presents a good introduction for those not familiar with the ICF.

Reference

Introduction to the international classification of functioning disability and health – ICF – in the context of vestibular rehabilitation.
Graziano M.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:293-6.

LARYNGOSCOPE

Vascularised tissue in salvage total laryngectomy
Reviewed by: Mark Puvanendran
September/October 2014 (Vol 23 No 4)
 

Chemoradiation (CRT) has become the mainstay for locally advanced laryngeal cancer since the RTOG 91-11 trial. Unfortunately there is still a substantial demand for salvage laryngectomies, which have a higher complication rate, the most notable being pharyngocutaneous fistula (PCF). Several small studies have suggested that using vascularised tissue from outside the radiation field reduces the risk of PCF; this systematic review aims to identify evidence for this. The authors are a distinguished international group, who have carried out a vigorous systematic review. The search strategy is clearly described; inclusion criteria and excluded studies are clearly detailed. The outcome considered, the presence or absence of PCF, is not subject to bias. Ultimately seven articles (591 patients) made the grade and were included in the analysis. The PCF incidence was 31.2% in the primary closure group compared with 22.2% in the flap reconstruction group. PCF carries a significant morbidity, increases hospital stay and may lead to death. The reduction of the incidence by one-third is a significant finding; this paper is essential reading for all head and neck surgeons and should inform future practice in salvage total laryngectomy.

Reference

Vascularized tissue to reduce fistula following salvage total laryngectomy: A systematic review
Paleri V, Drinnan M, van den Brekel MW, et al.
THE LARYNGOSCOPE
2014;124(8):1848-53.

NEUROSURGERY

Caffeine consolidates memory?
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Although caffeine has been touted as a cognitive enhancer, promoting vigilance, improving reaction times, and facilitating passive learning, the role of caffeine on short memory has been inconsistently described while studies on long-term memory are few. The authors of this paper conducted a randomised, double-blind, placebo-controlled trial at Johns Hopkins exploring memory consolidation in caffeine-naïve, healthy young volunteers. After performing an incidental encoding task involving visual images in an indoor-outdoor judgment paradigm, participants received either placebo or a dose equivalent to one short, eight-ounce cup of Pike Place Starbucks coffee. Baseline, 1-hour, and 3-hour saliva samples were obtained to measure caffeine metabolite levels. Participants returned to perform a second task to evaluate their recognition performance. The study showed that a one-time dose of caffeine administered after an incidental learning task enhanced a participant’s ability to differentiate similar images in a task 24 hours later, suggesting that caffeine intake improves long-term memory consolidation. The authors conclude that although further research is needed into the effects of caffeine on memory consolidation, the current evidence indicates that caffeine has benefits beyond prevention of neuronal loss.

Reference

Morning Joe or after-dinner espresso? Improved memory consolidation after caffeine administration.
Kelly KM, Mikell CB, McKhann GM
NEUROSURGERY
2014:74(6)N8-N11.

NEUROSURGERY

Flexible neuroendoscopic management of hydrocephalus
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Neuroendoscopy has revolutionised the management of intracranial clinical conditions and its applications are continuously expanding. In this article, the authors have described their 17 year experience using a flexible neuroendoscope to manage fourth ventricle outflow obstruction in patients with hydrocephalus. Traditionally, patients with fourth ventricle outflow obstruction are managed with a ventriculoperitoneal shunt or endoscopic third ventriculostomy. The authors performed endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty in 30 patients. Of these, 26 patients had long-term follow-up; 17 (65.3%) of these had clinical improvement and did not require further procedures. Nine (34.7%) did not improve. Of these, eight required another procedure (seven shunts, and one endoscopic procedure) and one patient died. The authors describe the procedure as safe, feasible and with minimal risk of periaqueductal injury.

Reference

Endoscopic transventricular transaqueductal magendie and luschka foraminoplasty for hydrocephalus.
Torres-Corzo J, Sánchez-Rodrıguez J, Cervantes D, et al.
NEUROSURGERY
2014:74:426-36.

NEUROSURGERY CLINICS OF NORTH AMERICA

Occipital nerve modulation for chronic migraine
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Chronic migraine is a source of significant disability, loss of productivity and impairment in health related quality of life. Pharmacotherapy of migraine includes preventive agents and abortive agents. Preventive agents include anticonvulsants, anti-depressants, beta-adrenergic blockers and serotonin antagonists. Abortive agents include non-steroidal anti-inflammatory agents, tryptans, opioids, ergot compounds and sedatives. This review article discusses the role of peripheral neuromodulation in the treatment of chronic migraine. Traditional neurosurgical procedures like dorsal root entry zone lesioning, dorsal root ganglionectomy, peripheral neurolysis and neurectomy have not gained any favour. On the other hand, occipital nerve stimulation is a non-destructive alternative. Although the mechanism of peripheral neuromodulation is unknown, two theories have been proposed for its mechanism of action – the first theory is similar to the pain gate theory implicated in the mechanism of spinal or peripheral nerve stimulation for somative neuropathic pain. The second theory is based on PET imaging which suggests that occipital nerve stimulation results in retrograde modulation of the brainstem nuclei involved in the trigeminal vascular system thus inhibiting migraine headaches.

Reference

Peripheral neuromodulation for treatment of chronic migraine headache.
Tavanaiepour D, Levy RM.
Neurosurgery Clinics of North America
2014:25(1):11-14.

NEUROSURGERY QUARTERLY

Artificial dura for sellar reconstruction
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

Transsphenoidal pituitary adenoma removal is often associated with large skull base defects and cerebrospinal fluid (CSF) leaks. This article adds to the existing literature on repair of the skull base defects to prevent CSF leaks. The authors used absorbable hemostatic cotton and gelatin sponge for intrasellar packing and a double layer of artificial dura mater and fibrin glue to manage CSF leaks. This obviated the need for tissue grafts. The authors suggest that over packing should be avoided to prevent compromise of the vascular supply, pituitary or optic chiasm function. The artificial dura used is water tight and is gradually absorbed to be replaced by connective tissue, thus forming a dura-like tissue to repair the sellar floor defect. The authors had an incidence of 1.3% CSF leaks postoperatively using this repair.

Reference

Sellar reconstruction using biomaterials after transsphenoid surgery in 449 cases of pituitary adenomas.
Du J, Qui B, Wang Y, et al.
NEUROSURGERY QUARTERLY
2014;24(1):22-6

NEUROSURGERY QUARTERLY

Familial glossopharyngeal neuralgia
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

The authors report the unusual occurrence of glossopharyngeal neuralgia in a 73-year-old male and his female sibling. The patients had bouts of sharp stabbing pain on the right side of the chin, ear, posterior tongue and pharynx lasting five to 10 seconds. The female sibling had syncopal attacks with paroxysmal pain. MRI scans showed a dolichoectatic vertebral artery compressing the glossopharyngeal nerve. 10 % lidocaine spray to the pharynx provided temporary relief. Pregabalin 150mg twice daily relieved the male patient’s symptoms and the female patient did not have any more syncopal attacks. This must be a one of the first reports of familial glossopharyngel neuralgia.

Reference

Glossopharyngeal neuralgia due to familial dolichoectatic vertebral artery.
Çöven Í, Çoban G, Horasanh B, Ílik MK.
NEUROSURGERY QUARTERLY
2014;24(1):44-6.

NEUROSURGERY QUARTERLY

Post-traumatic pseudoaneurysm causing near fatal epistaxis
Reviewed by: Gauri Mankekar
September/October 2014 (Vol 23 No 4)
 

This case report describes a rare case of near-fatal epistaxis with loss of consciousness in an 18-year-old boy, two months after head injury. The patient had repeated episodes of profuse epistaxis associated with loss of consciousness requiring blood transfusion. CT scan and MRI showed a destructive midline giant mass in the skull base lateralising to the left side, eroding the skull base, reaching the sphenoid sinus and posterior nasal boundaries. Initial CT angiography showed a giant aneurysm originating from the infraophthalmic segment (cavernous portion) of the left internal carotid artery. Carotid stenosis, unusual for an 18 year old, was noted at the origin of the pseudo aneurysm. The patient underwent transcervical ligation of the left carotid in the neck after angiography supported a good collateral circulation. Despite this procedure the epistaxis continued and a subsequent angiogram revealed small feeder vessels from the ophthalmic artery feeding the neck of the pseudoaneursym. The patient underwent a left carotid artery ligation (supraclinoidal) with exclusion of the ophthalmic artery via a left pterional craniotomy. Although traumatic carotid pseudoaneursyms are a rare cause for epistaxis, clinicians should be able to make early diagnosis, split second decisions and manage the situation promptly as the mortality rate can be as high as 50%.

Reference

Near-fatal epistaxis from traumatic giant carotid artery pseudoaneursym: a case report.
Rashad S, Hassan T, Eldawoody HF.
NEUROSURGERY QUARTERLY
2014;24(1):56-62.

ORL

TORS for OSA: outcomes and bench-marking
Reviewed by: Zi Wei Liu
September/October 2014 (Vol 23 No 4)
 

This is a large multicentre retrospective observational study of the outcomes of transoral robotic surgery (TORS) for obstructive sleep apnoea (OSA) in 243 cases. Tongue base and supraglottic level obstruction is the main indication for TORS in OSA patients. Postoperatively, patients experienced significant improvements in apnoea-hypopnoea index (AHI), Epworth sleepiness score (ESS) and lowest O2 saturation without a significant change in BMI. 53.8% of patients were no longer continuous positive airway pressure (CPAP) dependent (AHI <15 and ESS <10) and 66.9% had a significant reduction in daytime somnolence and cardiovascular risk factors (AHI <20, ESS <10). The most common complication is temporary mild hypogeusia. Forty-five percent of patients received a temporary tracheostomy as routine practice in some centres. In this series TORS was performed as part of a multi-level procedure in 86% and patients also received nasal surgery (59%), tonsillectomy (60%) and uvulopalatopharyngoplasty (UVPP) (60%). Follow-up time was short (minimum three months) and long-term efficacy of TORS cannot be determined from these data alone. The multifactorial nature of OSA is reflected in the need for multi-level procedures and accurate pre-operative assessment of key contributory factors to OSA is crucial to successful outcomes. However, it is difficult to establish the effects of TORS alone given most patients require multiple procedures. Long-term follow-up data is required on efficacy and rates of recurrence.

Reference

Clinical outcomes and complications associated with TORS for OSAHS: a benchmark for evaluating an emerging surgical technology in a targeted application for benign disease.
Vicini C, Montevecchi F, Campanini A, et al.
ORL
2014;76(2):63-9.

ORL

Which patients habituate to tinnitus? The role of trigger factors and success of tinnitus retraining therapy
Reviewed by: Zi Wei Liu
September/October 2014 (Vol 23 No 4)
 

Tinnitus arises from perception of electrical activity in the auditory system without external stimulus. Although a very common symptom, few patients are sufficiently troubled by tinnitus to seek medical attention. Those that do are said to associate tinnitus with negative emotional states through a learning process, generating a conditioned reflex. This study looked at the effectiveness of tinnitus retraining therapy (TRT) when related to severity of tinnitus, presence of hyper- and hypoacusis and identifiable trigger factors. A total of 294 patients who had experienced incapacitating tinnitus for at least six months were treated, followed up for a minimum of 18 months and had outcomes assessed using a visual analogue scale and Tinnitus Handicap Inventory (THI). Eighty percent of patients improved following treatment and all those with mild or recent onset of symptoms improved. Where the main symptom is tinnitus, 90% improve following treatment. With associated hyperacusis, 78% of patients improve. Where hearing loss is associated with tinnitus, only 59% of cases improve. The study group was able to identify factors which precipitated tinnitus onset in 66% of patients. They were able to show significantly better habituation where a trigger factor was identified (91% vs 56%). In patients with hypoacusis and absence of trigger factors, the outlook was worst (28% improvement). The authors suggest TRT should be adapted in patients without trigger factors correlating with tinnitus and that hearing aids should be used to complement therapy where necessary.

Reference

Impact of Identifying Factors Which Trigger Bothersome Tinnitus on the Treatment Outcome in Tinnitus Retraining Therapy.
Molini E, Faralli M, Calzolaro L, Ricci G.
ORL
2014;76(2):81-8.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

“I’ve got sinus”
Reviewed by: Charlie Giddings
September/October 2014 (Vol 23 No 4)
 

This edition of the journal tackles headaches in otolaryngology, especially those thought to be rhinogenic in origin. For patients presenting with “sinus headache” symptoms a comprehensive history, detailed examination of the nose and correlation with imaging is essential. Meticulous investigation is as important as a close working relationship with a neurologist. International classifications of headache support acute rhinosinusitis as a cause of secondary headache if in conjunction with appropriate clinical findings. The literature is less clear with regard to chronic sinusitis, and this edition of the journal is a must read for any budding rhinologist. The review recognises conflicting literature as there is cross over between primary headache symptoms, and many studies lack strict diagnostic criteria and outcome measurements. Some studies have suggested that up to 90% of sinus headaches may be migraine, others studies reveal that migraine headache may not present in isolation. Much needed consistency in the management of this group of patients is needed and the article is a reiteration that surgery is far from the first choice treatment. Further quality literature would be welcome to define if headache attributed to disorders of the nasal mucosa, turbinates or septum, formerly “intranasal mucosal contact point headache”, is a remote justification for surgery.

Reference

What do we know about rhinogenic headache?
Mehle ME, Schreiber CP.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2014;47:255-68.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Confirmation that Epley is more effective than watchful waiting for p-BPPV
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This systematic review of eight papers posed the question ‘What is the effectiveness of watchful waiting compared to the Epley manoeuvre (EM) in patients diagnosed with posterior canal benign paroxysmal positional vertigo (BPPV) regarding symptom relief?’. Posterior semicircular canal BPPV (p-BPPV) is the most common form of BPPV, a disorder that has a significant impact on daily living. Up to 37% of patients cannot work and 18% avoid leaving their homes. This review of eight papers suggested that for ‘subjective symptom relief’ at one week, all studies showed a strong effect (varying from 20% to 59%) in favour of the EM. This effect was found to decrease over a longer follow-up period. The authors highlight the discrepancy in study protocols, with some advocating repeated cycles of the manoeuvre, which may account somewhat for the wide variation in efficacy. The authors conclude that, given the low cost and low risk of side-effects, the EM should be considered in every patient with p-BPPV and suggest increasing training for general practitioners to perform this procedure in the community.

Reference

Rapid systematic review of the Epley Maneuver for treating posterior canal benign paroxysmal positional vertigo.
Van Duijn JG, Isfordink LM, Nij Bijvank JA, et al.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2014;150(6):925-32.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

How to make a quinsy simulator
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This study evaluated the success of a peritonsillar abscess simulator for training residents in the skill of abscess drainage. Although not technically difficult, the authors concede that new residents may be intimidated by the prospect of having to perform this procedure during their first on-call. Simulators allow for safe repetition and a controlled environment to develop one’s confidence without having to manage patient anxiety and distress at one’s first attempt. A latex mould with indentations representing the tonsils and uvula was created over a clay cast. This was secured at the end of a 2.5 inch diameter pipe to simulate the limited space of the oropharynx. A small balloon filled with vanilla pudding and placed behind 3mm-thick polyurethane foam simulated the abscess lying behind mucosa and submucosal space. Lips were created from clay and the oral opening was 3cm high and 5cm wide. A rubber tongue taken from a mannequin was secured in the oral cavity. A flexible scope was mounted with video recording. The pilot study evaluated residents and medical students in performing abscess drainage and evaluated their responses. All participants felt that the simulator replicated the skills necessary to drain a quinsy. Ninety percent agreed that the simulator helped in learning how to anaesthetise the area and aspirate the abscess. Fifty percent felt it was a good anatomical representation. The authors claim an initial cost of 10 dollars, with disposable parts costing 25 cents, and demonstrate their simulator to be a low-cost tool for providing training whilst minimising risk to patients.

Reference

Novel peritonsillar abscess task simulator.
Taylor SR, Chang CWD
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2014;151(1):10-3.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Sparse evidence for benefit of hearing aids for tinnitus
Reviewed by: Hannah Blanchford
September/October 2014 (Vol 23 No 4)
 

This section of the journal helpfully highlights a recent Cochrane review. It aims to help clinicians evaluate the effectiveness of interventions for tinnitus. The authors of the Cochrane review, for which only one randomised controlled trial met the inclusion criteria, concluded that current evidence for prescribing hearing aids for tinnitus is limited. This RCT of 91 patients with hearing loss above 2kHz compared hearing aids with sound generators and found no difference in outcomes (measured by the Tinnitus Handicap Inventory). As only one paper was eligible for inclusion, the authors highlight the deficit of robust evidence in this field. The commentators suggest the authors should have concluded that patients with tinnitus and mild hearing loss who receive tinnitus retraining therapy (TRT) and either a sound generator or an open hearing aid find an improvement in their tinnitus over time, but that current research does not allow us to define whether this is due to the sound generators, hearing aids, TRT or none of these. Also, if part of the improvement is due to sound generators or hearing aids, there is no evidence to suggest that one is better than the other. The authors suggest that, despite the absence of evidence in favour of hearing aids for tinnitus, where the only significant downside of hearing aids is cost, and the patient accepts this, it may still be reasonable to offer a trial of hearing aids.

Reference

Cochrane corner: amplification with hearing aids for patients with tinnitus and co-existing hearing loss.
Schilder AGM, Burton MJ, Eby TL, Rosenfeld RM.
OTOLARYNGOLOGY - HEAD AND NECK SURGERY
2014;150(6):915-18.

Otology & Neurotology

Fine tuning!
Reviewed by: Anand Kasbekar
September/October 2014 (Vol 23 No 4)
 

This neat little study provides us with evidence to quote when we are asked to find that elusive tuning fork on the postoperative ward round after tympanomastoid surgery. Essentially the authors, from Wolverhampton, UK, compared the Weber test with the scratch test in 56 major tympanomastoid operations and found that the scratch test is better! Overall, Weber's test had a sensitivity of 73.2% and specificity of 100% compared with a sensitivity of 89.3% and specificity of 100% for the scratch test. Bear in mind that a head bandage needs to be present and the ‘scratch’ should be performed over the centre of the forehead on the bandage.

Reference

How reliable is the "scratch test" versus the Weber test after tympanomastoid surgery?
Iacovidou A, Giblett N, Doshi J, Jindal M.
OTOLOGY & NEUROTOLOGY
2014;35(5):762-3.

Otology & Neurotology

Myringoplasty in children with cleft palate
Reviewed by: Anand Kasbekar
September/October 2014 (Vol 23 No 4)
 

Although we know that cleft palate (CP) patients generally have poor eustachian tube function, little is known on how these patients fare after myringoplasty when compared to the general population. Do they really perform worse? Previously published literature has mixed views. This well-conducted French retrospective study compares the results of underlay cartilage myringoplasty in children with and without CP. Both groups had an average age of 10.5 years at operation. Thirty-two CP patients had 32 matched non-CP controls and the closure rate of the perforation was the same in both groups (84%), helped by the cartilage support I suspect. The authors state that the matching process selected control patients with greater otologic disease hence the closure rate was the same and not better than in CP patients. Hearing results were however significantly worse in the CP group, but they were worse to begin with. Overall the message seems to be that if cartilage is used, the anatomical closure rate should be the same. Hearing outcome is likely to be worse in CP patients whichever method of grafting one uses.

Reference

Results of myringoplasty in children with cleft palate: a patient-matched study.
Harterink E, Leboulanger N, Kotti S, et al.
OTOLOGY & NEUROTOLOGY
2014;35(5):838-43.

PEDIATRIC ALLERGY AND IMMUNOLOGY

Is there a link between rhinitis and depression?
Reviewed by: Evangelia Tsakiropoulou
September/October 2014 (Vol 23 No 4)
 

Rhinitis and asthma are global health problems, increasingly common in childhood. There is a growing interest on the impact of respiratory allergies on quality of life, however, the association between allergic rhinitis and psychologic characteristics in children remains poorly understood. This study from Italy explored if there was a connection between rhinitis and depression in 1283 subjects aged 10-13 years old. Depressive and anxious mood states were assessed using the Depression and Anxiety in Youth Scale, along with spirometry and skin prick tests. Anxiety (16%) and depression (13.6%) rates were higher than comparable literature when rhinitis was present. Additionally, female gender was directly linked to anxiety but not with depression.. The authors state that female gender is an indirect risk factor for both depressive state and rhinitis. The authors recognise the self-reported data as a study limitation. Furthermore they did not explore any other psychological or environmental variables that could influence the relation between rhinitis and mood. The introduction of mood management in clinical care along with control of rhinitis could reduce disease burden.

Reference

Rhinitis as a risk factor for depressive mood in pre-adolescents: a new approach to this relationship
Audino P, La Grutta S, Cibella F, et al.
Pediatric Allergy and Immunology
2014:25(4):360-5.

RHINOLOGY

Bacterial biofilms in patients with chronic rhinosinusitis: a confocal scanning laser microscopy study
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

Biofilms on sinonasal mucosa have been implicated in the development of chronic rhinosinusitis. Current methods to investigate biofilms on sinonasal mucosa include traditional light microscopy, electron microscopy and confocal microscopy. This study investigates the presence of biofilms in 61 patients with chronic rhinosinusitis and septal deviation undergoing primary functional endoscopic surgery, and 25 controls (no chronic rhinosinusitis but septal deviation present), using confocal scanning laser microscopy. Bacterial biofilms were detected in 90% of patients with chronic rhinosinusitis, significantly more than in controls, in which 56% were biofilm positive. The point prevalence of biofilms in the control group was found to be relatively high compared to other similar studies. A possible explanation for this was that patients undergoing septoplasty were used as the controls in this study whereas in other studies reporting low prevalence of biofilms in the control group were completely free of nasal complaints (undergoing skull base surgery). This may point to a role for biofilms in the pathogenesis of patients with nasal obstruction without chronic rhinosinusitis. However, further studies are required.

Reference

Bacterial biofilms in patients with chronic rhinosinusitis: a confocal scanning laser microscopy study.
Danielsen KA, Eskeland O, Fridrich-Aas K, et al.
RHINOLOGY
2014;52(2):150-5.

RHINOLOGY

External nasal valve collapse: validation of a novel outcome measurement tool
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

In this study, the authors devised a grading system that measures external nasal valve collapse in each nostril both at rest and on deep inspiration. This is based on a subjective measurement score ranging from 0-4. This grading system was then validated by firstly assessing reliability (inter-rater agreement and test-retest repeatability) using sixteen rhinologists scoring clinical photographs separately on two occasions one year apart. Secondly, its clinical relevance in patients undergoing septorhinoplasty for external nasal valve collapse was evaluated with a prospective observational case series of twenty-six patients who were scored pre- and post-operatively. The devised scoring system was found to be reliable with substantial agreement between 16 surgeons which were reproducible over time. All patients in the prospective series showed significant improvement in their external valve score. The quality of life measured by the SNOT-22 tool also showed significant improvement after surgery. This is the first study to propose a scoring system for external nasal valve collapse and to validate it

Reference

External nasal valve collapse: validation of novel outcome measurement tool.
Poirrier Al, Ahluwalia S, Kwame I, et al.
RHINOLOGY
2014;52(2):127-32.

RHINOLOGY

Patient comfort following FESS and Nasopore® packing: a double blind, prospective, randomised trial
Reviewed by: Lakhbinder Pabla (Bal)
September/October 2014 (Vol 23 No 4)
 

This study aimed to determine patient comfort associated with nasal packing (a self-dissolving polyurethane foam pack) and the parameters of post-operative bleeding, nasal breathing, a feeling of pressure, headache, and general well-being and sleep disturbance, compared to no packing. One side was packed with Nasopore® after bilateral FESS whilst the opposite was not packed, thus acting as the control. A total of 57 patients were included across two centres and the observation period included the days of the inpatient stay. There were no significant differences between sides for post-operative bleeding and nasal breathing. The feeling of pressure was slightly less on the side packed with Nasopore® on post-operative days two and three. The authors suspect that this result was attributed to increased crusting in the absence of a pack. No trend could be observed regarding which side patients described as subjectively better. The main strength of this study is its methodology, in that it is a double-blind, prospective, randomised trial. Overall, this study concluded few differences between the side packed with Nasopore®, and the unpacked side, and suggests further studies to evaluate this.

Reference

Patient comfort following FESS and Nasopore® packing, a double blind, prospective, randomized trial.
Kastl KG, Reichert M, Scheithauer MO, et al.
RHINOLOGY
2014;52(1):60-5.

SAUDI JOURNAL OTO-RHINO-LARYNGOLOGY & HEAD & NECK SURGERY

The role of budesonide saline solution for nasal irrigation in the management of allergic fungal rhinosinusitis: a prospective study
Reviewed by: B Viswanatha
September/October 2014 (Vol 23 No 4)
 

Allergic fungal rhinosinusitis is a non-invasive form of rhinosinusitis that often recurs despite aggressive treatment. This prospective trial was conducted from February to August 2009 and included seventeen patients. The study employed budesonide saline solution as nasal irrigation on a twice-daily protocol for three weeks. All patients underwent pre- and post-endoscopic assessment using the Kupferberg staging system, and patient questionnaires (the Modified Arabic Sinonasal Outcome Test (MA-SNOT)). The important findings were: budesonide saline irrigation improved the overall well-being of all the patients both objectively and subjectively; endoscopic staging showed significant improvement when this treatment protocol was utilised; endoscopic examination revealed a decrease in allergic mucin; patient symptom scores, assessed by the MA-SNOT, improved significantly for all categories; and an improved sense of smell and decreased rhinorrhoea was observed in many patients. The authors state that this is the first study reported in the literature on the treatment of allergic fungal rhinosinusitis using budesonide saline solution, and conclude that it is a useful tool in the management of allergic fungal rhinosinusitis.

Reference

The efficacy of budesonide on management of allergic fungal rhinosinusitis.
Osma M, Amen A ,Tariq AF, et al.
Saudi Journal Oto-Rhino-Latyngology & Head & Neck Surgery
2014:16(1):20-23

SLEEP AND BREATHING

Positional therapy and surgery for OSA
Reviewed by: Vik Veer
September/October 2014 (Vol 23 No 4)
 

Every woman instinctively seems to know that if you roll a male sleeping companion on their side, they tend to sound less like a hog. The medical literature is finally catching up; an ever increasing catalogue of articles now describe this manoeuvre as ‘positional therapy’ (PT). An Amsterdam centre performed a retrospective analysis of its surgical outcome data on obstructive sleep apnoea (OSA) patients. The authors then performed a subgroup analysis based on whether the OSA severity was dependant on sleeping position or not. 48.9% of the 139 study population had positional OSA, but all patients were treated with a form of palatoplasty with or without radiofrequency ablation to the tongue base. It seems that surgery in patients with non-positional OSA resulted in a more pronounced reduction in the apnea-hypopnea index (AHI) than in patients with positional-type OSA. In positional OSA patients, the use of PT in some cases ‘cured’ patients bringing the AHI to below five. PT also greatly augmented the benefit gained from surgery in this patient group. The authors illustrated their case rather imaginatively by creating a theoretical flowchart for patients in their retrospective study. They exposed the fact that by having prior knowledge of positional OSA status, patients were able to effectively cure themselves with PT, thereby avoiding any surgery. Patients with non-positional OSA treated with surgery could also be converted to positional OSA patients post-operatively, allowing them the option of PT and further improving their results. The final message is clear; look carefully at the AHI results in different sleeping positions, and consider PT a valid treatment option in OSA patients.

Reference

Theoretical approach towards increasing effectiveness of palatal surgery in obstructive sleep apnea: role for concomitant positional therapy?
van Maanen JP, Witte BI, de Vries N.
SLEEP AND BREATHING
2014;18(2):341-9.

SLEEP AND BREATHING

Tonsillectomy for OSA
Reviewed by: Vik Veer
September/October 2014 (Vol 23 No 4)
 

This study describes the outcome of tonsillectomy in 34 adult obstructive sleep apnoea (OSA) patients who had grade three or four tonsils. The idea was to quantify the benefit of tonsillectomy in OSA patients compared to tonsillectomy in conjunction with more traditional OSA operations such as palatoplasty. In short, the results were very good when compared to most OSA surgery outcomes. A surgical response rate (defined as a 50% or greater reduction in the apnoea-hypopnoea index (AHI)) was seen in 71.4% of severe OSA patients, 77.7% of moderate OSA patients and 75% of mild OSA patients. Similar results were seen when analysing the respiratory disturbance index (a measure of events that disturb the sleep of the patient). The classic Freidman case series described the results of tonsillectomy with palatal surgery, which achieved roughly an 80% surgical response rate. One would wonder then how clinically beneficial palatal surgery is in these patients? The authors did attempt some subgroup analysis; however the numbers become rather small and difficult to comment on. Ideally the polysomnography results in each category would have been available (including for grade 1 and 2 tonsils), or enough power to do a subgroup analysis with a palatal surgery cohort followed by a crossover arm. These and other ideas, however, would make a modern ethics panel baulk in protest. In conclusion, I think most people know that removing big tonsils helps people breathe. This study is another step towards defining that with greater precision.

Reference

Effects of tonsillectomy on sleep study parameters in adult patients with obstructive sleep apnea - a prospective study.
Tan LT, Tan AK, Hsu PP, et al.
SLEEP AND BREATHING
2014;18(2):265-8.

THE HEARING JOURNAL

Potential hearing advantages in bilingual individuals
Reviewed by: Linnea Cheung
September/October 2014 (Vol 23 No 4)
 

In this short article by two American professors of neuroscience, the potential benefits of the bilingual brain over that of the monolingual in neural speech encoding are explored. They go on to review the work carried out by a group from the Northwestern University Institute of Neuroscience (one member of whom is also the author of this article) on this very topic in brief detail. This research of auditory neural responses to one syllable shows that a group of bilingual adolescents demonstrate better subcortical encoding of speech when compared with IQ and socioeconomically matched monolingual adolescents, both in quiet and in noise conditions, with a more marked effect in noise. Follow-up results illustrated greater consistent brainstem and cortical responses in the bilingual group compared to the monolingual group. There was positive correlation between response to signal with language proficiency as well as with selective attention in the bilingual group. Logical suggestions to explain these relationships include the presence of competing languages when subjects are trying to accurately perceive the speech signal in the presence of noise, and that the activation and suppression of different languages in the bilingual brain might strengthen efferent connections between the frontal cortex and brainstem. The research raises further questions regarding whether the effect of ageing and hearing loss may have an impact on speech-in-noise performance between bilinguals and monolinguals given that we already know speech-in-noise performance declines with age. It would be interesting to see how multilingual brains (i.e. more than two languages) compare even to bilingual individuals' performance, and with testing a variety of syllables, before we can decide whether it is truly advantageous to speak more than one language.

Reference

Bilingualism enhances neural speech encoding.
Kraus N, Anderson S.
THE HEARING JOURNAL
2014;67(7):40.

THE LANCET RESPIRATORY MEDICINE

The mighty allergy
Reviewed by: Badr Eldin Mostafa
September/October 2014 (Vol 23 No 4)
 

The coexistence of eczema, rhinitis and asthma was studied in a prospective cohort of children aged four and eight years in 12 European countries. The diseases were documented by a questionnaire and serum specific IgE to six allergens. The aim of the study was to determine whether the coexistence of these diseases was IgE related or a chance finding. The absolute excess of any comorbidity was 1·6% for children aged four years and 2·2% for children aged eight years; 44% of the observed comorbidity at age four years and 50·0% at age eight years was not a result of chance. Children with comorbidities at four years had an increased risk of having comorbidity at eight years. The final conclusion was the coexistence of all three diseases in children is more than expected by chance alone and that IgE hypersensitisation is not the dominant causal mechanism of comorbidity. Other factors seem at play and these should be studied as well.

Reference

Comorbidity of eczema, rhinitis, and asthma in IgE-sensitised and non-IgE-sensitised children in MeDALL: a population-based cohort study.
Pinart M, Benet M, Anesi-Maesano I et al.
THE LANCET RESPIRATORY MEDICINE
2014;2(2):131-40.

ACTA OTOLARYNGOLOGICA

Day case stapes surgery under local anaesthetic in Finland
Reviewed by: Victoria Possamai
July/August 2014 (Vol 23 No 3)
 

The authors start by stating that the common occurrence of postoperative vestibular disturbance may preclude day case stapes surgery. They carried out a prospective study of 20 patients undergoing stapedotomy under local anaesthetic and measured postoperative symptoms and recorded nystagmus with video-oculography, 30 minutes postoperatively. The nystagmus and vestibular symptoms showed no correlation. Nine patients had spontaneous horizontal nystagmus without gaze fixation (seven of nine showing an irritative pattern). Seven patients described nausea, though only one vomited. Nine experienced vestibular symptoms immediately postoperatively (vertigo in five, floating sensation in two and unspecific dizziness in two). All but one described this as mild-moderate. In five of these patients this had fully resolved within the first 50 minutes, however the duration of symptoms in the remaining four patients is not stated, and is highly relevant to the validity of the conclusion reached; that day case stapes surgery is a feasible approach.

Reference

Immediate postoperative nystagmus and vestibular symptoms after stapes surgery.
Hirvonen TP, Aalto H.
ACTA OTOLARYNGOLOGICA
2013;133:842-5.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Topical steroid sprays: importance of physical and chemical characteristics
Reviewed by: Edward W Fisher
July/August 2014 (Vol 23 No 3)
 

Topical nasal corticosteroids are so widely prescribed that perhaps the otolaryngologist’s thoughts are dominated more by efficacy than the differences between formulations and delivery method. We should take more interest in this subject. This paper from Memphis reviews the subject of side-effects, formulations and the volume of the agents. I would recommend this article, as I learned much that I perhaps should already have known. Subjects such as the reported incidence of adverse effects in all sprays (5-10%), candidiasis, the (doubtful) link with septal perforations, the effects of alcohol or thixotropic agents, potassium sorbate and the adherence of sprays (and its importance) are all covered. The aqueous versus aerosol difference seems to have been overplayed in the past, with little evidence that one causes more epistaxis than the other.

Reference

Intranasal corticosteroids topical characteristics: side effects, formulation and volume.
Petty DA, Blaiss MS.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(6):510-13.

AUDIOLOGY NEUROTOLOGY

Alternative middle ear implant fixation
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

This cadaveric temporal bone study examined the function of a Vibrant Soundbridge device, when the floating mass transducer (FMT) was attached to the short process of the incus rather than the long process. Fixation of the FMT to the short process of the incus confers the advantage of avoiding a posterior tympanotomy, whilst also reducing the risk of facial nerve and chorda tympani damage. Laser doppler vibrometry was used to measure movement of the stapes footplate and round window membrane, reflecting the input to the cochlea and intracochlear fluid dynamics, respectively. No significant difference was found in the velocity responses of the stapes or the round window, up to 6KHz. The authors conclude that short process FMT fixation may be an efficient and safe alternative surgical approach, though further work is required to achieve an optimal technique that will guarantee firm and reliable fixation in the long term.

Reference

Alternative Fixation of an Active Middle Ear Implant at the Short Process Incus.
Schraven SP, Dalhoff E, Wildenstein D, et al.
AUDIOLOGY NEUROTOLOGY
2014;19:1-11.

AUDIOLOGY NEUROTOLOGY

BAHA in single sided deafness
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

The authors of this paper sensibly start off by stressing the disability and impaired quality of life associated with single sided deafness (SSD). They highlight the potential for a bone anchored hearing aid (BAHA) to rehabilitate this group of patients, whilst acknowledging that it will not be taken up by all. There follows a retrospective review of patients presenting with SSD, aiming to identify the reasons why patients do not proceed to surgery and, ultimately, to optimise the rehabilitation of future patients. The authors reviewed 102 patients who had undergone a BAHA assessment, analysing the results of audiometry during a BAHA trial (tests of speech recognition in nose, multi-directional gain, and sound localisation), a Glasgow Health Status Inventory (GHSI) survey, and, for those who had refused BAHA, a questionnaire assessing their reasons. Overall, 29% of patients with SSD opted to receive BAHA. Interestingly, duration of deafness did not impact on the decision to proceed to BAHA surgery, perhaps due to the self-selected nature of this group. There was no statistically significant difference between the scores of the implanted and non-implanted groups in any domain of the GHSI. There were two reasons, on average, why patients refused BAHA, including absence of benefit during testing (59%), the need for surgery (35%), aesthetic concerns (41%) and the cost of the prosthesis (44%). The authors recommend a minimum improvement of 20% in understanding of speech-in-noise or a 4dB improvement in aided thresholds with a BAHA on a headband, before considering surgery.

Reference

Baha-Mediated Rehabilitation of Patients with Unilateral Deafness: Selection Criteria.
Saroul N, Akkari M, Pavier Y, et al.
AUDIOLOGY NEUROTOLOGY
2014;19:85-90.

AUDIOLOGY NEUROTOLOGY

Cone beam and micro- CT to assess minimally invasive cochlear implantation
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

This study reports the use of cone beam computed tomography (CT), to assess electrode position, and micro-CT, to assess the extent of intra-cochlear trauma, following cochlear implantation using a direct cochlear access approach in eight cadaveric temporal bones. This approach utilises an image-guided robot to drill a 1.8mm tunnel from the mastoid surface to the inner ear, followed by a manual electrode insertion. The aim of this technique is to provide a more optimal angle of electrode insertion than might be available with other minimally invasive techniques, e.g. the suprameatal approach. The authors concede some of the disadvantages of this approach, including the need for a tympanomeatal flap, cost and the routine use of ionising radiation. Just 3/8 procedures resulted in an atraumatic insertion into the scala tympani, with the rest demonstrating disruption of the basilar membrane or incorrect positioning of the electrode in the scala media or vestibuli. Five out of the eight procedures required the use of traditional surgical instruments to position or advance the electrode array via the tympanomeatal flap and tympanotomy. At an estimated surgical time of two hours, it is a little difficult to see the benefit of this technique over the standard facial recess approach (other than avoiding what the authors describe as a ‘substantial’ mastoidectomy). Nonetheless, this is early work and it will be interesting to see how robotic techniques develop in cochlear implantation in the future.

Reference

Cone Beam and Micro-Computed Tomography Validation of Manual Array Insertion for Minimally Invasive Cochlear Implantation.
Wimmer W, Bell B, Huth ME, et al.
AUDIOLOGY NEUROTOLOGY
2014;19:22-30.

AUDIOLOGY NEUROTOLOGY

Simulation of middle ear surgery
Reviewed by: Stephen James Broomfield
July/August 2014 (Vol 23 No 3)
 

The authors of this paper describe the development of a computer model for simulating middle ear surgery. The need for such a model is clear, and otologists, young and old, struggle with the difficulty of balancing the need to train new surgeons with the need to protect patients from iatrogenic harm. Whilst temporal bone training remains the gold standard, the authors highlight some of its limitations; inability to reproduce disease, unrealistic environment (e.g. no mucosal bleeding), no measure of functional results. The authors used micro-magnetic resonance imaging to build a finite-element model of the ossicular chain. Anatomical measurements and middle ear mechanical parameters from published temporal bone studies were incorporated. The model was analysed by assessing the middle ear transfer function. Surgeons were then able to manipulate the simulated ossicles, whilst receiving haptic feedback, real-time measures of ossicular displacement and functional results of surgery. Undoubtedly this type of simulation will form a part of otological training in the future, in addition to its use in researching middle ear mechanics and the development of ossicular prostheses.

Reference

Validation Method of a Middle Ear Mechanical Model to Develop a Surgical Simulator.
Kazmitcheff G, Miroir M, Nguyen Y, et al.
AUDIOLOGY NEUROTOLOGY
2014;19:73-84.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Changing trends in the management of osteoradionecrosis
Reviewed by: Sampath Chandra Prasad
July/August 2014 (Vol 23 No 3)
 

In the wake of new drugs that have been introduced for ORN like pentoxifylline, tocopherol, clodronate etc, traditional ‘conservative’ management of osteoradionecrosis (ORN) including minimal surgical debridement and hyperbaric oxygen therapy (HBOT) is under review. This study is a retrospective review of treatment outcomes of ORN of the mandible with specific reference to the evolving role of medical management with pentoxifylline (400mg twice daily), tocopherol (1000 IU/mg/day) and doxycycline (100 mg daily). The authors reviewed the presentation and management of 71 patients treated for ORN of the mandible at the regional head and neck unit during a 15-year period, and categorised them into three grades using the Notani classification: grade I (n=28), grade II (n=16), and grade III (n=27). Twelve patients with grade I ORN, three with grade II, and 10 with grade III, were prescribed medical treatment. Of these, three with grade I, and two with grade II ORN were cured, and progression of the disease had halted and there was satisfactory control of symptoms in eight with grade I and four with grade III disease. Patients who failed to respond to conservative treatment were further analysed for the need for free flap reconstruction. Medical management was introduced as a standard treatment after January 2006. Of the 39 patients diagnosed before this, 20 (51%) required resection and free flap reconstruction compared with only 8/32 (25%) after it had been introduced.

Reference

Changing trends and the role of medical management on the outcome of patients treated for osteoradionecrosis of the mandible: experience from a regional head and neck unit.
D’Souza J, Lowe D, Rogers SN.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2014;52(4):356-62.

COCHLEAR IMPLANTS INTERNATIONAL

A special signal processing algorithm developed to improve speech recognition in noise
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

ClearVoice is a special signal processing algorithm developed by one of the cochlear implant companies with the aim to improve speech recognition and listening comfort in noise. The study's objectives were to evaluate speech recognition in multiple listening conditions using several noise types with HiRes 120 and ClearVoice (Low, Medium, High) and to determine which ClearVoice program was most beneficial for everyday use. The authors assessed 15 postlingually deafened adults who attended four sessions; speech recognition was assessed at sessions one and three with HiRes 120 and at sessions two and four with all ClearVoice programs. Test measures included sentences presented in restaurant noise (R-SPACETM), in speech-spectrum noise, in four- and eight-talker babble, and connected discourse presented in 12-talker babble. Participants completed a questionnaire comparing ClearVoice programs. The results revealed that significant group differences in performance between HiRes 120 and ClearVoice were present only in the R-SPACETM; performance was better with ClearVoice High than HiRes 120. Among ClearVoice programs, no significant group differences were present for any measure. Individual results revealed most participants performed better in the R-SPACETM with ClearVoice than HiRes 120. For other measures, significant individual differences between HiRes 120 and ClearVoice were not prevalent. Individual results among ClearVoice programs differed and overall preferences varied. Questionnaire data indicated increased understanding with High and Medium in certain environments. It seems that, although there are several improvements, cochlear implants are still far for optimising speech recognition in noise.

Reference

Postlingual adult performance in noise with HiRes 120 and ClearVoice Low, Medium, and High.
Holden LK, Brenner C, Reeder RM, Firszt JB.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):276-86.

COCHLEAR IMPLANTS INTERNATIONAL

Acute mastoiditis in children with cochlear implants: can we save the device?
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

Acute otitis media and its complications (including acute mastoiditis) are device-threatening conditions, along with the associated morbidity in implanted children. Despite the significant risks associated with mastoiditis, including compromise of the implant, there are no specific guidelines on the management of this population. The authors aimed to develop a treatment algorithm based on their experience. A retrospective chart review included eight patients, who experienced mastoiditis, in the context of cochlear implantation, during a period in which 806 implants had been performed. The median age at which mastoiditis occurred was 37 months, and the mean time from implantation to mastoiditis was 9.5 months. All patients underwent drainage of the middle ear in conjunction with intravenous antibiotics, and two additionally underwent post-auricular incision and drainage. All devices were saved and no explantation was performed. The authors propose an algorithm that involves rapid initiation of aggressive antibiotic therapy and a low threshold for conservative operative intervention, resulting in effective resolution of infection, while allowing preservation of the implant. A national or international multi-centre study with large numbers of patients would help us establish a valid treatment algorithm for each complication of cochlear implant patients.

Reference

The management of acute mastoiditis in children with cochlear implants: Saving the device.
Osborn HA, Cushing SL, Gordon KA, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):252-6.

COCHLEAR IMPLANTS INTERNATIONAL

Electrode differentiation. How useful is it in device tuning?
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

Device tuning is very important in cochlear implantation and fine details are usually underestimated. The authors assessed the effect of deactivating indiscriminable cochlear implant (CI) electrodes for unilaterally implanted adults using the BKB (Bamford-Kowal-Bench) sentence test in quiet and in pink noise (signal-to-noise ratio of +10dBA) and the adaptive Coordinate Response Measure (CRM). Each CI recipient who failed electrode differentiation (ED) in at least one electrode-pair, based on results of a pure-tone pitch-ranking task received two research programmes to try out in a cross-over study. Research programmes (RP) either employed discriminable electrodes only or the most discriminable two-thirds of the electrodes in the electrode array for CI recipients failing ED for more than a third of the electrodes. The participants were also asked to subjectively report improvement of or decline in sound quality in everyday listening situations. There was significant improvement in CRM speech reception thresholds, BKB sentence scores in quiet, and also in pink noise after deactivating indiscriminable electrodes. Very interesting study. However, identification of the appropriate electrodes for de-activation may be challenging.

Reference

Clinical use of electrode differentiation to enhance programming of cochlear implants.
Saleh SM, Saeed SR, Meerton L, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl. 4):S16-8.

COCHLEAR IMPLANTS INTERNATIONAL

Bilateral cochlear implantation in Friedreich's ataxia
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

Although Friedreich's ataxia patients may have normal or near normal sound detection thresholds, it is not rare for many individuals to show abnormal neural conduction along their central auditory pathways. Electrophysiological testing can show abnormal or absent cochlear nerve and auditory brainstem recordings, in the presence of normal pre-neural cochlear function (otoacoustic emissions or cochlear microphonics). This pattern of normal pre-neural cochlear function and disrupted neural conduction lies within the spectrum of auditory neuropathy (ANSD). The authors highlight the fact that the majority of the literature on ANSD treatment has focused on paediatric patients with the ‘dyssynchrony’ type of ANSD, rather than the true neuropathy type underlying the hearing loss in Friedreich's ataxia patients. The authors report a very interesting case of a patient with Friedreich's ataxia, who had bilateral moderate hearing loss with poor speech discrimination, that improved significantly with bilateral cochlear implantation. An interesting study that contributes to our knowledge on auditory neuropathy and its management.

Reference

Bilateral cochlear implantation in Friedreich's ataxia: A case study.
Frewin B, Chung M, Donnelly N.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):287-90.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in a ski-slope high-frequency hearing loss and chronic external ear pathology, using a slim straight electrode array
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

The authors describe a case of cochlear implantation (using a straight slim electrode array) in a patient with ski-slope high-frequency hearing loss and chronic external ear canal infections. The recurrent infections precluded the consistent use of hearing aids with moulds. His speech discrimination in quiet and in noise was poor and his hearing loss was interfering with his ability to work. After years of frustration, this patient decided to risk losing his low-frequency residual hearing and was implanted with a slim straight electrode array. Hearing preservation was achieved and he gained a remarkable improvement in his hearing performance. The authors concluded that the good outcomes were the result of the combination of hearing presentation surgery, electrode design, and intensive auditory training. Finally, they suggest that this case report reinforces the statement that patients who do not fulfil the standard criteria for CI should be carefully considered on an individual basis. This is very reasonable. However, the particular case had a very short follow-up (only five months) in order to see if hearing preservation remains through time. Moreover, other alternative solutions (such as hybrid electrode arrays or other implants / aids) should be considered in such cases (although this particular patient refused them).

Reference

The use of Nucleus® CI422 in a ski-slope high-frequency hearing loss and chronic external ear pathology: A case study.
Távora-Vieira D, Rodrigues S.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):291-4.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in children when one ear is out of the criteria
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

Cochlear implantation, in a child with one ear within the criteria for cochlear implantation and the other out of the criteria, is a relatively new issue for discussion. Of course there is a wide range of asymmetrical hearing loss: single-sided deafness is at one end of the spectrum. Amplification in asymmetrical hearing loss is usually difficult, it is often not possible to adequately aid the poorer ear; therefore patients often experience compromised hearing with adequate aiding of their better ear only. The impact of hearing with one ear on speech development, education, and employment may be considerable. The authors reported in this study eight paediatric cases of cochlear implantation who had the contralateral ear out of the criteria for cochlear implantation. The authors concluded that in all eight children cochlear implant provided benefit. However, the small number of participants and the lack of long-term robust assessments weaken these claims.

Reference

Cochlear implantation in asymmetrical hearing loss for children: Our experience.
Tzifa K, Hanvey K.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S56-61.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear nerve deficiency: a very challenging situation
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

In this study the authors review the issue of cochlear nerve deficiency (CND) which is a very challenging situation in young profoundly deaf children, as the decision to proceed with cochlear or brainstem implantation (ABI) is often very difficult. Of course the assessment process is critical and magnetic resonance imaging (MRI), using very detailed submillimetric sequences, is mandatory for all profoundly deaf children to diagnose CND. Audiologic confirmation (behavioural or electrophysiological), especially using electric auditory brainstem response (EABR), testing may allow some quantification of auditory neural tissue and help decide whether a cochlear implant will be beneficial. According to the authors, age and cognitive development are other critical factors in determining ABI benefit. However, hearing outcomes from both cochlear implants and ABIs are variable and likely to be limited in children with CND. A proportion of children will get no benefit. Usually the implants would be expected to provide recognition of environmental sounds and understanding of simple phonetics. Most children will not develop normal speech and they will often need to learn to communicate with sign language. The ABI involves a major neurosurgical procedure and, at present, the long-term outcomes are unknown. The authors concluded that it is essential that parents who are considering this intervention have plenty of time to consider all aspects and the opportunity for in depth discussion. The last statement is very true. However, we have to develop more accurate measures and explore predictors, in order to inform parents in this very difficult situation.

Reference

The management of cochlear nerve deficiency.
Freeman SR, Stivaros SM, Ramsden RT, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S27-31.

COCHLEAR IMPLANTS INTERNATIONAL

Poor use of sequential bilateral cochlear implantation
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

The investigation of factors contributing to poor or no use of sequential bilateral cochlear implantation is very important, as it may substantially improve cost-effectiveness. The authors assessed six cases of poor sequential bilateral cochlear implant use (partial and complete non-use) using a semi-structured interview, as part of a service evaluation and development audit to improve the quality of a paediatric implant service, for sequential users. The issues explored were related to appearance, expectations of both the benefits and the challenges of adjustment, personal motivation for the implant and for engagement in rehabilitation, and dislike of the sound. The results revealed that appearance, unrealistic expectations, dislike and difficulty adjusting to the sound of the second implant, and motivation were very important determinants of poor use. Although the number of participants is very small, some useful conclusions can be drawn from this study, in order to limit poor use of sequential bilateral cochlear implantation.

Reference

Factors associated with poor use of sequential bilateral cochlear implants in young people: A preliminary audit of poor users.
Emond A, Moore M, Tjornby C, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S40-3.

COCHLEAR IMPLANTS INTERNATIONAL

Psychosocial development in cochlear implant children
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

This study assessed self-reported quality of life (QoL) of children with a cochlear implant (CI), comparing results with two published reports from the past decade. The authors assessed 33 children with cochlear implants with a mean age of 10 years, mean implantation age of 1.3 years, and mean CI experience of six years. Children in all three studies completed a self-report QoL questionnaire that included seven benefit and six problem items, rated on a 5-point Likert scale. The outcomes revealed agreement across studies in overall benefit and problem ratings. Environmental awareness and frustration reduction were the most and least positively rated outcomes, respectively. Items contributing to overall ratings differed across studies. Current CI recipients rated speech production, making new friends, and understanding speech more positively and taking extra care of the device more negatively than previous generations of paediatric CI users. Overall, benefits outweighed problems of the device, according to children using CI. Differences in issues motivating self-report ratings reflect changes in CI candidacy, technology, and social participation over the past decade. The authors concluded that their outcomes emphasise the need for clinicians to address not only communication needs, but also QoL issues in order to optimise outcomes in children using CI. It is expected that implanted children’s needs change through the years and as cochlear implantation evolves, not only due to the scientific developments but also due to the changes of the children themselves (expectations, social differences, etc.).

Reference

A comparative study of psychosocial development in children who receive cochlear implants.
Warner-Czyz AD, Loy B, Roland P, Tobey EA.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):266-75.

COCHLEAR IMPLANTS INTERNATIONAL

Sequential bilateral cochlear implantation. Factors that affect the use of the second implant
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

The authors aimed to explore the demographic or performance variables associated with inconsistent use of a second implant in paediatric recipients of sequential bilateral cochlear implants. A retrospective chart review was conducted on paediatric recipients of sequential bilateral cochlear implantation. Children were divided into two age groups, 5-9 and 10-17 years of age. For each group, the authors examined whether inconsistent use of the second implant (CI-2) was associated with a variety of demographic variables, or speech-perception scores. The results revealed that in children aged 5-9 years, inconsistent use of CI-2 was not significantly associated with any demographic variable, but was related to both the word-recognition score with CI-2, and the difference in word-recognition scores between the first implant (CI-1) and CI-2. In children aged 10-17 years, these relationships were not significant and the authors attributed it to the small number of subjects. Finally, CI-2 word-recognition scores across all children were significantly correlated with the age of implantation for both CI-1 and CI-2, and the time between CI-1 and CI-2 surgeries. The factors associated with the everyday use of the second implant in sequential bilateral implantation are very important, as they are closely associated with the cost-effectiveness of the procedure and should be thoroughly investigated in all cochlear implant centres.

Reference

Factors influencing consistent device use in paediatric recipients of bilateral cochlear implants.
Fitzgerald MB, Green JE, Fang Y, Waltzman SB.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(5):257-65.

COCHLEAR IMPLANTS INTERNATIONAL

What about a hearing aid at the contralateral side?
Reviewed by: Thomas Nikolopoulos
July/August 2014 (Vol 23 No 3)
 

This study explored if the low frequency information from a hearing aid improved the perception of stress and intonation by English-speaking children with cochlear implants (CI). In addition, the authors investigated if users rely more on the cues of duration and amplitude to perceive stress and intonation. Nine children with bimodal stimulation (cochlear implant and hearing aid) participated in two experiments. The first measured the just audible change in F 0 (pitch) and amplitude for a speech-like word ‘baba’. The second experiment examined the children's ability to identify focus in natural and manipulated sentences. Overall, group results did not show a bimodal advantage in perceiving stress and intonation. However, the children were significantly better at perceiving focus in sentences with natural speech compared with manipulated speech in both the CI and bimodal conditions. The authors suggested that in the absence of pitch cues, amplitude and duration cues are used to perceive stress and intonation. However, the majority of children only perceived amplitude changes greater than the changes typically found in speech, implying duration cues were the most valuable. Finally the authors concluded that, in children with cochlear implants, cues to F 0 may not be essential for prosody perception and in the absence of cues to F 0 and amplitude, duration may offer an alternative cue. The small number of participants (a bimodal advantage was not found in all subjects) and the limited measures used weaken any outcomes (positive or negative) on the contralateral use of a hearing aid. Therefore, appropriate tuning and a trial are still the only ways to explore if a contralateral hearing aid would provide benefit in a particular implantee.

Reference

The perception of stress and intonation in children with a cochlear implant and a hearing aid.
Hegarty L, Faulkner A.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S35-9.

Ear and Hearing

Mild and Unilateral hearing loss in childhood
Reviewed by: Dr Vinaya KC Manchaiah
July/August 2014 (Vol 23 No 3)
 

The presence of even mild degrees of hearing loss and unilateral loss in early childhood can negatively affect typical development, although they are hard to identify and diagnose early. The main aims of the current study were to: (1) document the proportion of children identified with mild bilateral or unilateral hearing loss (MBUHL) before and after the implementation of a universal newborn hearing screening program (UNHS); and (2) to examine the clinical characteristics and audiologic management of this population of children. This population-based study involved an analysis of data on children with hearing loss which had been collected prospectively over a 20-year period from 1990 to 2010 in Canada. The proportion of all children with hearing loss identified with MBUHL before and after implementation of UNHS and their clinical profiles were documented. Also, the factors affecting amplification decisions and amplification use were examined. A total of 381 of 823 children (46.3%) aged 0 to 18 years who were identified with permanent non-acquired hearing loss presented with MBUHL. The proportions identified were similar in the pre- and post-UNHS periods. However, before UNHS children were identified at a median age of 5.0 years compared with a median of 0.8 years, post-UNHS. Progression of hearing loss was documented for 22% of all children, and for the group identified since UNHS, 32.4% experienced deterioration in hearing thresholds. Although 87.2% of children received recommendations for amplification, more than 50% experienced considerable delay from identification to amplification. Age at identification and severity of hearing loss in the better ear were associated with amplification decisions for bilateral but not unilateral loss. UNHS has lowered age of confirmation of MBUHL by four to five years, although delay to amplification suggests uncertainty of the benefit of intervening early for these losses.

Reference

Mild bilateral and unilateral hearing loss in childhood: A 20-year view of hearing characteristics, and audiologic practices before and after newborn hearing screening.
Fitzpatrick EM, Whittingham J, Durieux-Smith A.
EAR AND HEARING
2014;35(1):10-8.

European Review of ENT

Cordectomies and the voice
Reviewed by: Dr Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

Although laryngeal malignancy is a devastating disease, treatment can be deleterious to function as well. This article discusses the effect of type II and III cordectomies on the sound intensity of the voice. Intensity depends on subglottic pressure, size of the sound conduit and on the power of adduction of the vocal folds. Comparing sound intensities for isolated vowels and vowels in context, the authors did not find any statistical difference between patients and controls. The anatomo-physiological changes to the vocal folds after surgery result in abnormal glottic closure and leaks. The authors conclude that patients adopt compensatory strategies at the level of the supraglottis and an increase in the subglottic pressures in order to achieve intelligibly powerful vowels.

Reference

The sound intensity after cordectomy of type II-III.
Wallet L.
EUROPEAN REVIEW OF ENT
2013;134(1):43-7.

European Review of ENT

Does your voice affect your career?
Reviewed by: Dr Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

Twenty naïve evaluators listened to 30 dysphonic voice samples and evaluated them in a four item questionnaire. They were asked to imagine the speaker according to five categories: health appearance, character, lifestyle and competence. One hundred and twenty-seven attributes were used. The authors retained 18 which were presented with their antonyms as a bipolar visual scale (from 0 to 10). The average scores for normal voices was 7.2, for mild dysphonia 5.7 and for severe dysphonia 4.7. It seems that the social image of dysphonic subjects is negative regardless of the degree of dysphonia. Dysphonic subjects are considered to be less healthy, uglier, less elegant, less social, less optimistic, less energetic, less intelligent and less reliable and last, unsurprisingly, more likely to be users of tobacco. Such a study emphasises the strong effect of voice on the mental image we form of a person. As professionals dealing with the larynx, we should be aware that we can deeply influence the whole persona of our patients and this should be included in our discussion, prior to any intervention which may affect the voice of the patient.

Reference

Social consequence of a dysphonic voice, design and validation of a questionnaire and first results.
Revis J, Robieux C, Ghio A, Giovanni A.
EUROPEAN REVIEW OF ENT
2013;134(1):35-41.

European Review of ENT

The facial nerve and speech
Reviewed by: Dr Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

The effect of facial paralysis on speech is an interesting subject. The authors evaluated the speech spectrogram of patients with facial paralysis using the Praat software. They found a real impact on the suprasegmental level. Repeated voluntary swallowing of the saliva significantly affected prosody with modifications of rhythmic structures. This was most pronounced during unguided reading, when the patient could not predict pauses and thus synchronise swallowing. Although the effects were not significant, we should be aware of this side-effect of facial paralysis and guide our patients to synchronise their speech with swallowing to avoid dysfluencies in speech which may increase their social handicaps.

Reference

Prosodic analysis of speech of patient affected by peripheral facial paralysis.
Robert M, Mauclair J, Lannadere E, et al.
EUROPEAN REVIEW OF ENT
2013;134:13-9.

FACIAL PLASTIC SURGERY

Conchal cartilage to reconstruct nasal septum
Reviewed by: Sunil Kumar Bhatia
July/August 2014 (Vol 23 No 3)
 

The authors discuss a problem frequently encountered, septal perforation. Unfortunately the most common cause is iatrogenic and previous surgery. The loss of the nasal septum is frequently also seen in repeated trauma and effective reconstruction using auricular cartilage is effective. However the use of this cartilage involves making this ‘bowl’ cartilage straight and imparting it with strength to support the nose, to allow for adequate nasal functioning. This paper, from authors in Italy, discusses the aetiopathogenesis of the loss of nasal cartilage and then patient analysis. Both these sections are well covered and the use of excellent colour photographs enhances the sections. They describe their technique of converting a curved flexible cartilage into a straight one, and increasing the structural strength, using partial thickness incisions and figure of eight sutures. There is an extensive review and discussion with good clinical photographs. Various donor sites are discussed as are the pros and cons. The importance of the effective support, in the form of the cartilaginous septum, as a prerequisite is again discussed.

Reference

Subtotal septal reconstruction by using conchal graft.
Boccieri A, Marianetti T.
FACIAL PLASTIC SURGERY
2013;29(6):479-86.

International Archives of Otorhinolaryngology

The temporomandibular joint and vertigo
Reviewed by: Dr Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

Dysfunction of the temporomandibular joint (TMJ) has been implicated in several otologic disorders, especially pain, tinnitus and conductive hearing loss. The authors explore the relation between TMJ disorders and vertigo in a geriatric population. The joint was assessed by digital pressure and recording tenderness and muscle spasm. Vertigo was assessed by a Katz questionnaire. This study showed that there is a significant association between TMD and vertigo. Moreover, the studied elderly people with TM dysfunction showed 17.61% more chance of presenting with vertigo than those without TMD. Although interesting, a cause-effect could not be convincingly presented. Both are common disorders in this studied population and both are multifactorial. However their association may be due to a third common factor rather than a causal relationship.

Reference

Probable Correlation between Temporomandibular Dysfunction and Vertigo in the Elderly.
de Moraes Marchiori LL, Oltramari-Navarro PV, Meneses-Barrivieira CL, et al.
INTERNATIONAL ARCHIVES OF
OTORHINOLARYNGOLOGY
2014;18(01):49-53.

International Journal of Language and Communication Disorders

Adolescent stuttering therapy
Reviewed by: Gauri Mankekar
July/August 2014 (Vol 23 No 3)
 

Treatment of stuttering in adolescents is an under researched subject although the psychological, social, vocational and economic implications in this group are tremendous. The authors of this article outline an integrated programme for stuttering adolescents, incorporating speech restructuring, cognitive behaviour therapy and communication skills training. The article highlights some of the challenges faced in collecting long-term data with adolescent research participants but also mentions the effectiveness of therapy in stuttering teenagers and emphasises the importance of therapy resources being made available for this group of patients.

Reference

Effectiveness of intensive group therapy for teenagers who stutter.
Fry J, Millard S, Botterill W.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(1):113-26.

International Journal of Language and Communication Disorders

Smart phone app in stuttering therapy!
Reviewed by: Gauri Mankekar
July/August 2014 (Vol 23 No 3)
 

This article discusses the efficacy of altered auditory feedback during scripted telephone conversations in stuttering therapy. The authors examined stuttering frequency under monaural auditory feedback with one combination (COMBO 2) of delayed auditory feedback (DAF) and frequency altered feedback (FAF) and two combinations (COMBO 4) of DAF and FAF during scripted telephone conversations. Stuttering was significantly reduced with both altered auditory feedback, although it was more significantly reduced with COMBO 4, probably indicating that second signals reduce stuttering along a continuum. The authors suggest that people who stutter can use specific software or smartphone apps that produce second speech signals to inhibit stuttering frequency effectively, during telephone conversations.

Reference

Stuttering inhibition via altered auditory feedback during scripted telephone conversations.
Hudock D, Kalinowski J.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2014;49(1):139–47.

JAMA FACIAL PLASTIC SURGERY

Whisking recovery after automated mechanical stimulation during facial nerve regeneration
Reviewed by: Bilal Gani Taib
July/August 2014 (Vol 23 No 3)
 

Facial paralysis is a disorder with profound consequences, both functional and psychosocial. Functional recovery from facial nerve transection and surgical repair is typically poor in rats and humans. Therefore therapies applied to rats may translate to humans. This study used 61 rats that had undergone a left facial nerve transection with microsurgical connection via two to three epineural nylon sutures. The rats were randomised into eight groups. Six groups received 0.5, 1.5 and 8Hz frequencies delivered by a whisk assist (WA) system designed to move the whiskers horizontally beginning eight days postoperatively, five days per week for 15 weeks. Two groups received restraint without stimulation. The low frequency stimulations (0.5 and 1.5Hz) failed to enhance recovery. Further, the higher frequency stimulation (8.0Hz) was actually detrimental to recovery.

Reference

Whisking recovery after automated mechanical stimulation during facial nerve regeneration.
Kleiss IJ, Knox CJ, Malo JS, et al.
JAMA FACIAL PLASTIC SURGERY
2014;16(2):133-9.

JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY

Immediate planned reconstruction following complex craniofacial reconstruction
Reviewed by: Sunil Kumar Bhatia
July/August 2014 (Vol 23 No 3)
 

The immediate reconstruction of 3-D cranio-facial defects is extremely difficult and can be more difficult than the ablation. Perfect shape and symmetry is required. In the past decade this has largely improved with CAD / CAM engineering. The authors report a one step technique that is fairly simple and allows for good results. They present a series of five patients that had complex orbito-frontal resections with immediate reconstruction. The resection was planned and an implant made preoperatively. Material used was Polyetheretherketone (PEEK), a material widely used in neurosurgery, and which shows good biocompatibility. This seems to be a reproducible and simpler method of reconstruction than using autologous bone or tissues. There is no donor site morbidity and excellent form and function. The equipment required and techniques are well accepted. CAD / CAM cranioplasty is well described and so is navigation. The resection is planned with virtual planning and allows an individualised accurate implant to be manufactured prior to surgery. This is an excellent technique and is of value to all facial surgeons. It does however require considerable back-up in the form of resources and equipment.

Reference

One-step primary reconstruction for complex craniofacial resection with PEEK custom-made implants.
Jalbert F, Boetto S, Nadon F, et al.
JOURNAL OF CRANIO-MAXILLOFACIAL SURGERY
2014;42:141-8.

JOURNAL OF CRANIOFACIAL SURGERY

Complications of plates in fibular free flaps
Reviewed by: Sunil Kumar Bhatia
July/August 2014 (Vol 23 No 3)
 

Good functional reconstruction of the mandible remains challenging for the maxillofacial surgeon. The fibula osteocutaneous flap is widely used as a method of mandibular reconstruction and it can withstand multiple osteotomies and requires hardware to adapt and hold the segments. There has also been significant improvement in the plate hardware. This is a single centre retrospective audit, looking at the plate-related complications following reconstructions of the mandible. They look at 41 reconstructions between 2004 and December 2012. Most common indication, in 30 cases, was resection for squamous cell carcinomas. Sixteen patients had postoperative adjuvant radiotherapy and one preoperative radiotherapy. Seven patients had chemotherapy, in addition to standard fractioned radiotherapy. The authors studied the complications of the plates used. Three types of plates were used; the mandible plates 2.0, locking plate 2.0 and locking plate 2.4. The commonest plates used the miniplates 86 with two complications, followed by 2.0 mandible plates two in 14 and then 2.0 locking plate one in 12 complications. Initially there were concerns that miniplates, with their smaller size had less strength and were predisposed to more complications. However, the newer miniplates, with their greater malleability and adaptability and lower profile, seem to have fewer complications. This study confirms that and the author’s first choice is the miniplate. A drawback is that with the use of multiple plates a period of intermaxillary fixation is required to maintain the occlusion. Also interesting is the fact that most complications occurred early within six months, and as expected the majority presented in patients that received radiotherapy. In patient numbers the study might be considered small but a total of 86 miniplates was used with only five ‘complications’, which is fairly conclusive.

Reference

Evaluation of plate-related complications and efficacy in fibula free flap mandibular reconstruction.
Zavattero E, Fasolis M, Garzino-Demo P, et al.
JOURNAL OF CRANIOFACIAL SURGERY
2014;25:397-9.

JOURNAL OF DERMATOLOGICAL TREATMENT

More tonsillectomy benefits
Reviewed by: Badr Eldin Mostafa
July/August 2014 (Vol 23 No 3)
 

Tonsillectomy has proven indications for obstructive sleep apnoea, recurrent infections and post-streptococcal sequels. For some time a deleterious effect on immunity was suggested in order to ban or limit tonsillectomies. In this work the aim of tonsillectomy was to reduce the production of autoreactive T cells, which may be implicated in psoriasis. The results highlight the benefit of tonsillectomy as a treatment for palmoplantar pustulosis and psoriasis. The findings of this study may not be limited to skin disorders but may be extended to other auto-immune disorders.

Reference

Tonsillectomy as a treatment for psoriasis: a review.
Wu W, Debbaneh M, Moslehi H, et al.
JOURNAL OF DERMATOLOGICAL TREATMENT
2014;24(6):482-6.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Consent for mastoidectomy
Reviewed by: Madhup K Chaurasia
July/August 2014 (Vol 23 No 3)
 

Mastoidectomy is a complex operation and often ill understood by patients. The risks involved are many, in terms of damaging vital structures inside the petrous temporal bones, resulting in major disability for the patient. In this publication the author has presented very detailed information offered to patients when obtaining consent for mastoidectomy extending to four A4 pages. The consent information comprises the actual operation, anaesthesia, possible damage to the facial nerve and other complications such as increased hearing loss, dizziness, tinnitus, taste disturbance, wound infection and numbness of the ear. The information also includes possible problems with a resulting mastoid cavity and the care protocol followed after the operation. For each item there is a tick box and space for questions from patients. The information leaflet was subjected to comments from patients in terms of understanding the text, any disagreements or grammatical mistakes and whether it was reasonable to offer all this information to patients in the form of a leaflet. The responses were very favourable. The text is simple and conforms to a reading age of 13-15 years, as determined by the text readability consensus calculator. The process involves the patient reading all this in the clinic, ticking boxes and then possibly responding with questions. The forms were brought by the patient in the preoperative appointment and only at this time the official hospital consent form was signed. At the outset, all this appears to be rather lengthy and tedious but serious complications can arise in a mastoid operation and patients may often not realise the gravity of the situation which exposed them to the risk involved in this surgery

Reference

Patient information leaflet on mastoid surgery risks: assessment of readability and patient understanding.
Pringall MB, Latesh BJ, Konieczny KM.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1078-83.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Cost effectiveness of on-site cytologists in the neck lump clinic
Reviewed by: Madhup K Chaurasia
July/August 2014 (Vol 23 No 3)
 

The purpose of one-stop neck lump clinics is quick diagnosis and compliance with the cancer pathway. The two hurdles which come in the way of diagnosis by fine needle aspiration (FNA) are the accuracy of the site of aspiration and adequacy of material to make a cytological diagnosis. The first hurdle can be overcome by the presence of an interventional radiologist but whether the presence of the cytologist in these clinics would overcome the second hurdle and be cost effective is questionable. In this study authors made a hypothetical estimate of cost effectiveness if an on-site cytologist was introduced to the one-stop neck lump clinic, in which they already had an interventional radiologist. In an analysis of 307 ultrasound guided fine needle aspiration cytology procedures performed over six months, cytological diagnosis was not obtained in 22% of these cases. On repeating the FNA and subsequent appointments, only 5% of these produced a firm diagnosis. It was then speculated what would be the savings if there was an on-site cytological assessment. Hypothetical calculations showed a maximum theoretical saving of about £3k over six months. Furthermore, the authors contend that not every non diagnostic FNA will be detected by on site cytological assessment. The literature suggests that reduction in non-diagnostic FNAs through on-site cytological assessment ranges from 70% to no difference at all. These facts suggest that introduction of an on-site cytologist will result in costs which may outweigh the benefits. The study is hypothetical and the actual answer can only be obtained by a direct comparison of a one stop clinic with an on-site cytologist, with one that does not have this facility. Furthermore, discrete use of clinical guidance can reduce the necessity for repeat FNAs in seemingly benign cases and suggest more alternative methods such as core biopsy or surgical excisional biopsy in others.

Reference

Clinics; is on site assessment of fine needle aspirate diagnostic adequacy cost effective?
Burgess C, Dias L, Maughan E, Moorthy R.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1122-26.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Is female nasal trauma increasing?
Reviewed by: Madhup K Chaurasia
July/August 2014 (Vol 23 No 3)
 

It is apparent that more and more women are attending with fracture of the nasal bones in general and especially due to non-domestic violence. The speculation is whether this is due to a changing culture and if this is related to what is described as ‘ladette’ attitudes of teenage females. In this study the authors observed an 825% rise in the treatment of women with nasal fractures in the five year period from 2004 to 2009. Accidental injury was the most common cause of fracture. Another common cause was sports-related injury. However, a quarter of these women had nasal injury as a result of non-domestic violence. The authors attribute this to the ‘ladette’ culture. ‘Ladette’ culture is characterised by women who behave in a boisterous, assertive or rude manner and engage in heavy drinking sessions, the expected outcome of which is fights resulting in nasal trauma. The increased incidence of nasal fractures in these girls and young women (13-20 years) is seemingly related to high consumption of alcohol which is facilitated by availability of cheaper drinks, longer public house hours and free entry for women. The higher incidence of nasal fractures in this age group was particularly confined to British white women. The authors support their views with data obtained from the Home Office’s British Crime Survey Episode Statistics. This rather disturbing finding calls for further research on alcohol consumption and its relation to nasal fractures and the need to guide Public Health policies.

Reference

Is there a change in epidemiology of nasal fractures in females in the UK?
Trinidade A, Buchanan M A, Farboud A, et al.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1084-87.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Surgery for failed CPAP therapy
Reviewed by: Madhup K Chaurasia
July/August 2014 (Vol 23 No 3)
 

Recent evidence supports an ever widening spectrum of morbidities associated with Obstructive Sleep Apnoea Syndrome, ranging from hypertension to the more recently recognised encouragement of tumour genesis due to hypoxia. Continuous positive airway pressure (CPAP) remains the mainstay of treatment, especially with patients with a BMI of over 35 where surgery is generally considered unsuitable. The problem lies in the poor compliance with CPAP therapy which ranges from 46-83% and this dwindles with the number of years these patients have been on this therapy. In this study, the authors picked up 17 patients who failed CPAP treatment. They were considered unsuitable for a localised operation and therefore underwent multilevel surgery for improvement of airway. These patients underwent a full assessment with BMI index, Epworth Sleepiness Scores and polysomnographic recordings. An assessment was also made with CT scans to measure various cephalometric parameters. The surgery offered was more extensive than modified uvulopalatopharyngoplasty. Some patients underwent coblation channelling of the tongue with or without midline glossectomy. Some also had lingual tonsil reduction and CobLAMO or submucosal lingualoplasty. The patients showed a significant clinical improvement measured in terms of apnoea–hypopnea index (AHI) and Epworth Sleepiness Scores before and after surgery. The standard criteria of AHI less than 20 and more than 50% reduction in AHI was met in 12 and five of them were ‘cured’ with an AHI of less than five. Interestingly enough, the BMI remained stable after surgery, indicating that the surgical outcome was unrelated to weight loss. The study is limited by small size and lacks a control group. However it provides useful information and possible avenues to deal with the highly prevalent problem of failure or lack of compliance with CPAP therapy.

Reference

Beyond Uvulopalatopharyngoplasty for Obstructive Sleep Apnoea; Single Surgeon Case Series of contemporary airway reconstruction.
Mackay SG, Jefferson NN, Mashall MS.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:1184-89.

JOURNAL OF VESTIBULAR RESEARCH

Mal de debarquement and motion sickness: is there a link?
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

Mal de Debarquement Syndrome (MdDS) is usually short-lived but in some patients, it can persist for months to years. The pathophysiology is not clearly understood. The association of this disorder with motion sickness has been reported. The purpose of this study was two-fold: to determine whether severity of motion sickness correlates with the severity and duration of MdDS and can an artificial horizon (AH) during motion prevent the development of MdDS (AH has been found to alleviate motion sickness). Twenty male students aged between 18 and 25 years were recruited. The experiment was conducted in a ship motion simulator (SMS) equivalent to a 1,200 tonne ship in moderate sea condition of 150cm waves. Over a 120-minute voyage, subjects were exposed to three earth-referenced scenes (AH) projected inside the closed SMS cabin (AH 0% when scene was parallel to SMS cabin wall; AH 35% and 75% when projections were scaled down to 35% and 75% of full movement). Two questionnaires were used to assess outcome: motion sickness susceptibility and Mal de Debarquement questionnaire. Subjects rated the severity and duration of MdDS symptoms after the three AH conditions. In 50%-67% of subjects, MdDS symptoms did not resolve immediately after the various AH exposures, persisting longer than 15 minutes in 27-35% of subjects (few after six hours). Most symptoms were mild but in 27% subjects, the symptoms were rated moderate. The most common MdDS symptoms were ‘rocking’ (38%) and ‘swaying’ (34%). Motion sickness scores were significantly less at AH 75%, due to a reduction in sensory conflict. There was a significant correlation between motion sickness during SMS runs and the severity and duration of MdD symptoms, leading the authors to conclude that both conditions might result from a failure of adaptation to new motion conditions. However AH did not prevent the development of MdD which may suggest the persistence of an abnormal cognitive reaction to motion, leading to a ‘phantom perception of motion’ - MdDS.

Reference

Mal de debarquement, motion sickness and the effect of an artificial horizon.
Tala D, Wiener G, Shupak A.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:17-23.

JOURNAL OF VESTIBULAR RESEARCH

Promethazine or lorazepam, which is superior for treatment of acute vertigo?
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

If you are involved in the treatment of acute vertigo in the emergency setting, this double-blind study will be of interest. One hundred and eighty-four patients, aged between 19 and 63 years, presenting with acute peripheral vertigo were randomised to receive either 25mg IV promethazine (group 1) or 2mg IV lorazepam (group 2). On visual analog scales (VAS) of 100mm, subjects rated the severity of pre-treatment vertigo and nausea and post-treatment vertigo and nausea after two hours. Other secondary outcomes were the need for a second dose and adverse side-effects (AE). Statistically, there were no differences between baseline vertigo and nausea in the two groups. The mean reduction in the intensity of vertigo at two hours post-treatment was greater in the promethazine than the lorazepam group (46.5mm vs 25.7mm; p <0.001). This difference was statistically significant. A similar finding was noticed with nausea. Twenty-seven patients in group 2 required a second dose compared with nine in group 1. The most common AEs were lethargy and drowsiness, both short-lasting, resolving before patients were discharged from the emergency room. Statistically, there were no differences in AEs between the two groups. The authors conclude that IV promethazine is superior to lorazepam in reducing vertigo and nausea. They discussed limitations of the study including the arbitrary 2-hour vertigo severity assessment, the lack of a placebo arm, the limited dosage regimes and alternative medications. What struck me was that the majority of their patients had Benign paroxysmal positional vertigo (BPPV) (158) compared with 15 and 11 for vestibular neuritis and Menière’s respectively. Interestingly, the BPPV patients were not treated with repositioning manoeuvres, until after the final outcome measurement. Their symptoms may therefore have resolved simply because they avoided positional triggers and not because of the medications. I think this is a major flaw in the study and it seems a bit excessive in my opinion to administer IV medication for BPPV.

Reference

Intravenous promethazine versus lorazepam for the treatment of peripheral vertigo in the emergency department: A double blind, randomized clinical trial of efficacy and safety.
Amini A, Heidari K, Asadollahi S, et al.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:39-47.

JOURNAL OF VESTIBULAR RESEARCH

Testing for otolith function
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

Due to recent developments in vestibular science, it is now possible to assess all five vestibular receptors independently in each ear. Testing for otolith function has been more challenging than that for semicircular canal function. Off-axis (eccentric) rotation and the subjective visual vertical (SVV) tests have been used to test otolith function. The authors conducted this study using a much simpler technique to assess otolith function in 12 healthy adult volunteers. Subjects were seated securely and blindfolded in a rotatory chair so that both head and body were on the same axis. Instead of eccentric rotation, the head was tilted 30⁰ to the right (+30⁰) and to the left (-30⁰) as the chair was rotated to a peak velocity of 360⁰/s. The subjects used a rod to indicate their sense of verticality (SVV) while stationary (head upright: 0⁰, 30⁰ tilt to right and then left) and during rotation (head upright: 0⁰, 30⁰ tilt to right and then left). The angle of deviation of the SVV was determined in all test positions. The authors found that in the 0⁰ position the SVV shifted more to one side. After applying a correction factor, they showed that head tilt enhanced the SVV – greater angle of verticality. The average SVV during head tilt and rotation was 5.3⁰ more than in the stationary position. This effect was dependent on rotation rather than direction of head tilt. The authors concluded this simple method could be used clinically to assess otolith dysfunction. Although simple, it’s not necessarily cheap or accessible as a rotatory chair is required.

Reference

Unilateral otolith centrifugation by head tilt.
Winters SM, Bos JE, Klis SFL.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:9-15.

JOURNAL OF VESTIBULAR RESEARCH

The optimum rise and fall time for tone burst cervical VEMP
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

Vestibular evoked myogenic potential (VEMP) testing, using short tone bursts, is now commonplace in many vestibular labs. However, the parameters of the stimulus have not been uniform. To determine the effect of the rise/fall time of the 500Hz short tone burst, the authors recruited 30 healthy adult volunteers aged between 18 years and 35 years. Cervical VEMPs were elicited with eight different rise/fall times (1ms to 8ms) at a common plateau time of 0ms. The stimulus intensity was 95dBnHL. Latencies (absolute and inter-peak) and amplitudes of the responses were analysed. As the rise and fall time increased, so were the mean absolute and inter-peak p13/n23 latencies (p <0.01). Further statistical analysis showed that a minimum difference of 2ms rise/fall time was required to produce a statistically significant difference in p13-n23 peak intervals. Larger amplitudes were observed at 2ms and 3ms but the variability in the standard deviation at these times was large. Although the amplitude at 1ms was slightly less than at 2ms and 3ms (but larger than all the rest), the variability of the standard deviation was much less, leading the authors to pick 1ms (plateau of 0ms) as the optimum rise / fall time. There is also the added advantage of saving time.

Reference

The effect of rise/fall time of 500Hz short tone bursts on cervical vestibular evoked myogenic potential.
Singh NK, Apeksha K.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:25-31.

JOURNAL OF VESTIBULAR RESEARCH

Vestibular disorders activities of daily living scale (VADL)
Reviewed by: Victor Osei-Lah
July/August 2014 (Vol 23 No 3)
 

The 28-item Vestibular disorders Activities of Daily Living scale (VADL) was specifically developed to assess the functional limitations faced by patients with vestibular disorders. There are three domains (12 functional, nine ambulatory and seven instrumental/task-related activities) and 10 ratings of independence. In this brief review, the author highlights the differences between this scale and others that are in routine use in vestibular rehabilitation clinics, namely the Dizziness Handicap Inventory (DHI), the Vestibular Rehabilitation Benefit Questionnaire (VBRQ) and the UCLA Dizziness questionnaire (UCLA-DQ). An important strength of the VADL is that it is better at measuring the levels of functional difficulties in patients with vestibular disorders, irrespective of diagnosis, than the others. It does more than assess quality of life by assessing the independence in activities of daily living of patients. The 10-rating levels of independence makes it a better instrument at detecting subtleties in functional limitations compared to the DHI (three levels) and UCLA-DQ (five levels). Although the VADL does not discriminate between vestibular diagnoses, it can differentiate between asymptomatic, healthy controls and patients with chronic vestibular symptoms. Furthermore, it is very sensitive to change after treatment. It is easy to use and therefore if this is not used routinely in your rehabilitation clinic, you may wish to include the VADL as a useful outcome measure.

Reference

Use of the vestibular disorders activities of daily living scale to describe functional limitations in patients with vestibular disorders.
Cohen HS.
JOURNAL OF VESTIBULAR RESEARCH
2014;24:33-8

LARYNGOSCOPE

Inferior turbinate reduction
Reviewed by: Mark Puvanendran
July/August 2014 (Vol 23 No 3)
 

Inferior turbinate surgery is a common ENT procedure; there are a multitude of techniques in use. This paper attempts to provide some evidence-based clarity to the situation. The authors have conducted a literature review, unfortunately there is no detail provided on the search strategy and the findings. Five papers are discussed in detail but there is no explanation as to why they have been selected. All the papers discussed are randomised trials and constitute level 1 evidence, however the techniques analysed, and the follow-up time vary enormously, making it difficult to draw any meaningful conclusions. The authors have suggested that submucosal resection and lateral displacement is the most effective technique at decreasing nasal obstruction due to inferior turbinate hypertrophy. Whilst this may instinctively seem correct the evidence provided is insufficient to draw this conclusion. Evidence for the optimum technique of turbinate reduction remains elusive.

Reference

Which inferior turbinate reduction technique best decreases nasal obstruction?
Larrabee YC, Kacker A.
LARYNGOSCOPE
2014;124(4):814-15.

NEUROSURGERY

Can reducing the dose of stereotactic radiation preserve hearing in patients with vestibular schwannomas?
Reviewed by: Gauri Mankekar
July/August 2014 (Vol 23 No 3)
 

It has been a challenge to preserve hearing following stereotactic radiosurgery (SRS) of vestibular schwannomas (VS). This study evaluated the association between computed tomography-based volumetric cochlear dose and loss of serviceable hearing after SRS in 59 patients of VS who met the study criteria. Intraobserver and interobserver reliability were assessed when determining modiolar point dose with the use of magnetic resonance imaging and computed tomography. The authors found that tumour related factors beyond the cochlear dose were more significant than the cochlear dose alone in dictating hearing outcomes. They have explained with the example of patients with excellent pretreatment hearing, smaller tumours, or tumours with a greater distance from the fundus who are more likely to have good long-term hearing irrespective of whether they are managed with SRS, microsurgery, or just observed. Reducing the radiation dose to the cochlea may play some role in improving hearing outcomes after SRS, but may necessitate reducing the margin dose or intentionally under treating the lateral portion in many cases. According to the authors, both these strategies would theoretically run the risk of reducing long-term tumour control and therefore, they do not advocate those strategies.

Reference

Significance of cochlear dose in the radiosurgical treatment of vestibular schwannoma: controversies and unanswered questions.
Jeffrey T. Jacob JT, Carlson ML, et al.
NEUROSURGERY
2014:74:466-74.

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

Sphincter trouble?
Reviewed by: Charlie Giddings
July/August 2014 (Vol 23 No 3)
 

This comprehensive edition of clinical review articles focuses on dysphagia, from basic science to the rehabilitation and treatment of difficult clinical problems. It is acknowledged early in the edition that the presence of dysphagia is associated with a longer inpatient stay, a 13-fold increase in mortality in rehabilitation patients, a reduced quality of life and huge healthcare costs. This review article in particular will be pertinent for those who see a small number of patients every year who may have cricopharyngeal muscle (CPM) dysfunction and be symptomatic. The diagnosis of CPM dysfunction is challenging and requires clinical and endoscopic evaluation of swallowing, videofluoroscopy and manometry in an appropriate setting. The review reiterates the importance of patient selection with CPM dysfunction, as those who have intact laryngeal elevation and pharyngeal contraction make the best surgical candidates for interventions targeting the sphincter. For those with an interest in this area a quality prospective study, including quality of life outcomes and morbidity, is much needed to compare endoscopic laser division of the CPM to the open approach.

Reference

Management of cricopharyngeus muscle dysfunction.
Khun MA, Belafsky PC.
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA
2013;46:1087-99.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Acute otitis externa guidelines
Reviewed by: Hannah Blanchford
July/August 2014 (Vol 23 No 3)
 

Acute otitis externa is probably one of the first conditions one learns how to treat as a doctor in ENT. This succinct review article summarises eight key recommendations for this frequent complaint and the level of evidence each is based on. It includes a helpful table of some ‘frequently asked questions’ and a list of instructions for patients. One recommendation is that in known or suspected non-intact tympanic membranes, non-ototoxic topical preparations should be prescribed. Another explains the importance of patient education to ensure drug delivery is optimal. The authors state the level of confidence in the evidence is high for the efficacy of topical treatment as initial management, but low regarding the comparative benefits of different ototopical preparations. The strongest recommendations are those regarding the provision of adequate pain relief and the need to avoid systemic antibiotics as initial therapy for diffuse, uncomplicated, acute otitis externa (unless there is extension beyond the ear canal or specific host factors). I would recommend a copy for each ENT emergency clinic.

Reference

Clinical Practice Guideline: Acute Otitis Externa Executive Summary.
Rosenfeld RM, Schwartz SR, Cannon CR, et al.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2014;150(2):161-8.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

How clean is your scope?
Reviewed by: Hannah Blanchford
July/August 2014 (Vol 23 No 3)
 

This small study swabbed ‘non-critical’ areas of their flexible fibreoptic laryngoscopes, immediately prior to use on patients. The investigators collected 17 samples from eye pieces, driver handles and light cables from flexible scopes that had undergone their department’s cleaning protocol (enzymatic sponge clean then immersion of the shaft in Cidex). Bacterial growth was found in 41% (n=7). The organisms found were of skin and oral flora origin. This paper highlights the wide variety of cleaning protocols in existence including the use of protective sheaths, which may also fail to address the problem of contamination of ‘non-critical’ areas of the scope. It adds to previous data showing contamination of scope handles. Importantly, the paper doesn’t address whether such contamination might lead to nosocomial infections or whether a bigger sample might have found pathogenic organisms. The authors suggest departments examine their cleaning protocols to ensure these ‘hidden sources of contamination’ are addressed.

Reference

Microbiological Sampling of the Forgotten Components of a Flexible Fiberoptic Laryngoscope: What Lessons Can We Learn?
Bhatt JM, Peterson EM, Verma SP.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;150(2):235-6.

OTOLOGY & NEUROTOLOGY

A revised coronal illustration of the ear
Reviewed by: Rebecca Heywood
July/August 2014 (Vol 23 No 3)
 

John Hopkins medical artist Max Brödel drew a black and white pen and ink coronal representation of the ear in 1939. It has been faithfully reproduced ever since and most of us will have seen it at some stage in textbooks and published literature. Although it is a beautiful illustration, it is not anatomically correct. It may even have been a preliminary sketch drawn prior to Brödel’s detailed anatomic observations made through dissection, examining histologic sections and watching surgery. The authors have identified three types of anatomic inaccuracy. The carotid artery and tympanic segment of the facial nerve may have been intentionally left out to avoid an overly cluttered drawing. Several structures have been ‘enhanced’, possibly to make them more prominent in the drawing: the cochlea, lateral semicircular canal and entire inner ear are all either enlarged or lie in an altered plane and the whole incus has been rotated almost 180°, presumably because it would otherwise be almost completely hidden behind the head of the malleus. Other errors are probably inadvertent, for example, the scutum is missing. While the drawing was probably meant as an artistic interpretation of the ear, it has been reproduced for decades as an anatomic depiction. The authors have therefore used high resolution fine-cut CT images and 3D virtual models to study the relationships of temporal bone structures and revised Brödel’s drawing. The result is a more anatomically accurate schematic with colour to enhance certain structures and create the illusion of depth. They comment that eventually this will likely be surpassed by a computer simulated depiction of the ear with genuine 3D features.

Reference

Revisiting Max Brödel’s 1939 classic coronal illustration of the ear.
Jackler RK, Gralapp CL, Mudry A.
OTOLOGY & NEUROTOLOGY
2014;35(3):555-60.

OTOLOGY & NEUROTOLOGY

Cochlear implantation outcomes may be worse in Ménière’s disease
Reviewed by: Rebecca Heywood
July/August 2014 (Vol 23 No 3)
 

A proportion of patients with Ménière’s Disease (MD) will ultimately develop bilateral profound hearing loss and may become suitable candidates for cochlear implantation. This study looks at 21 patients implanted in an ear affected by MD and compares consonant nucleus consonant (CNC) scores to those of 178 implanted adult non-MD patients. Nineteen patients had bilateral MD and two patients had unilateral MD with idiopathic hearing loss in the contralateral ear. All patients included in the study had had their implant for at least six months. Subjective improvement in vertiginous symptoms was reported postoperatively by five of the six patients with active MD at the time of cochlear implantation (CI). Patients with a longer duration of MD symptoms achieved better word scores than those with a shorter duration but the difference was not statistically significant. MD patients as a group overall, and specifically those with inactive disease had significantly lower postoperative CNC scores than non-MD implanted patients, though the authors note that all of the scores of the MD group as a whole fell within the range of scores of the large non-MD sample. Those who had previously had surgical or vestibular ablative procedures for MD had significantly better outcomes than those who had only medical management; it is postulated that this may be due to arrest of an underlying irritative neural stimulus preventing further damage to neuronal conduction. The authors conclude that MD patients have generally worse outcomes after CI than the non-MD population but that CI in those with active disease may give similar outcomes to the non-MD population.

Reference

Cochlear implantation in Ménière’s disease patients.
McRacken TR, Gifford RH, Kahue CN, et al.
OTOLOGY & NEUROTOLOGY
2014;35(3):421-25.

PLASTIC AND RECONSTRUCTIVE SURGERY

Publish or perish
Reviewed by: Sunil Kumar Bhatia
July/August 2014 (Vol 23 No 3)
 

Most doctors have submitted papers and very rarely is the paper accepted outright. In fact the majority are not accepted initially. Not to worry, you are in good company. Only 9% of 6000 manuscripts submitted annually to the Journal of the American Medical Association are accepted. Nearly 85% of manuscripts submitted to ‘Plastic and Reconstructive Surgery’ are initially rejected. Even Stephen Hawkin’s paper on ‘black hole radiation’ was rejected initially. There are a number of articles on ‘how to get published’ and reasons why manuscripts are rejected. This article is different, as it also discusses how to approach the reviewer’s comments and advises on approaches to revision of the manuscript. The authors discuss the process of peer review and provide pointers on accepting rejection and tackling the revisions as well as guidance on peer review. There is a good flow chart that plots choices after manuscript rejections. Candid and well written, this is an easy paper to read and assimilate. It is also useful to learn how to do a good peer review of a manuscript.

Reference

Manuscript rejection: How to submit a revision and tips on being a good peer reviewer.
Kotis SV, Chung KC.
PLASTIC AND RECONSTRUCTIVE SURGERY
2014;133(4):958-64.

Acta Otolaryngologica

Day case stapes surgery under local anaesthetic in Finland
Reviewed by: Victoria Possamai
May / June 2014 (Vol 23 No 2)
 

The authors start by stating that the common occurrence of postoperative vestibular disturbance may preclude day case stapes surgery. They carried out a prospective study of 20 patients undergoing stapedotomy under local anaesthetic and measured postoperative symptoms and recorded nystagmus with video-oculography 30 minutes postoperatively. The nystagmus and vestibular symptoms showed no correlation. Nine patients had spontaneous horizontal nystagmus, without gaze fixation (seven of nine showing an irritative pattern). Seven patients described nausea, though only one vomited. Nine experienced vestibular symptoms immediately postoperatively (vertigo in five, floating sensation in two and unspecific dizziness in two). All but one described this as mild-moderate. In five of these patients this had fully resolved within the first 50 minutes, however the duration of symptoms in the remaining four patients is not stated, and is highly relevant to the validity of the conclusion reached that day case stapes surgery is a feasible approach.

Reference

Immediate postoperative nystagmus and vestibular symptoms after stapes surgery.
Hirvonen TP, Aalto H.
ACTA OTOLARYNGOLOGICA
2013;133:842-5.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

How effective is balloon sinuplasty in uncomplicated chronic sinusitis
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

This prospective randomised controlled study was conducted on 92 patients with chronic rhinosinusitis [50 balloon sinuplasty and 42 functional endoscopic sinus surgery (FESS)] for six months. Occurrence of postoperative nasal bleeding, duration of prescription of pain medication use, recovery time, postoperative nasal toilet and short-term symptom improvement were all significantly better for balloon sinuplasty versus FESS. Balloon sinuplasty is an effective treatment in patients with uncomplicated sinusitis, who meet the criteria for medically necessary FESS. Hoping in future further studies will be conducted for a longer duration of follow-up.

Reference

Standalone balloon dilation versus sinus surgery for chronic rhinosinusitis: a prospective, multicentre, randomized, controlled trial.
Cutler J, Bikhazi N, Light J, Truitt T, Schwartz M.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(5):416-22.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Lacking of medical / surgical strategies for cystic fibrosis chronic rhinosinusitis
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

Chronic rhinosinusitis (CRS) is a life-long disease in cystic fibrosis (CF) patients that can lead to substantial morbidity and decreased quality of life. This review evaluates the available literature and provides an update concerning the patho-physiology, current treatment approaches and future pharmaceutical tactics in the management of CRS in patients with CF. Advances in the care of patients with CF have improved pulmonary outcomes and survival. In addition, rapid developments regarding the underlying genetic and molecular basis of the disease have led to numerous novel targets for treatment. However, clinical and basic scientific research, focusing on therapeutic strategies for CF-associated CRS, lags behind the evidence-based approaches currently used for pulmonary disease. A multidisciplinary approach will be necessary to develop consistent and evidence-based treatment paradigms.

Reference

Cystic fibrosis chronic rhinosinusitis: a comprehensive review.
Chaaban MR, Kejner A, Rowe SM, Woodworth BA.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(5):387-95.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Lidocaine and nasal packing after nasal surgery
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

A prospective, randomised, double-blind controlled trial was conducted in 63 sinusitis patients undergoing functional endoscopic sinus surgery (FESS). At the conclusion of the operation, 2% lidocaine-soaked biodegradable synthetic polyurethane foam was used. Pain was evaluated using a visual analogue scale at postoperative 1, 4, 8, 16, 20 and 24 hours. In addition, the amount of gauze that cleaned the blood around the nose was counted. Heart rate, rhythm and blood pressure were checked preoperatively and postoperatively to evaluate the influence of lidocaine on vital signs. Postoperative pain was decreased in the lidocaine group at all the postoperative time periods. Lidocaine reduced postoperative bleeding at postoperative 8 and 24 hours. Changes of blood pressure from preoperative values in the lidocaine group were not different from those in the control group. Heart rate in the lidocaine group was more stable than that in the control group. Lidocaine-soaked packs significantly reduced postoperative pain without significant changes in vital sign. It is a useful method to reduce pain / nose discomfort during the early post FESS period.

Reference

Effect of lidocaine-soaked nasal packing on pain relief after endoscopic sinus surgery.
Mo MJ, Park Y, Chung Y.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(6):e174-e7.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Management of nasal polyposis with Montelukast
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

The purpose of this study was to determine the impact of montelukast and leukotriene antagonists treatment alone and in conjunction with intranasal steroid on nasal symptoms, objective clinical outcomes and immune parameters in nasal polyposis. Twelve studies fulfilled eligibility: five randomised control trials and seven cases series. The montelukast group showed significant improvements in nasal polyposis symptoms over placebo; however, these randomised trials were unable to be combined via meta-analysis. Montelukast is an effective tool for treating nasal polyposis, with limited benefit as an adjunctive therapy. Additional study is required to determine the most beneficial strategy and patient population for their use.

Reference

Leukotreine antagonists in nasal polyposis: a meta-analysis and systemic review.
Wentzel JL, Soler ZM, DeYoung K, Nguyen SA, Lohia S, Schlosser RJ.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(6):482-9.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Nasal toilet and nasal surgery
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

This is a good study. It is a prospective, controlled study, approved by the Institutional Review Board of Gachon University Gill Medical Center, of 30 patients for nine months. The aim was to evaluate the effect of maxillary sinus saline irrigation after surgery. Maxillary sinus saline irrigation is effective in the prevention of poor prognostic factors, such as the prevention of purulent rhinorrhoea, extensive granulation formation and polyp recurrence after endoscopic sinus surgery.

Reference

The effect of maxillary sinus irrigation on early prognostic factors after endoscopic sinus surgery: a preliminary study.
Kim ST, Sung UH, Jung JH, Paik JY, Woo JH, Cha HE, Kang IG.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(5):e158-e61.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

Promote healing after endoscopic sinus surgery
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

Steroid-infused absorbable nasal dressings after sinus surgery have been used to improve wound healing and to reduce the early recurrence of polyps . This study is small. Twenty patients, only, who underwent bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis were recruited and randomised into two groups with / without triamcinolone, TA(20mg)-soaked bioabsorbable dressing in both nasal cavities. The purpose of this study was to evaluate the systemic effects and safety of steroid-impregnated absorbable nasal packing after ESS. Serum cortisol, 12-hour urine cortisol, serum adrenal-corticotrophichormone (ACTH) and serum osteocalcin were measured preoperatively and on postoperative days 2 and 10. The serum cortisol levels were significantly suppressed at postoperative days one and two in the TA group. However, their systemic effects changes are not statistically significant.

Reference

Systemic effects and safety of triamcinolone-impregnated absorbable nasal packing after endoscopic sinus surgery: a randomized, double-blinded, placebo-controlled study.
Hong SD, Kim JH, Dhong H-J, Kim HY, Chung S-K, Chang YS, Sohn JH.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(5):407-10.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

The impact of patient education and treatment of allergic rhinitis
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

Allergic rhinitis is associated with illness, disability, health care costs and comorbidities such as asthma. A series of patient surveys, between 2006 and 2011, was conducted. This article compares data regarding disease burden, treatment patterns and patient expectations in Middle Eastern countries with those from other regions. The survey highlighted the relatively low use of intranasal corticosteroids, the current ‘gold standard’ treatment for allergic rhinitis. Patient education must play a central role in treatment decision making, particularly in the Middle East, to achieve higher patient satisfaction. The health care practitioners in the Middle East should be more strongly encouraged to use intranasal steroidal sprays for their patients.

Reference

The impact and treatment of allergic rhinitis in the Middle East: a comparison with the landmark allergy surveys from other worldwide regions.
Hadi UH, Rahman HA.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(6):490-4.

AMERICAN JOURNAL OF RHINOLOGY & ALLERGY

The microdebrider versus the Blakesley forceps in FESS polypectomy
Reviewed by: Laith Tapponi
May/June 2014 (Vol 23 No 2)
 

Functional endoscopic sinus surgery (FESS) represents the ‘gold standard’ therapy when medical treatment fails. The availability of different tools raises the question of which one provides significant advances in technique and surgical outcome. This is a good prospective randomised single-blind study, designed to analyse 311 cases of bilateral nasal polyposis. Each patient served as his / her own control, meaning that one side was operated on using the Blakesley forceps and the opposite side using the micro debrider. The follow-up period was 12-14 months. Gender, age, allergy and eosinophilia did not affect the surgical prognosis. The Blakesley forceps caused a significantly lower nasal polyposis recurrence rate but yielded a higher rate of synechia formation than the microdebrider.

Reference

Surgical treatment of nasal polyposis: A comparison between cutting forceps and microdebrider.
Tirelli G, Gatto A, Spinato G, Tofanelli M.
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2013;27(6):e202-e6.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Minimal gap interpositional arthroplasty versus aggressive gap arthroplasty in temporomandibular joint ankylosis
Reviewed by: Sampath Chandra Prasad
May/June 2014 (Vol 23 No 2)
 

Arthroplasty in temporomandibular joint (TMJ) ankylosis is managed by three basic techniques; gap arthroplasty, interpositional arthroplasty and joint reconstruction. In this three-year, prospective, study of 15 patients, the authors evaluate whether or not aggressive gap arthroplasty is essential in the management of ankylosis of the TMJ. Of the 15 patients (17 joints), 12 had unilateral and three had bilateral involvement, with trauma being the most common cause. A minimal gap of 5-8 mm was created in all 15 patients and interpositional gap arthroplasty was achieved by insertion of temporalis fascia. Eleven patients had unilateral coronoidectomy and four had bilateral coronoidectomy based on Kaban's protocol. Preoperative assessment included recording of history, clinical and radiological examinations, personal variables, the aetiology of the ankylosis, the side affected, and any other relevant findings. Patients were assessed postoperatively by a surgeon unaware of the treatment given for a minimum of three years, which included measurement of the maximal incisal opening, presence of facial nerve paralysis, recurrence, and any other relevant findings. Preoperative maximal incisal opening was 0-2 mm in eight cases and 2-9 mm in nine. Postoperatively adequate mouth opening of 30-40 mm was achieved in all cases, with no recurrence or relevant malocclusion during three-year follow up. The authors conclude that aggressive gap arthroplasty is not essential in the management of ankylosis of the TMJ and that minimal gap interpositional arthroplasty with complete removal of the mediolateral ankylotic mass is a feasible and effective method of preventing recurrence.

Reference

Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis? – A prospective clinical study of 15 cases.
Babu L, Jain MK, Ramesh C, Vinayaka N.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(6):473-8.

COCHLEAR IMPLANTS INTERNATIONAL

Another study investigating how patients and families choose their implants
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors describe the procedure followed by the Cochlear Implant Centre in involving the patients in their choice of device and tabulate the reasons given by patients for choosing a particular device. A retrospective service evaluation of 43 adults and 19 children was carried out and the data was analysed. The results revealed a wide range of reasons for choosing a particular device (fit and comfort, reputation of the company, look of the device and colour options, easiness to use,  smaller size of the processor, reliability, remote control, battery options, different programmes and extra features, direct repair management, future proof and local knowledge). However, it was interesting to find that the single most common reason for choosing a particular device was related to the aesthetics and comfort of the device. This is in contrast with the results reported by the other study in the same issue and shows that many factors may influence the related assessments (how many devices were available, type of interview, age of participants, etc.).

Reference

Patients' involvement in choosing a cochlear implant.
Chundu S, Stephens N.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):165-8.

COCHLEAR IMPLANTS INTERNATIONAL

Langerhans cell histiocytosis and bilateral cochlear implantation
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

Otologic disorders associated with Langerhans cell histiocytosis (LCH) are rather frequent in this rare proliferative disease and can affect up to one third of patients. Treatment of local and systemic disease may include medical, surgical and radiation therapies. Involvement of the temporal bone can lead to conductive and, rarely, sensorineural hearing loss. The authors report a case of a 45-year-old female with known bilateral temporal bone LCH. Following bilateral partial labyrinthectomy, post-operative testing showed a Hearing in Noise Test (HINT) result in quiet of 17%. Left-sided cochlear implant followed by immunosuppressive therapy for persistent disease showed marked improvement with post-operative HINT in a quiet room of 80% and 63%, at one and two years. This decline in performance led the authors to decide on right side post-labyrinthectomy cochlear implantation. However, it is not clear why HINT deteriorated and how medical treatment affected it. Nevertheless, 55 months after left implantation, and 10 months after right cochlear implantation, binaural post-operative HINT in quiet was 81%. The authors concluded that surgical excision of LCH lesion remains a mainstay of treatment for temporal bone involvement and that bilateral cochlear implantation with adjuvant immunosuppression demonstrated both immediate and delayed improvement in auditory function after staged cochlear implantation in the setting of persistent disease. Although the results seem promising we should be very cautious in this particular disease and long-term follow-up is needed.

Reference

Bilateral cochlear implantation in bilateral Langerhans cell histiocytosis.
Segel JM, McKinnon BJ.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):178-80.

COCHLEAR IMPLANTS INTERNATIONAL

A case report showing how a teenager with progressive hearing loss and severe learning difficulties can be helped with a cochlear implant
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

This paper describes the assessment and subsequent cochlear implantation of a teenager with progressive sensorineural hearing loss and severe learning difficulties. He had been diagnosed with trisomy 3P syndrome and severe additional disorders with global developmental delay. Imaging had demonstrated a primitive otocyst in one ear and Mondini dysplasia in the other ear. However, he eventually became a relatively good hearing-aid user. Unfortunately, his hearing deteriorated and this affected his behaviour, communication and quality of life. Finally, he did not want to use his hearing aid as it provided limited benefit. Although the assessment process was rather challenging, the decision for cochlear implantation had taken into account all the pros and cons. His mother and teacher helped to prepare him and the (re)habilitation and tuning sessions were modified in order to accommodate the related difficulties and his slow progress. However, the outcome of this particular deaf teenager with additional disorders indicates how flexible the assessment, the tuning and the (re)habilitation should be in order to provide the maximum benefit.

Reference

A difficult case: severe learning difficulties and patient selection.
Ford J, Bradley J.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s23-s5.

COCHLEAR IMPLANTS INTERNATIONAL

Assessing outcomes of bilateral implantation in the UK
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

In 2009, the UK National Institute for Health and Care Excellence published guidance for cochlear implantation: all suitable children are eligible to have simultaneous bilateral cochlear implants or a sequential bilateral cochlear implant if they already had received one. Fifteen UK cochlear implant centres formed a consortium to carry out a multi-centre audit. The audit involves collecting data from simultaneously and sequentially implanted children at four intervals: before bilateral cochlear implants or before the sequential implant, one, two, and three years after bilateral implants. The measures include localisation, speech recognition in quiet and background noise, speech production, listening, vocabulary, parental perception, quality of life, and surgical data including complications (reported in another study). As the audit passed the two year point the authors reported data from 850 children. However, due to the short follow-up there were few results on sound localisation and speech recognition in noise. Auditory perception and speech intelligibility showed an improvement with time for simultaneously implanted children. With regard to the sequentially implanted children, there was a wide variation in the results. It seems that the two year interval is too early for any definite conclusions and this study gives us only a flavour of what we should expect.

Reference

United Kingdom National Paediatric Bilateral Cochlear Implant Audit: Preliminary results.
Cullington H, Bele D, Brinton J, Lutman M.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S22-6.

COCHLEAR IMPLANTS INTERNATIONAL

Can we perform cochlear implantation under local anaesthesia?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors reviewed a patient series of 16 cochlear implantations performed under local anaesthetic, including a description of the centre's technique for this procedure. They also described the application of a method for calculation of the potential morbidity / mortality avoided by using this technique. The assessment included the 16 patients’ preoperative medical and anaesthetic notes and the calculation of predicted individual P-POSSUM scores (physiological and operative severity score for the enumeration of mortality and morbidity). The results revealed that all 16 patients were implanted successfully with no significant complications. Age range was 26-92 years, with an average of 68 years. The patients’ average predicted mortality score associated with a general anaesthetic was 8.6% and the respective morbidity score was 58%. The authors concluded that cochlear implantation under local anaesthesia seems to be a safe and effective procedure. It has the benefit of avoiding the operative mortality risk predicted by P-POSSUM scores. Therefore, a potential group of cochlear implant recipients considered ‘unfit’ or high risk for general anaesthesia may be operated under local anaesthesia. An interesting and useful study. However, a larger study assessing patients’ discomfort and surgeons’ related problems is needed.

Reference

How we do it: Local anaesthetic cochlear implantation.
Toner F, Jackson CP, Toner JG.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):232-5.

COCHLEAR IMPLANTS INTERNATIONAL

Comparison of implanted children with additional disorders with hearing controls
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors compared 14 deaf children with cochlear implants (CIs) and developmental disabilities with a hearing control group of seven children of similar ages and similar disabilities in a cross-sectional study of language and functional skills. Daily functional skills were measured using the Paediatric Evaluation of Disability Inventory (PEDI), which provides standard and scaled scores in self-care, mobility and social functioning domains. Language was assessed using the Preschool Language Scales which provide standard scores and age equivalents. Most children in this study (90.5%) had cognitive disabilities and 57% had motor disabilities. Compared with hearing controls, children with CIs were less likely to have functional independence in any PEDI domain. Children with CI had significantly lower median social functioning standard scores compared with controls. However, after controlling for nonverbal cognitive abilities and language level, the difference was no longer significant. Among children with CI, age at implant and duration with device were not associated with PEDI scores. The authors concluded that although children with CI and developmental disabilities were found to have similar functional skills as hearing children with similar disabilities regarding the PEDI domains of self-care and mobility, they had lower social function standard scores. This lower social functioning among children with implants was attributed to the possible lower language levels and possible language deficits seen in the CI group. However, several design problems of the study (e.g. small numbers, quite heterogeneous groups) weaken these very interesting outcomes.

Reference

Functional performance among children with cochlear implants and additional disabilities.
Meinzen-Derr J, Wiley S, Grether S, Choo DI.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):181-9.

COCHLEAR IMPLANTS INTERNATIONAL

Does aetiology of deafness affect cochlear implant outcome in deaf children?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors retrospectively assessed 163 children implanted between 1996 and 2008 (0-18 years, mean 5 years). The mean follow-up was 65 months. Aetiology of deafness was found in 104 cases and 69 children (52%) suffered from hereditary hearing loss. All children showed improvement in their auditory performance. However the authors found that children with connexin-26 mutation performed significantly better and children with Usher and CHARGE-syndrome significantly worse. Post-meningitic and post-septic children were slower in progress but reached the same levels of performance later on. The authors concluded that the primary cause of deafness, among other factors, has a considerable impact on outcome of rehabilitation and this should be taken into account in designing aetiology-adjusted therapy modules. Again, mixing-up prelingual with postlingual deaf children with wide variation in ages and experience weakens the outcomes and suggest that future studies should control their comparisons for all confounding factors.

Reference

Influence of etiologic factors on speech perception of cochlear-implanted children.
Janeschik S, Teschendorf M, Bagus H, Arweiler-Harbeck D.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):190-9.

COCHLEAR IMPLANTS INTERNATIONAL

Does anaesthesia affect intraoperative monitoring of cochlear implant function in children?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

Intraoperative electrical impedance measurements, electrically evoked stapedial reflex threshold (ESRT) and evoked compound action potential (ECAP) are supposed to be very helpful in postoperative tuning of the device following implantation in young children. The authors’ aim was to evaluate the effects of intravenous anaesthesia on intraoperative monitoring of cochlear implant function in paediatric cochlear implantees. It was a prospective study of 29 children aged from 18 months to 11 years. All children had bilateral severe to profound sensorineural hearing loss. Patients were maintained on an infusion of Fentanyl at 0.3‐0.6  ugm / kg / hr and Propofol at 4‐8 mg / kg / hr intraoperatively. Intraoperative measurements were done after performing the train of four tests on the adductor pollicis muscle. The results revealed that ESRT was unaffected by intravenous anaesthesia. Electrical impedance and ECAP were not affected by any technique of anaesthesia. Therefore, the authors concluded that intravenous anaesthesia with the above mentioned protocol has little or no effect on the intraoperative auditory thresholds and is therefore recommended for determining these thresholds during cochlear implant surgery. A rather reassuring study, telling us to continue using these measurements under anaesthesia, with a standard protocol.

Reference

Effect of total intravenous anaesthesia on intraoperative monitoring of cochlear implant function in paediatric patients.
Jana JJ, Vaid N, Shanbhag J.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):169-73.

COCHLEAR IMPLANTS INTERNATIONAL

Does cochlear implantation surgery affect taste?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors assessed the risk of taste disorders following the classical cochlear implantation surgery that involves mastoidectomy and posterior tympanotomy. Twenty-six patients underwent a taste test before, three days after and six weeks after cochlear implantation surgery. The taste sensations were evaluated. Patients’ self-ratings of taste function were also obtained. In addition, the surgeons provided information concerning the intraoperative status of the chorda tympani. The results revealed that 19% (5 of 26) of the patients had postoperative taste dysfunction, as measured either subjectively or objectively or both. One of these five individuals had taste disturbance as assessed by both subjective and objective measures; in another, it was merely reported subjectively. Three patients were subjectively asymptomatic but the postoperative taste test revealed a dysfunction. Sixteen percent of the patients in whom the chorda tympani was reported to be preserved intraoperatively had a postoperative taste dysfunction. Although the chorda tympani was rerouted in five patients, only two of them (40%) had transient taste disorder. In two of those patients with postoperative taste dysfunction, the chorda tympani was not intraoperatively exposed. However, these individuals experienced postoperative taste problems. The recovery rate was 100% at six weeks after surgery. The authors concluded that cochlear implantation entails only a minimal risk of taste dysfunction and that this is a rather transient problem. Although the results are interesting, it is already well known from stapes surgery that cutting off the chorda tympani does not cause significant problems in the majority of patients and that any related disturbance usually disappears with time. Moreover, the surgical reports are often inaccurate regarding chorda tympani and therefore the related studies ambiguous.

Reference

Taste sensation following cochlear implantation surgery.
Alzhrani F, Lenarz T, Teschner M.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):200-6.

COCHLEAR IMPLANTS INTERNATIONAL

Electrode array in the internal auditory canal of malformed ears. What do we do?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors in this case report underline the importance of a radiological technique which allows 3D imaging of the cochlear implant electrode position postoperatively in cases of cochlear malformation, and show a technique to prevent a repeat of cochlear implant electrode insertion in the internal auditory canal (IAC). A one and a half-year-old patient with an incomplete partition (IP) III cochlear malformation was implanted and it was later discovered that the speech processor could not be tuned because the electrode array had been inserted into the IAC. The single plain postoperative X-ray was not sufficient to detect the incorrect insertion of the cochlear implant electrode array. However a three-dimensional radiology showed that the array was inserted in the IAC. During revision surgery, the original cochlear implant electrode was temporarily left in place under the assumption that it would block the entrance to the IAC and prevent IAC insertion of the replacement electrode. Indeed, the second array was correctly inserted as confirmed by three-dimensional radiology. The authors concluded that postoperative three-dimensional radiological assessment after cochlear implant surgery should be done in cases of malformation.  In addition, they suggest that leaving the original electrode in place can help to prevent a repeat incorrect insertion of the electrode. Although the whole case study is interesting and probably useful in malformed cochleas, the three-dimensional illustrations and the figures were of rather poor quality and difficult to interpret

Reference

Identification and revision of a displaced cochlear implant electrode in the internal auditory canal.
Todt I, Rademacher G, Ernst A.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):236-9.

COCHLEAR IMPLANTS INTERNATIONAL

Has hydroxyapatite bone cement any complications when used in cochlear implantation?
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors aimed to report the complications of using hydroxyapatite (HA) bone cement when implanting a cochlear implant (CI) device. A case series of three patients who had undergone cochlear implantation are presented in this study. A bony defect was seen in the external auditory meatal wall posteriorly in all three cases. This was intimately related to the site of HA bone cement, which had been used to anchor the electrode array at the time of the original implantation. Persistent otorrhoea was usually a feature at clinical presentation. The authors removed the HA bone cement and repaired the bony defect. This resulted in resolution of the otorrhoea in all cases. The authors concluded that the use of HA bone cement in cochlear implantation may cause dehiscence of the external auditory meatal wall. Taking into account that their current belief is that the electrode array does not need to be secured with cement, they recommend that HA cement should not be used to secure the electrode array in cochlear implantation surgery. I believe that a small number of centres still use it.

Reference

Complications of hydroxyapatite bone cement use in cochlear implantation?
Gaskin JA, Murphy J, Marshall AH.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):174-7.

COCHLEAR IMPLANTS INTERNATIONAL

Implanted children with cerebral palsy. The need for specific outcome measures
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors aimed to review the evidence for cochlear implantation in children with cerebral palsy and evaluate the current outcome measures in this group of patients. The evidence in the literature revealed that cognitive functioning appears to be the most important prognostic factor when considering cochlear implantation in children with cerebral palsy. On the other hand, physical impairment was not found to negatively impact the outcome of cochlear implantation. The authors highlight the lack of appropriate outcome measures and conclude that the current lack of a suitable set of outcome measures appropriate to this group of patients, should not lead clinicians to conclude that any impact upon quality of life is limited, or less significant when compared to children without complex needs. Although this is very clear and evident, the design and evaluation of such measures seems to be difficult as their continuous lack indicates.

Reference

The need for specific outcome measures when evaluating cochlear implantation in hearing impaired children with cerebral palsy.
Bruce IA, Markey A, Henderson L, Green KMJ.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s35-s7.

COCHLEAR IMPLANTS INTERNATIONAL

Ototoxicity and cochlear implantation
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors assessed the outcome of cochlear implantation in patients deafened by ototoxic drugs and compared it with the outcome of implantation in sudden sensorineural hearing loss (SSNHL) with a similar duration of deafness. Primary outcome measure was post-implantation Bamford-Kowal-Bench (BKB) score in quiet in both groups. Secondary outcome measure was any significant complications following implantation. The authors identified retrospectively 14 patients in the ototoxic group, who were matched with 13 patients in the SSNHL group. The postoperative BKB score in the ototoxic group ranged from 33 to 100% (median score 91%). One patient had bilateral CI. One patient required explantation following an infection. The postoperative BKB score in the SSNHL group ranged from 16 to 100% (median score 88%). One patient in this group could not be tested using this method as he / she did not have open set speech discrimination. Two patients in this group had bilateral CI. The authors found no statistically significant difference in the BKB scores in the two groups and concluded that patients with profound hearing loss due to ototoxic agents can be rehabilitated successfully with CI. The outcomes may be variable and may be dependent on the underlying pathology for which the ototoxic agents were prescribed. The last conclusion means that additional disorders or diseases may affect the outcome. This is reasonable and true for all implantees. The wide variation and the small numbers of patients do not help in the clarification of the issue studied.

Reference

Cochlear implantation in patients deafened by ototoxic drugs.
Nichani J, Bruce IA, Mawman D, Khwaja S, Ramsden R,
Green K.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):207-12.

COCHLEAR IMPLANTS INTERNATIONAL

Surgical safety and complications of bilateral paediatric cochlear implantation
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

Bilateral paediatric cochlear implantation (CI) in the UK was approved in 2009 and a prospective multi-centre National Paediatric Cochlear Implant Audit was established in order to collect a large dataset of paediatric implantations. The aim of the surgical part of the audit, reported in this study, was to collect data on surgical practice, outcomes and complications. The data came from 14 surgical centres and was collected prospectively, including simultaneous and sequential bilateral as well as unilateral implantations. The data included several details such as age at implantation, aetiology of deafness, implant type, duration of surgery, the use of electrophysiological testing, and the use of pre- and postoperative imaging. Data of major and immediate minor complications were also collected. The results took into account 1397 CI procedures in 961 CI recipients; 436 bilateral simultaneous, 394 bilateral sequential, and 131 unilateral cochlear implantations. The overall major complication rate was 1.6% (0.9% excluding device failure) and was similar following bilateral CI compared to sequential and unilateral CI. The authors concluded that this prospective multi-centre audit provides evidence that bilateral paediatric CI is a safe procedure in the UK, thus endorsing its role as a major therapeutic intervention in childhood deafness. Although multi-centre studies have several weaknesses, large numbers are always helpful and give a rough estimate of the global picture of bilateral cochlear implantation with regard to surgical safety.

Reference

Results of a prospective surgical audit of bilateral paediatric cochlear implantation in the UK.
Broomfield SJ, Murphy J, Emmett S, et al.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(Suppl.4):S19-S21.

COCHLEAR IMPLANTS INTERNATIONAL

The incidence of auditory neuropathy as calculated from a newborn hearing screening programme in the UK
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The author aimed to estimate the prevalence and incidence of auditory neuropathy spectrum disease (ANSD) in the neonatal intensive care unit (NICU) population in Avon. Data was collected from the Newborn Hearing Screening Programme database to determine the number of babies with bilateral sensorineural hearing loss. Then, all available related data and audiological paper records were reviewed to determine the number of babies diagnosed with ANSD, their behavioural hearing thresholds and how the babies were managed. The average incidence of congenital bilateral sensorineural loss was 1.53 per 1000 births (range 1.03 to 1.94 per 1000 births); the average incidence of ANSD was 0.24 per 1000 births (range 0 to 0.52 per 1000 births). Over a period of eight years, 21 out of 134 (15.7%) children identified with abnormal air and bone conduction auditory brainstem response (ABR) thresholds were diagnosed with ANSD. The major shortcoming in this study is the fact that children with ANSD who were born in maternity units without being admitted to intensive care units were not diagnosed and taken into account. However, the follow-up audiological assessment was very interesting. It showed that the audiogram hearing thresholds cannot be predicted from the initial test results when ANSD is diagnosed, although the majority of children with no ABR will show at least a degree of hearing loss in the audiogram.

Reference

The prevalence of auditory neuropathy spectrum disorder in neonates referred from the Newborn Hearing Screening Programme in Avon (Greater Bristol Area).
Midgley E.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s15-s17.

COCHLEAR IMPLANTS INTERNATIONAL

The outcomes of implanted children with additional disorders or auditory neuropathy
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors assessed the benefit of cochlear implantation (CI) in (A) 70 children with complex needs (CD) and (B) 22 children with auditory neuropathy spectrum disease (ANSD). As outcome measures, a category scale score from 0 to 10 (0-100%) for speech perception and an alternative scale score from 0 (non-user) to 4 (great benefit) were used based on a broader view of benefit when speech tests were not applicable. The results revealed that children with CD had a mean alternative scale score of 3.0 (clear benefit). Forty-eight children with cognitive disabilities scored significantly worse than the 22 children with solely physical disorders, 2.6 vs. 3.8. The mean score for 29 children tested with standard speech tests was 7.7 (77%). Five out of six non-users had cognitive disabilities. The standard speech test battery was applicable in 19 / 22 children (86%) with solely physical disabilities, but only in 10 / 48 (21%) of children with cognitive disabilities. Thirteen out of 22 children with CI and ANSD were old enough to be evaluated by speech tests and had a mean speech category score of 8.3. For 20 children, improved language skills and better social interaction was reported. The two non-users were implanted late. The authors concluded that CI was beneficial to the vast majority of children with CD. Children with cognitive dysfunction had poorer speech and language development, but still benefited clearly from CI. Finally children with ANSD without cognitive difficulties had outcomes similar to those of implanted children without CD. A very interesting study, although children with ANSD might not be included in a study of children with CD.

Reference

The Oslo experience of cochlear implant in children with complex disorders and auditory neuropathy spectrum disorder.
Bunne M.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s31-s4.

COCHLEAR IMPLANTS INTERNATIONAL

The parents’ view on cochlear implantation of deaf children with additional disorders
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

The authors assessed parents’ perspectives on their experiences of, access to, and outcomes from cochlear implantation for their child with complex needs. Purposive sampling was used to recruit 10 parents of children with varying additional disabilities. The age range of the children was between 2 and 11 years at the time. A semi-structured interview format was used to collect data and the interviews were audio recorded and transcribed for analysis. Thematic content analysis was used to explore the data. The results were analysed using the following pattern. Individual themes were clustered together to form four main themes describing parents’ perspectives and experience. The four main themes were: ‘Assessment process’, ‘Reported benefits of cochlear implantation’, ‘Wearing the processor’ and ‘Educational issues’. The outcomes were very interesting as parents described in detail their views that were sometimes surprising or unexpected. They appreciated changes in their child's communication and social changes where the child was included more in family life. Challenges relating to delays in the assessment process were reported. Similarly, the difficulties associated in accessing the technology were identified and perceived by some parents as discriminatory. One of the most interesting findings was the report from one parent that before implantation his child was diagnosed as having severe learning difficulties and the diagnosis following implantation was no learning difficulties. This highlights the ‘severe’ difficulties in diagnosis, assessment and (re)habilitation of these children.

Reference

Children with complex needs and cochlear implants: The parent's perspective.
Mulla I, Harrigan S, Gregory S, Archbold S.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(S3):s38-s41.

COCHLEAR IMPLANTS INTERNATIONAL

The protein pejvakin in human spiral ganglion cells
Reviewed by: Thomas Nikolopoulos
May/June 2014 (Vol 23 No 2)
 

Although cochlear implantation is one of the most successful methods of management for profound deafness, the exact aetiology and pathophysiology of deafness remain obscure. DFNB59 gene encodes the protein pejvakin (PJVK) and its mutations cause autosomal recessive auditory neuropathy as well as other forms of sensorineural hearing loss. The authors performed an immunohistochemical study and explored the distribution of PJVK protein in surgically obtained human cochleae. The human cochleae had normal hearing thresholds before the operation that was performed for brain tumours using a transcochlear approach. The expression of PJVK was located in the cell bodies of all spiral ganglion neurons rather than the nerve fibres that were labelled with Tuj 1 antibody. As Tuj 1 antibody stained the cytoplasm of type 1 cells, PJVK antibody labelled both type 1 and type 2 cells. The nuclei of the neurons were also PJVK-positive. No labelling was seen in the structures within the organ of Corti and the stria vascularis. The authors demonstrated for the first time the expression of PJVK in human spiral ganglion neurons. It remains to be seen how these advances in gene and protein research will lead to prevention or treatment of deafness

Reference

Distribution of pejvakin in human spiral ganglion: An immunohistochemical study.
Liu W, Kinnefors A, Boström M, Edin F, Rask-Andersen H.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(4):225-31.

CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY

Vestibular migraine
Reviewed by: Susan A Douglas
May/June 2014 (Vol 23 No 2)
 

This is a review of the diagnosis and treatment of vestibular migraine. Migraine is a common illness and migraine - related dizziness occurs in up to 3% of the population. Many patients may go untreated because the diagnosis may be difficult and controversial. The categories of migraine accepted by the international headache society do not reflect the complex presentations of patients presenting with vestibular migraine. Clinical practice and research has begun to separate patients into ‘definite vestibular migraine’ and ‘probable vestibular migraine’. Vertigo may trigger migraine and therefore patients with vestibular migraine should be suspected of having vestibular end organ disease unless proven otherwise. Migraine associated vertigo may not present as the classic horizontal or torsional rotatory vertigo of peripheral vestibular disease. This may present as a horizontal-rotatory sensation or a ‘to-and-fro’ type sensation. Migraine is described by the International Headache Society in the International Classification of Headache Disorders, second edition (ICHD-II) as ‘migraine with prolonged aura’, ‘basilar migraine’, ‘migraine aura without headache’, ‘childhood periodic syndromes’, ‘benign paroxysmal vertigo (BPV) of childhood’, ‘migrainous infarction’. This system only recognises vertigo as a part of Basilar migraine or BPV of childhood. The most widely accepted classification of migraine related dizziness is the ‘Neuheuser criteria’, which defines ‘definite’ and ‘probable’ migraine. The best treatment strategy of patients suspected of vestibular migraine is dietary / lifestyle modification, anti nausea / anti emetics for acute attacks of vertigo and preventative medication for those with persistent disruptive symptoms. This is a well-written review examining the diagnosis and treatment of vestibular migraine. An article that is worthwhile reading for anyone with an interest in vertigo.

Reference

The challenge of vestibular migraine.
Sargent EW.
CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY
2013;21:473-9.

HEAD & FACE MEDICINE

Variable expressivity of familial cherubism
Reviewed by: Bilal Gani Taib
May/June 2014 (Vol 23 No 2)
 

Cherubism is classified within the group of benign osteo-fibrous lesions. It is a rare (less than 1 in 10,000) genetic disease with a dominant autosomal inheritance pattern exhibiting variable penetrance and expressivity. It originates from a mutation of the SH3BP2 (SH3-domain binding protein 2), which is located at chromosome 4pl6.3. Phenotypically it manifests as abnormal growths of the facial bones, around the age of four, mainly affecting the jaw. Complications include sight loss due to optic neuropathy, obstruction of upper airways and abnormalities in the development and appearance of teeth. Diagnosis is made histologically with the presence of randomly assorted multi-nucleated giant cells in the vascular stroma of the fibrous connective tissue. The differential diagnosis includes fibrous dysplasia, odontogenic cyst, juvenile ossifying fibroma, giant cell granuloma, fibrous osteoma and osteosarcomae hyperparathyroidism. This case series describes a gentleman (patient 1), who first presented with the disease, his sister and her son (patient 2), who also has the disease. Patient 1 presented with multiple epidermal cysts with numerous malpositioned teeth, and a polypoid formation in the right maxillary sinus as well as orbital involvement. According to the Raposo-Amaral classification he is a grade VI. The female patient exhibited no signs whilst patient 2 (her son) presented with dental abnormalities, odontogenic cysts and non-specific headaches. According to the Raposo-Amaral classification he is a grade III. Diagnosis was confirmed with genetic analysis in which all three relatives were found to have SH3BP2 R415Q / normal genotype, in which the risk of transmission is 50%. This reports helps illustrate that when grouped by sex, expressivity amounts to nearly 100% in men and 50 to 75% in women. The paper suggests that an additional grade, grade 0, be added to the Raposo-Amaral classification for asymptomatic carriers.

Reference

Variable expressivity familial cherubism: woman transmitting cherubism without suffering the disease.
Pérez-Sayáns M, Barros-Angueira F, Suárez-Peñaranda JM, García-García A.
HEAD & FACE MEDICINE
2013;9:33.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Optimum hearing aid prescription for tinnitus intervention
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

For many years, the management of tinnitus has included the use of hearing aids. However, in many studies, the focus has been on hearing amplification rather than on the relief of tinnitus. The main goal of this study was to examine the effect of high frequency hearing aid amplification using the DSL(I/O) v5.0 prescriptive procedure on short-term tinnitus relief. The authors recruited 25 adults between the ages of 34 and 81 years who had experienced troublesome tinnitus from two years to 54 years. All participants had mild to moderate sensorineural hearing loss (SNHL) up to 8 kHz and moderate to severe between 9 and 16 kHz. None of them had used hearing aids prior to the study. Various tinnitus measures were obtained to quantify self-perception, loudness and pitch of the tinnitus. Thirteen speech files simulating the effect of change in DSL(I/O) v5.0 prescription in high frequency amplification were recorded. After being fitted with a master hearing aid according to their hearing loss, participants were instructed to listen to the speech files and select the level of amplification that makes their tinnitus least audible. The most preferred output was a 6 dB reduction at 2 kHz (26.4%) followed by a similar reduction at 4 kHz (14.7%) and a 3 dB reduction at 2 kHz by 11.76% of participants. The lower the pitch of the tinnitus, the lower the preferred DSL(I/O) v5.0 setting. The authors conclude that when fitting hearing aids for tinnitus relief, the DSL(I/O) v5.0 prescription and a reduction of 3 dB across the frequency when the pitch of tinnitus is ≤ 4 kHz are a good starting point, but the comfort and audibility of the tinnitus by the individual should not be ignored.

Reference

Prescription of hearing-aid output for tinnitus relief.
Shekhawat GS, Searchfield GD, Kobayashi K, Stinear CM.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:617–25.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Risks posed by the use of portable digital audio players
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

Portable digital audio players (DAP) have virtually become fashion accessories nowadays. Some of them have estimated maximum sound output levels between 101 dBA and 107 dBA. However, many users are either ignorant about, or adopt a nonchalant attitude to the potential risk DAPs pose to hearing. The authors recruited 237 children aged between 10 years and 17 years from different schools (state and private) to study the relationship between DAP listening behaviours (duration / volume) and measured sound pressure levels, audiometric levels and self-reported symptoms of hearing loss. The students completed a 37-item questionnaire covering self-reported hearing health, frequency of recreational noise exposure, symptoms of hearing loss, frequency and usage of DAP in various situations, headphone / earphone fit, and use of hearing protection and knowledge of hearing loss prevention. Participants were asked to play a favourite song on their DAP at a typical self-identified maximum volume setting while the sound level pressure was measured. Objective evaluation of hearing was obtained with tympanometry and air-conduction pure tone audiometry. Parents of the participants completed a six-item questionnaire to determine the socioeconomic background. The daily personal noise exposure level – Lex (8 hr) was calculated, among others. The authors reported a positive correlation between the duration / loudness levels and the age of subjects: the older they were, the more likely they were to listen for longer periods of time at louder levels. Subjects who had listened to their DAPs for five years or more had higher average pure tone audiometry (PTA) thresholds at 4 and 8 kHz. The prevalence of tinnitus was 23.6% to 26.2% but in disagreement with other studies, the authors found no correlation with loudness levels in this study. However, in those who self-reported hearing loss, the high frequency PTA average was higher. Interestingly, but rather worryingly, the same people ‘believed doctors could restore their hearing’. It is obvious from this study that more education on hearing protection among the youth is needed!

Reference

Audiometric thresholds and portable digital audio player user listening habits.
Feder K, Marro L, Keith SE, Michaud DS.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:606-16.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Pragmatic skills essential to develop spoken language in children with cochlear implants
Reviewed by: Gauri Mankekar
May/June 2014 (Vol 23 No 2)
 

An increasing number of children are receiving cochlear implants (CIs) early in childhood. But CIs do not ensure that a child will develop spoken language easily. Pragmatic skills have proven to be essential in fine tuning spoken language. These skills and their relationship with spoken language in children with CIs under the age of three years was studied by these authors. They compared the linguistic and pragmatic skills of children undergoing cochlear implantation at 12 months old with those implanted between 13 and 26 months old. The authors found that CI does provide deaf children with a good opportunity to develop language skills but severe difficulties in early social experiences and interaction mediated by language still persist. They did not find any significant difference in vocabulary size or early grammar skills amongst children implanted prior to 12 months of age and those implanted after 12 months of age. They recommend that interventions taking into consideration the improvement of pragmatic skills should be undertaken even on very young children with CI.

Reference

Linguistic and pragmatic skills in toddles with cochlear implant.
Rinaldi P, Baruffaldi F, Burdo S, Cristina M.
INTERNATIONAL JOURNAL OF LANGUAGE AND
COMMUNICATION DISORDERS
2013;48(6):715-25.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

A small series of superficial circumflex iliac artery perforator flap for intraoral reconstruction
Reviewed by: Sunil Kumar Bhatia
May/June 2014 (Vol 23 No 2)
 

Tissue loss in the head and neck region can be caused by a variety of mechanisms, most commonly following resection of malignant disease. These can lead to defects that are challenging, often requiring microvascular tissue transfer. The authors introduce a perforator flap based on the superficial circumflex iliac artery; it is a modification of the original groin flap. This has been used for lower limb reconstructions and the authors present an elegant article about this flap’s first use intraorally. While this is a small series, this is the first described use of this flap for intraoral reconstruction. There were four patients that had intraoral and one with pharyngeal resection and reconstruction. The authors describe excellent cosmetic and functional outcomes with flap.  The flap is reported to be very pliable and thus would work well for intraoral reconstruction.  The authors make an effort to compare the functional outcome of this flap, but are hampered by the small numbers. It would seem this flap is at least as good as the more conventional flaps used for intraoral reconstruction. One small difficulty might be the small calibre of the vessels. The article also discusses intraoral microvascular reconstruction in general and there is a succinct but valuable discussion of the various options.

Reference

The superficial circumflex iliac artery perforator in intra-oral reconstruction.
Green R, Rahman KMA, Owen S, Paleri V, Adams J, Ahmed OA, Ragbir M.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1683-7.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Jejunal flap for pharyngolaryngectomy defect
Reviewed by: JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
May/June 2014 (Vol 23 No 2)
 

This is a paper of 368 consecutive cases on 366 patients who had a hypopharyngeal defect reconstructed with a jejunal flap. Of these cases, 71% were for T3/T4 tumours. The average time to swallow was 12 days with a full oral diet achieved by 92% of patients. They had an 8% leak rate and 10% stricture rate. Abdominal complications occurred in 4%. The authors concluded that the jejunal flap consistently reproduces good functional results. They acknowledge an operator-dependent phenomenon associated with this operation.

Reference

Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 consecutive cases.
Perez-Smith D, Wagels M, Theile DR.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:9-15.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Mandibular contouring
Reviewed by: Catherine Treacy
May/June 2014 (Vol 23 No 2)
 

This is a paper from China outlining mandibular contouring for correction of a square jaw as an aesthetics concern for East Asians. They describe, essentially, four types of contouring procedure including one involving a Medpore implant. Whilst it is uncommon that Western units will encounter this problem this is a useful guide to changing a square to an oval shaped face.

Reference

How to achieve a balanced and delicate lower third of the face in orientals by mandibular contouring.
Chen T, Khadka A, Hsu Y, Hu J, Wang D, Li J.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:47-56.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Nasolabial flap for lip reconstruction
Reviewed by: Catherine Treacy
May/June 2014 (Vol 23 No 2)
 

This paper suggests the use of a nasolabial flap for the reconstruction of intermediate to large lip defects. The authors advocate an algorithm for its use in defects, 30% of which are regarded as simple when the commissure is not intact. There were 21 cases and they suggest good functional and aesthetic results and a reliable flap. There were no cases of microstomia.

Reference

The nasolabial flap as a one-stage procedure for reconstruction of intermediate to large lip defects with functional and aesthetic assessments.
Tan N-C, Hsieh C-H, Riva FMG, Jeng S-F.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:352-57.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Prediction of leaking jejunal flaps
Reviewed by: Catherine Treacy
May/June 2014 (Vol 23 No 2)
 

This paper from Hong Kong reviews 96 patients, five of which had clinical leakage and 12 radiological leakage. The authors concluded that serum albumin and white cell count identify the presence of anastomotic leakage from the jejunal flap. Serum albumin was also an early predictor of leakage so early interventions could be employed. The albumin was relevant as early as three days following surgery; a higher white cell count became significant only after day seven. They suggest there is a strong benefit in monitoring postoperative serum albumin.

Reference

Early prediction of anastomotic leakage after free jejunal flap reconstruction of circumferential pharyngeal defects.
Chan JY, Liu LHL, Wei WI.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:376-81.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Sensate flap for oromandibular reconstruction
Reviewed by: Sunil Kumar Bhatia
May/June 2014 (Vol 23 No 2)
 

With the advent and now progress of microvascular techniques and expertise, the two frontiers are reducing morbidity and increasing functional outcomes. This is an excellent example of the latter. They initially dissected out on cadaveric specimens the nerve supply to the lateral lower leg and show it has a dual supply lateral sural cutaneous nerve and a previously unknown nerve they name recurrent superficial peroneal nerve. The innervated flap for intraoral reconstruction is vastly superior to the non-innervated one and may be critical in the maintenance of function and in enhancing remaining quality of life. The authors present a series of 31 patients that required composite mandibular reconstruction that were done with a sensate fibula. Intraoperatively the lateral sural cutaneous nerve or the recurrent superficial peroneal nerve was chosen as donor and anastamosed to the lingual or the greater auricular nerve. The outcomes were measured with the analysis of speech, type of food consumption and oral competence. At least six months later, on testing, 28 had some sensory return, including thermal and pinprick sensation. Better results were obtained in patients when the lingual nerve was used with end to end neurorrhaphies. Only three out of the five patients using the greater auricular nerve showed any sensory return. The authors define success by a return of sensation. The main advantage then is the detection of poorly fitting prostheses and limiting damage to the oral mucosa. They also report encouraging results, despite a small sample (3/31 end to end neurorrhaphy).  I think there is merit in their discussion, innervated flaps are superior to non-innervated ones and surgical skill plays a large part in functional outcomes. The functional outcomes should be assessed to determine the outcome.

Reference

The sensate fibular osteoneurocutaneous flap in  oromandibular reconstruction: clinical outcomes in 31 cases.
Boyd JB, Caton AM, Mulholland RS, Granzow JW.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2013;66:1695-701.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Subscapular flap for oro-facial defect
Reviewed by: Catherine Treacy
May/June 2014 (Vol 23 No 2)
 

This retrospective article from Montreal looks at 16 patients who underwent mandibular reconstruction with a latissimus dorsi flap. The flap comprised of one or two skin paddles and one bony component based on the angular branch of the thoracodorsal artery. Donor site complications were minimal. Fourteen patients were able to recommence oral nutrition. Diction returned to normal in all but one case. The authors propose that the single flap offers volumes of tissue with a reliable anatomy. The pedicle measured between 2.5 cm and 8 cm in length and it was thought this could reliably supply up to 20 cm of bone from both the medial and lateral scapula. They advocate it is a useful flap providing sufficient skin and oral lining, soft tissue bulk and bone stock.

Reference

Chiameric subscapular free flap for complex oro-facial defects.
L’Heureux-Lebeau B, Odobescu A, Harris PG, Guertin L, Danino AM.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2013;66:900-5.

JOURNAL OF VESTIBULAR RESEARCH

Could VEMPs be used to diagnose Ménière’s disease?
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

Currently, the AAOHNS criteria are used to diagnose Ménière’s disease (MD). There is no specific diagnostic test. The aims of this study were two-fold: a) to determine the specificity and sensitivity of cervical vestibular evoked myogenic potentials (VEMPs) and caloric test and b) to compare these two tests with the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) stages of MD. Retrospective data of patients attending a specialist vertigo clinic were analysed. There were 114 patients with a diagnosis of definite unilateral MD were included. A decreased or absent VEMP on the side of MD was classified as ‘appropriately identified with VEMP’. In addition to the latency and amplitudes, the percentage VEMP asymmetry was computed. Caloric test was done by irrigating the ears with 2ml of water at 4oC for 20 seconds and the degree of canal paresis (CP) was calculated (>20% was considered abnormal). Combining the results of both click and tone burst VEMPs, half of the patients (50%) were ‘appropriately identified’ and 50% were ‘inappropriately identified with VEMPs’. The specificity for VEMP was 48.9% when the MD subjects were compared with 1056 other dizzy patients. This major limitation of using non-MD patients to determine the specificity was addressed by the authors. The sensitivity and specificity of the caloric test in the MD patients were 37.7% and 51.5% respectively. The differences between VEMPs and caloric test results did not reach statistical significance. No firm conclusions could be made on the sensitivity of VEMPs versus stage of MD, however it was higher for stages I and II but not for III. We are a long way off finding a diagnostic test for MD. Until then, clinicians will continue to use the AAOHNS criteria.

Reference

The diagnostic value of vestibular evoked myogenic potentials in patients with Meniere’s disease.
Egamia N, Ushio M, Yamasoba T, Yamaguchi T, Murofushi T, Iwasaki S.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:249-257.

JOURNAL OF VESTIBULAR RESEARCH

Effect of age, gender and anxiety on motion sickness
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

It is known that children are more susceptible to motion sickness than teenagers, and females more than males. However motion sickness susceptibility (MSS) is not all that clear in older people. This study was designed to assess the effect of age, gender and the anxiety-trait on MSS in healthy subjects (167 adults) and dizzy patients (n = 94). Depending on vestibular tests, the dizzy patients were subdivided into those with vestibular loss (VL; unilateral or bilateral) and without vestibular loss (nVL; BPPV, migraine and Ménière’s). All subjects completed the short form of the MSS Questionnaire (MSSQ) and the Trait Anxiety Questionnaire (STAI – A and STAI – B). The MSSQ has two parts: symptoms in childhood (MSA) and after childhood (MSB). For the patients, a third section was added to attain a measure of MSS after onset of dizziness – MSV. For all three groups, MSA scores were significantly higher than MSB scores and were positively correlated (P<0.001). Mean MSV scores were lower for VL than for nVL patients. MSB and MSV scores were not significantly different (P>0.05). Posthoc analysis showed that MSSQ scores were significantly lower for VL patients than healthy subjects (P<0.01) which in turn were significantly lower than for nVL patients (P<0.001). These group differences were not affected by age, gender or anxiety-trait. However MSSQ scores declined with age for both females and males but across all age groups, female scores were higher, as supported by previous studies. The relationship between anxiety and MSS was small and limited to healthy subjects.

Reference

Motion sickness susceptibility in healthy subjects and vestibular patients: Effects of gender, age and trait-anxiety.
Paillard AC, Quarck G, Paolino F, Denise P, Paolino M, Golding JF, Ghulyan-Bedikian V.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:203-10.

JOURNAL OF VESTIBULAR RESEARCH

Effects of ageing on dynamic visual acuity
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

Dynamic visual acuity (DVA) enables the maintenance of visual acuity when the head is moving. This is primarily due to the vestibulo-ocular reflex (VOR). Whereas near distances rely more on linear VOR and far distances on angular VOR, there is some evidence that the cervico-ocular reflex (COR) makes a small contribution to DVA in general. This study was designed to assess the effect of ageing on DVA during locomotion, with specific emphasis on the distance of the visual target, walking velocity and neck receptor input. Thirty healthy subjects with no history of vestibular disorder, neck pathology, neuromuscular disease or falls were divided into three groups: Young (20-30 years), Older 1 (65-74 years) and Older 2 (75-85 years). There were 10 subjects in each group. The DVA was determined by positioning the visual target at 3m (far distance) and 0.5m (near distance) at walking speeds of 0.75m/s and 1.5m/s on a treadmill. For selected trials, COR was precluded by the use of a rigid cervical collar in order to assess the contribution of COR to DVA. A difference of P<0.05 was considered significant. Near DVA was significantly better in the Young than the two Older groups, worse when COR was restricted and at the faster walking speed. This finding was interpreted by the authors to indicate that COR augments linear VOR when the object is closer to the eyes. Far DVA was not affected by COR restriction in all age groups but it was significantly better at 0.75m/s than at 1.5m/s (p<0.001) but this was independent of age. Therefore in healthy older people, a decline in DVA at faster speeds places no limitations on daily activities. No extrapolations could be made for speeds greater than 1.5m/s or in older people with neck and vestibular pathology. A key limitation of the study, addressed by the authors, was the inability to assess the effect of the smooth pursuit system.

Reference

Dynamic visual acuity (DVA) during locomotion for targets at near and far distances: effects of aging, walking speed and head-trunk coupling.
Deshpande N, Tourtillott BM, Peters BC, Bloomberg JJ.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:195-201.

JOURNAL OF VESTIBULAR RESEARCH

Is vestibular rehabilitation effective in posterior circulation stroke?
Reviewed by: Victor Osei-Lah
May/June 2014 (Vol 23 No 2)
 

Whereas the value of vestibular rehabilitation is well established for peripheral vestibular disorders, the same could not be said for central vestibular disorders. Twenty-five patients admitted with posterior circulation stroke were included. They all received instructions on routine balance and mobility exercises while on admission. On discharge from hospital, they were randomised into two groups: a) rehabilitation group (12 subjects) and b) home exercise group (13 subjects), who also served as controls. The rehabilitation group were further randomised into two: the first received standard supervised vestibular rehabilitation (VR) and the second, supervised visual feedback posturography training (VFPT). The home group continued with the balance and gait exercises they were taught, at home without supervision. Validated outcome measures used were the Berg Balance Scale (BBS), the ‘Time and Go’ (TUG), the Dynamic Gait Index (DGI), the Dizziness Handicap Inventory (DHI) and mCTSIB. Assessment was done at baseline and after a six-week exercise programme. Posttreatment outcomes were statistically significantly better in all treatment groups. However, it was surprising that there were no statistically significant differences between the posttreatment outcomes of the three groups – there was no advantage of a supervised over an unsupervised exercise regime! The authors suggest that the small sample sizes were likely to be responsible for this. As usual, larger studies are needed but the point was made that rehabilitating patients with central vestibular pathology can be worthwhile.

Reference

Vestibular rehabilitation in acute central vestibulopathy: a randomized controlled trial.
Balci BD, Akdal G, Yaka E, Angin S.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:259-67.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

E-survey of transoral robotic surgery transoral robotic surgery experience
Reviewed by: Hannah Blanchford
May/June 2014 (Vol 23 No 2)
 

Since 2009, transoral robotic surgery (TORS) has been used as a minimally invasive approach to access pharyngeal tumours. Forty-five out of 300 TORS-trained surgeons in the United States responded to an electronic questionnaire. They reported a total of 2015 TORS procedures. A minority (10.6%) were performed in previously irradiated patients. Sixty-two percent of surgeons initiated feeding on day 0-1. Death was reported in 0.3% of cases. The complication rate was lower for surgeons who performed more than 50 cases. Only 6.7% of respondents reported performing a staged neck dissection before the TORS procedure. Eighty-four percent of respondents identified oropharyngeal carcinoma as the most common indication for TORS. One surgeon reported using TORS for T4 staged tumours. Local flap reconstruction was used in 12.6% of cases. Postoperative haemorrhage was the most common complication affecting 3.1%. For surgeons performing over 50 cases, the haemorrhage rate was 2.8% whereas for those performing fewer than 25, it was 4.5%. The survey was limited because two of the respondents accounted for nearly half of the cases. One of these surgeon’s haemorrhage rate was only 0.7%, which would have affected the average. It was also a retrospective survey and as such, was subject to recall bias and may represent estimations rather than exact incidence. Although this represents the largest series of TORS procedures to date, I look forward to future multi-centre prospective series. These will enable us to build a more robust picture of the true frequency of complication rates.

Reference

Surgeon experience and complications with transoral robotic surgery (TORS).
Chia SH, Gross ND, Richmon JD.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;149(6):885-92.

Rhinology

Pilot study of submucosal radiofrequency for epistaxis in hereditary hemorrhagic telangiectasia
Reviewed by: Lakhbinder Pabla
May/June 2014 (Vol 23 No 2)
 

This prospective pilot study investigates the safety and efficacy of submucosal radiofrequency for hereditary haemorrhagic telangiectasia (HHT) patients with mild to moderate epistaxis. Sixteen consecutive patients underwent day case procedures under local anaesthetic where radiofrequency was applied to one or both sides of the nasal septum (50 joules per puncture). Overall, the procedure was well tolerated and the frequency of epistaxis per day and per month was significantly lower after radiofrequency. The duration of bleeding also decreased from over 10 minutes to less than five minutes in two thirds of patients. Thirteen of the 16 patients were satisfied with the technique and would request it for subsequent procedures to treat repeated bleeding. This minimally invasive, day case-based treatment under local anaesthetic presents an interesting option for patients with HHT with mild-moderate epistaxis. However, this study has a small sample size and a relatively short mean follow-up of 16 months, which may have had an impact on the results obtained and their statistical value. Therefore additional studies are required before any firm conclusions can be drawn on this procedure.

Reference

Pilot study of submucosal radiofrequency for epistaxis in hereditary hemorrhagic telangiectasia.
Mortuaire G, Boute O, Hatron PY, Chevalier D.
RHINOLOGY
2013;51(4):355-60.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Allergic fungal sinusitis or eosinophilic mucin rhinosinusitis?
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Rhinosinusitis is a highly prevalent condition and its effective management depends on accurate diagnosis. Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis are sub types of this condition and differentiation between them is important. In this article the authors have looked retrospectively at 34 patients and made an attempt to identify features to differentiate one from the other and also address the accompanying comorbidities such as asthma. This is a retrospective study and therefore only those investigations done in the past have been taken into account. Eosinophilic mucin rhinosinusitis has presence of eosinophils in the nasal secretions but the IgE levels are not raised and there are no fungi although they can be missed with inadequate staining. In the allergic fungal rhinosinusitis the fungi are visible and the IgE levels are raised in addition to the above features. The authors found 26 patients to have eosinophilic mucin rhinosinusitis and eight to have allergic fungal sinusitis. The former was associated with a higher incidence of asthma and the latter was prone to early orbital involvement. Surgical intervention was done more often in the eosinophilic mucin rhinosinusitis. The use of antifungal agents has not been highlighted here. The message conveyed is that both these conditions have identical clinical presentation but follow different clinical courses. A matter of concern that has been highlighted is that allergic fungal rhinosinusitis had more complications but fewer surgical interventions, this being a more aggressive clinical condition. There is therefore no doubt that further studies are required to establish definitive criteria and be able to diagnose one condition from the other.

Reference

Allergic fungal sinusitis and eosinophilic mucin rhinosinusitis: diagnostic criteria.
Uri N, Ronen O, Marshak T, Parpara O, Nashashibi M, Gruber M.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:867-71.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Cholesteatoma of external auditory canal
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Cholesteatomas mainly present in the middle ear or the mastoid and established methods of treatment follow. However those presenting in the external auditory canal form a slightly unusual diagnosis and the treatment can be inadequate. A small series of eight patients with external auditory canal cholesteatoma is presented. Purulent otorrhoea and otalgia were the main complaints and some cases presented with sensorineural hearing loss affecting high tones. Axial and coronal computed tomography (CT) scans assessed the extent of the local involvement. The images showed bony erosion in all these cases. Biopsy was carried out to exclude squamous cell carcinoma and the authors were also aware of malignant otitis externa as possible diagnoses. The pathogenesis has been attributed to reduced migratory capacity of the canal epithelium but none of the cases in the series had recognisable aetiology. These cases were treated with a post-auricular surgical approach. The external auditory canal was drilled to remove the cholesteatoma and the defect repaired with tragal cartilage graft. Recurrence occurred in one of the eight patients. The principles of treatment were eradication of disease and also preservation of structure and function of the external auditory canal. None of these required skin grafting. Classification of external auditory canal cholesteatoma has been presented and the article provides helpful reading.

Reference

Operative management of external auditory canal cholesteatoma: case series and literature review.
Sayles M, Kamel HA, Fahmy FF.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:859-66.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Hormonal basis of rhinitis in pregnancy
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Congestion of the nose is a common symptom in the final six weeks of pregnancy. This usually disappears completely about two weeks following child birth. In different questionnaire-based studies the prevalence of pregnancy rhinitis ranges from 11-32%. The present study included 30 pregnant Malaysian women. At the start of the study they were in their first trimester and did not have any preceding history of nasal allergy or sinusitis and had normal appearance of the ear, nose and the throat. A validated rhinitis questionnaire was given to complete and any local pathologies were excluded with a nasal examination. Blood samples were taken for oestrogen, progesterone, human growth hormone and insulin-like growth factor 1 (IGF-1) levels. This was repeated in the same patients in the second and third trimesters and results subjected to statistical analysis. Sixteen of the 30 patients (53.3%) developed symptoms of rhinitis. In those suffering from rhinitis, the level of oestrogen and IGF-1 increased in the third trimester but this was not statistically significant. The levels of growth hormone and progesterone did not increase in either group. Interestingly, 14 of the 16 rhinitic subjects gave birth to females compared with seven out of the 14 non-rhinitic subjects, and this difference was statistically significant. All four hormones have a role in increasing nasal congestion. Oestrogen has a direct cholinergic effect increasing local production of acetyl choline. Growth hormone stimulates IGF-1 which has been linked to the regenerative activity of the nasal mucosa and also to the formation of nasal polyps. Progesterone increases nasal congestion through increased blood volume and enhanced vasodilation. It should however be noted that all four hormones do not potentiate any allergic mechanism and pregnancy is associated only with increased congestion and reduced nasal patency. It is speculated that higher level of oestrogen associated with female births results in a higher incidence of rhinitis in expectant mothers. Relieving nasal congestion would certainly improve the quality of life in pregnant women but it is questionable if treating what is physiologic and lasts only a trimester is worth the risk of possibly inducing pathologic detriment in the babies born.

Reference

Hormonal changes causing rhinitis in pregnancy among Malaysian women.
Indirani B, Raman R, Omar SZ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:876-81.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Role of antifungal drugs in indolent mucomycosis or paranasal sinuses
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Antifungal drugs such as Amphotericin B are commonly used in treatment of fungal rhinosinusitis. Whether or not this treatment is required in immune-competent patients is the issue addressed in this article. The authors report four cases who had indolent mucomycosis involving the paranasal sinuses. All these patients presented with foul odour, postnasal drip and nasal stuffiness. The diagnosis was made with computed tomography (CT) scans which showed opacity of the maxillary sinus. None of these patients had invasion into the orbit or the anterior cranial fossa. The subjects were treated with functional endoscopic sinus surgery and followed up with postoperative CT scans three months after surgery. Apparently none of these patients had invasive mucormycosis. Apart from postoperative cephalosporin, no other drug treatment was given. Follow-up of these patients did not show any recurrence of the mucomycosis. The authors therefore contend that it is not necessary to use antifungal drugs in indolent mucomycosis which is noninvasive and occurs in immune-competent patients. They have of course emphasised the need to correct the cause of immune deficiency and do mention the need for antifungal treatment in invasive fungal sinusitis. Surgical debridement should also be carried out in these patients. Paranasal sinus mucomycosis is an extremely rare condition with life threatening possibilities particularly if it is invasive. However these authors have tried to offer reassurance that in noninvasive disease the use of antifungal drugs is unnecessary.

Reference

Indolent mucomycosis of paranasal sinus in immunocompetent patients: are antifungal drugs needed?
Jung H, Park SK.  
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:872-5.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

What causes secondary recurrence of pleomorphic adenoma?
Reviewed by: Madhup K Chaurasia
May/June 2014 (Vol 23 No 2)
 

Although pleomorphic adenoma is a benign tumour of the parotid it has a tendency to recur several years after its removal. Primary recurrence is in itself difficult to treat and secondary recurrence offers a much greater challenge for curing this disease. This is a retrospective review of 32 patients who had recurrence of pleomorphic adenoma. The recurrence was studied in terms of epidemiology, anatomical and pathological data, type of surgical treatment and adjuvant radiotherapy, if used. It was observed that younger patients, under 25 years had earlier recurrence. Treatment by parotidectomy or enucleation did not make any difference in the time of first recurrence. The time of subsequent recurrences decreased. The histopathological characteristics which seem to increase the risk of recurrence were deep lobe involvement, multi focality, hypocellarity, rupture of the capsule and maximal nodule size. It is emphasised that in younger patients the extent of necessary surgery should not be compromised. It was also observed that secondary recurrence occurs much quicker but is not related to the number of previous interventions and other factors usually associated with primary recurrence. However there is a greater risk of secondary recurrence in cases with multifocal tumour observed at first surgery. Facial paralysis is the main complication of pleomorphic adenoma surgery and the risk of this is higher with retrograde dissection. The risk of facial paralysis increases significantly in surgery for secondary recurrence. The criteria for adjuvant radiotherapy are specified. It is observed that radiotherapy may delay but will not prevent recurrence. The role of preoperative magnetic resonance imaging (MRI) in the treatment of recurrence is emphasised. This is particularly important if the tumours are multifocal. In these, the high secondary recurrence rate of 28% over six years seems to suggest that the clinician can only control the disease but not cure it.

Reference

Prognostic factors for secondary recurrence of pleomorphic adenoma: a 20 year retrospective study.
Mallard O, Wagner R, Joubert M, Belemazure A S, Rio E, Durand N, Espitalier F.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:902-07.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Method of surgical resection affects reporting of margins of excision of tumours in the oral cavity
Reviewed by: Sampath Chandra Prasad
May/June 2014 (Vol 23 No 2)
 

It is important to obtain tumour-free resection margins in patients with oral cancer. Pathological processing is known to cause tissue to shrink, which affects the reported margins, and it is postulated that the method of resection also has an effect. In this interesting study the authors used a pig model to demonstrate that the method of resection influenced the surgical margin in oral cancers. They marked standardised simulated lesions on the tongues of 15 live anaesthetised pigs and divided each lesion into four equal sections. They were resected, each with a margin of 10 mm, using cutting diathermy, coagulative diathermy, harmonic scalpel and a conventional scalpel. After processing, the excision margins were measured. With cutting diathermy and coagulative diathermy, shrinkage of the soft tissues was minimal, relative to the margin of the simulated lesion compared with the harmonic scalpel (p=0.001) and conventional scalpel (p=0.001). Cutting diathermy and coagulative diathermy caused significant thermal damage (p=0.001). The authors stress that the method of resection affects the surgical margin and that diathermy resulted in thermal injury and denaturing of the underlying muscle. But there was less tissue contraction than when the harmonic scalpel and conventional scalpel were used. The authors go on to say that the method of resection may therefore affect the interpretation of the histological results, which in turn may have implications regarding adjuvant treatment.

Reference

Does the method of resection affect the margins of tumours in the oral cavity? Prospective controlled study in pigs.
George KS, Hyde NC, Wilson P, Smith GI.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(7):600-3.

RHINOLOGY

Long-term results of functional endoscopic sinus surgery in children with chronic rhinosinusitis with nasal polyps
Reviewed by: Lakhbinder Pabla
May/June 2014 (Vol 23 No 2)
 

Chronic rhinosinusitis with nasal polyps (CRSwNP) has a major impact upon the quality of life of paediatric patients and their families. The aim of this study was to assess long-term results of functional endoscopic sinus surgery (FESS) in children with CRSwNP and to determine outcomes, symptoms, quality of life and complications. A combined prospective and retrospective study was based on a quality of life questionnaire sent to all children with CRSwNP who received FESS between 2000-2010. Fourty-four children underwent FESS – nine had cystic fibrosis and 10 had asthma. The mean follow-up period was 4.0 years (+/- 2.5) with a mean age at surgery of 13 years (+/- 2.9). Significant improvement was found in quality of life parameters, especially in nasal symptoms showing that FESS is a good treatment in children with CRSwNP. Furthermore, even children with cystic fibrosis showed good results. Although this study shows some promising results with a long follow-up period, it is important to note that is only partly a prospective study. In addition, the outcomes of surgery are based on subjective questionnaires and not physical examinations, which could lead to possible bias

Reference

Long-term results of functional endoscopic sinus surgery in children with chronic rhinosinusitis with nasal polyps.
Cornet ME, Georgalas C, Reinartz SM, Fokkens WJ.
RHINOLOGY
2013;51(4):328-34.

ACTA OTOLARYNGOLOGICA

Round window vibroplasty an effective hearing rehabilitation option in chronic ears
Reviewed by: Victoria Possamai
Mar/Apr 2014 (Vol 23 No 1)
 

This study comes from Uppsala in Sweden, and reports experience with a small group (n=7) of patients in whom the Vibrant Soundbridge active middle ear implant was implanted into the round window. These patients had a diagnosis of cholesteatoma or osteoradionecrosis, with post surgical anatomy precluding effective use of conventional hearing aids. Reasons included need for blind sac closure, non functional middle ears, chronic suppurative otitis media or otitis externa and abnormally shaped external meatus and canal following meatoplasty. The lack of normal middle ear anatomy precluded incus-vibroplasty, and three of the seven had a fixed stapes footplate, though the preference for round rather than oval window implantation in the other patients was not explained. Pre and postoperative, unaided and aided, thresholds were compared. Preoperative aided thresholds were gained from attempted conventional hearing aid use. There was no significant deterioration in residual hearing levels following surgery. Postoperative aided hearing levels were comparable with preoperative levels, in five of seven patients. Of the remaining two patients, one had a deterioration in aided levels post op, the other an improvement, giving a conclusion overall of comparable hearing with some improvement at high frequencies. The Glasgow Benefit Index showed a benefit in all six patients who completed it between +3 to +64 (-100 to +1000 = unchanged). Cone beam computed tomography (CT) was used to assess the position of the implant in relation to the round window membrane (RWM). Authors concluded that the angle of the implant to the RWM is much less important than contact between the floating mass transducer (FMT) and RWM provided by the fascial graft. They also described using further fascia and Tisseel glue to secure the FMT and electrode cable and had no problems with dislocation of the FMT from its position (mean follow up 26 months). This small study suggests this may be an option in patients with complex middle ear disease, for whom conventional hearing aids are not effective.

Reference

Round window vibroplasty in chronic ear surgery:comparison with conventional hearing rehabilitation.
Edfeldt L, Rask-Andersen H.
ACTA OTOLARYNGOLOGICA
2013;133:814-25.

ACTA OTORHINOLARYNGOLICA ITALICA

Transoral robotic surgery for tongue base tumours
Reviewed by: Miles Bannister
Mar/Apr 2014 (Vol 23 No 1)
 

Robotic surgery for upper aero-digestive tract tumours is becoming established in the largest head and neck cancer centres in the UK. Work has mostly centred on laryngeal tumours, though as experience grows, tumours at other sites can be accessed. An ENT team in Rome report a short case series (13 patients) of T1-2 tongue base tumours removed using robotic surgery with synchronous neck dissections for metastatic disease. Patient recovery was quicker after surgery with less morbidity as a less extensive resection was possible – no reconstructions were necessary. These savings in operative time and in-patient stay actually justified the initial cost of the Da Vinci robot. As the precision of robotic surgery permits better functional outcomes after surgery, arguments for further robot procurement may prove irresistible.

Reference

Transoral robotic surgery (TORS) for tongue base tumours
Mercante M, Ruscito P, Pellini R, Cristalli G, Spriano G.
ACTA OTORHINOLARYNGOLICA ITALICA
2013;33:230-5.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Dynamics and safety of steroid-impregnated nasal packs after ESS
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

The use of depot triamcinolone for rhinitis has fallen out of favour in the UK, at least in part because of the lack of control of steroid dosage and dynamics, once the depot has been made. In the post operative group of patients the situation is different, with most patients receiving some sort of medication in the days and weeks following surgery, in addition to douching. The technique of applying steroid as triamcinolone in a foam or (as here) incorporated in a dissolvable pack (here Nasopore was used) seems to have some merit since the main focus of steroid application is the organ in question (the nasal lining). This study looked at blood tests to evaluate the function of the adrenocortical axis in the days following surgery. They found that the systemic effect of this pack was significant and measurable, but lasted 10 days or so before normalising. As always the risk-benefit equation must be considered.

Reference

Systemic effects and safety of triamcinolone-impregnated nasal packing after endoscopic sinus surgery: a randomized double-blinded, placebo-controlled trial
Hong SD, Kim JH, Dhong H-J, Kim JY, Chung S-K, Change YS, Sohn JH.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(5):407-10.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Nasal surgery in sleep-disordered breathing: manage patient expectations
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

This compact review of the literature covers the subject of the relevance of nasal obstruction and its treatment to snoring and obstructive sleep apnoea (OSA). The not very surprising conclusion is that managing nasal obstruction can, at best, improve the severity of sleep-disordered breathing symptoms subjectively, but that nasal obstruction is rarely a causative factor in the production of sleep apnoea and snoring. Treatment has a modifying, rather than a curative effect. Surgical treatment had disappointing effects on objective findings such as apnoea-hypopnoea index (AHI) and on other objective parameters for OSA severity. The surgeon should exercise some caution in the promises made to patients prior to nasal interventions in snorers, or those with sleep apnoea. The only real ray of sunshine in this review is that nasal surgery convincingly helps the tolerance of OSA patients to their continuous positive airway pressure (CPAP) machine. This is often the reason that the ENT surgeon is referred such patients.

Reference

The role of the nose in sleep-disordered breathing
Meen EK, Chandra RK.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(3):213-20.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Olfaction, sinusitis and asthma in determining quality of life and depression
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

This study looked at quality of life indicators in patients with rhinitis and rhinosinusitis (with and without polyps) and correlated these with a variety of other indices, particularly olfactory function (normosmia / hyposmia / anosmia), asthma and anxiety-depression. Clinicians will not be surprised that quality of life was affected a lot by olfactory dysfunction. Quality of life and anxiety-depression were affected independently by these factors: asthma, chronic rhinosinusitis and olfactory dysfunction.

Reference

Olfactory dysfunction in asthma as risk factors for poor quality of life in upper airway diseases
Katotomichelakis M, Simopoulos E, Zhang N, Tripsianis G, Danielides G, Livaditis M, Bachert C, Danielides V.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(4):293-8.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Scanning in trauma patients with olfactory problems
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

This study of head trauma cases attempted to correlate smell disturbance reporting, smell testing and imaging findings [magnetic resonance (MR) and single photon emission computed tomography (SPECT)]. The question of malingering was touched on and also the importance of being able to spot problems in individuals with multiple head trauma such as boxers or other ‘contact sports’ participants. The imaging findings concentrated on the frontal lobes and the olfactory apparatus (such as signs of contusion) and olfactory assessment was made using a threshold test and a qualitative (forced-choice) test, which helped to find malingerers. The sensitivity of MR and SPECT alone were not impressive, but when added together the figures approached or exceeded 90%. These findings were interesting, but I am not convinced that the dual tests will find themselves used routinely in the UK, where the benefit to clinic patients seems uncertain. The matter of monitoring sportsmen is an altogether different topic and involves more than just otolaryngologists: perhaps there should be more monitoring of this at-risk group.

Reference

Estimation of sensitivity and specificity of brain magnetic resonance imaging and single photon emission computed tomography in the diagnosis of olfactory dysfunction after head traumas
Atighechi S, Zolfaghari A, Baradaranfar M, Dadgarnia M.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(5):403-6.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

The ‘compensatory turbinate’ is a real phenomenon
Reviewed by: Edward Fisher
Mar/Apr 2014 (Vol 23 No 1)
 

Turbinate surgery of some sort, especially on the contralateral side to a severe septal deviation, is traditional practice in the UK and I recollect an eminent ENT surgeon telling his own surgeon ‘do not forget the turbinate’ as he was being anaesthetised for his own septoplasty. So is this just tradition, or does it have a basis in physiology? The authors have undertaken a meticulous study of computed tomography (CT) scans in children and adults with severe septal deviations versus those with little or no deviation. They measured the cross sectional area of the front, middle and back of the inferior turbinates and compared the side of deviation with the contralateral side. The good news is that the ‘compensatory’ turbinate phenomenon is not seen in children, suggesting that it is an acquired process in patients with deviations. Of course, whether it should be treated surgically is another story, but this anatomical study does tend to support that practice.

Reference

Unilateral inferior turbinate bone hypertrophy: Is it compensatory or congenital
Aslan G, Uzun L, Ugur MB, Uckurt YS, Sagun OF, Yazicilar O.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(4):255-9.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

In vivo animal model shows no disadvantages of osteosynthesis with pins compared to titanium screws for condylar fractures
Reviewed by: Sampath Chandra Prasad
Mar/Apr 2014 (Vol 23 No 1)
 

The advantages of resorbable pins have been proved in craniofacial surgery. Here, the authors extend its use to fractures of the condylar head, which is surgically challenging. The authors aimed to compare in vivo, the stability of fixation of condylar fractures in sheep using sonic bone welding and standard titanium screws. There were ten patients in each group. The stability of the osteosynthesis and maintenance of the height of the mandibular ramus were assessed. The results were analysed macroscopically, radiologically and histologically. There were no significant differences between the two groups in any parameters. The height decreased by 1-2 mm in both groups compared with the opposite side but this was of no consequence in humans. The volume of the condyle increased considerably in both groups, mainly because callus had formed and it was impossible to immobilise the animals postoperatively. The results showed no significant disadvantages for pin fixation compared with osteosynthesis using titanium screws and they support the use of sonic welding for fractures of the condylar head in humans.

Reference

Treatment of fractures of the condylar head with resorbable pins or titanium screws: an experimental study.
Schneider M, Loukota R, Kuchta A, Stadlinger B, Jung R, Speckl K, Schmiedekampf R, Eckelt U.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(5):421-7.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Outcomes of transoral robotic surgery for oropharyngeal cancer
Reviewed by: Sampath Chandra Prasad
Mar/Apr 2014 (Vol 23 No 1)
 

Due to the fact that conventional surgery is technically demanding and involves high morbidity, transoral procedures have been developed in recent years. In this prospective study the authors analysed the oncological and functional results of transoral robotic surgery (TORS) to find out if it was suitable as a minimally invasive treatment for oropharyngeal cancer. Thirty-nine patients with oropharyngeal cancer were treated by TORS. The authors assessed overall and disease-free survival by the Kaplan-Meier test. They also used videopharyngography and the functional outcome swallowing scale (FOSS) to evaluate swallowing. They used nasometry to estimate hypernasality, and acoustic waveform analysis to evaluate the voice. Thirty-seven patients (95%) had histologically clear margins of resection. Overall survival at two years was 96% and disease-free survival 92%. An oral diet was tolerable after a mean of six (range 1-18) days. No serious swallowing difficulties were seen on the videopharyngogram. Thirty-six of 38 patients could swallow well (97%) with FOSS scores ranging from 0 to 2 (one patient had a poor score but was able to take an oral diet after postural training). Voices were maintained close to the normal range on the acoustic waveform analysis. The authors conclude that TORS is a valid treatment for selected patients with oropharyngeal cancer and this led to shorter hospital stays with more rapid functional recoveries of swallowing and decannulation.

Reference

Oncological and functional outcomes of transoral robotic surgery for oropharyngeal cancer.
Park YM, Kim WS, Byeon HK, Lee SY, Kim SH.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(5):408-12.

COCHLEAR IMPLANTS INTERNATIONAL

Neurotrophins and cochlear implants: a promising combination
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2014 (Vol 23 No 1)
 

The authors’ aim was to review the literature with regard to the current trends for treating sensorineural deafness by enhancing spiral ganglion neuron (SGN) survival using neurotrophins combined with cochlear implants, and to identify areas for future research and development. They undertook a literature search on PubMed and Google scholar using terms: neurotrophins, cochlear implants (CIs), and sensorineural to identify the most recent and significant publications. The abstracts were read to identify relevant papers; these were accessed in full and analysed for this review.  Although several papers attempt to investigate the issue, the picture is not yet at all clear. So far experiments using osmotic pumps to deliver neurotrophins have been successful for short-term enhanced survival of SGNs following aminoglycoside ototoxicity in animal models. They have demonstrated the re-sprouting of radial nerve fibres from SGNs towards the source of delivery. In addition electrical stimulation, gene and cell-based therapy have increased SGN survival to varying degrees. However, osmotic pumps carry a high risk of infection, therefore CIs coated in a drug containing polymer or hydrogel are a realistic alternative for sustained delivery of neurotrophins. Increased SGN survival combined with neuronal re-growth raises the possibility for CIs to stimulate discrete SGN populations. Unfortunately, the duration of treatment needed for long-term survival still remains unclear and further work is needed. Therefore, it remains to be seen if this promising combination will have practical and sustainable results in the future.

Reference

Neurotrophins and cochlear implants: A solution to sensorineural deafness?
Sameer MA, Qureishi A, Pearson R, O'Donoghue G.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):158-64.

COCHLEAR IMPLANTS INTERNATIONAL

An interesting attempt to combine electric and acoustic hearing stimulation in implantees with full electrode insertion and residual low frequency hearing
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2014 (Vol 23 No 1)
 

The authors assessed the auditory performance of cochlear implant users with electric stimulation (ES) and electro-acoustic stimulation (EAS) with special attention to the processing of low-frequency temporal fine structure. Six implanted patients showing low-frequency residual hearing were fitted with a speech processor that provides both electric and acoustic stimulation. Assessment consisted of monosyllabic speech identification tests in quiet and in noise at different presentation levels, and a pitch discrimination task using harmonic and disharmonic intonating complex sounds. All tasks were performed with ES only and with EAS. The results revealed that speech outcomes in noise showed significant improvement with EAS when compared to ES. Whereas EAS did not yield better results in the harmonic intonation test, the improvements in the disharmonic intonation test were remarkable, suggesting better coding of pitch cues requiring phase locking. The authors concluded that: a) patients with residual hearing in the low-frequency range still have good phase-locking capacities, allowing them to process fine temporal information, b) ES relies mainly on place coding but provides poor low-frequency temporal coding, whereas EAS also provides temporal coding in the low-frequency range, c) patients with residual phase-locking capacities can make use of these cues. This study is very interesting as EAS was used in fully implanted patients who had some residual hearing. However, the numbers are small and a more comprehensive assessment is needed.

Reference

Combined electric and acoustic hearing performance with Zebra® speech processor: Speech reception, place, and temporal coding evaluation.
Vaerenberg B, Péan V, Lesbros G, De Ceulaer G, Schauwers K, Daemers K, Gnansia D, Govaerts PJ.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):150-7.

COCHLEAR IMPLANTS INTERNATIONAL

The effect of synchronous multi electrode stimulation on implantees’ discrimination
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2014 (Vol 23 No 1)
 

We all know that the major advances in speech discrimination of cochlear implant devices now rely on the improvement of the speech strategies and the way they stimulate the cochlea. Most cochlear implants implement stimulation strategies which apply sequential electrical pulses to encode acoustic signals such as speech, noise and sounds via electrical stimulation of the auditory nerve. Parallel stimulation of adjacent electrodes has been employed in recent cochlear implant systems in an attempt to further improve coding of pitch information. The authors investigated whether parallel stimulation of three adjacent electrodes enhances rate pitch perception compared with single electrode stimulation. Most comfortable loudness (MCLs) levels were assessed in single and multi electrode condition in 12 subjects. Rate pitch discrimination was determined by means of an adaptive procedure (two-interval two-alternative forced choice, 2I2AFC) at individual MCL in the single- and multi-electrode condition at base frequencies of 100, 200, 283, 400 and 566 pulses per second (pps). The results revealed that to achieve MCL in the multi-electrode condition, significantly higher stimulation current compared with single stimulation was required. No significant difference between single- and multi-electrode condition just noticeable differences in rate discrimination group was found. In contrast, a pairwise comparison of individual results in a subgroup recruited out of successfully completed runs at high base rates showed statistically an improved rate discrimination in 17 of 24 runs in the multi-electrode condition. The authors concluded that there is a potential effect of parallel stimulation on the rate of discrimination. It seems that further refinements and tests are required in order to clarify the issue of synchronous multi-electrode stimulation on implantees’ discrimination.

Reference

New parallel stimulation strategies revisited: Effect of synchronous multi electrode stimulation on rate discrimination in cochlear implant users.
Bahmer A, Baumann U.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):142-9.

CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY

Are there tests that allow us to diagnose Ménière’s disease?
Reviewed by: Susan A Douglas
Mar/Apr 2014 (Vol 23 No 1)
 

The diagnosis of Ménière's disease has traditionally been clinical. This review considers newly developed and emerging diagnostic techniques for the diagnosis of Ménière's disease. These include cervical and ocular vestibular-evoked myogenic potentials (VEMPs), cochlear hydrous analysis using masking procedures and three dimensional fluid attenuation inversion recovery magnetic resonance imaging (MRI) following instillation of intratympanic gadolinium. The VEMP is a neurophysiological test. VEMP can be measured from the contracted cervical muscles (cVEMP) via the sternocleidomastoid muscle or the extra ocular muscles (oVEMP). Curthoys demonstrated that the otolithic input to the sternocleidomastoid arises mainly from the saccule and that from the inferior oblique, mainly from the utricle. These tests can therefore be used as a measure of utricular and saccular function but they are limited by poor sensitivity. VEMPs are also reduced or absent in vestibular neuritis, benign positional paroxysmal vertigo and vestibular schwannoma. CHAMP (cochlear hydrops analysis masking procedures) testing is a modification of the traditional auditory brainstem response (ABR) where the ABR is masked at different frequencies. The normal response is a prolonged latency delay of wave V but in Ménière's disease the latency is shortened. This test has been reported to have high sensitivity and specificity but this has not been verified in all studies. This appears to be dependent on the definition used for the abnormal latency. Imaging studies have shown reduced or absent perilymph enhancement in patients with Ménière's disease. Intratympanic gadolinium enhanced 3D FLAIR MRI has shown potential as the first in vivo imaging modality for identifying clinically relevant endolymphatic hydrops. Fiorno demonstrated that all patients with Ménière's disease showed abnormal perilymph enhancement, compared to controls who demonstrated no abnormal perilymph enhancement. This is a well written article describing some of the newer diagnostic techniques which may add to the clinical and vestibular testing for Ménière's disease.

Reference

Novel techniques for the diagnosis of Ménière's disease.
Le CH, Truong AQ, Diaz RC.
CURRENT OPINION IN OTOLARYNGOLOGY HEAD AND NECK SURGERY
2013;21:492-6.

EAR AND HEARING

Older persons’ ability to recognise speech in noise
Reviewed by: Vinaya KC Manchaiah
Mar/Apr 2014 (Vol 23 No 1)
 

Speech perception in noise is reported to be one of the most frequent complaints of people with hearing loss. Hearing loss is one of the most frequent chronic conditions associated with older adults; hence they may have reduced ability to recognise speech in noisy situations. The aims of this study included: (1) to investigate whether the rate of decline in older persons’ ability to recognise speech in noise over time differs across age and gender; and (2) to determine the extent to which demographic, health-related, environmental and cognitive factors influence the change in speech-in-noise recognition over time. Large samples of the Longitudinal Ageing Study Amsterdam were used (n = 1298) with the data covering three to seven years of follow-up (mean: 4.9 years; 3025 observations; baseline ages: 57 to 93 years). Hearing ability was measured by a digit triplet speech-in-noise test (SNT) yielding a speech reception threshold in noise (SRTn). Multi-level analyses were used to model the change in SRTn over time. Firstly, interaction terms were used to test differences in rate of decline across subgroups. Secondly, for each of the following factors the authors determined the influence on the change in SRTn: age, gender, educational level, cardiovascular conditions, and information processing speed, fluid intelligence, global cognitive functioning, smoking and alcohol use. This was done by calculating the percentage change. Results suggest that, on average, respondents’ speech reception threshold in noise deteriorated significantly over time. Only information processing speed relevantly influenced the change in speech reception threshold in noise over time. These results indicate that the decline in older persons’ speech-in-noise recognition over time accelerated for older ages. Decline in information processing speed explained a moderate proportion of the SRTn decline. These results also indicate the relevance of declining cognitive abilities of older persons to recognise speech in noisy environments.

Reference

Decline in older persons’ ability to recognize speech in noise: the influence of semographic, health-related, environmental, and cognitive factors
Pronk M, Deeg DJH, Festen JM, Twisk JW, Smits C, Comijs HC, Kramer SE.
EAR AND HEARING
2013;34(6):722-32.

HEAD & FACE MEDICINE

Significant dental rehabilitation by application of a modified miniplate in the hard palate for a patient with a large anterior maxillary defect
Reviewed by: Bilal Gani Taib
Mar/Apr 2014 (Vol 23 No 1)
 

This report describes the use of an H-shaped titanium miniplate inserted into the hard palate with the use of orthodontic elastics in a modified obturator prosthesis to allow immediate placement of the prosthesis and improve its stability in a patient with a large maxillary defect. A 36-year-old man was referred with a diffuse swelling of the anterior maxilla. Magnetic resonance imaging (MRI) and histology revealed this to be a well differentiated squamous cell carcinoma occupying two thirds of the anterior hard palate and skin of the right nasal ala. A right submandibular lymph node was also recognised. Preoperative intra-arterial chemotherapy and radical surgery was planned. The prosthesis was made with two holes in its anterior aspect. The free ends of the H-locking plate were bent to protrude through the holes. Orthodontic elastics retained the prosthesis by securing the two free ends of the H plate through these holes. The denture was fitted and fixed with three screws in the hard palate. The soft tissue was reconstructed with a partially double-folded free radial forearm flap. The prosthesis facilitated retention of the ointment gauze, the facial contour and the ability to ingest a soft diet two weeks after the surgery. The patient was able to insert and remove the prosthesis himself. A more definitive prosthesis with the addition of clasps was also used. The patient declined reconstruction of the maxilla using a bony flap and dental implants. Follow-up two years after the operation has been uneventful. The H-shaped miniplate prevented counter rotation clockwise when biting, may reduce overloading of the remaining teeth and prosthesis induced stomatitis as well as allowing for good postoperative observation of the surgical site. The patient was able to eat a wide range of foods. The risks of using such a technique include the possibility of a screw loosening and mini-plate fractures. However, this was not observed in this case.

Reference

Significant improvement in temporary dental rehabilitation by notable miniplate application in the hard palate for a patient with a large anterior maxillary defect: a case report / technique article.
Ishikawa S, Kik~uchi N, Kobayashi T, Yamanouchi H, Tachibana H, Iino M.
HEAD & FACE MEDICINE
2013;9:34.

HEARING, BALANCE AND COMMUNICATION

Fatigue in Ménière’s Disease
Reviewed by: Vinaya KC Manchaiah
Mar/Arp 2014 (Vol 23 No 1)
 

Ménière’s Disease is a disorder of the inner ear that can affect hearing and balance to a varying degree. It is characterised by episodes of vertigo, tinnitus and hearing loss. This study was aimed at exploring the role of fatigue and its predisposing and consequential factors and consequences, on quality of life and social participation. A total of 728 members of the Finnish Ménière Association completed a postal survey. Questions focused on the symptoms of Ménière’s Disease, sense of coherence, positive attitude, participation and restriction problems classified by the International Classification of Function (ICF), and general health related quality of life (EQ-5D). Results suggest that 70% of the subjects reported fatigue and in 30% fatigue was moderate or strong. Fatigue was associated with reduced quality of life and complaints of vertigo attacks, balance problems and hearing loss. In addition, mobility related symptoms and mood disorders in a broad sense were the most significant determinants of fatigue. Sense of coherence and attitude were predictors of reduced vitality. Results also suggested that isolation could be a consequence of fatigue. The authors conclude that fatigue is a common complaint in Ménière’s Disease, reducing quality of life and leading to social and personal isolation. Fatigue is also associated with personality trait and anxiety disorders. They suggest that positive attitude and physical activity might help to reduce anxiety and escape the social and personal isolation.

Reference

Fatigue in Ménière’s disease
Levo H, Kentala E, Rasku J, Pyykkõ I.
HEARING, BALANCE AND COMMUNICATION
2013; [E-pub ahead of print] DOI:10.3109/21695717.2013. 835090.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

United Airways welcomes you on board: prepare for a bumpy ride!
Reviewed by: Christos Georgalas
Mar/Apr 2014 (Vol 23 No 1)
 

Anyone remotely aware of the developments in modern rhinology over the last 20 years knows of the ‘unified airway’ concept: upper and lower airways share comparable histology as well as comparable inflammation pathways. The clinical significance of this is obvious: not only does chronic rhinosinusitis (CRS) often co exist with asthma and lower airway disease, but, more critically, treatment (including, but not limited to surgery) of CRS can help improve lower airway disease. Or so one would let you believe… Despite the near-uniform agreement over this statement, there has been very little good quality research to support it. In this meta-analysis, the authors attempt to bring together all the studies assessing the effect of functional endoscopic sinus surgery (FESS) on asthma disease severity and control. The authors found 22 studies, of which only 11 were prospective and none had a control group (let alone being randomised). The commonest outcome measure was self-reported asthma control, although no study used a validated outcome measure. Only three studies assessed asthma attacks and six admissions for asthma, however in use of medication as well as most subjective outcomes there was a clear improvement following surgery. This however was not obvious in objective measures such as FEV1. A meta-analysis can only be as good as the studies it refers to. Judging from the quality of the studies included, the meta-analysis is more than anything a clear indicator of the need for a randomised controlled trial on the effects of FESS on asthma control.

Reference

A systematic review and meta-analysis of asthma outcomes following endoscopic sinus surgery for chronic rhinosinusitis.
Vashishta R, Soler ZM, Nguyen SA, Schlosser RJ.  
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2013;3(10):788-94.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Beware of placebo effects in hearing aid trials
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

Placebo is not only applicable to medications, but to devices as well. There have been some suggestions that hearing aid benefit and performance can be influenced by the placebo effect. The aim of this study was to investigate the reliability of the placebo effect in hearing aid users. 16 adult hearing aid users aged from 61 years to 86 years took part. All subjects had mild to moderate symmetrical sensorineural hearing loss, normal middle ear function and had been hearing aid users for at least a year. The test hearing aids were two Starkey A312 Strata behind-the-ear hearing aids with the same programming and prescription. One was labelled ‘new’ with a yellow case and the other, conventional with a beige case. For half of the group the casing was switched so that ‘new’ was beige and ‘conventional’ was yellow. The outcome measures were a speech-in-noise test (FAAF), sound quality rating test and personal preference. In the last test, subjects were asked to indicate their hearing aid preference from three options: ‘the new hearing aid is best’, ‘the conventional hearing aid is best’ or ‘I cannot tell any difference’. FAAF scores were significantly higher (almost double) for the ‘new’ than the ‘conventional’ hearing aid in 75% of participants. Only 19% performed worse with the ‘new’ aid. Mean ratings for sound quality were also significantly higher with the ‘new’ hearing aid. 12 participants preferred the ‘new’ hearing aid but none declared preference for the ‘conventional’. The rest were indifferent. The authors conclude that placebo effects have a reliable impact on measures of hearing aid benefit. They suggest that this effect ought to be controlled in hearing aid trials.

Reference

Placebo effects in hearing-aid trials are reliable.
Dawes P, Hopkins R, Munro KJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:472-7.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Delayed-onset hearing loss in Chinese children
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

This study was done to emphasise the well accepted fact that newborn hearing screening does not identify all children with congenital permanent hearing loss. A cross-section of 28,546 pre-school children who had previously passed newborn hearing screening in a region in South China consented to the study. They were all tested with transient evoked otoacoustic emissions and 28,006 (98.11%) passed. The rest, 540 (1.89%), received further audiological evaluation at referral centres after which 22 children (0.077% or 0.77/1000) were identified with permanent childhood hearing impairment – eight bilateral moderate, 10 bilateral mild and two each of unilateral mild and unilateral moderate sensorineural hearing loss. The authors conceded that excluding ‘at-risk’ children in this cross-sectional cohort may have contributed to the low prevalence when compared with other studies. Their conclusion is valid: that hearing surveillance in pre-schoolers is essential.

 

Reference

Screening of delayed-onset hearing loss in preschool children in the mid-south of China
Chen G, Fu S, Luo S, Zhang W, Yang G.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:568-71.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Early cochlear implantation enhances cortical maturation in ANSD children
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

Previous studies have shown that the cortical auditory evoked potential (CAEP) P1, a marker for central auditory maturation can be recorded in 50-70% of children with auditory neuropathy spectrum disorder (ANSD). In those children, behavioural and understanding of speech in the presence of degraded signals are likely to be better with hearing aids. The authors studied the effect of maturation in two groups of ANSD who were implanted. The Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS) was used to obtain a measure of auditory integration in all participants. The first was a retrospective review of 24 ANSD children, all of whom had been fitted with cochlear implants and had about 0.8 years of implant use. The mean age of P1 testing was 3.1 years. The second group of 11 children were studied longitudinally: P1 and IT-MAIS were determined pre and post cochlear implantation. In the first group, P1 responses were present in 100%, but in 11 children the latency was normal while it was delayed in 13 children. The only significant factor that differentiated between normal and delayed P1 latency was age at implantation; latency was normal in the early implanted children (mean age 1.88 years) and delayed in the later implanted children (mean age 4.07 years). Furthermore, the children with earlier latencies had higher behavioural outcomes as determined by their higher IT-MAIS scores. In the longitudinal study, after six months of implant use, P1 latency was normal or improved after implantation in 10 of 11 children (in three, P1 was normal pre implant and remained unchanged, in seven, P1 improved from either ‘delayed’ to ‘normal’ or ‘abnormal’ to ‘delayed’ and in one, a ‘normal’ P1 progressed to ‘delayed’ after implantation). Similarly, there was a significant correlation between P1 latency (maturation) and behavioural outcomes (IT-MAIS scores). These findings led the authors to suggest that there might be a critical period for implanting children with ANSD and the P1 latency could be used as a prognostic biomarker to predict behavioural outcomes in such children.

Reference

Central auditory maturation and behavioural outcome in children with auditory neuropathy spectrum disorder who use cochlear implants
Cardon G, Sharma A.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:577-86.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Internet-based screening test for occupational noise-induced hearing loss
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

The authors tested the reliability of an internet-based speech-in noise test (Earcheck) as a tool to detect the onset of noise-induced hearing loss (NIHL) against the traditional periodic pure tone audiometry (PTA) in a group of construction workers.  The Earcheck test requires subjects to identify 27 words by clicking a corresponding button on a computer, from which the speech reception threshold (SRT) is determined. 249 male construction workers were recruited but only 210 were included in the final analyses. In addition to the Earcheck test, all participants had a seven-frequency PTA (0.5 kHz to 8 kHz). The mean age was 45.7 years (SD 10.0) and job tenure 25.8 years (range one to 46 years, SD 11.4). In 83.3% of participants, the daily noise exposure exceeded 80 dBA. Most participants (70%) reported difficulties in understanding speech in noise compared with 27.7% with difficulties in the quiet. The authors reported significantly positive linear associations between Earcheck and PTA speech-in-noise intelligibility. However, the sensitivity and specificity of the Earcheck in identifying NIHL, were graded as modest (68% and 71% respectively). They discuss factors that could have influenced the specificity and sensitivity including masking levels, learning effects of the tests and the testing environment. Nevertheless, provided the testing procedure is modified, the Earcheck test can be a valuable addition to the tools already used in occupational hearing screening efforts.

Reference

The applicability of a speech-in-noise screening test in occupational hearing conservation.
Leensen MCJ, Dreschler WA.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:455-65.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Labyrinthine ossification in sudden sensorineural hearing loss
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

The push for cochlear implantation for unilateral sudden sensorineural hearing loss (SSNHL) probably prompted this study. Temporal bone images of 64 patients were studied by an experienced radiologist who was blinded to the clinical history of the patients. 55 patients had constructive interference in steady state (CISS) magnetic resonance imaging (MRI) and 18 had high resolution computerised tomography (HRCT) (nine had both MRI and CT). The median durations between onset of the sudden hearing loss and imaging were three days for CT (0 – 730 days) and 42 for MRI (0-820 days). The degree of ossification involving the cochlea and lateral semicircular canal was graded separately between zero and six (zero = nil and six = eburnation). Cochlear ossification was present in 14 patients (12 CT and two MRI). Eight of these were unilateral (seven ipsilateral) and four showed bilateral ossification. Interestingly, in six patients who had cochlear ossification on CT, the MRI was normal. 19 patients showed lateral semicircular canal ossification (12 CT and nine MRI). Of these six patients underwent both CT and MRI and ossification was present in only two on MRI. Overall, 22% of this cohort showed cochlear ossification (30% if the lateral canal ossification is included). The authors admit one limitation of the study to be the small number of patients but advocate for HRCT in patients with SSNHL as cochlear implantation may be required. I have a number of queries with the study. There was no mention of the possible aetiology of the SSNHL although admittedly, most are deemed to be idiopathic. The degree of ossification was not mentioned either. No explanation was offered for why cochlear ossification was present in some contralateral ears. Was there an underlying inflammatory process? In places where cochlear implantation is not contemplated for unilateral SSNHL, I doubt if HRCT could be justified routinely.

Reference

Prevalence of labyrinthine ossification in CT and MR imaging of patients with acute deafness to severe sensorineural hearing loss.
Braun T, Dirr F, Berghaus A, Hempel JM, Krause E, Müller J, Ertl-Wagner B.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:495 – 499.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Prevention of noise induced hearing loss in vivo
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

Noise remains one of the most common causes of deafness (NIHL). Noise causes the spiral modiolar artery (SMA) which forms the strial vascularis to constrict. It has been shown in previous studies that TNF-α induces sphingosine-1-phosphate (SIP), a potent vasoconstrictor of SMA. This experimental study explores the use of a TNF-α antagonist, etanercept, to improve the cochlear microcirculation in order to prevent NIHL. Twelve albino guinea pigs (NIHL animal models) were divided into two treatment groups: group 1 received etanercept and group 2, normal saline. Serial measurements were of capillary diameter, cochlear blood flow and threshold shift [measured by auditory brainstem response (ABR)] were determined at 30 minute intervals up to 210 minutes. Before injecting the animals with the respective solutions, the capillary diameter in the two groups were comparable after 60 minutes of observation. The animals were then subjected to a sustained noise at 106 dB SPL for 30 minutes and received their respective injections. Capillary diameter and cochlear blood were significantly greater in the etanercept group at every point of measurement than in the normal saline group. At onset and immediately after noise exposure, the hearing thresholds in both groups were comparable. Beyond 90 minutes after noise exposure, hearing thresholds in the etanercept group were either maintained or improved whereas those of the controls declined significantly. The authors conclude that etanercept improved cochlear blood flow and prevents permanent threshold shift in noise exposed guinea pigs and may serve as a promising treatment for NIHL.

Reference

TNF-inhibition using etanercept prevents noise-induced hearing loss by improvement of cochlear blood flow in vivo
Arpornchayanon W, Canis M, Ihler F, Settevendemie C, Strieth S.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:545-52.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Tone pip ABR is a better predictor of hearing than click ABR
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

The study was conducted to assess the predictive value of tone pip ABR in babies referred via the newborn hearing screening programme (NHSP), and their behavioural hearing levels at follow-up. 94 babies (188 ears) with a significant hearing impairment born between January 2002 and September 2007 were included. Data from 160 ears were available for analysis all of whom had click ABR thresholds recorded. Tone pip (tp) at 4 kHz was recorded for 34 left and 37 right ears respectively. At 1 kHz, tone pip was recorded in 19 left and 18 right ears. The mean age for behavioural audiometry at follow-up was 3.86 years. Two thirds of the tests were PTA or play audiometry and one third, insert-VRA at four frequencies (0.5 kHz to 4 kHz). The authors present several scatter plots comparing clkABR / tpABR and depicting behavioural thresholds at follow-up. The standard deviation of the difference between the follow-up thresholds and tpABR was 10.5 dB for 4 kHz and 16.8 dB for 1 kHz. Click ABR was a poorer predictor of hearing status at follow-up: a standard deviation difference of between 21.7 dB and 24.7 dB. This study adds weight to the use of frequency-specific measures such as tpABR in neonatal diagnostic audiometry but more work is needed for bone conduction testing.

Reference

Predictive value of hearing assessment by the auditory brainstem response following universal newborn hearing screening.
Stevens J, Boul A, Lear S, Parker G, Ashall-Kelly K, Gratton D.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:500–6.

INTERNATIONAL JOURNAL OF AUDIOLOGY

What is the best estimate of the 4 kHz air-bone gap?
Reviewed by: Victor Osei-Lah
Mar/Apr 2014 (Vol 23 No 1)
 

Air-bone gap (ABG) at 4 kHz in subjects with no other evidence of conductive hearing loss is commonly seen in clinical audiometry. This is believed to be anomalous but estimates of the size of the ABG are variable in the literature. To provide an accurate estimate, the authors pooled the data of four published and unpublished studies comprising 249 subjects who had normal hearing and 188 others who had sensorineural hearing loss (SNHL). In all subjects, air and bone conduction thresholds were determined for both automated (AMTAS) and manual audiometry. The two studies that tested the normal hearing subjects showed small ABG at 0.5, 1 and 2 kHz (-1.7 to 0.3 dB) and a larger mean ABG at 4 kHz of 10.6 dB. Similarly in the SNHL subjects, small ABGs of -7 to 1.7 dB were seen at 0.5, 1 and 2 kHz compared with a larger ABG of 14.1 dB at 4 kHz. However, the gap at 4 kHz was even larger, the greater the air conduction threshold at that frequency (from 10.1 dB for AC thresholds of 5 to 10 dB to 20.1 dB for AC thresholds above 60 dB), suggestive of a dependence on ABG for cochlear sensitivity in subjects with normal hearing. Age did not affect the 4 kHz ABG. The authors conclude that to avoid the 4 kHz ABG, the Reference Equivalent Threshold Force Level for subjects with SNHL should be adjusted by -14.1dB.

Reference

False air-bone gaps at 4 kHz in listeners with normal hearing and sensorineural hearing loss
Margolis RH, Eikelboom RH, Johnson C, Ginter SM, Swanepoel DW, Moore BCJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:426-532.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Maxillary osteotomy effects in cleft lip and palate patients
Reviewed by: Gauri Mankekar
Mar/Apr 2014 (Vol 23 No 1)
 

Currently there is weak evidence regarding the impact of maxillary osteotomy on patients with cleft lip and palate (CLP). Osteotomy is usually performed in adolescence after completion of facial growth to correct abnormal facial structure associated with CLP. The authors of this paper investigated the nature of the effect of maxillary osteotomy on the perceptual outcomes of velopharyngeal function in 12 consecutive patients with CLP. They also studied whether the speech changes seen three months after surgery persisted for longer when the maxilla was more stable. They found that maxillary osteotomy affects patients with and without CLP differently. Surgery impacts speech negatively in patients with CLP and the changes seen at three months postoperatively seem to persist and are stable at 12 months postoperatively. These findings can influence the type of information given to patients with CLP for informed consent prior to maxillary osteotomy. The evidence also suggests that the management of acquired velopharyngeal insufficiency following maxillary osteotomy can be undertaken at an earlier point than the current practice of 12 months postoperatively.

Reference

Effect of maxillary osteotomy on velopharyngeal function.
Pereira VJ, Sell D, Tuomainen J.
INTERNATIONAL JOURNAL OF LANGUAGE AND
COMMUNICATION DISORDERS
2013;48(6):640-50.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Antibiotic prophylaxis in plastic surgery
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from Italy prospectively studies 1100 patients over a one year period undergoing elective, reconstructive or cosmetic procedures. They were divided into one of four groups being clean, clean-contaminated, contaminated, or dirty. Those from the last two categories were excluded as were those undergoing antibiotic therapy or postoperative recovery within an intensive care unit. The groups were further subdivided based on whether superficial skin surgery, a clean procedure, microsurgery or prosthetic surgery, and a clean contaminated procedure was used. In total 229 out of 978 patients (23.4%) received antibiotic prophylaxis of either a beta-lactam or clindomycin if allergic. Their results indicated that superficial skin surgery such as local flaps, grafts and mucosal excisions had a 1% infection rate without antibiotics. Clean procedures, such as rhinoplasty, had a 1% infection rate when antibiotics were selectively used. There was a 1.3% infection rate for microsurgical and prosthetic surgery and a 5.3% infection rate with clean-contaminated procedures. With these results they conclude no prophylaxis is required in superficial skin surgery and simple mucosa excisions regardless of co-morbidities. They also state that antibiotic prophylaxis is always indicated in microsurgical operations and prosthetic surgery, and clean contaminated procedures of the oral cavity. They are of the opinion that the best option is clean surgery and rhinoplasty antibiotic prophylaxis only indicated when the operation lasts more than three hours and / or an American Society of Anesthesiologists (ASA) grade of three or more is present.

Reference

Perioperative antibiotic prophylaxis in plastic surgery: a prospective study of 1100 adult patients.
Toia F, D’Arpa S, Massenti MF, Amodio E, Pirrello R, Moschella F.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:601-9.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Don’t forget the internal mammary
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from Belgium describes seven cases of free flap reconstruction in the vessel depleted neck. Four of the patients had previously had bilateral neck dissections, (unilateral in three), and all had radiation therapy. The reconstruction was for oesophageal stenosis or fistula, five cases of a salivary fistula, and an oral cancer in the other two. No vein grafts were required. The mean pedicle length was 14.3 cm. This easily accessible predictable vessel appears to provide a good alternative to pedicle flaps or when angiography fails to show a suitable readily accessible predictable vessel.

Reference

The role of the internal mammary vessels as recipient vessels in secondary and tertiary head and neck reconstruction.
Roche NA, Houtmeyers P, Vermeersch HF, Stillaert FB, Blondeel PhN.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:885-92.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Fixing the cartilage in microtia
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper arises from the authors’ experience of problems with wires used to fix costal cartilage and to overcome its tendency to return to its original state. They researched four materials over a 24 year period where wire, non absorbable monofilament, absorbable monofilament, and non absorbable sutures had been used. Their sample was heavily weighted as in only 10 of the 122 cases a monofilament suture was used. They did however compare absorbable versus non absorbable techniques and conclude that absorbable sutures were better if they did not encounter the problems of exposure or deformity (thought to be caused by loosening of the fixation material).

Reference

An investigation of the fixation materials for cartilage frames in microtia.
Sakamoto A, Kiyokawa K, Rikimaru H, Watanbe K, Nishi Y.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:584-9.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Is size all that matters?
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper is an attempt to identify mechanisms of why haematomas compromise flaps in the absence of a pressure effect and pedicle thrombosis. It is a literature review relating haematoma to tissue compromise, with a clinical comparison made between free vascularised flaps and rhytidectomy skin flaps. The authors outline that early animal models confirm the detrimental effect of red cell and clot on tissue viability. The review then outlines the interrelated effect of neutrophils, cytokines and activation of complement. They explain how it is not just local pressure effect and support their conclusion that emergency surgical exploration should be considered regardless of tension from the tissue envelope. There is however quite a step between being considered and undertaken.

Reference

Why haematomas cause flap failure: an evidence based paradigm.
Glass GE, Nanchahal J.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:903-10.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

K wire fixation of a blowout fracture
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from Japan examines 18 cases of blowout fractures, where in simple fracture cases after manual reduction of the soft tissue through the antrum, a wire was placed to directly support the fracture segment in five cases, and a bone graft harvested from the maxillary sinus in a further 13. They claim this has the advantages of rigid fixation and minimal morbidity without requiring an orbital approach. Orbital approaches run the risk of reduced visual acuity and blindness. Therefore any approach that could avoid these catastrophes has its merits. I cannot help wondering why somebody would want to use this technique.

Reference

Transzygomatic kirschner wire fixation for the treatment of blowout fracture.
Yasumura K, Mikami T, Yabuki Y, Ooishi K, Hosono M, Yamamoto Y, Iwai T, Maegawa J.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:875-82.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Pectoralis minor for facial reanimation
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from the UK describes a unit’s experience of 561 patients over a 27 year period. Of these, 528 were pectoralis minor muscle, 28 lattissimus dorsi, three gracilis, and two extensor digitorum brevis (EDB). The method involved sural nerve harvest, extended parotidectomy approach and muscle harvest. They assessed 354 patients as having good static position with symmetrical exposure of the teeth in response to emotion. A further 159 patients were assessed as having good movement but without symmetrical complete tooth exposure. The remaining 48 had poor movement or no improvement. A further 153 patients received revisional procedures ranging from debulking of muscle (the most common revision) with adjustment of the nasolabial fold. Late onset tightness of the muscle in the static position affected 13% of patients. The results also suggested that the younger group of patients appeared to fare better than the older.

Reference

Pectoralis minor muscle transfer for unilateral facial palsy reanimation: an experience of 35 years and 637 cases.
Harrison DH, Grobbelaar AO.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:845-50.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Spreader grafts for nasal patency
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This is an attempt in a paper from Brazil to determine subjectively and objectively the functional results of a spreader graft in an open cosmetic rhinoplasty.  The authors assess 20 patients operated upon by one surgeon, evaluated 90-100 days after the surgery with a questionnaire for the patient and measuring nasal cross sectional area as objective assessment. There was a significant subjective improvement following surgery with a mean minimal change in cross sectional area of 0.3 cm² for the left and no significant change for the right. They conclude by stating open structure rhinoplasty using spreader graft is effective although recognise their short follow-up period and sample size.

Reference

Nasal patency after open rhinoplasty with spreader grafts.
Pochat VD, Alonso N, Mendes RRS, Cunha MS, Menezes JVL.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:732-8.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

The geometry of the V-Y and keystone flap
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper applies mathematics to the V-Y flap. The authors  show that the value of the apex angle of the flap should be between 20 and 60o. A value of 40o appears to provide a good compromise between the length of the flap and minimising the size of the defect to be closed. Greater than 40o increases the width of the secondary defect. Less than 40o decreases the length of the flap. Obviously the skin is regarded as a rigid tissue during the calculations. The keystone flap uses the same principles and they claim a small abnormal secondary defect after advancement. This is obviously at the expense of further scarring.

Reference

Geometrical analysis of the V-Y advancement flap applied to a keystone flap.
Pauchot J, Chambert J, Remache D, Elkhyat A, Jacquet E.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:1087-95.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Trapdoor orbital fractures in children
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This retrospective paper from Toronto examines 18 children who underwent surgical exploration of a trapdoor orbital floor fracture. Sixteen of these 18 patients achieved either complete or near complete resolution of diplopia. The computed tomography (CT) based assessment demonstrated the vulnerability of the inferior rectus muscle due to its close proximity to the orbital floor and lack of periorbital fat for protection. They advocate early surgical intervention. However the average time to surgery in this cohort was 9.7 days. UK practice would suggest that paediatric trapdoor fractures would present soon after the injury and surgery is undertaken as soon as practically possible after the diagnosis is made, often within a few days. In addition they outline the vulnerability of the inferior rectus muscle. In the vast majority of such explorations it is the fat trapped that reduces the ocular motility.

Reference

Paediatric orbital floor trapdoor fractures: outcomes and ct-based morphologic assessment of the inferior rectus muscle.
Neinstein RM, Phillips JH, Forest CR.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:869-74.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Tube feeding in head and neck cancer resection
Reviewed by: Catherine Treacy
Mar/Apr 2014 (Vol 23 No 1)
 

This paper from Glasgow creates an algorithm for patients undergoing head and neck surgery to be fed by nasogastric or percutaneous endoscopic gastrostomy (PEG) feeding. They examine their experiences of consecutive head and neck cancer patients over a five year period. They concluded that all patients undergoing radiotherapy, radiotherapy and chemotherapy, or involving the mandible or T4 carcinoma of the oropharynx required to be PEG fed. They also conclude, as one may expect, the more advanced the tumour and the poorer the dietary consistency score, the more likely that PEG feeding would be required.

Reference

Guideline for prophylactic feeding tube insertion in patients undergoing resection of head and neck cancers.
Jack DR, Dawson FR, Reilly JE, Shoaib T.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65:610-15.

JOURNAL OF VESTIBULAR RESEARCH

Betahistine treatment in managing vertigo
Reviewed by: Fiona Barker
Mar/Apr 2014 (Vol 23 No 1)
 

Betahistine is still commonly used in the UK and elsewhere as part of the management of vestibular dysfunction and particularly Ménière’s Disease. This paper presents a summary of some of the work done to elucidate the action of histamine in animal models. Links are made to human trials of betahistine both for Ménière’s and for shortening the time course of vestibular compensation in general, but there is little critical appraisal of the differing levels of the quality of evidence cited. The authors conclude that there are likely to be dose and duration effects on the efficacy of betahistine. There is clearly a need for further research in this area and a priority should be that studies are methodologically rigorous and large enough to study dose and duration dependent effects. In an era of supposedly evidence-based medicine, critical appraisal of existing evidence, that could inform future research, is key to ensuring that drug prescription is appropriate, effective and safe.

Reference

Betahistine treatment in managing vertigo and improving vestibular compensation: Clarification
Lacour M.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:139-51.

JOURNAL OF VESTIBULAR RESEARCH

Vestibular dysfunction: prevalence, incidence and need for targeted treatment
Reviewed by: Fiona Barker
Mar/Apr 2014 (Vol 23 No 1)
 

This paper provides a useful summary of research into the prevalence and incidence of various common forms of vestibular dysfunction such as benign paroxysmal positional vertigo (BPPV), migraine and Ménière’s. It also gives an overview of some of the work on the impact of vestibular disorders on quality of life. The link is also made between vestibular dysfunction and falls. As falls are a ‘big hitter’ in terms of chronic disease burden, this is a useful link to make for anyone arguing that closer attention should be paid to vestibular loss. The focus of this paper is to provide a rationale for targeted pharmacologic interventions and as such they highlight some of the gaps in evidence for effective treatments particularly in the case of vestibular loss where the cause is not clearly established or the pathophysiology less well understood. There was relatively little attention given to the research evidence on vestibular rehabilitation. In this paper it was only mentioned in terms of treatment for bilateral vestibular loss whereas there is good evidence to support its use in unilateral vestibular loss. This paper does provide a helpful summary of prevalence, incidence and the need for treatment of vestibular dysfunction. However the summary of treatment options and the evidence for them is somewhat limited and viewed through the prism of the search for pharmacological interventions.

Reference

Vestibular dysfunction: Prevalence, incidence and need for targeted treatment
Agrawal Y, Ward BK, Minor LB.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:113-17.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Swallowing exercises for head and neck patients
Reviewed by: Hannah Blanchford
Mar/Apr 2014 (Vol 23 No 1)
 

The prevalence and impact that radiation induced dysphagia has on quality of life has motivated these authors to develop a ‘swallowing preservation protocol’.  It builds on evidence that pre-treatment and early referral for swallowing therapy improves outcomes. The study investigated 85 patients undergoing either radiotherapy or chemoradiotherapy for head and neck cancer. This swallowing preservation protocol was applied before, during and after treatment.  The theory is that exercise of pharyngeal, laryngeal and oral structures maintains a range of motions and counters the effects of radiation induced fibrosis that restricts movement and leads to dysphagia.  Patients met with a speech-language pathologist once a week, starting two weeks before treatment and continuing until two months after treatment. The patients were divided into two groups:  ‘compliant’ or ‘non-compliant’ depending on their self reported use of daily exercises. There was no difference in xerostomia, dysgeusia and odynophagia between the two groups. However, there was an association between the ‘compliant’ group and a faster return to a normal diet. This group was also less likely to develop oesophageal stenosis or require a gastrostomy. The authors acknowledge their study was limited by the two months’ follow-up and lack of other objective swallowing tests. The protocol demands a high level of engagement from patients who are required to attend weekly meetings for education and therapy. This regular contact may be the key to its success, but also, the reason that other centres may find implementing such a programme so difficult.

Reference

Swallowing preservation exercises during chemoradiation therapy maintains swallow function.
Duarte VM, Chhetri DK, Liu YF, Erman AA, Wang MB.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;149(6):878-84.

SEMINARS IN HEARING

Hearing aids and cognition
Reviewed by: Vinaya KC Manchaiah
Mar/Apr 2014 (Vol 23 No 1)
 

This discussion paper provides a good overview of the role of cognition in hearing aid use and also describes the recent work aimed at determining individual cognitive spare capacity or the ability to process speech heard in noise in ways that may be relevant for communication. In the last decade much work has been done in relation to understanding the importance of cognitive abilities in hearing function and also in understanding how decreased hearing loss and decreased cognitive abilities may have added disadvantage to patients compared to any one problem alone. In addition, it has also been well established that successful listening with advanced signal processing in digital hearing aids is associated with individual working memory capacity, which is the cognitive ability to keep information in mind and process it. Different types of cognitive processing may be required in different situations. For example, when listening in noise it may be necessary to inhibit irrelevant information and appraise misheard information. There is evidence that simply hearing a spoken utterance consumes cognitive resources and may do so to different degrees for different individuals. To determine just how useful different kinds of signal processing are, it is important to examine to what extent they help individual hearing aid users cope with the kind of cognitive demands that may arise in everyday listening situations. These findings have significant implications to both research in this area and more importantly to clinical practice.

Reference

Cognitive spare capacity as a window on hearing aid benefit
Rudner M, Lunner T.
SEMINARS IN HEARING
2013;34(4):298-307.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Information on rhinosinusitis: Does YouTube help?
Reviewed by: Madhup K Chaurasia
Mar/Apr 2014 (Vol 23 No 1)
 

Information is easy to obtain from the internet, but whether it is really useful, particularly for medical conditions, is a matter of speculation and opinion. Chronic rhinosinusitis is one of the commonest ailments affecting quality of life and as claimed by this article, more than the quality is adversely affected by chronic obstructive pulmonary disease. It is therefore only natural that these patients tend to seek information from the internet. In this presentation, the authors have undertaken a detailed analysis of information supplied by selecting the first 100 YouTube videos obtained on searching for ‘sinusitis’. Factors noted were the number of views, the number of likes or dislikes , the uploaded source, symptoms described and a wide range of management options cited in the videos. These were then categorised on merit of the medical information supplied with reference to the European position paper on rhinosinusitis  and nasal polyps management guidelines (2012). A second author separately assessed the videos to provide quality control and statistics were applied to results. Only 45% five per cent of the videos were deemed to be ‘useful’ and 27% contained ‘potentially misleading’ and even ‘dangerous’ content, the presented examples of which reflect most extreme stretches of imagination! Ninety percent of videos uploaded by medical professionals had useful information whereas 43% of those uploaded by individual users were misleading. Individual users selected the shorter and less useful information. No doubt the authors feel there should be a system to direct lay persons to verifiable and credible information, possibly peer reviewed, but whether one can govern the so called freedom of information is another matter!

Reference

YouTube as a source of information on rhinusinusitis: the good, the bad and the ugly.
Biggs TC, Bird JH, Harries PG, Salib RJ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:749-54.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Nasal sprays for local anaesthesia can spread infection
Reviewed by: Madhup K Chaurasia
Mar/Apr 2014 (Vol 23 No 1)
 

It is common practice to constitute a solution containing Lidocaine Hydrochloride 5% by volume and 0.5% Phenylephrine Hydrochloride w/v for nasal anaesthesia to carry out various examination procedures and cauterise the nose. Contamination of these solutions and subsequent spread of infection to another patient is taken for granted as something unlikely to happen. This study explores the possibilities of cross-infection between patients resulting from this practice. The study was carried out by using this spray on patients and then doing a culture on the anaesthetic solution. This was supported by another arm of the study which was an in vitro experiment. In this, the spray was done on a growth of staphylococcus and then the solution cultured for these organisms. Interestingly enough both the pump and the bottle proved to be contaminated in two out of 10 patients and the same result was obtained in the in vitro study. This is attributed to the fact that use of these pumps can have a ‘suck back’ effect, drawing bacteria from patients back into the containers. Alternative devices have been mentioned. The authors contend that it is not safe to continue this practice and single use containers should be used and disposed afterwards. This of course will increase the cost but will avoid cross contamination between patients. The study raises a possibly contentious point in terms of costs. One can take some solace from the fact that most patients do not require local anaesthesia.

Reference

Risk of contamination of Lidocaine Hydrochloride and Phenylephrine Hydrochloride topical solution: in vibo and in vitro analyses.
Jog M, Sachitananda R, Syeed K.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:799-801.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Vocal cord paralysis due to rare causes in upper thorax
Reviewed by: Madhup K Chaurasia
Mar/Apr 2014 (Vol 23 No 1)
 

Generally speaking, paralysis of the right vocal cord draws attention to possible lesions in the brain or skull base and paralysis of the left vocal cord raises suspicion about mediastinal lesions, usually bronchogenic carcinoma. In this interesting article, the authors have emphasised the need for detailed computed tomography (CT) imaging of the upper thorax, which has helped them pick up rare causes of vocal cord paralysis. A case of Ortner’s (cardiovocal) syndrome has been mentioned which caused paralysis due to compression of the left recurrent laryngeal nerve in the aorto-pulmonary window diminished in space by left atrial enlargement. Another case with left vocal cord paralysis had pseudoaneurysm of the aortic arch causing compression. Paralysis of the right laryngeal nerve occurred due to a cervical spinal osteophyte in another patient due to pressure on the nerve behind the inferior cornu of the thyroid cartilage. One patient had right vocal cord paralysis due to a tracheal diverticulum, an incidental anomaly stated to be seen in 1% of autopsies. Finally, a case of tortuous oesophagus causing left vocal cord paralysis has been illustrated. There is a beautiful presentation of CT images in all these cases and minute radiological details of paralysed vocal cords and adjoining structures have been highlighted to identify the paralytic state. These conditions can easily be missed but no doubt the reader would be wary of these rare causes which the authors of this highly illustrative publication have been very fortunate to add to their experience.

Reference

Uncommon and rare causes of vocal fold paralysis detected via imaging.
Sobrino-Guijarro B, Virk JS, Singh A, Lingham RK.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:691-8.

COCHLEAR IMPLANTS INTERNATIONAL

An adult questionnaire assessing the speech, spatial and qualities of hearing was adapted for use with children, parents and teachers
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

All objective measures usually need subjective confirmation and this is also true with regard to the assessment of speech, spatial and qualities of hearing in young implantees. Moreover, a broad evaluation of the additional benefit provided to children by a second bilateral cochlear implant requires such an assessment. As no paediatric tool provided detailed evaluation of performance in the areas of daily listening in which benefit was likely to be demonstrated, an adult questionnaire was adapted by the authors of the present study. Items of the Speech, Spatial and Qualities of Hearing Scale (SSQ) focused mainly, although not exclusively, on hearing functions requiring the binaural system. The adapted child, parent and teacher versions of the SSQ retained the structure of rating listening performance in everyday scenarios across the domains of speech perception, spatial hearing and other qualities of hearing. Modifications were minimised, although deletion of some items and wording changes were required, and some subdomains could not be included. Observation periods were introduced so that parents and teachers observe performance prior to providing ratings. The suggested minimum age is 11 years for the child version and five years for the parent and teacher versions. Instructions indicate interview-style administration in which interpretation of the described listening scenarios can be clarified and use of the ruler-style response format demonstrated. Wide application is needed in order to fully evaluate the usefulness of this adapted assessment in implanted children.

Reference

Adaptation of the speech, spatial, and qualities of hearing scale for use with children, parents, and teachers.
Galvin KL, Noble W.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):135-41.

COCHLEAR IMPLANTS INTERNATIONAL

Belgium: one of the leading countries in cochlear implantation
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

It seems that Belgium remains one of the leading countries regarding cochlear implant utilisation / provision. This may very well be attributed to the fact that Belgium, and especially the northern region, Flanders, has been a centre of expertise in cochlear implants and early hearing screening for many years. Some of their surgeons and engineers were pioneers in the development of cochlear implants and in 1998 Flanders was the first region in Europe to implement a universal hearing screening programme for all neonates. The Belgian National Institute for Health and Disability Insurance has reimbursed cochlear implants in children and adults since 1994 and bilateral implantation in children under the age of 12 since February 2010. The evidence shows that in 2010, 93% of severe-to-profound deaf preschool children in Flanders had received cochlear implants and 25% had bilateral implants. Although the situation in adults is less clear, the fact that on average twice as many adults as children are implanted every year in Belgium is very promising.

Reference

Accessibility to cochlear implants in Belgium: State of the art on selection, reimbursement, habilitation, and outcomes in children and adults.
Raeve LD, Wouters A.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s18-s25.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in the United Kingdom: another developed country with high uptake in children and low uptake in adults
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

It is well known that the United Kingdom has one of the most organised National Health Services (NHS). The history of cochlear implantation in the UK is interesting as it shows the gradual pathway from private funding to NHS bilateral paediatric cochlear implantation (since 2009). During the period between 1982 and 1990, when a number of individual teams ran programmes using charitable funding, the British Cochlear Implant Group approached the UK Department of Health, who agreed to set up a four-year pilot study of 10 programmes, including one children’s programme. The outcomes were collected and analysed by the Medical Research Council’s Institute of Hearing Research. The results, showing positive outcomes for adults and children, were published in 1995 and subsequently funding was provided directly by the NHS. The implementation of a Universal Newborn Hearing Screening programme in the UK further improved early diagnosis and referral. As a consequence, in 2011 the figures showed that 74% of estimated eligible children aged 0–3 years had received implants and 94% by the age of 17. However, for adults the figures are considerably lower, with only about 5% of those eligible for an implant actually receiving one. The reasons for this include, to a lesser degree, the fact that guidelines by the National Institute of Clinical Excellence (NICE) are stricter than in some other European countries, but mainly because of lack of awareness among candidates and professionals, both of criteria for eligibility and of the potential advantages from cochlear implantation. It seems that the adult population should now be the target in the UK.

Reference

Cochlear implants in the United Kingdom. Awareness and utilization.
Raine C.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s32-s37

COCHLEAR IMPLANTS INTERNATIONAL

How implantees or their families choose the cochlear implant model
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

The authors in this study tried to investigate how patients choose their cochlear implant (CI) model when they are allowed to do so, and which factors are considered most important in the decision-making process. The authors sent a postal survey to 87 families of children with cochlear implants who met certain inclusion criteria. Patients were asked to rate certain factors from 0 to 10 depending on their importance in the decision-making process. Sixty-four patients replied (response rate 74%). In most cases (83%), the parents and / or children were involved in the decision regarding the choice of implant. Eighty-nine percent of patients received information about the choices of CI from the CI team. Patients also accessed information directly from the manufacturer, from other CI users and from websites. The most important factor in choosing a CI model was robustness and reliability (mean score 9.6), followed by comfort (9.4), size / shape (9.2), and control system / ease of use (8.9). All patients were happy with the choices they made. Although many issues are involved in the information provided and the influence of the internet or the market itself, it is always interesting to assess how families choose a certain model of cochlear implant and what they feel is important.

Reference

What factors influence patient and parent choice of cochlear implant model for children?
Clamp PJ, Rotchell T, Maddocks J, Robinson PJ.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):130-4.

COCHLEAR IMPLANTS INTERNATIONAL

Listening effort: is it reduced in bilateral implantees?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

The authors attempted to investigate the listening effort expended by adolescents and young adults using implants versus their peers with normal hearing when these two groups were achieving similar speech perception scores. In addition, bilateral and unilateral implantation was compared. Eight participants with bilateral cochlear implants and eight with normal hearing aged 10-22 years were included. Using a dual-task paradigm, participants repeated consonant‐nucleus‐consonant words presented in noise and performed a visual matching task. Signal-to-noise ratios were set individually to ensure the word perception task was challenging but manageable for all. Reduced performance on the visual task in the dual-task condition relative to the single-task condition was indicative of the effort expended on the listening task. The results revealed that the cochlear implant group, when using bilateral implants, expended similar levels of listening effort to the normal hearing group when the two groups were achieving similar speech perception scores. For three individuals with cochlear implants, and the group, listening effort was significantly reduced with bilateral compared to unilateral implants. Although the numbers are rather small and there are inherent difficulties in measuring listening effort, these preliminary data suggest that reduced listening effort is a benefit that some individuals gain from bilateral cochlear implants.

Reference

Measuring listening effort expended by adolescents and young adults with unilateral or bilateral cochlear implants or normal hearing.
Hughes KC, Galvin KL.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(3):121-9.

COCHLEAR IMPLANTS INTERNATIONAL

Paediatric cochlear implantation in Japan: a different situation
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

It is amazing how different the situation is in different countries regarding cochlear implantation rates of utilisation / provision which cannot be attributed entirely to the financial status and the health system of an individual country. The Japanese health-care system covers all aspects of cochlear implantation, from diagnosis to implantation, to mapping and habilitation aftercare. We should also take into account that Japan has the third largest developed economy. However, the uptake rate for cochlear implants is lower than that of countries with similar economic status; Japan has an uptake rate of approximately 1% of potentially suitable subjects of all ages, compared with 5.6% in the USA. With regard to children, only 3-4% of children under the age of three are being implanted at less than 18 months of age. This is in accordance with the Japanese ENT Academy’s guidelines, which currently puts the minimum age limit for implants in children at 18 months. Moreover, there are significant problems in the neonatal screening programmes in various parts of the country. It seems that even the richest countries in the word face considerable problems in screening, diagnosis, implantation and after-care.

Reference

New expectations: Pediatric cochlear implantation in Japan.
Oliver J.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s12-s17.

COCHLEAR IMPLANTS INTERNATIONAL

Rapid changes in cochlear implantation in China
Reviewed by: Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

China has one of the fastest growing economies in the world. In addition, the numbers of general population and deaf candidates for cochlear implantation are huge in comparison with most other countries in the developed and the developing world. However, the numbers of implantees are rather limited. This situation seems to have changed in the last few years, as by 2010, universal hearing screening programmes had been implemented in 20 of the 32 Chinese provinces. In large cities 95% of babies are screened in hospital-based programmes. In more remote areas babies with high-risk factors for hearing loss are referred to screening centres within one month of birth and leaflets about identifying deafness are distributed. Moreover, China is in the process of developing a national reimbursement scheme for medical care. In 2009, the Chinese government set up a project to implant 1500 children aged one to five over the next three years, and in 2011, the government agreed to fund implants for an additional 17,000 children over four years. However, the situation is still far from ideal as cochlear implant penetration in China is currently less than 5% of potential paediatric candidates. On the other hand, cochlear implantation is continuing to expand at great speed, and it is hoped that the infrastructure and capacity will continue to grow and develop in the coming years.

Reference

Enter the dragon – China’s journey to the hearing world.
Liang Q, Mason B.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s26-s31.

HEAD & FACE MEDICINE

Adenomatoid odontogenic tumour associated with odontoma: a case report and critical review of the literature
Reviewed by: Bilal Gani Taib
Jan/Feb 2014 (Vol 22 No 6)
 

Odontogenic tumours and hamartomas encompass a large variety of rare lesions that originate from odontogenic tissue. The nomenclature regarding the various lesions is somewhat confusing as different terms are used to describe similar lesions. In this case a 32 year old male presented with an asymptomatic, well delineated, unilocular, hypodense tumour in the left posterior mandible. These findings suggested a benign cystic odontogenic lesion. The lesion was completely enucleated and the cystic capsule was found to adhere to a thin hard tissue resembling a tissue. Microscopic analysis revealed a cystic cavity with flattened, non keratinised squamous epithelium. In other areas swirls of fusiform cells, ribbons of ameloblast like cells and islands of odontogenic epithelium were observed. However no duct-like structures were found. Despite this, the overwhelming histological evidence led to the diagnosis of adenomatoid odontogenic tumour (AOT) associated with odontoma. No recurrence was identified eight months post surgery. A review of the literature using the different nomenclatures revealed 11 other case reports, with histological images. The mean age of the cohort was 24.4 years old and nine out of 11 of the odontoma associated variants were located in the posterior mandible. This together with the common findings of ducts lined by columnar ameloblast like cells has led the authors to conclude that AOH represents developmental failure of the third molar.

Reference

Adenomatoid odontogenic tumor associated with odontoma: a case report and critical review of the literature.
Gomez RS, Castro WH, Gomes CC, Loyola AM.
HEAD & FACE MEDICINE
2013;9:20.

HEAD & FACE MEDICINE

The detection of oral pre-malignant lesions with an autofluorescence based imaging system (VELscopeTM) – a single blinded clinical evaluation
Reviewed by: Bilal Gani Taib
Jan/Feb 2014 (Vol 22 No 6)
 

The increasing prevalence of oral squamous cell carcinomas (OSCC) is a growing problem in many European countries. This combined with the fact that the disease specific five-year survival rate, especially for patients with advanced oral cancer, has not improved significantly means that early detection of these lesions is vital. Precursor lesions may exist as erythro or leukoplakias. Current standard diagnostic procedure is the conventional oral examination (COE) under white light conditions with a visual and tactile assessment of the whole oral cavity.  One caveat is differentiating between normal mucosa and micro invasive carcinomas. Hence the surgical biopsy is the gold standard in identifying pre malignant or malignant lesions. However, at this stage the lesion is usually cancerous. An alternative technique is the use of auto fluorescence. Used since 1924, the principle is based on naturally occurring fluochromes that are located in the epithelium and the submucosa (e.g. collagen, elastin) and which are irradiated with different excitation wavelengths. When irradiated with wavelengths between 375 and 440 nm, the dysplastic tissue due to a disruption of the fluochromes emits a darker colour whereas healthy tissue remains pale. In order to test this hypothesis a group of 120 patients with suspicious oral pre-malignant lesions were separated into two groups. Group One patients were examined with just the conventional white light regimen whereas Group Two patients were examined using the same technique with the addition of an autofluorescence visualisation device (VELscopeTM). 52 biopsies were obtained from suspicious areas. Despite having a higher sensitivity (22.0%) the autofluorescence visualisation device was found to be less specific (8.4%). This would mean that people would be over diagnosed if they were not used to the device. The autofluorescence outcomes are subjective upon the examiner’s experience, hence any users will require training, as was carried out in this study.

Reference

The detection of oral pre- malignant lesions with an autofluorescence based imaging system (VELscopeTM) - a single blinded clinical evaluation.
Hanken H, Kraatz J, Smeets R, Heiland M, Blessmann M, Eichhorn W, Clauditz TS, Groebe A, Kolk A, Rana M.
HEAD & FACE MEDICINE
2013;9:23.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Appreciation of music after cochlear implantation
Reviewed by: Victor Osei-Lah
Jan/Feb 2014 (Vol 22 No 6)
 

The authors illustrate how musical hearing ability can be exceptionally good in some cochlear implant users by comparing an adult implant user with five adults with normal hearing. The implant user was a 30 year old female who had played the piano for 17 years prior to losing her hearing to autoimmune inner ear disease. She had no residual hearing in the left ear and a moderate to profound loss in the right ear (70 dB to 100dB from 0.25 – 4 kHz). The study was done seven months after bilateral cochlear implantation. The five ‘controls’ were amateur musicians with no formal musical training, all of whom had good sight reading abilities but admitted to not having pitch-perfect abilities. The first experiment was the music perception test (CAPM) which assessed pitch direction discrimination, melody and instrument (timbre) recognition. Experiments Two, Three and Four assessed absolute and relative pitch, consonance rating and melody segregation respectively in both groups. Overall, the implant user’s performance was comparable to the normally-hearing adults. For instance, the user’s pitch direction discrimination thresholds were close to the minimum of 0.5 semitones. Melody recognition was better than the controls but the user fared worse in the recognition of instruments. The authors conclude that a sound processor designed to improve speech perception can provide adequate perception of music but further work on improving fine temporal structure and timbre recognition is needed.

Reference

A cochlear implant user with exceptional musical hearing ability.
Maarefvand M, Marozeau J, Blamey PJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:424–32.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Auditory neuropathy spectrum disorder – to implant or not to implant
Reviewed by: Victor Osei-Lah
Jan/Feb 2014 (Vol 22 No 6)
 

Auditory neuropathy spectrum disorder (ANSD) is increasingly being diagnosed worldwide but rehabilitating children with this condition is challenging. Several studies use speech recognition as the outcome for rehabilitation. The use of cochlear implantation (CI) in ANSD has increased. The authors conducted a systematic review to investigate the evidence base for CI. After applying a strict inclusion and exclusion criteria to several studies published between 1950 and 2012, 27 studies (in children under 16 years) specifying objective speech recognition measures were selected. They were all published between 2006 and 2012. All studies were either observational or cohort studies published in English. The majority of the children were profoundly deaf. 15 studies had no comparison groups and a variety of materials were used to assess speech recognition without specifying the stimulus levels. Pre operative results were rarely reported and the duration of post activation speech discrimination assessment varied widely. Some studies reported no significant differences between ANSD and SNHL scores. Most of the studies did not control for potential confounding factors such as aetiology of hearing loss and developmental status of the children. The authors concluded that whereas the evidence for CI in ANSD is weak, it should not preclude its use as clear benefits have been reported. They discuss the practical and ethical dilemmas for a randomised controlled trial and suggest a multicentre longitudinal study in order to look for better evidence.

Reference

Does cochlear implantation improve speech recognition in children with auditory neuropathy spectrum disorder? A systematic review.
Humphriss R, Hall A, Maddocks J, Macleod J, Sawaya K, Midgley E.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:442-54.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Back in the ASSR
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The auditory steady-state evoked responses (ASSR) have been considered reliable for hearing threshold estimation purposes in uncooperative individuals. They have been applied in studies to assess the hearing level of children wearing hearing aids or candidates for a cochlear implant, and in non-cooperative adults when other methods [auditory brainstem response (ABR), slow vertex response (SVR)] do not achieve a satisfactory determination of the auditory threshold morphology. The N1-P2 acoustic change complex (ACC; Ostroff et al, 1998) is an objective method similar to the slow vertex responses (SVR) to brief stimuli (tone pips, clicks, short speech tokens), but is exclusively elicited by changes in continuous sounds. The change introduced in a continuous tone or noise can be  a variation of the frequency or of the intensity, or a silent gap. The cortical response modification determined by these changes can be recorded not only in normal hearing listeners, but also in patients with sensorineural hearing loss, cochlear implants, auditory processing disorders and children as young as six years of age. The authors compared the ACC recordings with the behavioural thresholds of detection of the intensity, frequency and temporal gap in a group of children with sensorineural hearing loss and hearing aids. They observed a good correlation between amplitude changes and the behavioural thresholds, but not with frequency changes or gap detection. In particular, the ACC amplitude increased proportionally to the increment of the change of intensity. This study represents another step forward in the search of a reliable method of assessment of the auditory discrimination abilities in children.

Reference

Prediction of aided and unaided audiograms using sound-field auditory steady-state evoked responses
Shemesh R, Attias J, Magdoub H, Nageris BI
INTERNATIONAL JOURNAL OF AUDIOLOGY
2012;51:746-753

INTERNATIONAL JOURNAL OF AUDIOLOGY

Behavioural versus electrophysiological measures
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The auditory discrimination abilities of adult listeners are usually tested with psychophysical methods. Conversely, electrophysiological tests are necessarily applied in children and non-cooperative subjects. The N1-P2 acoustic change complex (ACC; Ostroff et al, 1998) is an objective method of detection of sound changes, i.e. recording of the cortical response modification determined by changes in continuous or long standing stimuli. It can be obtained by varying the frequency or the intensity of a pure tone or noise stimulus, or by introducing a silent gap. Despite the morphologic similarity with the slow vertex responses (SVR) to brief stimuli (tone pips, clicks, short speech tokens), the ACC are exclusively elicited by changes in continuous sounds. Interestingly, it can be recorded not only in normal hearing listeners, but also in patients with sensorineural hearing loss, cochlear implants, auditory spectrum disorders and children as young as six years of age. The authors compared the behavioural thresholds of detection of the amplitude and spectrum change and temporal gap with those of the recordings of ACC. They observed a good correlation between the amplitude changes and the behavioural thresholds, but not with frequency changes or gap detection. In particular, the ACC amplitude increased proportionally to the increment of the acoustic change of intensity. This study represents another step forward in the search for a reliable method of assessment of the auditory discrimination abilities in children.

Reference

Auditory discrimination: the relationship between psychophysical and electrophysiological measures.
He S, Grose JH, Buchman CA.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2012;51:771-82.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Chirp vs tone pip stimuli: which is better?
Reviewed by: Victor Osei-Lah
Jan/Feb 2014 (Vol 22 No 6)
 

For several years, broadband clicks have been used to elicit the auditory brainstem response (ABR). Recently, tone-pips which are more frequency specific are being used instead of clicks but they are time-consuming. Another emerging stimulus is the narrow band CE Chirp which has been found to generate much larger amplitude than the tone pip in adults. The three-fold aim of this study was to compare ABR amplitude to tone pip and chirps, to estimate corrected ABR threshold (nHL to eHL) for chirps, and to identify further work needed to make NB CE-Chirps a standard stimulus in children. 30 babies referred via the English Newborn Hearing Screening Programme (NHSP) for diagnostic audiometry were recruited for the study. A total of 42 ears were tested: 21 with 4 kHz stimuli and 21 with 1 kHz stimuli and the response amplitude, response quality (Fmp) and residual noise were compared for both tone pip and chirps. At 4 kHz, 49 waveform pairs satisfying the NHSP clear response criteria were obtained for both stimuli. At 1 kHz, 42 waveform pairs were similarly obtained. The chirp response was larger in 98% of the 4 kHz comparison and for all of the 1 kHz comparisons. The Fmp was also significantly higher for chirps and overall, chirp responses were 64% larger than tone pip responses, closer to those obtained by clicks. Residual noise did not significantly affect the waveforms of either stimulus. The authors suggest that chirps can be an alternative to tone pips especially where ABR amplitudes are low. Another advantage could be significant reductions in time. They suggest further work to make chirps more routinely applicable in NHSP.

Reference

Comparison of ABR response amplitude, test time, and estimation of hearing threshold using frequency specific chirp and tone pip stimuli in newborns.
Ferm I, Lightfoot G, Stevens J.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:419–23.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Hearing and diet
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

Have you ever considered a relationship between food intake and susceptibility to acquired hearing loss? It is an emerging trend in the field of audiology, although the variability in outcomes across studies hinders the possibility of a clear-cut final statement. One possibility is that dietary quality influences hearing status by mediating vulnerability of the inner ear to noise insult and to age related changes. Uncertain results of current studies are probably related to differences in the measures used to quantify nutrient intake, where in most instances a single nutrient is analysed, failing to recognise interactions between multiple nutrients. The authors examined the potential relationship between diet and hearing by an overall dietary quality approach, based on the Healthy Eating Index (HEI), developed by the US Department of Agriculture’s Center for Nutrition Policy and Promotion. It estimates the conformity of a person’s diet to the US Dietary Guidelines for Americans (Kennedy et al, 1995). Researchers at the University of Florida at Gainesville contrasted the HEI  with the hearing thresholds of a sample of  21,004 adults aged 20 to 69 years, collected during the National Health and Nutrition Examination Survey (1999 -2002). The epidemiological study (Curtin et al, 2012) was based on random selection, within specific demographic distributions, of a sample that was representative of the entire US population. Controlling for age, race / ethnicity, sex, education, diabetes and noise exposure, the authors found, not unexpectedly, a significant negative relationship  between diet and hearing thresholds at higher frequencies, i.e. worse dietary quality was associated with lower hearing sensitivity. No statistically significant relationship between diet and hearing was found at lower frequencies. Taken with caution (and some irony), it seems that “we hear what we eat”. At least, this might apply to the North American population

Reference

Healthy diets, healthy hearing: National Health and Nutrition Examination Survey, 1999 – 2002.
Spankovich C, Le Prell CG.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:369-76.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Self-service hearing aids?
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The World Health Organization (WHO) estimates that 639 million people worldwide have a permanent, mild to profound hearing loss; 80% of them live in low- and middle-income nations, especially in parts of the developing world such as sub-Saharan Africa and South Asia. In these countries, fewer than 3% of hearing-impaired individuals have access to hearing aids, owing to lack of an audiological infrastructure. The authors propose a ‘do-it-yourself’ amplification device, designed to be managed entirely by the user without the need for professional support, specialised add-on equipment, or computer access. The user first assembles the low-cost device from a selection of basic hearing-aid parts, then self-administers an automatic, in situ hearing test. The self-fitting hearing aid then applies a prescriptive fitting rule derived from the National Acoustics Laboratory (NAL) to yield an appropriate gain / frequency response and compression parameters. Users may further fine-tune and train the settings to their individual preferences using an onboard button or associated remote control. This interesting study tried to assess the ability of 40 South African and 40 Chinese hearing-impaired adults to  assemble a pair of self-fitting hearing aids by following instructions that were written and illustrated. 95% of South African and 60% of Chinese participants completed the assembly task, either on their own or with assistance from their partners. 63% of South Africans and 18% of Hong Kong participants assembled both hearing aids without errors. A higher level of education, health literacy, younger age and a more prestigious occupation were significantly associated with independent task completion. It can be concluded that individuals of diverse backgrounds can manage the self-fitting hearing-aid assembly task as long as their literacy and cognitive level allow the reading of instructions and captioned illustrations. The consequences of the possible provisions of these kinds of hearing aid to the developing countries are palpable.

Reference

Hearing-aid assembly management among adults from culturally and linguistically diverse backgrounds: Toward the feasibility of self-fitting hearing aids.
Convery E, Keidser G, Caposecco A, Swanepoel DW, Wong LLN, Shen E.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:385-93.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Targeted surveillance after newborn hearing screening
Reviewed by: Victor Osei-Lah
Jan/Feb 2014 (Vol 22 No 6)
 

Hearing screening of all newborns in England started in 2002 with the Newborn Hearing Screening Programme (NHSP). Whereas early screening can identify babies with significant permanent childhood deafness (PCHI), it is well known that PCHI can occur later in childhood. Traditionally, babies with certain risk factors for hearing loss have been followed up at around age eight months and sometimes later (targeted surveillance), even if they passed the NHSP. The authors, from the NHSP-England programme centre, questioned the evidence-base for this approach by retrospectively analysing data for 2,307,880 children born between 01/04/2006 and 30/09/2009. In that cohort, 69,050 children fulfilled the criteria for targeted surveillance and were offered appointments but only 55.3% (38,192) attended. 76% (29,347) of attendees had satisfactory hearing but only 103 (0.35%) had a PCHI. The rest had a non-permanent hearing impairment or had a mild PCHI. Further analysis of the 103 children identified the five most common risk factors with the highest prevalence of later-onset of PCHI to be: syndromes (other than Down’s) associated with hearing loss; neonatal intensive care unit (NICU) with referral in both ears at otoacoustic emissions (OAE) test and pass result both ears at automated auditory brainstem response (AABR); craniofacial anomaly; Down’s syndrome; and congenital infection. The authors conclude that, “there is no evidence that well babies with a bilateral fail result on the OAE stage of the screen and a bilateral pass result on the AABR stage should be subjected to targeted surveillance”. However, they caution that professionals should be aware of the possibility of later onset PCHI in the remaining children, no matter how small.

Reference

Effectiveness of targeted surveillance to identify moderate to profound permanent childhood hearing impairment in babies with risk factors who pass newborn screening.
Wood SA, Davis AC, Sutton GJ.
INTERNATIONAL JOURNAL OF AUDIOLOGY

INTERNATIONAL JOURNAL OF AUDIOLOGY

The earlier the CI, the best for spoken language
Reviewed by: Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The rationale for early cochlear implantation (CI) is to provide auditory signals during the sensitive periods in which spoken language skills develop rapidly in normally hearing children. The auditory information delivered by CI provides much of the critical and complex information necessary for learning spoken language. Despite this, on average, language development in children with CIs lags behind that observed for normally hearing peers. In this prospective work the authors compared the language skills of  98 children who received CIs before 2.5 years with 62 children who received them between 2.5 and five years of age. Language was assessed at four, five, or six years after CI using the Comprehensive Assessment of Spoken Language, a global language comprehension and expressive measure normalised on the analysis of 1700 children in the USA. In general, younger children achieved higher scores than those implanted at a later age for vocabulary, expressive syntax and pragmatic judgments. However, in both groups, some children performed much worse than the group mean, especially for grammar and pragmatics, while some scored brilliantly above the mean. While these occasional individual outcomes remain to be investigated, on average spoken language abilities appear to be directly correlated to the precocity and quality of speech exposure. The number of words heard during the first year after a CI plays a major role in language skills and academic performance at later school age.

Reference

Influence of implantation age on school-age language performance in pediatric cochlear implant users.
Tobey EA, Thal D, Niparko JK, Eisenberg LS, Quittner AL, Wang YY.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:219-29.

NEUROSURGERY

Shortage of neurosurgeons in the United States?
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 

This is a thought-provoking and well researched article about the neurosurgical workforce in the United States. For the study, the distribution of practising US neurosurgeons was merged with census data to yield density indices of neurosurgeons by state; a survey assessing practice characteristics was emailed to practising neurosurgeons; and a compilation of job advertisements for US neurosurgeons was evaluated. The statistical analysis was inconclusive as many neurosurgeons are subspecialised and the data were not designed to establish patient demand. The authors conclude that there is no rational or objective basis for knowing or even guessing how many neurosurgeons is enough and how many neurosurgical residency positions should be approved or funded. They suggest that demand ratios should be reevaluated by region and subspecialty to consider changes in neurosurgery practice.

Reference

Is there a shortage of neurosurgeons in the United States?
Rosman J, Slane S, Dery B, Vogelbaum MA, Cohen-Gadol AA, Couldwell WT.
NEUROSURGERY
2013;73:354-66.

NEUROSURGERY

Transoral approach to cranio-vertebral junction pathologies
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 


This article reports the evolution and extensive experience of the authors with trans-oral approach to cranio-vertebral pathologies over 30 years. Of the 479 patients operated, nearly half of the operations were performed for rheumatoid myelopathy via a ‘standard’ trans-oral approach and others for congenital abnormalities and tumours. The authors report that the number of cases of rheumatoid disease requiring cranio-vertebral decompression has decreased since the 1990s with the disappearance of the indication. In addition, the evolution of the trans-nasal surgical approach is providing a narrow but less morbid approach to the cranio-vertebral junction. Trans-oral approaches, especially, palate-splitting approaches are associated with significant oropharyngeal morbidity and post-operative oedema. The authors conclude that the trans-oral approach is likely to survive due to its relative simplicity and the advantage of low cerebrospinal fluid (CSF) complication rate when treating lower clival and cranio-vertebral pathologies.

Reference

Evolution of trans-oral surgery: three decades of change in patients, pathologies and indications.
Choi D, Crockard HA.
NEUROSURGERY
2013;73:296-304.

NEUROSURGERY QUARTERLY

Closure of CSF leaks in absence of nasal endoscopy
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 

This study describes the management of cerebrospinal fluid (CSF) rhinorrhoea in six patients in a resource poor practice in Nigeria. Surgical endoscopy is not available in this region due to the costs involved. In such a situation, the author describes a simple intracranial extradural surgical technique for the frontobasal repair of CSF rhinorrhoea. All six patients had post-traumatic complex skull base fractures with associated tension pneumoencephalus. A wide based composite subgaleal pericranial flap was used via a bifrontal craniotomy for repair. The CSF leak stopped immediately in all cases and anosmia was the only procedure related complication. The authors conclude that this technique appears to be very effective in skull base surgical practice in resource poor settings.

Reference

Surgical repair of cerebrospinal rhinorrhoea in a resource poor practice: a low cost surgical technique with case illustrations.
Adeleye AO
NEUROSURGERY QUARTERLY
2013;23(2):127-32.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Epistaxis algorithm
Reviewed by: Hannah Blanchford
Jan/Feb 2014 (Vol 22 No 6)
 

This audit of 147 patients in a tertiary care hospital in the USA presenting with idiopathic epistaxis has been used to derive an algorithm for epistaxis management. One of this study’s strengths is that all patients were assessed by an ENT resident at the time of their presentation. The documentation of bleeding points as ‘anterior’ or ‘posterior’ is therefore relatively reliable as nasendoscopy was performed when anterior rhinoscopy was insufficient. The failure rate of patients undergoing chemical cautery with silver nitrate for anterior epistaxis was 21%. The failure rate from non-dissolvable packing was significantly higher (57.4%). Failure was defined as epistaxis requiring intervention within 7 days of initial treatment. For patients requiring admission, mean inpatient stay was shorter in patients who underwent directed vascular control than those treated by packing (5.3 vs 6.8 days). This paper also demonstrated better results for patients presenting with recurrent epistaxis treated by directed vascular control (ligation / embolisation) compared to packing. The recurrence rate of 54.5% after packing for posterior bleeding is a useful figure to consider when counselling patients about their likely inpatient course of treatment. Interestingly, the results didn’t demonstrate a significant difference between recurrence rate and the duration of non-dissolvable packing, providing evidence that shorter packing duration is not associated with treatment failure. Perhaps controversially, the algorithm suggests directed vascular control if initial chemical cautery fails in anterior epistaxis.

Reference

Outcomes analysis in epistaxis: development of a therapeutic algorithm.
Shargorodsky J, Bleier BS, Holbrook E, Cohen JM, Busaba N, Metson R, Gray ST.
 OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;149(3):390-8.

OTOLOGY & NEUROTOLOGY

Percutaneous versus transcutaneous bone conduction devices: complications and audiological outcomes
Reviewed by: Rebecca Heywood
Jan/Feb 2014 (Vol 22 No 6)
 

The percutaneous bone anchored hearing aid was originally conceived in order to reduce the attenuation and distortion of sound passing through the skin and soft tissues and also to overcome the discomfort associated with traditional bone conduction devices exerting constant pressure over the mastoid area. Although the bone anchored hearing aid (BAHA) has become very popular in several clinical situations, adverse skin reactions can occur and the osseointegrated implant may be lost through infection or trauma. These complications are particularly prevalent in children. Recently a transcutaneous bone conduction device with intact skin, the Sophono, has been introduced to try to reduce these complications. Here the authors compare adverse effects and audiological outcomes in a group of six paediatric Sophono recipients with a matched control group of six patients using the BAHA. None of the patients suffered any adverse skin reactions in this small group. One Sophono user reported pressure discomfort, which was alleviated by reducing the magnet strength. One BAHA user presented with a loose implant and the abutment was therefore coupled to a second sleeper implant. Not surprisingly the audiological results with the Sophono demonstrated reduced gain compared to the BAHA, particularly at high frequencies where five to 10dB better thresholds were obtained with the latter. These values mirror those reported when transcutaneous and percutaneous bone conduction were compared at the inception of the BAHA. The speech reception threshold was 8dB better with the BAHA than the Sophono. Skull simulator measurements also suggested that the BAHA Divino is 10dB louder than the Sophono. Although this study is small, it suggests that the Sophono is appealing in terms of reduced skin complications and implant loss at the expense of optimal audiological outcome.

Reference

Comparison between a new implantable transcutaneous bone conductor and percutaneous bone-conduction hearing implant.
Hol MKS, Nelissen RC, Agterberg MJH, Cremers CWRJ, Snik AFM.
OTOLOGY & NEUROTOLOGY

OTOLOGY & NEUROTOLOGY

Music appreciation in early-deafened late-implanted cochlear implant recipients
Reviewed by: Rebecca Heywood
Jan/Feb 2014 (Vol 22 No 6)
 

Outcomes in early deafened, late-implanted (EDLI) cochlear implant (CI) recipients are difficult to quantify compared to conventional CI recipients as they do not achieve the same audiological outcomes and outcome has to be measured to a certain degree by quality of life (QoL) measures. The perception of music in post lingually deafened CI users is generally felt to be unsatisfactory, whereas early deafened, early implanted CI users report high enjoyment of music though their ability to perceive music has been shown to be worse than that of post lingually deafened users. In this paper the authors examine self-reported perception and enjoyment of music as a factor which can contribute to QoL in EDLI users. 22 participants, deafened before the age of six and implanted after the age of 16, were studied. They completed the Dutch Musical Background Questionnaire (DMBQ, assessing satisfaction with listening to music, self-perceived quality of music and self-reported perception of the elements of the music), Nijmegen Cochlear Implant Questionnaire (NCIQ, CI specific HRQoL instrument), the Cochlear Implant Functioning Index (to assess auditory related functioning of CI users), Speech, Spatial and Qualities Questionnaire (SSQ, environmental and spatial hearing) and word recognition scores. 60% of participants reported music to sound pleasant. The self-perceived quality of music was reported positively in general. The majority reported that they could follow the lyrics, recognise the instruments and follow the melody. Higher enjoyment and better perception of music did not correlate with higher QoL, better everyday hearing ability or better word recognition, however. The authors comment that although speech perception outcomes in EDLI users tend to be poor compared to EDEI or post lingually deafened users, EDLI users show high enjoyment and satisfaction with listening to music and this may give additional support for CI candidacy in this group.

Reference

Music and quality of life in early-deafened late-implanted adult cochlear implant users.
Fuller C, Mallinckrodt L, Maat B, Baskent D, Free R.
OTOLOGY & NEUROTOLOGY
2013;34:1041.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Concepts in practice of voice rest after surgery
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Voice rest, complete or relative is widely recommended after surgery on the vocal cords for lesions such as nodules, polyps, granulomas, intermediate lesions and malignancy. Whether this is actually necessary and if there is a uniform practice in the UK, is what this article has endeavoured to establish through a nationwide survey. The survey comprised seven questions with multiple choices and opportunity for further comments. The recipients of the survey were members of the expert panel of ENT UK. The authors first sought clarification of the definitions of ‘complete’ and ‘relative’ voice rest. 86.5% of respondents agreed that complete voice rest meant absolutely no phonation at all. There were variations in the concept of ‘relative’ voice rest but it generally meant not straining the voice as in shouting, using the telephone, singing and likewise. Relative voice rest was most commonly instituted by otolaryngologists for various pathologies of the vocal fold. The number of respondents who advocated relative voice rest varied largely, suggesting that there was no uniformity in the practice. The experience of the respondents and their sub-specialities did not show any association with variations in the use of relative voice rest after surgery. Most respondents advised one to two days of voice rest. The length of time for which the voice rest was advised again showed a wide variation in practice and neither was this consistent for specific pathologies. However, surgeons with less than 10 years’ experience were more likely to recommend fewer days of voice rest. Once again, the advice was not related to the length of experience or sub-speciality of the respondents. In the discussion the authors emphasise the lack of consistency in institution of complete or relative voice rest after vocal fold surgery. The study however does not take into account the compliance or post-operative voice quality. Some studies in literature suggest that the use of relative voice rest is as good as complete voice rest, the latter being disadvantageous because it leads to deprivation. There is mention of experimental studies which suggest that phonation contributes to the remodelling of the vocal fold matrix and may perhaps encourage rather than hamper repair. The study reveals a very wide variation in practice and emphasises the need for more research to standardise the use of voice rest, relative or complete.

Reference

Voice rest after vocal fold surgery: current practice and evidence.
Coombes AC, Carswell AC, Carswell AJ, Tierney PA.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:773-9.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Do microbials play an important role in persistently discharging mastoid cavities?
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

The aetiology of a persistently discharging mastoid cavity ranges from environmental / medical conditions such as diabetes, poor hygiene, immune deficiency and radiation, through factors relating to the cavity dimensions such as the facial ridge and residual pathology, to antecedents which cause the ear problem such as cholesteatoma and perforation. Little has been published about the role of microbes perpetuating mastoid cavity instability and whether the solution lies in medicinal treatment or revision surgery. In this study the authors included 121 revision procedures for unstable open cavities on 101 patients. Pre-operative or intra-operative swabs were taken for aerobic, anaerobic and fungal cultures based on clinically evident infection in the cavity. 42 out of 79 culture specimens produced no growth, 37 had a positive result and in five there were multiple microbials cultured. The commonest organisms were staphylococcus aureus and pseudomonas aeruginosa. Six out of 15 staphylococcus aureus specimens showed resistance to Penicillin but all were susceptible to Cefalexin and Flucloxacillin. As for p-aeruginosa, two were resistant to Gentamicin but all sensitive to Ciprofloxacin. E-coli was grown in one specimen and was resistant to all oral antibiotics tested, but sensitive to meropenem and amikacin. There were no significantly different findings in terms of positive culture in patients with and without cholesteatoma. The authors contend that antimicrobial resistance, as found in this study, was insignificant, and is therefore not responsible for continuation of instability in an open mastoid cavity. The role of microbials is further side-lined by the fact that less than half the specimens produced positive cultures. The solution therefore lies in revision or obliteration of the mastoid cavity. In revision, emphasis should be placed on surgical factors such as the facial ridge, the mastoid tip and good saucerisation. For obliteration, the authors prefer the superior and inferiorly based flaps which appears highly successful. This article provokes thought towards the cost of aural clinics and emphasises the role of early intervention in unstable mastoid cavities.

Reference

Unique microbiology of chronically unstable canal wall down tympanomastoid cavities: considerations for surgical revision.
Gulth MB, Tan BYB, Santermara BL, Atlas MD.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:458-62.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Head mirror or electrical head light?
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Instrumentation changes as technology develops. It is not always true that these changes are distinctively beneficial. Whilst it is understood that head mirrors are a bit difficult to get used to, it is a matter of speculation whether the head lights help one to see more. This study attempts to answer the question. A comparison was made between three types of head lights and the head mirror in terms of the illuminance achieved and the field of illumination. It was noted that the head lights provided brighter illumination whereas with the head mirror a better field of illumination was achieved. Visual identification and acuity was carried out by use of the Landolt C table which was down scaled and placed inside the nasopharynx of a full scale skull model. A comparison of visual results was made between a group of 13 medical students and 10 otolaryngology specialists. In the student group the mean number of letters identified with a head light and head mirror were not statistically different. It was the consultant group who proved to have a better visual acuity with the head mirror. In a review of the literature, interesting deployment of reflected light as far back as in 1585 is mentioned. The head mirror has shown some advantage in examining deep narrow spaces without producing shadows. It is therefore contended that in skilful hands the head mirror has an advantage over the head light in providing alignment with the optical axis and thus reducing blind spots. The article provides an interesting comparison of devices but in terms of practicality, and perhaps with invention of an everlasting battery, the head light will have the upper hand.

Reference

Head mirror versus head light: illumination, visual identification and visual acuity for otolaryngological examination.
Lin CH, Hsu HT, Chen BY, Huon LK, Lin YZ, Hung SH.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:744-8.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Improvement of voice with anti-reflux treatment
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Voice changes are often associated with laryngopharyngeal reflux (LPR). This is a very common problem seen in the practice of otolaryngology. Due to wide variation in the symptoms and signs of LPR, diagnosis can be difficult unless a 24-hour pH monitoring is carried out. In this study the assessment of LPR was done by reflux symptom index scores and the assessment of voice was done by voice symptom scale scores. The assessments were made in the first appointment and then three months later. Some of the patients were also assessed after six months. It was noted that the reflex symptom index score was reduced after treatment with anti-reflux medication after three months suggesting an improvement in the reflux. The same was true of patients who were assessed at six months, who showed a further reduction in reflux symptom index scores. The voice symptom scale was also reduced at three and six months. These findings were statistically significant. There was also a statistically significant correlation between the improvement in reflux symptom index scores and the improvement in voice symptom scale scores. A few studies with similar results are quoted in the literature, one of which did not show any improvement with anti-reflux treatment. All patients in this study also received voice therapy and therefore there is some debate as to which of the two treatments was more effective. The authors emphasise that LPR causes deterioration of voice and its management should include anti-reflux treatment for prolonged time. The signs and symptoms of LPR remain controversial, at least to some extent, but it can be said that improvement in voice is a useful achievement, as noted in this study, and it perhaps justifies the use of PPIs.

Reference

The effect of anti-reflux treatment on subjective voice measurements of patients with larynogopharyngeal reflux.
Beech TJ, Cambell G, McDermott AL, Patch AJ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:590-4.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Monitoring anticoagulant and antiplatelet therapy in patients with epistaxis
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Epistaxis is one of the most common problems in otolaryngology and, according to this publication, formed 1% of all emergency admissions in the unit. In recent years, there has been a sharp rise in the use of antiplatelet and anticoagulant medication used for atrial fibrillation, cardiovascular accidents, pulmonary embolism and deep vein thrombosis. Their use is crucial in patients with metallic heart valves. This study describes a two-phased audit on interference with antiplatelets and anticoagulants in patients admitted with epistaxis. In the first phase, the retrospective data was collected on various aspects of management, withholding anticoagulant / antiplatelet therapy, bleeding after discharge of such patients and any embolic or cardiac episodes. An algorithm was then devised and implemented. In patients in whom bleeding was controlled with nasal packing, aspirin and clopidogril were not withheld at all. If warfarin was given for ‘relative’ indications, such as atrial fibrillations without complications and single deep vein thrombosis (DVT), it was omitted only whilst the packs were in situ and then restarted immediately thereafter. If patients had ‘absolute’ indications for anticoagulants, such as a stroke / cerebrovascular accident (CVA), DVT, pulmonary embolism (PE) and metallic heart valves, warfarin was continued. If the international normalised ratio (INR) was above normal range, warfarin was omitted to bring it down into the therapeutic range. In patients with uncontrolled bleeding, a discussion was arranged with the haematology department and cardiologists. Aspirin was withheld whilst packs were in situ but Clopidogrel was continued, unless discussion with the cardiologist allowed it to be withdrawn. As for warfarin in uncontrolled bleeding situations, if given for relative indications, it was omitted whilst the packs were in situ and restarted immediately thereafter. If warfarin was used for absolute indications, haematological advice was always sought and full reversal was considered with or without heparin infusion, depending on its indications and cardiology advice. In this way the authors greatly reduced the incidence of withdrawal of anticoagulant and antiplatelet medication and this did not result in any untoward complications from the cardiac or haematological point of view. It is suggested that the protocol should be standardised and the management of cases of epistaxis should not be detrimental to patients suffering from more serious conditions.

Reference

Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients.
Biggs TC, Baruah P, Mainwaring J, Harries BG, Salib RJ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Pre-emptive anaesthesia for control of post tonsillectomy pain in children
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

Poor control of pain after tonsillectomy results in a poor recovery phase characterised by discomfort, nausea, vomiting and continued need for analgesia. This also can delay discharge which is desired early in the present economic climate. In this study the authors compare peri-operative and post-operative severity of pain by having a control group of 80 children who had only local infiltration of surgery with a study group that received pre-emptive analgesia by way of rectal diclofenac (2mg per kg) intravenous paracetamol (15mg per kg) and intravenous Tramadol (2mg per kg) administered over 15 minutes during the induction of general anaesthesia. The study appears to be adequately randomised. Tonsillectomy was done by dissection. The nurses who assessed pain were blinded to this study. Pain assessment was done in the intra-operative phase by assessing haemodynamic parameters such as heart rate and arterial pressure values. In the post-operative period visual analogue scale was used and the requirement for analgesia noted. Results showed that in the control group – that is children receiving only infiltration anaesthesia – increased pain during surgery was observed, in terms of increased heart rate and arterial pressure values, the former being statistically significant. There was also a higher requirement for analgesia during the stay in the hospital but no delay in resuming oral intake. At home children who did not receive pre-emptive analgesia (the control group) had much higher pain scores and required far more analgesia than the study group. There was also a lower incidence of post operative nausea and vomiting in this study group. The authors emphasise that immediate pre operative administration of analgesia is an important factor in controlling pain during and after tonsillectomy.

Reference

Pre-emptive triple analgesia protocol for tonsillectomy pain control in children: double-blind, randomised, controlled, clinical trial.
El-Fattah AMA, Ramzy E.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:383-91.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Symptoms without pathology – is it somatisation?
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

It is estimated that about a third of all patients attending primary and secondary health care centres have symptoms which cannot be supported with clinical findings or investigations. Are these due to somatisation or do they have a real cause? Somatoform disorder is characterised by failure to explain symptoms of a known medical condition, there sometimes being a related medical condition to this, and the symptoms cause distress. They are not accounted for by another mental disorder and are not intentionally produced or feigned. In this revealing article, the authors have discussed the possible aetiology of such situations. This comprises psychopathology such as children ‘somatising’ symptoms exhibited by other members of the family, selective perception influences and habitual attention to a part of their own body causing them to habitually focus on a body part. The role of depression and anxiety have also been implicated and as they decrease, the symptoms resolve. Hypochondriasis may be connected with somatisation. There follows an interesting discussion on specific ENT conditions and the authors have tried to draw a line between the possibility of somatisation and actual causes. Dizziness has been attributed to anxiety and this can also produce some positive results. Tinnitus, which essentially is considered to be due to de-afferentation of tono-topically organised central auditory structures, results in random activity of neurons in the auditory cortex. However there is often a complex correlation of tinnitus with depression and anxiety. Many patients present with apparent Eustachian tube dysfunction but normal tympanogram. Treatments have only a placebo effect. The cause of impaired hearing with normal audiogram is often obscure, and may be related to auditory psychological and linguistic factors. Catarrhal and postnasal drip is essentially a misnomer and this may be due to altered sensations and sensitivity to normal mucus production. Clearing the throat may often form a habit. Other conditions mentioned are atypical facial pain, dryness of the nose, globus pharynges and functional dysphonia. The message conveyed here is that most medical explanations bypass the reality of symptoms. The authors feel that the patient’s symptoms should be legitimised and a tangible mechanism for the symptoms should be offered. The solution lies in offering cognitive behaviour therapy and dealing with comorbid depression and anxiety. Psychological help is useful in patients with related problems. The information here is valuable and can help avoid unnecessary surgery, cut costs and improve patient satisfaction.

Reference

Medically unexplained symptoms and somatisation in ENT.
Ullas G, McClelland L, Jones NS.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:452-7.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

The role of rhinology care, pathways and primary care
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

One of the commonest referrals in otolaryngology is of patients suffering from rhinosinusitis. As per one survey in England, the condition affects 13.7% of the population. It is therefore important that these referrals should be appropriate and thus help in reducing time and cost of management. In 2007 primary care guidelines were formulated by the European Position Paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps. Based on this, the authors devised an algorithm for primary care management and referral of patients with rhinosinusitis. This involved treating the condition with intra nasal steroid sprays for about 12 weeks with the addition of antibiotics if the discharge from the nose was purulent. The protocol also applied to bilateral nasal polyps but if the polyps were unilateral, a fast track referral was advised. Oral antihistamines were recommended if there were symptoms of allergy. If the treatment failed CT scan of the sinuses with skin prick tests was recommended and after this a referral to secondary care was considered appropriate. 55 consecutive referrals were audited. It was noted that only 22% of patient referrals complied with the suggested primary care pathway. The duration of symptoms was reported in only 78% of patients and only 61% had findings of a nasal examination recorded. There was even greater variation in the duration of treatment, ranging from four weeks to four years. This study therefore showed that the suggested primary care pathway did not reduce the number of referrals, nor was it practised in most patients. Undoubtedly this suggests that a lot of work is yet to be done. Reasons for failure of compliance have not been mentioned, but it does appear that the short training period in otolaryngology does not foster enough confidence in every General Practitioner to manage these cases.

Reference

Do rhinology care pathways in primary care influence the quality of referrals to secondary care?
Su N, Cheang PP, Khalia H.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:364-7.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

The significance of bony changes in patients with nasal polyposis
Reviewed by: Madhup K Chaurasia
Jan/Feb 2014 (Vol 22 No 6)
 

A computed tomography (CT) scan for paranasal sinuses is an important pre-operative investigation and plays a significant role in the management of these cases. Bony involvement, especially erosion of the bones of the paranasal sinuses, is generally considered in relation to the nature of the polyposis – whether benign, intermediate or malignant. In this detailed study correlating radiological changes picked up on CT scans in patients with nasal polyposis, the authors have emphasised the significance of these changes in relation to the severity of the polyposis based on Lund Mackay score and the nature of these polyps. This is a retrospective analysis of 104 patients with nasal polyps, compared with a gender matched control group. The three main changes noted were expansion, erosion and thickening of the bones. It was the medial wall of the orbit which most frequently showed bony erosion and expansion. Bony thickening was most often seen in the sphenoid sinus walls. Ninety-three percent of the patients with nasal polyps showed bony changes, whereas none of these changes were noted in the control group. These changes have bearings on the outcome of surgery and also serve as a warning against risk of damage especially to the medial wall of the orbit. There was also a correlation between the severity of polyps and the total expansion, erosion and thickening score and this may help to explain higher complication rates in patients who have very extensive polyposis because the bones are involved as well. The presence of bony changes may also help in deciding whether or not to send the polyps for histology. The article provides useful reading and adds an important dimension to the management of chronic rhinosinusitis, also hinting that the bony changes are not always associated with malignancy.

Reference

Sino nasal bony changes in nasal polyposis: prevalence and relationship to disease severity.
Siddiqui J, Millard R, Eweiss AZ, Beale T, Lund VJ.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:755-9.

WORLD JOURNAL OF SURGICAL ONCOLOGY

Intra-operative hypoglossal nerve monitoring
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 

In this article, the authors report the use of intra-operative hypoglossal nerve monitoring in four patients who underwent extensive oral surgery for tongue lesions. One patient had squamous cell carcinoma of the anterior aspect of the tongue; the second patient had recurrence of squamous cell carcinoma tongue and had history of previous surgery; the third patient (child aged six years) had hemangiolymphangioma of the right side of neck, floor of mouth and tongue and the fourth patient had obstructing macroglossia due to amyloidosis, secondary to multiple myeloma. All patients underwent extensive variations of glossectomy with floor of mouth resection and neck dissection. The authors used intra-operative hypoglossal nerve monitoring but did not compromise on the margin in patients with carcinoma and sacrificed the hypoglossal nerve when it was involved by tumour. The authors suggest that intra-operative hypoglossal nerve monitoring should not be used in patients undergoing a classic hemiglossectomy for the first time for a tongue or floor of mouth lesion as it increases cost to the patient. Also in cases of carcinoma, it is difficult to compromise positive margins in order to preserve function. The authors recommend usage of intra-operative hypoglossal nerve monitoring in challenging cases wherein patients have undergone prior surgery and have complicated anatomical conditions, scar and fibrotic tissue.

Reference

Hypoglossal nerve monitoring, a potential application of intraoperative nerve monitoring in head and neck surgery.
Duque CS , Londoño AF, Penagos AM , Urquijo DP, Dueñas JP.
WORLD JOURNAL OF SURGICAL ONCOLOGY
2013;11:225.

WORLD JOURNAL OF SURGICAL ONCOLOGY

Malignant melanoma in the oesophagus
Reviewed by: Gauri Mankekar
Jan/Feb 2014 (Vol 22 No 6)
 

Melanoma is usually a malignant cutaneous tumour but can rarely occur on mucosal surfaces like the oesophagus, especially in the elderly. The authors present a rare case of oesophageal melanoma occurring in a 60 year old man with a history of 50 years of smoking. The patient underwent a diagnostic endoscopy for dysphagia and chest pain and was found to have a polypoidal tumour in the lower third of the oesophagus, which on biopsy was compatible with malignant melanoma. A transhiatal oesophagectomy with subcarinal lymphadenectomy and isoperistaltic gastric tube replacement of the oesophagus was performed. Nine months after surgery, the patient developed ischaemic colitis, and metastasis in the mesentery. His disease progressed and he died one year after the oesophagectomy. The authors conclude that diagnosis of this rare condition is difficult and usually made late as the symptoms are non specific and there is often a low suspicion level due to the rarity of the disease. This is especially so in the absence of evident melanin granules, as diagnostic errors may occur, because the lesions are not considered as showing clearly differentiated carcinoma. Although radiological studies such as oesophagography, computed tomography and magnetic resonance imaging can identify and locate the tumour, the diagnosis can only be established by upper digestive endoscopy with biopsy and immunohistochemical studies.

Reference

Primary malignant melanoma of the esophagus: a rare and aggressive disease.
Morita F, Ribeiro Jr U, Tacconi MR , Takeda FR, Rafael da Rocha J, de Ligabó G, de Melo E, Pollara WM, Cecconello I.
WORLD JOURNAL OF SURGICAL ONCOLOGY
2013;11:210.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Sense of smell and sexual desire: more work needed on this!
Reviewed by: Mr Edward W. Fisher
Jan/Feb 2014 (Vol 22 No 6)
 

This small study from the University of Padua in Italy aimed to find a link between sexual desire (using an established measure) with the olfactory threshold to n-butanol threshold using Sniffin’ sticks. They looked at a group of older men (at or over 65 years) and young men (20-36 years). The back-story is that pheromones are thought to play a part in human sexuality, and olfactory threshold could reasonably be considered to have some link to a person’s receptiveness to pheromones and that declining sexual desire with old age could in some way link to fewer olfactory neurones. Not surprisingly, the older men had poorer indices for sexual desire and olfactory function compared to the younger group – but within the younger group there was a correlation between sexual desire and olfactory acuity, which was absent in the older group. The authors are surprised at the lack of correlation in the older group and wonder whether this is because sexual desire in older men is more complex, perhaps with more psychological inputs than in the younger group.

Reference

Olfactory sensitivity and sexual desire in young adult and elderly men: an introductory investigation
Ottaviano G, Zuccarello D, Frasson G, Scarpa B, Nardello E, Foresta C, Marioni G, Staffieri A.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(3):157-61.

AUDIOLOGICAL MEDICINE

Auditory cortical responses in noise
Reviewed by: Mr Diego Zanetti
Jan/Feb 2014 (Vol 22 No 6)
 

The perception, segregation and identification of a significant sound pattern in background noise rely upon the integrity of the cochlea and on the processing of the incoming signal at various levels in the central auditory nervous system (CANS). Its interpretation is then performed by the auditory cortical areas, which are usually studied by electrophysiological methods such as late auditory evoked potentials, or slow vertex responses. To date, there is little knowledge of the effects of background noise on these auditory cortical potentials. The authors conducted a clinical trial on 20 normal hearing young subjects; they evoked the cortical potentials with a standard oddball paradigm with binaural stimulation and competitive noise at different signal-to-noise ratios (SNRs) (quiet, +20, +10, 0dB). The amplitude and latency of the N1, P2 and P3 waves were measured for each SNR. As expected, no significant differences in the morphology or the parameters of the responses were observed between the quiet and +20 SNR condition; when the noise level increased, significant latency shifts and amplitude of the N1, P2, and P3 waves were detected. The results indicate a significant change in the activity of higher-order neurons in the auditory area when challenged with concurrent sound and noise. These normative data constitute the basis for further clinical studies that could shed light on the mechanisms of central processing of relevant sound, such as speech, in a noisy environment. The consequences would be an improvement of the strategies applied in auditory rehabilitation methods and technological advances by the hearing aid and cochlear implant manufacturers.

Reference

Auditory cortical processing in noise in normal-hearing young adults.
McCullagh J, Musiek FE, Shinn JB.
AUDIOLOGICAL MEDICINE
2012;10:114-21.

COCHLEAR IMPLANTS INTERNATIONAL

A new American Cochlear Implant Alliance Foundation
Reviewed by: Mr Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

It is now emerging that of the estimated population of candidates in the USA who could benefit from a cochlear implant, only a small percentage receives one. The authors attribute this fact to the low awareness among both the general public and the medical community, the lack of universally sanctioned medical / clinical guidelines for best practices in cochlear implantation and audiology after-care, and the funding problems in both the private and public sector. The authors believe that the situation may be improved by a new non-profit organisation that brings together surgeons, audiologists, speech and language pathologists and representatives of cochlear implant manufacturers, as well as deaf people with and without implants. This new organisation is the American Cochlear Implant Alliance Foundation, or the ‘ACI Alliance’. The mission of the ACI Alliance is to advance access to the gift of hearing provided by cochlear implantation through research, advocacy and awareness. It is committed to eliminating barriers to cochlear implantation by sponsoring research, driving heightened awareness and advocating for improved access to cochlear implants for patients of all ages across the USA. It seems that the establishment of similar non-profit organisations across countries may indeed improve the situation and give deaf people better access to cochlear implants.

Reference

ACI Alliance – The American Cochlear Implant Alliance Foundation.
Niparko JK, Zwolan T.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s2-s3.

COCHLEAR IMPLANTS INTERNATIONAL

Biofilms are one of the most important threats in cochlear implantation
Reviewed by: Mr Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

Acute and chronic otitis media are very significant complications following cochlear implant surgery and are sometimes related to implant extrusion, wound breakdown, or even meningitis. However, the literature is rather poor regarding optimal methods of investigation and management, especially taking into account the fact that some of these patients have to undergo explantation and revision surgery. This paper describes a case of a two-year-old child who had a recurrent infection and wound breakdown following implantation that led to explantation, although the patient had systemic antibiotics and surgical repair. The microbiology evaluation revealed biofilm in the magnet pocket and S aureus. Finally the child was implanted in the other ear. The authors suggest early explantation in cases with wound breakdown, especially with exposure of the implant and in patients with longstanding infection. In cases which are diagnosed early and in cases with no wound breakdown they recommend a beta lactam antibiotic with rifampicin as the first line treatment. Of course these recommendations cannot be based on a small number of cases and large studies or meta-analyses should help us reach a consensus on this important issue.

Reference

Case report – Biofilm infection of a cochlear implant.
Vaid N, Vaid S, Manikoth M.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):117-119.

COCHLEAR IMPLANTS INTERNATIONAL

Utilisation and awareness of cochlear implants in the United States
Reviewed by: Mr Thomas Nikolopoulos
Jan/Feb 2014 (Vol 22 No 6)
 

This article reviews all issues around cochlear implantation in the USA and tries to explain low utilisation rates. The author takes into account three facts: first that there are approximately 35 million adults with measurable hearing loss in the United States, secondly that around one to 1.5 million children and adults (with severe to profound hearing loss) are potential implant candidates, and thirdly that less than 100,000 adults and children have received a cochlear implant; she concludes that the utilisation rate is approximately 5-6% among the candidate population. This is rather alarming when we take into consideration that 70-90% of people with severe and profound hearing loss use amplification in the USA. This very low utilisation rate is attributed by the author to various factors, including the lack of widely accepted ‘best clinical practices’ and the opposition of the deaf community and the various misconceptions or lack of accurate information related to cochlear implantation. It is amazing that in 2013 we still discuss such issues and that as yet there is no consensus among professionals, health authorities and deaf organisations in order to ensure management options and access to cochlear implantation when appropriate for all deaf adults and children.

Reference

Cochlear implantation in the world’s largest medical device market: Utilization and awareness of cochlear implants in the United States.
Sorkin DL.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s4-s12.

ACTA OTORHINOLARYNGOLOGICA ITALICA

Accessory nerve monitoring in neck dissection
Reviewed by: Miles Bannister
Nov/Dec 2013 (Vol 22 No 5)
 

Accessory nerve injury rates increase with the extent of neck dissection, so nerve monitoring in these cases is uncontroversial. The shoulder syndrome that can result is defined as a deficit in movement or scapula winging. This small series (25 cases) reveals no such cases following intra-operative nerve monitoring, though shoulder pain unsurprisingly remains in 88% of patients at 12 months. Whilst this is a useful prospective study, it provides no such control group for comparison. However, when compared to historical complication rates reported by others, the article should offer enough evidence for those wishing to change practice; a medico-legal case for such nerve monitoring may soon be irresistible too.

Reference

Minimizing shoulder syndrome with intra-operative spinal accessory nerve monitoring for neck dissection.
Lee C-H, Huang N-C, Chen H-C, Chen M-K.
ACTA OTORHINOLARYNGOLOGICA ITALICA
2013;33:93-6.

ACTA OTORHINOLARYNGOLOGICA ITALICA

Submandibular gland removal in oral cavity cancer
Reviewed by: Miles Bannister
Nov/Dec 2013 (Vol 22 No 5)
 

Conservation surgery and organ preservation has been an issue of growing importance for almost 20 years. Submandibular gland sacrifice to control metastatic neck disease in the treatment of oral cavity squamous cell carcinoma can produce xerostomia with resulting osteoradionecrosis of the jaw. This article presents the third largest series evaluating gland involvement, asking whether the gland can be preserved, whilst lymph nodes alone are dissected. 5.5% of glands were affected by metastases, overwhelmingly by direct invasion (8/13 cases); other metastases developed in the presence of level 1 lymph node involvement. The authors therefore argue that submandibular glands can safely be preserved in the absence of invasion or lymph node metastases. The article is informative and the study’s retrospective nature is sound, particularly as level 1 evidence for this dilemma will remain elusive.

Reference

Is it necessary to remove submandibular glands in squamous cell carcinomas of the oral cavity?
Basaran B, Ulusan M, Orhan K, Orhan S, Gunes S, Suoglu Y.
ACTA OTORHINOLARYNGOLOGICA ITALICA
2013;33:88-92.

ANNALS OF OTOLOGY, RHINOLOGY& LARYNGOLOGY

Confirming diagnosis of cholesteatoma on CT?
Reviewed by: Mr Maher El Alami
Nov/Dec 2013 (Vol 22 No 5)
 

Computed tomography (CT) bone densitometry may help to distinguish inflammation from cholesteatoma on CT (Hounsfield Units on CT). Ninety-one patients undergoing mastoid surgery for chronic middle ear disease had pre-operative CT scan densitometry. Intraoperatively the extent of their disease was mapped and the clinical diagnosis was confirmed by histological analysis. Revision cases were excluded. Seventy-eight were identified as having cholesteatoma in different parts of the middle ear and often with other associated pathologies (effusion, granuloma, granulations). 61.5% of cholesteatomas had typical bone erosion visible on CT. CTs were reviewed by three different examiners blinded to the patient’s details. Even though CT densitometry managed to distinguish isolated non-cholesteatomatous lesions on CT it failed to distinguish cholesteatoma from inflammatory conditions. This study however helped to arrive at a better system for describing and comparing pre- and intraoperative findings in the ear. An interesting study looking at cholesteatoma diagnosis and the limitations of preoperative imaging.

Reference

Is preoperative computed tomographic density measurement of soft tissue helpful in diagnosis of cholesteatoma?
Dong-Hee L, Choung-Soo K, Chang-Woo P, Dae-Young C.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
121(12):792-97.

ANNALS OF OTOLOGY, RHINOLOGY& LARYNGOLOGY

Rise of the machines: transaxillary robotic thyroid surgery
Reviewed by: Mr Maher El Alami
Nov/Dec 2013 (Vol 22 No 5)
 

Approaching the thyroid gland via the axilla is an interesting concept and the use of a surgical robot offers the option of surgery without a neck incision. Initially the surgery has been performed by two ipsilateral axillary incisions; the authors in this series describe their experience for total thyroidectomy through one incison. Twenty-nine patients over a year-long period were included. Indication for surgery was papillary thyroid cancer and inclusion criteria were thyroid lobe size smaller than 6.5cm, BMI < 35, excluding patients with neck metastasis and previous neck treatment. Approach was via a unilateral 8-9cm axillary incision and dissection was performed by cautery and harmonic scalpel. The technique is described in detail and some pictures are included. Mean operative time was 178 minutes. There was no postoperative hypocalcaemia, but two cases of transient hoarseness (side was not specified) with clear tumour margins. Robotic surgery has attracted a lot of interest and introduces new possibilities in surgery.

Reference

Single-incison robot assisted transaxillary surgery for early-stage papillary thyroid cancer.
Ciabatti PG, Burali G, D’ascanio L.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
121(12):811-15.

ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

T-14 to the rescue!
Reviewed by: Ananth Vijendren
Nov/Dec 2013 (Vol 22 No 5)
 

In this climate of NHS reforms and economic struggle, procedures concluded to have ‘limited clinical benefit’ have come under immense scrutiny by various members of the health care profession. Top of this list is tonsillectomy. The authors thus set out to rectify this misconception by using a validated patient reported outcome measure questionnaire, the Paediatric Throat Disorders Outcome Test (T-14) to measure the benefits of tonsillectomy and adenotonsillectomy in children under the age of 16. Fifty-four children undergoing the procedure for recurrent tonsillitis and obstructive sleep apnoea were recruited. The questionnaires were completed preoperatively and at three and six months post surgery, where significant improvements were seen (p < 0.0001). This paper adds further evidence to the 2009 position paper published by ENT UK that tonsillectomy produces profound changes in a patient’s quality of life and should therefore justify its clinical value as a funded NHS procedure.

Reference

Application of the paediatric throat disorders outcome test (T-14) for tonsillectomy and adenotonsillectomy.
K Konieczny, TC Biggs, S Caldera.
ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
2013;95:410-14.

BMC EAR, NOSE AND THROAT DISORDERS

Inability to smell your coffee?
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol 22 No 5)
 

In this study, the authors reviewed replies of 1000 patients with anosmia, to their online survey. The patients submitted an account of their subjective experiences of how they have been affected by anosmia and, in addition, they answered 43 specific questions about the consequences of their olfactory dysfunction. The study revealed that anosmia affects quality of life and causes practical problems. Smell loss-induced social isolation and smell loss-induced anhedonia can severely influence quality of life. Imagine not being able to smell your partner’s perfume or your favourite early morning cuppa! The authors found that the practical problems were less severe and were mainly related to hazard avoidance, food related and problems in managing odours. Not being able to change children’s nappies when they are “stinky” can cause parenting issues. The authors conclude that, while the practical problems of olfactory dysfunction are dwarfed by those of visual impairments, smell loss-induced social isolation and smell loss-induced motivational anhedonia have outsized detrimental effects on quality of life of these patients and a comprehensive solution can only be provided by research into an effective treatment.

Reference

Hidden consequences of olfactory dysfunction: a patient report series.
Keller A, Malaspina D.
BMC EAR, NOSE AND THROAT DISORDERS
2013;13(8):1-20.

BMC EAR, NOSE AND THROAT DISORDERS

Microbiology of otorrhoea in North Ethiopia
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol 22 No 5)
 

In this retrospective study over three years, the authors reviewed results of a total of 228 ear discharge samples which were tested for bacterial isolation. Of these 204 (89.5%) cases were found to have bacterial isolates; 115 (56.4%) were gram negative bacteria; predominantly proteus species (27.5%). Of individuals who had ear infection, 185 (90.7%) had single bacterial infection while 19 (9.3%) had mixed infections. And of all the bacterial isolates, 192 (94.1%) had multiple antibiotic resistant pattern – non-Lactose Fermenter Gram Negative Rods (46.0%), Klebsiella species (47.7%) and Pseudomonas species (48.5%) were resistant against the commonly used antibiotics. The authors conclude that in view of the very high prevalence of ear infection in the study area with majority of the bacterial isolates being resistant to multiple antibiotics, susceptibility testing is mandatory before prescribing any antibiotics.

Reference

Bacterial isolates and drug susceptibility patterns of ear discharge from patients with ear infection at Gondar University Hospital, Northwest Ethiopia.
Muluye D, Wondimeneh Y, Ferede G, Moges F, Nega T.
BMC EAR, NOSE AND THROAT DISORDERS
2013;13(10):1-5.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

A preliminary report on the use of endoscope and concealed incisions for small benign tumours of the accessory parotid gland
Reviewed by: Sampath Chandra Prasad
Nov/Dec 2013 (Vol 22 No 5)
 

While the most common conventional approaches for benign tumours of the parotid gland are the standard parotidectomy incision, a modified standard parotidectomy incision and a face lift incision, the authors have used a modified endoscopic approach with minimal concealed incisions for the resection of benign tumours of the accessory parotid gland in five patients. They described three incisions, the first of which is 1.5-2cm long, and applied at the margin of the tragus. Two additional incisions each 1cm long were applied, one along the inferior postauricular crease behind the lobule of the ear and the other in the temporal region of the scalp above the hairline. The incision at the margin of the tragus was continued as far as the parotid capsule. The skin flaps were dissected and raised above the surface of the capsule and a surgical plane developed. The two additional incisions were continued subcutaneously to connect to the tunnel. A rigid 30° 4mm endoscope was introduced through any of the incisions with the other two used for instrumentation. Sufficient illumination and magnification allowed for clear identification of the buccal branch of the facial nerve and other anatomical structures which were preserved. In all five cases, the tumours were confined to the accessory lobe of the parotid, with tumour sizes between 0.7 to 2.5cm in diameter. In all cases, the tumour and surrounding tissues were completely resected and removed by extracapsular dissection without damage to the facial nerve in any of the cases. The authors conclude that though this procedure provides excellent cosmesis in comparison with modified standard parotidectomy incisions and facelift incisions, the procedure is more time consuming but only until the technique had been mastered. The small number of cases is a limitation of the study and the authors need to define the limits of application of this technique in terms of the site, size and nature of the tumours in the parotid.

Reference

Minimally invasive endoscopic resection of benign tumors of the accessory parotid gland: an updated approach.
Li B, Zhang L, Zhao Z, Shen G, Wang X.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(4):342-6.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Balloon catheter sialoplasty – a histological analysis
Reviewed by: Sampath Chandra Prasad
Nov/Dec 2013 (Vol 22 No 5)
 

Obstructive sialoadenitis is the most common non-neoplastic disorder of the salivary glands. By using an expandable balloon catheter to dilate ductal stenosis during sialoendoscopy it is possible to dilate a stenotic duct and remove large stones with or without a basket. However, the use of different angiocatheters or dedicated balloons is still empirical. In this pilot study the authors assessed the feasibility and safety of balloon dilatation of the submandibular gland (Wharton's duct) to standardise its clinical application for the treatment of patients with obstructive sialadinitis. They performed balloon catheter sialoplasty on four ducts from two fresh adult cadavers. They used a non-compliant dilating balloon catheter 6mm in diameter at a pressure of 12 × 10(5)Pa for a total of three minutes and then examined the ducts histologically. There was no serious acute damage to the wall of Wharton's duct apart from minor changes on the epithelium. There was no interruption in the full thickness, or laceration of the mucosal epithelium. Although this is a small study, they have shown the safety of balloon catheter sialoplasty for the first time as assessed histologically after dilatation of the duct.

Reference

Balloon catheter sialoplasty: a safety and feasibility pilot study.
Sionis S, Vedele A, Brennan PA, Fanni D, Puxeddu R.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(3):228-30.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Use of spacers for mandibular defects after resection of mandible preceding definitive osseous reconstruction
Reviewed by: Sampath Chandra Prasad
Nov/Dec 2013 (Vol 22 No 5)
 

The authors propose the use of rigid polyethylene and silicon spacers in mandibular defects as an interim measure before definitive osseous reconstruction after mandibular resections for locally aggressive benign disease. The authors point out that the current intermediate reconstruction systems provide only structural rigidity to reconstitute mandibular continuity and some degree of soft tissue support. They fail to meet the demands of maintenance of space and are not designed to facilitate re-entry and removal. Even more problematic is intermediate condylar reconstruction, which has not been intelligently designed. They propose to redesign intermediate reconstruction prosthesis to provide not only immediate structural rigidity and to support the healing of soft tissues, but also to maintain an adequate space for reconstruction while remaining technically simple to insert and remove. A virtual model using computed tomography (CT) and 3-Matic software was made that allowed three dimensional printing of a silica plaster replica of the neomandible on which a custom plate was adapted. The mandibular segment was resected through an intraoral approach and spacer introduced. The spacer consisted of a rigid condyle / ramus unit (ultra-high molecular weight polyethylene) and a separate flexible body spacer (inert, non-toxic medical and food grade silicon rubber). The spacer was left in place for six to eight weeks and definitive reconstruction performed through an extraoral approach using corticocancellous bone graft. 38 patients were treated this way. Thirty-seven patients had uncomplicated mucosal healing and only one patient (who did not adhere to follow up protocol) had large mucosal dehiscence over the spacer. The authors argue that while primary reconstruction saves time and resources, it is seldom in the patient’s best interests and may result in compromised aesthetic and functional results that are difficult or impossible to rectify. They point out that secondary reconstruction of the mandible defect can be effected in a patient who is in physiologically optimal condition and better able to withstand reconstructive surgery. It allows the surgeon to reassess not only the adequacy of the excision but also the cosmetic outcomes of the reconstruction during healing and if necessary make changes in the final reconstructive plan to optimise the aesthetic result. Finally, grafting in an environment that is sealed from the oral cavity improves the likelihood of uncomplicated healing.

Reference

Interim reconstruction and space maintenance of mandibular continuity defects preceding definitive osseous reconstruction.
Ferreti C, Rikhotso E, Muthray E, Reyneke J.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2013;51(4):319-25.

COCHLEAR IMPLANTS INTERNATIONAL

Can bilaterally implanted children identify emotion in speech and music?
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2013 (Vol 22 No 5)
 

It is now the time to explore specific issues of the everyday life of implanted children. Identification of emotion in speech and music is an important element in children’s quality of life. The present study examined the ability of prelingually deaf children with bilateral implants to identify emotion (i.e. happiness or sadness) in speech and music. The authors performed two experiments. Participants in experiment one were 14 prelingually deaf children from five to seven years of age who had bilateral implants and 18 normally hearing children from four to six years of age. They judged whether linguistically neutral utterances produced by a man and woman sounded happy or sad. Participants in experiment two were 14 bilateral implant users from four to six years of age and the same normally hearing children as in experiment one. They judged whether synthesised piano excerpts sounded happy or sad. The results revealed that bilaterally implanted children’s accuracy of identifying happiness and sadness in speech was well above chance levels but significantly below the accuracy achieved by children with normal hearing. Similarly, their accuracy of identifying happiness and sadness in music was well above chance levels but significantly below that of children with normal hearing, who performed at ceiling. For the 12 implant users who participated in both experiments, performance on the speech task correlated significantly with performance on the music task and implant experience was correlated with performance on both tasks. Another study showing us that implanted children’s quality of life does not depend only on speech perception and production. Device strategies should be modified accordingly.

Reference

Children with bilateral cochlear implants identify emotion in speech and music.
Volkova A, Trehub SE, Schellenberg EG, Papsin BC,
Gordon KA.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):80-91.

COCHLEAR IMPLANTS INTERNATIONAL

Force controlled robotic drill in cochlear implantation
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2013 (Vol 22 No 5)
 

As hearing preservation has been the aim of a growing number of implant procedures, minimising the trauma sustained by the cochlea during cochleostomy has emerged as a key issue. The aim of this paper was firstly, to assess the cochlea disturbances during manual and robotic cochleostomy formation and secondly, to determine whether the use of a smart micro-drill would be feasible during human cochlear implantation. The disturbances within the cochlea during cochleostomy formation were analysed in a porcine specimen by creating a third window cochleostomy, preserving the underlying endosteal membrane, on the anterior aspect of the basal turn of the cochlea. A laser vibrometer was aimed at this third window, to assess its movement while a traditional cochleostomy was performed. Six cochleostomies were performed in total, three manually and three with a smart micro-drill. The smart micro-drill was further used to perform live human robotic cochleostomies on three adult patients undergoing cochlear implantation. The results revealed that in the porcine trial, the smart micro-drill preserved the endosteal membrane in all three cases. The velocity of movement of the endosteal membrane during manual cochleostomy was approximately 20 times higher on average and 100 times greater in peak velocity, than for robotic cochleostomy. Moreover, the robot was safely utilised in theatre in all three cases and successfully created a bony cochleostomy while preserving the underlying endosteal membrane. It seems that the smart micro-drill may have some very important advantages in hearing preservation cochlear implant surgery. However, more patients and reproducible conditions and results are needed to confirm the results of this interesting study.

Reference

A smart micro-drill for cochleostomy formation: a comparison of cochlear disturbances with manual drilling and a human trial.
Coulson CJ, Assadi MZ, Taylor RP, Du X, Brett PN, Reid AP, Proops DW.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):98-106.

COCHLEAR IMPLANTS INTERNATIONAL

Pragmatics and free conversation of school age deaf implanted children
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2013 (Vol 22 Nov 5)
 

Most outcome studies in paediatric cochlear implantation focus on speech perception and speech production. However, everyday life is related to pragmatics and free conversation. The present study investigated the conversational skills of 20 children with cochlear implants, aged between nine and 12 years, in free conversation with their hearing peers. The pragmatic skills of these 20 deaf / hearing pairs or dyads were compared with the pragmatic skills of 20 hearing / hearing dyads. Pragmatic skills were analysed in terms of conversational balance, conversational turn types and conversational maintenance. The impact of the participants’ level of speech intelligibility was also investigated. The results revealed that children with cochlear implants tend to dominate conversations with their hearing peers. They initiated more topics, took longer turns, asked more questions and tended to make more personal comments while their hearing friends tended to use more conversational devices and minimal answers. In contrast, pairs of matched hearing children were very balanced in all of these aspects of conversation. It was a very interesting finding that speech intelligibility did not appear to impact consistently on the pragmatic skills of the children with cochlear implants but all children had a relatively high level of speech intelligibility. Although the number of studied children is small, the results encourage us to assess implanted children in a less traditional way and explore their everyday life rather than evaluate them with laboratory type tests

Reference

The conversational skills of school-aged children with cochlear implants.
Toe DM, Paatsch LE.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):67-79.

COCHLEAR IMPLANTS INTERNATIONAL

Software analysis for cochlear implant signals
Reviewed by: Thomas Nikolopoulos
Nov/Dec 2013 (Vol 22 No 5)
 

Besides surgery and (re)habilitation, basic science and related electronic and audiology refinements are very important in the field of cochlear implantation and especially in the development of new technology. Being able to display and analyse the output of a speech processor that encodes the parameters of complex stimuli to be presented by a cochlear implant is useful for software and hardware development as well as for diagnostic purposes. As the authors state, this firstly requires appropriate hardware that is able to receive and decode the radio frequency (RF)-coded signals, and then processing of the decoded data using suitable software. The PCI-IF6 clinical hardware together with the Implant Communicator and Matlab Toolbox research software libraries, are supposed to provide the necessary functionality. RFcap is a standalone Matlab application that encapsulates the relevant functions to capture, display, and analyse the RF-coded signals. Such an analysis tool can be applied in basic research and clinical diagnostics. It remains to be seen if this tool can help us in current clinical practice and if it can contribute to new technology development.

Reference

RFcap: a software analysis tool for multichannel cochlear implant signals.
Kong LW, Dillier N
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):107-16.

HEAD & FACE MEDICINE

Esthesioneuroblastoma: one of the causes of proptosis
Reviewed by: Bilal Gani Taib
Nov/Dec 2013 (Vol 22 No 5)
 

Esthesioneuroblastoma is a rare neuroectodermal malignant nasal cavity neoplasm originating from the sensory olfactory epithelium. First described in 1924 its incidence follows a bimodal distribution, which peaks in the second and sixth decades. Both genders are affected equally and owing to its non specific symptoms there is usually a long prodromal period. Local rates of recurrence and / or metastases after treatment are between 25-50%; despite this, the five year disease free survival rate is 80%. A 60-year-old gentleman presented with nasal obstruction and bleeding, a bulging of the left eye, together with a decrease in visual acuity over one and a half years. He also noticed a rapidly increasing swelling over the nasal bridge and associated headaches and neck pain. His past medical and family history were insignificant. Local examination revealed a diffuse, firm, non tender swelling with irregular margins in the glabella, left maxillary and nasal bridge regions. There was also proptosis of the left eye with anterior, inferior and lateral deviation of the eyeball. No evidence of metastatic spread was found. In this case a fine cut computed tomography (CT) scan as opposed to a magnetic resonance imaging (MRI) scan was used to locate the extent of the mass to both nasal cavities and ethmoid sinuses with a destroyed nasal septum. The mass extended laterally into the left infratemporal region with destruction of the posterolateral wall of the left maxillary sinus. Additionally there was left infraorbital extension via the destruction of the medial wall of the left orbit resulting in the proptosis. Superiorly the mass extended to the frontal sinuses but there was no intracranial involvement. Inferiorly there was destruction of the hard palate with intraoral extension. Histopathology revealed monomorphic malignant round cell tumours with a rosette formation consistent with esthesioneuroblastoma. The patient was advised to have chemotherapy / radiotherapy. Chemotherapy is usually offered to patients with locally advanced or metastatic disease. A combination of radiotherapy and surgery yields the best curative rates.

Reference

Esthesioneuroblastoma: one of the causes of proptosis.
Ansari S, Ahmad K, Dhungel K, Gupta MK, Amanullah MF.
HEAD & FACE MEDICINE
2013;9:19.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Nasal packing after septoplasty [Title added by PC]
Reviewed by: Christos Georgalas
Nov/Dec 2013 (Vol 22 No 5)
 

“Primum non nocere” – first, do no harm. This ancient adage stands true today as much as always. However, in this time of patient-friendly and cost-conscious care it could be rephrased to also include, “First, avoid causing the patient unnecessary discomfort”, as well as, “First, avoid spending resources unwisely”. Doctors tend to be a rather conservative bunch: despite the fact that nasal packing after septoplasty has been shown in a number of studies to be unnecessary, it is still used in some practices (thankfully, rarely nowadays in the UK or in the Netherlands). This well designed and performed meta analysis is a good example of putting good science and statistics in the service of good old-fashioned common sense. The authors assessed eleven randomised control trials from a total of 1477 patients, as well as three prospective and two retrospective studies. It was clear from the comparison that, while nasal packing did not decrease bleeding, septal hematomas or perforations, adhesions or residual deviated nasal septum, it was associated with increased postoperative infection. Indeed, it is in assessing the incidence of uncommon events such as complications that meta analysis shows its value. A clinically important but statistically difficult to prove decrease of a complication from 2% to 1% , while it will not show in any study with less than 1000 participants, can be identified when results are pooled. There were some grey areas in the meta analysis, namely the presence of significant heterogeneity as well as the non disclosure in some studies of whether the patients underwent inferior turbinate surgery. However, overall the results are clear and convincing: in modern septal surgery, there is very little use for nasal packing.

Reference

Is nasal packing necessary after septoplasty? A meta-analysis.
Banglawala SM, Gill M, Sommer DD, Psaltis A, Schlosser R, Gupta M.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2013;3:418-24.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Feelings about the non-use of the hearing aid
Reviewed by: Diego Zanetti
Nov/Dec 2013 (Vol 22 No 5)
 

The negative psychosocial consequences of untreated hearing loss, namely social isolation, loneliness and depression can be softened by hearing aids (HAs), which can increase quality of life. However, many adults with a hearing loss do not seek help, and less than half of those who do decide to adopt hearing aids. In many international reports, up to a quarter of the adults who own hearing aids never or hardly ever use them. To provide these ‘non-users’ with the best help, hearing care professionals need to have an in-depth understanding of the non-users’ beliefs and feelings with regard to the non-use. In this qualitative study, 11 hearing aid owners (aged 54 – 80 years) who reported that they never or hardly ever used their HA underwent an individual face-to-face semi-structured interview, aimed at exploring their beliefs and feelings towards their non-use. The results included indifference, self-annoyance, frustration, powerlessness, shame, and guilt. Their feelings were related to beliefs about: (1) the severity of their hearing handicap with and without hearing aids; (2) who or what was responsible for the non-use; and (3) the attitudes of significant others towards the non-use. In conclusion, hearing-aid non-users differ in their beliefs and feelings towards the non-use, and a patient-centred approach is needed.

Reference

Qualitative interviews on the beliefs and feelings of adults towards their ownership, but non-use of hearing aids.
Linssen AM, Joore MA, Rianne KH, Minten RKH, van Leeuwen YDC, Anteunis LJC.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:358-66.

INTERNATIONAL JOURNAL OF AUDIOLOGY

How does the vibrant sound bridge compare with hearing aids?
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The vibrant sound bridge (VSB) provides another choice for patients with conductive and mixed hearing loss who for a variety of reasons cannot use conventional hearing aids satisfactorily. The aim of this study was threefold: to determine the effects of VSB-round window (RW) surgery, to establish the effect on hearing by the VSB-RW application in individuals with a mixed hearing loss or conductive hearing loss, and to compare these results with hearing outcomes obtained with traditional hearings aids (speech perception in quiet and in noise test situations). Eighteen adults were recruited, 13 of whom had a mixed loss and five, pure conductive loss. All patients had used conventional hearing aids in the preceding two years. The outcome measures analysed were postoperative surgical findings / experience, bilateral bone conductive thresholds pre- and postoperatively, VSB-aided thresholds versus pre-operative unaided thresholds, pre- and postoperative speech recognition in quiet and noise. Postoperative testing was done quarterly over 12 months. Five patients required revision surgery; otherwise there were no surgical complications. Bone conduction thresholds remained largely unchanged post-operatively but VSB-aided thresholds were at least 40dB better than unaided preoperative levels. Whereas speech recognition in quiet with the VSB was comparable to hearing aids, speech recognition in noise was far superior with the VSB. The authors discuss the limitations of the study and recommend a thorough preoperative assessment and a bone anchored hearing aid (BAHA) trial before considering VSB.

Reference

A comparative study of hearing aids and round window application of the vibrant sound bridge (VSB) for patients with mixed or conductive hearing loss.
Marino R, Linton N, Eikelboom RH, Statham E, Rajan GP.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:209–18.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Methods for obtaining VEMPs by bone conduction
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The best way to achieve satisfactory muscle tension for eliciting vestibular evoked myogenic potentials (VEMPs) continues to exercise the minds of clinicians. Two of these methods are head elevation (subject supine) and head rotation (subject sitting upright). This study compared these two methods to elicit cervical VEMP (cVEMP) by bone conduction (BC). Two groups of 20 adult volunteers who had no ear disorders were recruited. The first group was younger, aged 23-38 years and the second group was older, aged 41-60 years. Initially, cVEMPs was elicited by the head elevation method while tapping Fz (midline of hairline) and inion (occiput) randomly with the bone conductor. The test was repeated on a different day by the head rotation method. The parameters of VEMPs analysed were the response rate, p13 and n23 latencies, p13-n23 amplitude and asymmetry ratio. The Fz and inion responses were compared in the two age groups. Tapping the inion elicited response in 100% of subjects regardless of method of achieving muscle contraction, compared with 65-70% from Fz. The difference was statistically significant. However, Fz yielded shorter p13 and n23 latencies than inion stimulation. There were no significant differences in VEMP characteristics between the two age groups. The authors conclude that BC at the inion is the optimal method of eliciting BC cVEMP by either the head elevation or rotation method.

Reference

Comparison of head elevation versus rotation methods for eliciting cervical vestibular-evoked myogenic potentials via bone-conducted vibration.
Tseng C-C, Wang S-J, Young Y-H.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:200–6.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Self-service hearing aids?
Reviewed by: Diego Zanetti
Nov/Dec 2013 (Vol 22 No 5)
 

The World Health Organization (WHO) estimates that 639 million people worldwide have a permanent, mild to profound hearing loss. 80% of them live in low- and middle-income nations, especially in parts of the developing world such as sub-Saharan Africa and South Asia. In these countries, fewer than 3% of hearing-impaired individuals have access to hearing aids, owing to the lack of an audiological infrastructure. The authors propose a ‘do-it-yourself’ amplification device, designed to be managed entirely by the user without the need for professional support, specialised add-on equipment, or computer access. The user first assembles the low-cost device from a selection of basic hearing-aid parts, then self-administers an automatic, in situ hearing test. The self-fitting hearing aid then applies a prescriptive fitting rule derived from the National Acoustic Laboratories (NAL) to yield an appropriate gain / frequency response and compression parameters. Users may further fine-tune and train the settings to their individual preferences using an onboard button or associated remote control. This interesting study tried to assess the ability of 40 South African and 40 Chinese hearing-impaired adults to assemble a pair of self-fitting hearing aids by following instructions that were written and illustrated. 95% of South African and 60% of Chinese participants completed the assembly task, either on their own or with assistance from their partners. 63% of South Africans and 18% of Hong Kong participants assembled both hearing aids without errors. A higher level of education, health literacy, younger age and a more prestigious occupation were significantly associated with independent task completion. It can be concluded that individuals of diverse backgrounds can manage the self-fitting hearing-aid assembly task as long as their literacy and cognitive level allow the reading of instructions and captioned illustrations. The benefits of the possible provision of these kinds of hearing aids to developing countries seem obvious.

Reference

Hearing-aid assembly management among adults from culturally and linguistically diverse backgrounds: toward the feasibility of self-fitting hearing aids.
Convery E, Keidser G, Caposecco A, Swanepoel DW, Wong LLN, Shen E.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:385-93.

INTERNATIONAL JOURNAL OF AUDIOLOGY

The earlier the cochlear implantation, the better for spoken language
Reviewed by: Diego Zanetti
Nov/Dec 2013 (Vol 22 No 5)
 

The rationale for early cochlear implantation (CI) is to provide auditory signals during the sensitive periods in which spoken language skills develop rapidly in children with normal hearing. Despite the auditory information delivered by CI, providing much of the critical and complex information necessary for learning spoken language, on average, language development in children with CIs lags behind that observed for normal hearing peers. In this prospective work the authors compared the language skills of 98 children who received CIs before the age of two and a half with 62 children who received them between two and a half and five years of age. Language was assessed four, five or six years after CI using the Comprehensive Assessment of Spoken Language, a global language comprehension and expressive measure normalised on the analysis of 1700 children in the USA. In general, younger children achieved higher scores than those implanted at a later age for vocabulary, expressive syntax and pragmatic judgments. However, in both groups, some children performed much worse than the group mean, especially for grammar and pragmatics, while some scored well above the mean. While these occasional individual outcomes remain to be investigated, on average spoken language abilities appear to be directly correlated to the precocity and quality of speech exposure. The number of words heard during the first year after CI has a major effect on language skills and academic performance at school age.

Reference

Influence of implantation age on school-age language performance in pediatric cochlear implant users.
Tobey EA, Thal D, Niparko JK, Eisenberg LS, Quittner AL, Wang YY.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:219–29.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Impact of adolescent speech problems on psychological well-being
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol No 5)
 

It is known that developmental stuttering is associated with poorer psychological well-being in adulthood. This paper highlights the impact of other developmental speech problems on psychological outcomes, or the impact of stuttering and speech problems. The British birth cohort dataset consisted of 217 cohort members who stuttered and 301 cohort members who had other kinds of speech problem at age 16, and 15,694 cohort members who had experienced neither stuttering nor other speech difficulties. The analysis showed that adolescents who experience speech difficulties other than stuttering are more likely than controls to be at risk of poorer mental health in adulthood. The authors suggest a need for therapeutic provision to address psychosocial issues for both stuttering and other developmental speech disorders in adulthood, as well as further research into the consequences.

Reference

The impact of adolescent stuttering and other speech problems on psychological well-being in adulthood: evidence from a birth cohort study.
McAllister J, Collier J, Shepstone L.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2013;48:458-68.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Study of gestures in aphasic patients
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol 22 No 5)
 

Gesture increases in the general population when speech is spatial in nature. This study aimed to describe the frequency and variability of spatial language and gesture use by three participants with aphasia in comparison to nine control participants. Participants with aphasia used significantly more gestures and also used gestures without spoken phrases when spatial vocabulary was unavailable. There were differences between participants with regards to the types of gestures that they used when they were unable to access language. Analysis of the gestures produced by people with aphasia suggests that they may provide an insight into their underlying language impairment. This study provides information about spatial gesture frequency and type in aphasia and adds to the existing knowledge about locative preposition difficulty in aphasic language.

Reference

Use of spatial communication in aphasia.
Johnson S, Cocks N, Dipper L.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2013;48:469-76.

JOURNAL OF VESTIBULAR RESEARCH

A low-cost gaze stabilisation test
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The computerised Gaze Stabilisation Test (CGST) is one of two tests used to measure the functional integrity of the vestibulo-ocular reflex (VOR). It measures the maximum head movement velocity at which an individual can accurately perceive a fixed-sized target (optotype) at least 60% of the time. The other test is computerised Dynamic Visual Acuity which measures change in visual acuity at a fixed velocity of head movement. Due to cost, CGST is not readily available. The authors devised a low-cost new GST (NGST) and this study tests the ease of application and test-retest reliability in 20 healthy subjects aged 20 to 40 years. The set-up and procedure for both were similar but the cost of the equipment for NGST was around $100; CGST costs at least 50 times more. All subjects attended two sessions for both CGST and NGST. At each session, static visual acuity (SVA) and maximum head movement scores for both passive and active head movements were obtained. As expected, there was a strong positive correlation between visits for CGST. For NGST, there was a strong positive correlation for active head excursion degrees and a moderate correlation for head movement velocity between the two visits. Performance for passive head movement was better during the second visit. The degree of head excursion was found to influence participants’ ability to identify the optoptype in the new test. At 130°/sec, only 70% gave correct responses but when 100°/sec was used as a cut-off point, the correct response rate increased to 95%-100% for both passive and active head movements. The authors conclude that NGST is cheap, easy to administer, with good test-retest reliability. The next challenge is to determine an accurate cut-off point for head excursions and to test patients with vestibular pathology.

Reference

Development of a new gaze stabilization test.
Lee C, Honaker JA.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:77-84.

JOURNAL OF VESTIBULAR RESEARCH

Migraine and vertigo: more than a chance association
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The distinct clinical entity of vestibular migraine (migrainous vertigo) is now well accepted in neurotological practice. This paper provides yet more evidence for how common vestibular symptoms are in migraineurs than in patients with tension-type headaches (TTH). The authors analysed data for 5111 patients with a primary headache disorder attending a tertiary headache centre over a 10-year period. The key vestibular symptoms were vertigo, dizziness and motion sickness but childhood equivalents of migraine, particularly cyclical vomiting and recurrent abdominal pains, were considered. There were two groups: migraine with vestibular symptoms (MwV) and migraine without vestibular symptoms (MwoV). Migraine was further sub-divided to those with aura (MwA) and without aura (MwoA). Of the 5111 patients, 1880 had migraine and 3231 had TTH. There was a female preponderance. Dizziness and vertigo were significantly more common in the migraineurs than TTH (p<0.0001). Of the 1880 migraineurs, 20.3% had MwV and the rest MwoV. The MwA patients were twice and 10 times as likely as those with MwoA and TTH respectively to have at least one vestibular symptom. A past history of cyclical vomiting or recurrent abdominal pains was very common in the MwV group. This finding is an established fact. Although very common in migraine sufferers, one may take issue with motion sickness being considered as a key vestibular symptom. The findings in this study provide further evidence for the link between migraine and vertigo.

Reference

The prevalence of vestibular symptoms in migraine or tension-type headache.
Akdala G, Özge A, Ergör G.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:101-6.

JOURNAL OF VESTIBULAR RESEARCH

Moving scenes and the dizzy patient
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

The observation that some patients with vestibular dysfunction find moving scenes or highly textured visual scenes intolerable is well known. This has been called visual vertigo or space and motion discomfort. A clinical experiment was done to measure the type and severity of symptoms of such patients. The authors recruited seven subjects with peripheral vestibular disorders and 25 healthy controls for the study. The subjects with vestibular disorders completed standard questionnaires to obtain a measure of their functional handicaps. All subjects performed gaze movements within a computerised virtual environment (BNAVE) which had the capacity to vary the visual environment i.e. ‘optic flow’ in terms of contrast and spatial frequency. The visual environment was changed for each visit (two days apart) during which subjects performed eight different head and eye coordination tasks within the BNAVE. Symptoms before and after each task were assessed with the Simulator Sickness Questionnaire (SSQ) and Subjective Unit of Discomfort (SUD) rates were determined. The results were not surprising but provide some experimental evidence for visual vertigo. Although symptoms of anxiety, oculomotor distress and disorientation were apparent in all subjects the longer the exposure to visual motion, symptoms were significantly worse in the vestibular group.

Reference

Symptoms elicited in persons with vestibular dysfunction while performing gaze movements in optic flow environments.
Whitney SL, Sparto PJ, Cook JR, Redfern MS, Furman JM.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:51-60.

JOURNAL OF VESTIBULAR RESEARCH

Types of head-shaking nystagmus in Menière’s patients
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

Head shaking nystagmus (HSN) is a valuable sign for the identification of peripheral vestibular asymmetry. This retrospective study was done to characterise the types of HSN seen in patients with definite Ménière’s disease (MD). Sixty-five patients were evaluated. The slow phase velocity (SPV) of nystagmus after shaking the head in the horizontal plane at 2Hz was recorded for one minute and the results were compared with the degree of caloric canal paresis (CP). In some patients, vertical or perverted nystagmus was elicited even though the headshaking was in the horizontal plane. Forty-four patients (68%) had pathologic HSN compared with 28 patients (43%) who had significant CP. Statistically, there was no correlation between the two. This is not surprising considering the difference in the stimulus frequency (0.003 Hz for caloric and 2 Hz for headshaking). Therefore, the authors’ claim that HSN is more sensitive than caloric test in MD patients is not entirely accurate. Pure horizontal HSN (PHSN) was present in 49% but in 46%, the nystagmus was mixed (horizontal and vertical). In four patients, HSN was perverted (i.e. vertical with no horizontal component). Thus in more than half of the patients, a vertical nystagmus was present. Although perverted-HSN is considered a cerebellar sign, the authors argue that a weak PHSN (SPV ≤ 4°/s) can be seen in MD. One key finding that distinguishes HSN of MD from that of vestibular neuritis is that in the latter, the nystagmus peaks immediately after headshaking whereas the peak is often delayed in MD.

Reference

Two-dimensional analysis of head-shaking nystagmus in patients with Menière’s disease.
Kim CH, Shin JE, Kim TS, Shim BS, Park HJ.
JOURNAL OF VESTIBULAR RESEARCH
2013; 23: 95-100.

JOURNAL OF VESTIBULAR RESEARCH

White matter lesions, dizziness and risk of falling in the elderly
Reviewed by: Victor Osei-Lah
Nov/Dec 2013 (Vol 22 No 5)
 

Balance difficulties are common in the elderly. The causes are often multifactorial. In this study the authors studied the effects of white matter changes and orthostatic hypotension on dizziness and verticality. Twenty-four adults with a history of orthostatic hypotension (OH) aged over 65 years were recruited. There were two control groups: a) 26 elderly (> 65 years) subjects without OH and b) 21 middle aged (< 65 years) with OH. All subjects had dizziness and completed the Dizziness Handicap Inventory (DHI). Vestibular assessment included the Subjective Visual Vertical (SVV), bithermal air caloric and static posturography. White matter lesions (WMLs) on magnetic resonance imaging (MRI) were divided into two groups: deep white matter (DWMH) and periventricular (PVH). Perception of verticality was most prominent in the elderly male with OH and was significantly worse than in any of the other groups. Another key finding was that the greater the volume of WMLs the worse the SVV in males (p<0.05). The authors suggest that WMLs in combination with OH are involved in the perception of verticality, which in turn induces subjective dizziness. Although extensive WMLs are anecdotally thought to induce subjective dizziness in the elderly, it would have been interesting if the authors had taken the opportunity to study the effect of WMLs without OH. That said, this study provides further evidence that dizziness could be caused by cerebral hypoperfusion.

Reference

The association between impaired perception of verticality and cerebral white matter lesions in the elderly patients with orthostatic hypotension.
Aokia M, Tanaka K, Wakaoka T, Kuze B, Hayashi H, Mizuta K, Ito Y.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:85-93.

NEUROSURGERY

Nasal morbidity after endoscopic transnasal surgery for skull base tumours
Reviewed by: Gauri Mankekar
Nov/Dec 2013 (Vol 22 No 5)
 

Endoscopic skull base surgery has become the most popular approach for removal of skull base tumours. This approach requires resection of structures known to contribute to sense of smell and mucociliary transport. This study, for the first time, attempts to evaluate the effects of this approach on sinonasal symptoms, olfaction and mucociliary transport (MCT). Patients with pituitary tumours underwent a transnasal trans-sphenoidal endoscopic approach (TTEA) whereas patients with other benign parasellar tumours underwent an expanded endonasal approach (EEA) with a vascularised septal flap. Patients’ symptoms were assessed with Visual Analogue scale, olfactometry (Barcelona smell test) and MCT saccharin test before and three months after surgery. The authors found that there was a short-term (three months) negative impact on patients’ olfaction and mucociliary clearance in the EEA group, but not in the TTEA group. They suggest that patients should be informed about the loss of smell to avoid litigation, and surgeons should modify flaps to avoid damaging olfactory neuroepithelium, especially in EEA.

Reference

Impairment of olfaction and mucociliary clearance after expanded endonasal approach using vascularized septal flap reconstruction for skull base tumours.
Alobid I, Ensenat J, Marino-Sanchez F, de Notaris M, Centellas S, Mullol J, Bernal- Sprekelsen M
NEUROSURGERY
2013;72: 540-6.

NEUROSURGERY

Olfactory mucosa and nerve repair
Reviewed by: Showkat Mirza
Nov/Dec 2013 (Vol 22 No 5)
 

Autotransplantation of olfactory ensheathing cells (OEC) into the damaged central nervous system is a potential therapeutic strategy for spinal cord injuries. One limiting factor has been the poor OEC yields from human mucosal biopsies. The authors describe a surgical technique for obtaining human olfactory mucosa from the superior turbinate, which was performed on 43 patients who were undergoing endoscopic sinus surgery. They found a greater yield of OECs was obtained from patients of a younger age. Patients with worse mucosal disease yielded poorer cultures. A higher yield of OECs was obtained from specimens harvested from the more caudal portions of the superior turbinate, that is closer to the cribriform plate. A useful contribution to establishing a uniform technique for obtaining human OECs from the nasal cavity.

Reference

Culture of olfactory ensheathing cells for central nerve repair: the limitations and potential of endoscopic olfactory mucosal biopsy.
Kachramanoglou C, Law S, Andrews P, Li Daqing, Choi D.
NEUROSURGERY
2013;72:170-9.

 

PEDIATRIC ALLERGY AND IMMUNOLOGY

Adenotonsillar hypertrophy (ATH): is there a local allergy?
Reviewed by: Evangelia Tsakiropoulou
Nov/Dec 2013 (Vol 22 No 5)
 

This is an interesting study aiming to answer the question: “Is there localised allergic reaction in the adenotonsillar tissues, which is not always reflected by an assay of systemic IgE?”. The study was conducted in southern China and enrolled 83 children between two and 13 years old, with ATH before adenotonsillectomy. Specific-IgE (sIgE) against 31 allergens was tested in the serum of all children and sIgE against 15 allergens were detected in adenotonsillar tissues from 20 of them. The main finding of the study is that all children were locally sensitised to more than two allergens at both tonsils and adenoid tissues, even though half of them did not test positive for sIgE antibodies in serum. Additionally, the most prevalent allergen in both tonsillar and adenoid tissues, was Dermatophagoides pteronyssius, followed by milk, D. farinae, Blomia tropicalis, and dog dander. Interestingly, the positive rate of sIgE antibodies in adenoids or tonsils was significantly higher than that in the serum. This supports the hypothesis of local atopy. A significant limitation in the present study, as the authors state, is that pollen allergens were not tested, also the relative small sample size. The findings suggest that there may be a potential localised allergic reaction in the adenotonsillar tissues even if not accompanied by systemic atopy in ATH children. On this basis, topical anti-inflammatory medication and specific immunotherapy in ATH could have a quite promising role, even, as the authors suggest, after adenotonsillectomy in cases with residual adenoids.

Reference

Local atopy is more relevant than serum sIgE in reflecting allergy in childhood adenotonsillar hypertrophy.
Zhang X, Sun B, Li S, Jin H, Zhong N, Zeng G.
PEDIATRIC ALLERGY AND IMMUNOLOGY
2013;24:422–6.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Early detection of nasal pharyngeal carcinoma with narrow band imaging
Reviewed by: Madhup K Chaurasia
Nov/Dec 2013 (Vol 22 No 5)
 

Nasopharyngeal carcinoma is highly prevalent in certain ethnic groups and is the sixth most common cancer affecting males. The presentation is usually delayed, with other features such as neck swelling from lymph node metastasis heralding this malignancy. The use of narrow band imaging and its superiority over white light is discussed in this article. Thirty patients with nasopharyngeal mass underwent examination with narrow band imaging and all were subjected to histological diagnosis. In the 21 patients who had no malignancy, the narrow band imaging showed regularly arranged follicular pattern and each follicle was composed of a pale centre with a surrounding dark periphery. In the eight patients with nasopharyngeal carcinoma narrow band imaging showed absence of such surface patterns and a reversal in the colouring of follicular patters and irregularity in their appearance. These had a dark brown centre and pale periphery. There was also brown speckling but this was also present in patients with adenoid tissue. The role of narrow band imaging and various features suggested to be diagnostic of malignancy have been discussed in the literature. It seems to be generally agreed that benign cases show well marked follicular patterns with much larger proportion of pale areas as compared to the brown periphery which is reversed in malignancy. Malignant lesions also present with irregular engorged vascular patterns or microvascular proliferative patterns. Controversy, however, does exist and some studies do not consider these findings specific of malignancy. In this particular study there is a clear demarcation of findings between malignant and non-malignant lesions but whether these criteria can be applied with certainty and exclude the necessity for histology cannot be established with a study involving a small number of cases. However, the article makes interesting reading and shows that narrow band imaging is undoubtedly helpful in increasing the suspicion where applicable.

Reference

Use of narrow band imaging in detection of nasopharyngeal carcinoma.
Thong JF, Loke D, Karumathil R, Sivasankarannair, Mok M.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:163-9.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Myringoplasty and hearing improvement
Reviewed by: Madhup K Chaurasia
Nov/Dec 2013 (Vol 22 No 5)
 

Hearing improvement is one of the aims of myringoplasty, but another reason for performing this operation is to achieve a closed middle ear cavity which is free from infection and discharge. An intact eardrum also allows the patient to swim without having to take strict precautions. In this study the authors carried out 169 operations on 160 patients. These were all adults. Perforations were classified as small (< 20%), medium (20-50%) and large (over 50%). The operations were done on ears without cholesteatoma and where no ossiculoplasty or mastoidectomy was required. In these 169 operations 15% acquired closure of the air bone gap within 10 decibels and 54% of cases had hearing thresholds which were better than 30 decibels postoperatively. The best hearing improvement occurred in the large perforations. The authors attribute this to a greater areal ratio pre- and postoperatively with increased area of the intact tympanic membrane. The hearing gain was smaller in patients with continuing otitis media, erosion of the ossicular chain and fixation of stapes. Prolonged chronic ear infection also resulted in some cochlear hearing loss. The message here seems to be that hearing gain in adults after myringoplasty should be stated with guarded optimism, and factors other than acquiring hearing gain should be considered for better quality of life.

Reference

Factors affecting hearing improvement following successful repair of tympanic membrane.
Thiel G, Mills RP, Mills N.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:349-53.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

The role of image guidance in rhinology and anterior skull base surgery
Reviewed by: Madhup K Chaurasia
Nov/Dec 2013 (Vol 22 No 5)
 

Locating anatomic sites during the course of an operation may be a challenging situation in functional endoscopic sinus surgery, especially if these have been distorted by previous surgery or tumour.  This is a single institution study in which a comparison was made between 174 patients undergoing surgery with image guidance and 134 without. All operations were performed by the senior author over a five year period. Anatomical localisation was achieved by optical tracking technology provided by Brain Lab which is a passive marking system. High resolution computed tomography (CT) imaging of the nose and the paranasal sinuses was done preoperatively and three dimensional images were constructed in axial, coronal and sagittal planes. Results showed an increasing tendency to perform image guidance surgery over the five year period. Image guidance surgery was used mainly for intermediate and advanced cases. Cases with tumours formed the highest percentage (71%) of patients undergoing image guidance surgery. This was followed by cases with sino-nasal polyposis where revision surgery was performed in cases with distorted anatomy. The authors have categorised the extent of sinus surgery and established valid criteria for resorting to image guidance although they contend that the facility should not replace sound anatomical knowledge of these complex anatomic regions. There were no major complications in either group although there were more minor complications in the imaged guidance group, possibly due to the complexity of these cases. The findings agree with the AAOHNS published guidelines on the use of image guidance surgery in rhinology.

Reference

Image guidance in rhinology and anterior skull base surgery: five year single institution experience.
Visvanathan V, McGarry DW.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:159-62

ACTA OTOLARYNGOLOGICA

Lumbar drains for traumatic CSF rhinorrhea
Reviewed by: Victoria Possamia
Sep/Oct 2013 (Vol 22 No 4)
 

This study from South Korea retrospectively reviewed patients treated for traumatic CSF rhinorrhea, both accidental and iatrogenic. The 117 patients are divided into those treated conservatively (n = 61) and those treated surgically (n = 56). The conservative group were treated for seven days with simple bed rest, head elevation, and avoiding nose blowing and Valsalva manoeuvres. If the leak persisted beyond seven days a lumbar drain (LD) was inserted for 4-7 days, draining 180mls/day. There was no difference found between the two groups with respect to recurrence rate or incidence of meningitis. However the authors do concede that drains may have a role in those patients whose leak does not settle with simple measures, as this study does not compare the speed of resolution with or without a drain, because all patients received the LD after seven days. The more interesting group is the post surgical patients who were either treated with or without additional LD insertion at the time of surgery. There were no differences between the two groups in clinicopathological factors to suggest that the severity of case differed between those treated with or without drains. The study found no difference in recurrence rate, incidence of meningitis or duration of hospital stay. The authors point out the high levels of observation and active management required with a drain in situ and potential risks associated with their use. The lack of a difference in outcome is therefore important in suggesting that the risk : benefit ratio favours not using post operative LDs.

Reference

The effectiveness of lumbar drainage in the conservative and surgical treatment of traumatic cerebrospinal fluid rhinorrhea.

Yeo NK, Cho GS, Kim GJ, Lim GC, Jang YJ, Lee BJ, Chung YS

ACTA OTOLARYNGOLOGICA

2013;133:82-90.

ACTA OTORHINOLARYNGOLOGICA ITALICA

Predicting neck dissection wound dehiscence
Reviewed by: Miles Bannister
Sep/Oct 2013 (Vol 22 No 4)
 

As medical management for metastatic neck disease has improved and in certain cases become the preferred treatment option, fewer dissections are being performed on the untreated neck. This paper from Rome offers an insight into which patients are most at risk from wound complications and demonstrates, again, how much Italy has to offer the head and neck oncology profession. This large retrospective study of 119 patients revealed greater rates of haematoma, dehiscence, flap necrosis and chyle leakage in patients after chemo-radiotherapy (p = 0.001) and in those patients undergoing radical neck dissections (p = 0.05), confirming previous work from Arkansas and Edinburgh. General patient health did not influence wound dehiscence. The article reviews the basic science research explaining the conclusions, advocates better counselling for patients undergoing neck dissection in such circumstances and is available in English.

Reference

Predictive factors for postoperative wound complications after neck dissection.
Pellini R, Mercante G, Marchese C, Terenzi V, Sperduti I, Manciocco V, Ruscito P, Cristalli G, Marchesi P, Pichi B, Spriano G.
ACTA OTORHINOLARYNGOLOGICA ITALICA
2013;33:16-22.

ALLERGY

Does Acupuncture work on patients with Allergic rhinitis?
Reviewed by: Laith Tapponi
Sep/Oct 2013 (Vol 22 No 4)
 

This is a multicentre, randomised, controlled large study of 238 participants, carried out by the Department of Medical Research in Daejeon, South Korea. The aim of this study was to present and to evaluate the efficacy and safety of acupuncture in the treatment of allergic rhinitis. Acupuncture did show a significantly greater effect on symptoms of allergic rhinitis. Similar studies need to be carried out in Europe and the UK.

 

Reference

A multicentre, randomized, controlled trial testing the effects of acupuncture on allergic rhinitis.
Choi SM, Park J-E, Li S-S, Jung H, Zi M, Kim T-H, Jung S, Kim A, Shin M, Sul J-U, Hong Z, Jiping Z, Lee S, Liyun H, Kang K, Baoyan L. ALLERGY
2013;68:365-74.

ALLERGY

New era in aspirin desensitisation?
Reviewed by: Evangelia Tsakiropoulou
Sep/Oct 2013 (Vol 22 No 4)
 

The coexistence of asthma and aspirin sensitivity in patients with nasal polyposis is a medical condition, known as Samter's triad or aspirin-exacerbated respiratory disease (AERD). Patients with this condition often present with recurrent nasal polyps and their management still remains problematic for the ENT surgeon. Many protocols of aspirin desensitisation have been proposed; however, quite a high incidence of side-effects is reported. Seventy patients with nasal polyps and AERD were included in this well conducted double-blind placebo-controlled study. The aim of the study was to investigate the efficacy of a low-dose aspirin desensitisation protocol. All patients underwent sinus surgery and treatment with topical nasal steroids. The protocol included an aspirin dose of 180 mg on the first day and of 800 mg on the second. The maintenance dose from the third day onwards was 100 mg daily. All patients were followed up to 36 months. The authors observed a trend in reduction of nasal polyp recurrence in the desensitisation group. They attribute the lack of significance to the high dropout rate. However, the low-maintenance aspirin dose of 100 mg daily might be another reason. We cannot overcome the fact that in the literature there is contradictory evidence about the clinical efficacy of 100 and 300 mg aspirin dosages. They also report significant improvement in the quality of life and reduction of clinical symptoms such as nasal airway obstruction, postnasal drip, headache and impairment of olfactory function. Additionally, no severe aspirin-related side-effects were observed. Although further studies are needed, low-dose aspirin desensitisation seems to be a promising therapeutic postoperative option in cases of recurrent nasal polyposis.

Reference

Low-dose aspirin desensitization in individuals with aspirin-exacerbated respiratory disease.
Fruth K, Pogorzelski B, Schmidtmann I, Springer J, Fennan N, Fraessdorf N, Boessert A, Schaefer D, Gosepath J, Mann WJ.
ALLERGY
2013;68:659–65.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Making sinus surgery simulators more ‘real’ in appearance
Reviewed by: Edward Fisher
Sep/Oct 2013 (Vol 22 No 4)
 

Endoscopic sinus surgery (ESS) training includes cadaver dissection and supervised operating, but the benefits of simulation in training are acknowledged in an increasing number of surgical disciplines. The learning curve in sinus surgery has been described for many years and simulation has the advantage of allowing some of this learning to happen without the risk of complications in real patients. The realism of the graphics used in widely available systems often leave much to be desired and this paper describes some textures and lighting effects which were used to augment the existing models in the simulation software. The method used incorporated haptic feedback from instruments and the authors claim that the software can be used on existing off-the-shelf hardware. The pictures shown in the paper were impressive and a step forward from the unsatisfactory ‘matt’ appearance of tissues that I have seen up to now. This approach seems to be where the future of ESS training lies

Reference

Towards photorealism in endoscopic sinus surgery simulation.
Ruthenbeck GS, Hobson J, Carney AS, Sloan S, Sacks R, Reynolds KJ.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(2):138-43.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Subtle voice changes after nasal airway surgery and FESS
Reviewed by: Edward Fisher
Sep/Oct 2013 (Vol 22 No 4)
 

This study looked at nasalance and acoustic voice parameters after a wide variety of nasal surgery: septum / turbinate surgery, endoscopic sinus surgery and a combination of both. We often notice in clinical practice that the voice changes transiently after surgery (becoming more ‘nasal’) but this settles with time. This is exactly what was found in this study, with the initial nasalance change (an increase, evident at 1 month post-operatively) settling after a period of 3-6 months, depending on the precise parameter chosen. This offers some reassurance when operating on voice professionals who have concurrent nasal problems.

Reference

Nasalance change after sinonasal surgery: analysis of voice after septoturbinoplasty and endoscopic sinus surgery.
Kim YH, Lee SH, Park CW, Cho JH.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2013;27(1):67-70.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Topical steroids and systemic steroids work better for polyps than topical alone
Reviewed by: Edward Fisher
Sep/Oct 2013 (Vol 22 No 4)
 

This randomised study does not surprise, but shows nicely that having a two week course of prednisolone (50mg per day) followed by topical mometasone furoate spray is more effective for all symptoms in nasal polyp patients (judged at seven and 12 weeks) than the use of spray alone. Risks for steroid unresponsiveness were massive polyposis and endoscopic signs of middle meatal discharge. Hyposmia / anosmia was more resistant to improvement than other symptoms, which is no surprise. No ancillary measures such as saline douching were used, which is a pity, since this has become much more commonplace as a routine ancillary treatment for polyp patients.

Reference

Does oral prednisolone increase the efficacy of subsequent nasal steroids in treating nasal polyposis.
Kirstreesakul V, Wongsritrang K, Ruttanaphol S.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26(6):455-62

ANNALS OF OTOLOGY, RHINOLOGY& LARYNGOLOGY

Smoking and nasal polyposis
Reviewed by: Mr Maher El Alami
Sep/Oct 2013 (Vol 22 No 4)
 

Nasal polyposis is multifactorial and genetic and, syndromic conditions aside, there is still no clear understanding of the aetiology of this condition. The authors of this study looked at patients referred for nasal polypectomy and investigated them for smoking habits and allergies. A control group of 25 non- and 25 smokers was also investigated regarding these parameters. Twenty-five percent of patients and 20% of the control group were found to have allergies confirmed on IgE measurement. There was no statistical correlation between allergy and polyps. Seventy percent of nasal polyp sufferers were smokers, with little correlation to length and extent of smoking. Cotin, a metabolite of nicotine, was measured in all patients and levels found to be raised in smokers. Smoking had an impact on the presence of polyps but not on the incidence of allergies in this study. This study was difficult to read and I struggled to find any new issues.

Reference

Analysis of the roles of smoking and allergy in nasal polyposis.
Gorgulu O, Ozdemir S, Canbolat EP, Saya C, Olhun MK, Akbas Y.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
121(9):615-19.

ANNALS OF OTOLOGY, RHINOLOGY& LARYNGOLOGY

Tonsillitis and endocarditis
Reviewed by: Mr Maher El Alami
Sep/Oct 2013 (Vol 22 No 4)
 

Streptococcal infections cause tonsillitis but may also produce complications such as endocarditis different to the delayed presentation of rheumatic fever. The frequency of this complication is not clearly known and in this study magnetic resonance (MR) scanning of the heart was used as it was considered to be the most sensitive diagnostic technique. Two hundred adults consecutively referred to hospital with severe tonsillitis were included. Seventeen of these had clinical suspicion of cardiac involvement and underwent MR scanning. All these patients were men (age 23-28). Those with signs of cardiac failure underwent cardiac biopsy. Severe chest pain was the main clinical sign; all had positive streptococci on swab and blood culture and electrocardiography (ECG) changes. All patients developed these signs whilst on treatment with penicillin.  Eight out of 17 had deranged cardiac enzymes, 16 had MR signs of endocarditis and biopsy confirmed the diagnosis in four of these patients. Post treatment scans after three months showed return of MR parameters to normal levels. This study suggests a high level of cardiac involvement in streptococcal tonsillitis, despite treatment with antibiotics. The question remains whether we actually underestimate this complication. Reassuringly, in these patients cardiac function returned back to normal

Reference

Streptococcal tonsillitis and acute streptococcal myocarditis: an unusual combination assessed by cardiac MRI and endomyocardial biopsy.
Mavrogeni S, Bratis K, KItsiou A, Kolovou G.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
121(9):604-8.

ANNALS OF OTOLOGY, RHINOLOGY& LARYNGOLOGY

Type of post-tonsillectomy pain and risk factors
Reviewed by: Mr Maher El Alami
Sep/Oct 2013 (Vol 22 No 4)
 

Can the severity and characteristics of post-tonsillectomy pain be used as a predictive factor for post-operative recovery and complications? The authors investigated 615 consecutive patients, based on questionnaires, describing their post-operative recovery over two weeks. Children’s carers were asked to complete the questionnaires on behalf of their children. A visual analogue scale (VAS) was used (0-5) for two weeks and once more beyond two weeks to assess pain; indication for surgery and re-admission details were also included. 363 patients responses were analysed. 69.8% were adults, 55.6% female, anaesthetic protocol was similar and bipolar diathermy tonsillectomy was used. Pain characteristics were defined as I (minor), II (significant pain until day three and afterwards declining), III (minor post-operative pain that peaks at the end of week one), IV (increasing pain that increases over and beyond two weeks), V (severe pain throughout the two weeks that slowly receeds). Type I pain (24.8%) was more common in children, most patients had maximum pain at day three (type II 50.8%). Types III (10.7%), IV (1.2%) and V (12.5%) were more common in adults. Bleed rates were 25.4% with a return to theatre of 5.1% of which one third was primary, while two thirds were secondary. At this point the paper became difficult to understand as the numbers seemed to make little sense However, there seemed to be a correlation between the persistence of pain and the occurrence of post-operative bleeds. The idea to distinguish quality and persistence of pain to identify patients at risk is an interesting concept. The authors fail to explain their system to categorise pain, their bleed rates are high, and there are better ways to assess pain in children. The numbers are confusing and all in all the results of this study are poorly summarised, fail to support the abstract of this paper and fail to add much to our understanding of this problem

Reference

Significant post-tonsillectomy is associated with risk of haemorrhage.
Sarny S, Habermann W, Ossmitz G, Stammberger H.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
121(12):776-81.

AUDIOLOGY NEUROTOLOGY

Bilateral versus binaural cochlear implantation
Reviewed by: Stephen Broomfield
Sep/Oct 2013 (Vol 22 No 4)
 

The Neurelec Digisonic SP binaural cochlear implant (CI) uses two electrodes with one implanted receiver-stimulator package, allowing for stimulation of both cochleae without the need for bilateral cochlear implantation. This study compared a group of binaural CI users (n = 7) with a group of simultaneously implanted bilateral CI (also Neurelec Digisonic SP devices) users (n = 6). Whilst there were some differences in performance between the two groups, these may represent heterogeneity in the groups given their small size. There was no statistically significant difference between the two groups in speech understanding in quiet or noise, sound localisation ability, or self-assessment of health status and hearing disability. The authors conclude that binaural CI is a valid alternative to bilateral CI in the stimulation of both auditory nerves. Further larger studies are required to assess whether there may be audiological advantages to binaural CI compared to bilateral CI, and also to confirm its long-term efficacy and safety. In the meantime, it is the health economic argument, offering bilateral cochlear stimulation at reduced cost, which is likely to favour this new technique of binaural CI, particularly in countries where routine bilateral implantation is not available.

Reference

Comparison between bilateral cochlear implants and Neurelec Digisonic SP binaural cochlear implant: speech perception, sound localization and patient self-assessment.
Bonnard D, Lautissier S, Bosset-Audoit A, Coriat G, Beraha M, Maunoury A, Martel J, Darrouzet V, Bebear JP, Dauman R.
AUDIOLOGY NEUROTOLOGY
2013;18:171-183.

AUDIOLOGY NEUROTOLOGY

Systemic steroids in sudden sensorineural hearing loss
Reviewed by: Stephen Broomfield
Sep/Oct 2013 (Vol 22 No 4)
 

This study examines the use of systemic steroids in idiopathic sudden sensorineural hearing loss, defined using stringent criteria. The outcome of a group (n = 79) treated with high dose dexamethasone (40 mg orally for 3 days, then 10 mg for 3 days) was compared with those of a previously studied group (n = 541) treated with prednisolone (100 mg orally for seven days, together with carbogen inhalations). The authors acknowledge the potential bias inherent to this retrospective study, which lacked any non-treatment control group. There was nonetheless, a significant improvement in both absolute hearing gain (dB) and functional hearing recovery (%) in the dexamethasone group (44.4 dB, 87%, respectively) when compared to the prednisolone group (15.1 dB, 57%). Although this study excluded patients with cochleovestibular disturbance, diffuse dizziness at presentation was associated with a worse recovery, as was severity of hearing loss (96% functionally relevant recovery in mild hearing loss, 50% in profound hearing loss, 43% in total deafness). Interestingly, there was no difference in recovery between those treated early (within 24 hours of onset of hearing loss) and those treated between two and seven days. Similarly, age was not found to be a negative prognostic factor. No significant adverse reactions were encountered in this study group. Given that there is uncertainty about the mechanism of action, efficacy, optimal route of administration and required dose (including the very high doses described in this article) of steroids in sudden sensorineural hearing loss, it is likely that this otological emergency will attract controversy for some time to come.

Reference

Effectiveness of systemic high-dose dexamethasone for idiopathic sudden sensorineural hearing loss.
Egli Gallo D, Khojasteh E, Gloor M, Hegemann SCA.
AUDIOLOGY NEUROTOLOGY
2013;18:161-70.

BMC EAR, NOSE AND THROAT DISORDERS

Facial plastic reconstruction in Netherton syndrome
Reviewed by: Gauri Mankekar
Sep/Oct 2013 (Vol 22 No 4)
 

The authors report a rare case of nasal cutaneous carcinoma in a patient with Netherton syndrome. The patient underwent surgical excision of the lesion with reconstruction of the full thickness nasal defect with a paramedian forehead flap and an epidermal turn-in flap. Netherton syndrome is characterised by three core features, namely congenital ichthyosiform dermatitis with defective cornification, atopic diathesis with high serum IgE levels and trichorrhexis invaginata (also called ‘bamboo hair’) which is pathognomonic of the disease. Although there is persistent inflammation of the dermis, profound scarring and fibrosis is not consistently observed. According to the authors, the chronic state of inflammation suggests a less than optimal environment for facial reconstructive surgery. However, the palpable softness and pliability of the skin-soft tissue envelope in the present case encouraged them to consider surgical reconstructive options. Wound healing was unremarkable in the sense that the chronic erythema and scaling of the skin remained stable and no delays or deficits of healing were observed. The cosmetic and functional results appeared very favourable. The authors conclude that development of cutaneous malignancies should be included as a possible complication in patients with Netherton syndrome and standard techniques of surgical facial reconstruction can be applied in these patients as healing and outcome do not appear to be negatively affected by the underlying disease.

Reference

Netherton syndrome - Why ENT surgeons should be aware of this rare disease - report of a case.
Kornelia EC, Wirsching K, Heinlin J, Gassner HG.
BMC EAR, NOSE AND THROAT DISORDERS
2013;13:7.

COCHLEAR IMPLANTS INTERNATIONAL

What access to cochlear implantation do deaf people have?
Reviewed by: Thomas Nikolopoulos
Sep/Oct 2013 (Vol 22 No 4)
 

This paper summarises the key issues of the articles published in the Special Issue supplement of Cochlear Implants International, ‘Do deaf people have access to cochlear implantation if they need it?’. It was very interesting to find that while there was a great difference between China, Japan, the UK and the USA, there were also some important commonalities. In the Flanders area of Belgium, paediatric utilisation rates are estimated at 93% of eligible children, with the UK and some European countries also reaching over 90% if the age at the time of implant is extended into the mid-teen years. In contrast, about 50% of US children who could benefit are receiving CI and the utilisation rate is lower still in Japan. In China, where cochlear implantation was later to begin on a large scale, the country’s huge population and dramatic income disparities combine to keep China’s current utilisation rate relatively low, though this could change in the future with current CI growth at 25% per year. However, the situation is totally different in adults. In all of the above mentioned countries, the numbers of implanted deaf adult people are not even close to the numbers of eligible candidates. This is rather surprising, as it is a common perception in the developed world that the number of candidate adults has become rather limited.

Reference

Access to cochlear implantation.
Sorkin DL.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(suppl. 1):s1.

COCHLEAR IMPLANTS INTERNATIONAL

A study of the performance of the Harmony behind-the-ear processor in patients who had been implanted with the first generation of Advanced Bionics implant systems
Reviewed by: Thomas Nikolopoulos
Sep/Oct 2013 (Vol 22 No 4)
 

In the beginning, the new Harmony™ behind-the-ear processor was only compatible to the newer generation implants, i.e. the CII and HiRes90K.  After further development of a new digital signal processing code the Harmony could also support the first implant generation, the ‘C1’ (Clarion 1.0 and 1.2). This study attempts to assess the performance of the new sound processor designed to be used with older generation cochlear implants (CIs) from Advanced Bionics (Stäfa, Switzerland). Speech perception tests (Freiburger monosyllables, Hochmair-Schultz-Meser sentence tests) were performed at a baseline appointment with the subject's clinical processor, followed by the fitting of the Harmony. After a 1 month take-home period the tests were repeated with the Harmony. Additionally, subjective evaluation through questionnaires and a structured interview were administered after upgrading to the sound processor ‘C1 Harmony’. Adult users of Advanced Bionics C1 series CIs (n = 29) participated in this study. The authors reported that the new processor provided superior performance in many, though not all, of the speech recognition measurements. Subjective reports indicated certain practical benefits from the new processor, particularly for previous users of body-worn processors. Overall, 80% of the subjects preferred the new processor. Although these encouraging results led to the decision to make the new C1 Harmony processor available to all existing users of the early C1 devices, we should take into account that the majority of patients (59%) reported only a low preference for the C1 Harmony processor and 17% preferred the previous processor. On the other hand, long-term outcomes may change.

 

Reference

Performance of the Harmony behind-the-ear processor with the first generation of Advanced Bionics Implant Systems.
Brendal M, Rottmann T, Lenarz T, Buechner A.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:36-44

COCHLEAR IMPLANTS INTERNATIONAL

An interesting study of the diversity of cochlear implant related practices in India
Reviewed by: Thomas Nikolopoulos
Sep/Oct 2013 (Vol 22 No 4)
 

India is a huge country with many languages and minorities. The clinics that work with implantees seem also to vary in their team philosophy, clinical practices, and service delivery. Therefore, it would be important to explore if this is actually true. Twenty-two clinics involved in the paediatric cochlear implant (CI) habilitation programme across India participated in the survey. The heads of the CI teams of the participant clinics completed a validated survey questionnaire containing multiple choice and open-ended questions on the details of the CI habilitation team, assessment and therapy protocols used, and other related clinical services. The categorical data obtained were analysed using descriptive statistical measures. The results were no surprise. Early identification / referral of deaf children, appropriate management of hearing impairment, funding for cochlear implants, continuous support of implantees, education and training programmes for professionals, decision processes for providing implants for children with additional disorders, choice of language or languages, assessment protocols, and outreach / consultation services are the main issues that vary among centres and need appropriate measures in order to meet approved guidelines. Central and local design may contribute to this direction.

Reference

Practices in habilitation of pediatric recipients of cochlear implants in India: A survey.
Jeyaraman J.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:7-21.

COCHLEAR IMPLANTS INTERNATIONAL

Can implantation of the common cavity malformation prevent meningitis?
Reviewed by: Thomas Nikolopoulos
ENT & Audiology News
 

Spontaneous cerebrospinal fluid (CSF) leak and meningitis are well known risks in children with congenital malformations of the inner ear. The authors present in this paper a two-year-old girl with bilateral common cavity defects, who had previously undergone cochlear implantation and developed contralateral CSF leak resulting in meningitis. After resolution of the infection, cochlear implantation was performed at the same time as definitive CSF leak repair. The child had been deriving hearing benefit from the bilateral implants. The concept of this presentation was that simultaneous cochlear implantation and repair of the CSF leak would decrease the chance of recurrent meningitis. As a conclusion, the authors claim that this case suggests a role for cochlear implantation to be combined with simultaneous CSF leak repair in children with a cochlear malformation, and that bilateral cochlear implantation at an early age may be warranted in these patients. Of course the question is: should we immediately repair a bony defect in an inner ear malformation, irrespective of whether we implant the child at the same time? Moreover, we should take into account that the bony defect had been missed in the pre-operative imaging of the first cochlear implantation.

Reference

Implantation of the common cavity malformation may prevent meningitis.
Roman BR, Coelho DH, Roland T Jr.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:56-60.

COCHLEAR IMPLANTS INTERNATIONAL

Dexamethasone eluting cochlear implant in animals. What can we conclude?
Reviewed by: Thomas Nikolopoulos
ENT & Audiology News
 

Cochlear implants (CIs) have the potential to initiate an inflammatory response that may lead to further hair cell damage. The desire to develop electrode arrays that can deliver drugs to the inner ear, led the authors to perform this study. Therefore, dexamethasone delivery via a drug-eluting CI was evaluated histologically, through assessing inflammatory cell infiltration. Thirty healthy, adult male guinea pigs were included and randomly assigned to one of three surgical groups that underwent cochleostomy of the basal turn. The experimental group (Group 1) of 12 animals was implanted with a dexamethasone-loaded silicone elastomer shaped like a CI electrode. The primary control group (Group 2) of 12 animals was implanted with a simple CI (non-eluting). A second control group (Group 3) of six animals underwent cochleostomy only. Inflammatory responses were compared between groups by evaluating inflammatory cell infiltration in inner-ear specimens at days 3 and 13. Statistical analysis revealed reduction in most of the inflammatory indices in Group 1 compared with Group 2. This was significant for fibrocyte, macrophage, and giant cell infiltration at day 3 as well as lymphocyte, macrophage infiltration, and capillary formation at day 13. Although the results are rather encouraging, it remains to be seen if similar procedures can be applied in humans.

Reference

Dexamethasone eluting cochlear implant: Histological study in animal model.
Farhadi M, Jalessi M, Salehian P, Ghavi FF, Emamjomeh H, Mirzadeh H, Imani M, Jolly C.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:45-50.

COCHLEAR IMPLANTS INTERNATIONAL

Is MRI safe after cochlear implantation?
Reviewed by: Thomas Nikolopoulos
ENT & Audiology News
 

Although in the early days of cochlear implantation, magnetic resonance imaging (MRI) was contraindicated for patients with cochlear implants, today cochlear implant design and MRI protocols have changed to allow implanted patients to enter the MRI field, in some cases without removal of the cochlear implant (CI) internal magnet. The authors presented a patient with bilateral implants who required MRI to investigate new neurological symptoms. Despite tight head bandaging applied according to the centre’s protocol, MRI at 1.5 T led to bilateral skin reactions and displacement of the magnet on the left. Both magnets were subsequently removed to allow the skin reactions to settle and for further imaging without artifact. The functioning of the patient's implants was not affected. The authors concluded that the final decision to recommend that a patient with a CI undergoes MRI, with or without removal of the internal magnet, requires close cooperation between the CI team, the physician requiring the scan, and the radiology team involved in the patient's care. The case study also highlighted the need for patients and relatives to be fully informed of the risks involved. In other words, MRI is supposed to be safe, but actually this may not be the case on certain occasions, especially with the magnet on.

Reference

Cochlear implants and magnetic resonance scans: a case report and review.
Broomfield SJ, Da Cruz M, Gibson WPR.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:51-5.

COCHLEAR IMPLANTS INTERNATIONAL

Mitochondrial deafness due to A7445G mutation and cochlear implantation
Reviewed by: Thomas Nikolopoulos
Sep/Oct 2013 (Vol 22 No 4)
 

Mitochondrial deafness has been well-known for many years. However, there are no large series exploring the outcome of cochlear implantation in affected individuals. The present study aimed to determine if cochlear implantation improved speech discrimination in the New Zealand pedigree with the A7445G mitochondrial DNA (mtDNA) mutation and sensorineural hearing loss (SNHL). Nine patients had their speech discrimination and pure tone audiograms evaluated before and after cochlear implantation. The authors reported that speech discrimination was greatly improved after implantation in this group of patients and concluded that individuals with mtDNA-related SNHL should be identified by screening and offered assessment for cochlear implant suitability because functional hearing improves following surgery. However, we should take into account that most of the subjects had progressive post-lingual deafness, some of the data were missing, and the most interesting point – whether the studied subjects had other disorders – was not discussed.

Reference

Cochlear implantation in mitochondrial deafness due to A7445G mutation.
Love RL, Bird P.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:28-31.

COCHLEAR IMPLANTS INTERNATIONAL

Parental perspective in a Southeast Asia country
Reviewed by: Thomas Nikolopoulos
Sep/Oct 2013 (Vol 22 No 4)
 

The authors attempted to assess parental views on the cochlear implant related benefits and shortcomings in a Southeast Asian country. Thirty parents of children with cochlear implants from a hearing impaired school completed open-ended questionnaires and the data were analysed using content analysis. As expected, a wide range of benefits and shortcomings were reported. In general, some of the reports on benefits and shortcomings were similar to previous results from western countries. However, it is very interesting to note that the single most reported shortcoming was related to cost, as many parents had to pay for the implant, although the country is among the richest in the area (at least as far as this can be concluded from the study). The other alarming finding was that only 70% and 36% of the parents respectively reported improved hearing and improved communication as the most common benefit. Of course, this may very well attributed to the type of questionnaire used. Another confounding factor is that all children were attending a special school for hearing impaired children

Reference

Parental reported benefits and shortcomings of cochlear implantation: Pilot study findings from Southeast Asia.
Chundu S, Manchaiah VK C, Stephens D; Kumar N.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:22-7.

COCHLEAR IMPLANTS INTERNATIONAL

Pre-implant radiologic assessment. Should we include MRI of the whole brain?
Reviewed by: Thomas Nikolopoulos
Sep/Oct 2013 (Vol 22 No 4)
 

Most cochlear implant centres include magnetic resonance imaging (MRI) of the temporal bones in the standard pre-implant assessment protocol. With regard to the need for whole brain MRI imaging, opinions are conflicting. This paper attempts to clarify the importance of whole brain MRI imaging in the pre-implant evaluation of both children and adults. The authors retrospectively reviewed 51 (12 adults and 39 children) sequential cases since they added whole brain MRI sequences to their cochlear implant assessment protocol. The results reported abnormalities on the whole brain sequences in 21 (41%) of the studied patients, five of 12 adults (42%) and 16 of 39 children (41%). Thirty-six (71%) patients subsequently had at least one implant inserted, 13 with abnormalities on whole brain MRI (36%) and 23 without. Of the 15 patients who did not undergo subsequent implantation, eight had positive findings on their whole brain MRI sequence (53%). There was no statistical difference in the probability of finding an abnormality on the whole brain MRI between those who did and those who did not go on to have an implant (p = 0.35). The authors concluded that abnormalities found in the whole brain MRI may be so severe to predict a very poor prognosis such that an implant may contribute little. However, this percentage was approximately 2% and concerned post-meningitis patients or cases with other severe diseases. On the one hand the additional cost is very small and on the other hand the possibility of finding severe abnormalities in a healthy candidate with negative history is very rare

Reference

MRI during cochlear implant assessment: Should we image the whole brain?
Proctor RD, Gawne-Cain ML, Eyles J, Mitchell TE, Batty VB.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:2-6.

COCHLEAR IMPLANTS INTERNATIONAL

Two cases of congenital cholesteatoma in 794 pediatric implantees. Is there any relation?
Reviewed by: Thomas Nikolopoulos
Sep/Oct 2013 (Vol 22 No 4)
 

Although secondary cholesteatoma has been described as a complication of cochlear implant surgery, the relationship of deafness and congenital cholesteatoma has not yet been explored. The authors retrospectively reviewed their departmental cochlear implant and cholesteatoma databases in their tertiary / quaternary paediatric centre. Cases of congenital cholesteatoma were identified. The proportion of congenital cholesteatoma cases in cochlear implant candidates was compared with the number of acquired cholesteatomas. The authors found in their paediatric cochlear implant population, two out of 794 patients (0.25%) as having a congenital cholesteatoma during their evaluation for implantation. No cases of primary acquired cholesteatoma were identified in this population at presentation or at follow-up to 18 years. The authors concluded that the 0.25% incidence of congenital cholesteatoma in their implantees was higher than expected and that it is likely that both subjects had an inherited form of hearing loss and a genetic contribution to the presence of congenital cholesteatoma. However, their claim that surgery should be staged to ensure complete removal of the cholesteatoma cannot be concluded from these two cases.

Reference

Congenital cholesteatoma and cochlear implantation: Implications for management.
Chung J, Cushing S, James A, Gordon K, Papsin BC.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:32-5.

COCHLEAR IMPLANTS INTERNATIONAL

Two cases of congenital cholesteatoma in 794 pediatric implantees. Is there any relation?
Reviewed by: Thomas Nikolopoulos
ENT & Audiology News
 

Although secondary cholesteatoma has been described as a complication of cochlear implant surgery, the relationship of deafness and congenital cholesteatoma has not yet been explored. The authors retrospectively reviewed their departmental cochlear implant and cholesteatoma databases in their tertiary / quaternary paediatric centre. Cases of congenital cholesteatoma were identified. The proportion of congenital cholesteatoma cases in cochlear implant candidates was compared with the number of acquired cholesteatomas. The authors found in their paediatric cochlear implant population, two out of 794 patients (0.25%) as having a congenital cholesteatoma during their evaluation for implantation. No cases of primary acquired cholesteatoma were identified in this population at presentation or at follow-up to 18 years. The authors concluded that the 0.25% incidence of congenital cholesteatoma in their implantees was higher than expected and that it is likely that both subjects had an inherited form of hearing loss and a genetic contribution to the presence of congenital cholesteatoma. However, their claim that surgery should be staged to ensure complete removal of the cholesteatoma cannot be concluded from these two cases.

Reference

Congenital cholesteatoma and cochlear implantation: Implications for management.
Chung J, Cushing S, James A, Gordon K, Papsin BC.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14:32-5.

HEAD & FACE MEDICINE

Malignant ossifying fibromyxoid tumour of the tongue: case report and review of the literature
Reviewed by: Bilal Gani
ENT & Audiology News
 

A 26-year-old male presented with a painless indolent mass in the dorsum of his tongue. He was made aware of it over two weeks. It was hard, 7 mm in diameter with tumour cells arranged in a diffuse or cord-like manner within an abundant fibromyxoid matrix and a small amount of metaplastic ossification. This was initially tentatively diagnosed as a chondromyxoid tumour, which is unusual in itself. After four years, a similar painless mass 20 x 18 x 10 mm was found in the same position. Macroscopically it had a reddish lobulated surface. Histologically it was found in the subepithelial connective tissue and proliferated in a multinodular fashion. It was not encapsulated and showed a high degree of cellularity. Morphological and immunohistochemical studies yielded an unusual pattern of results. Finally, the combination of cord like cells, the presence of osteoid and its high cellularity led to the diagnosis of a malignant ossifying fibromyxoid tumour (OFMT). Only seven cases have been reported to occur in the oral cavity, with the majority (70%) occurring in the subcutaneous tissue of the upper and lower limbs. This is the only reported case of OFMT arising in the tongue. Additionally they normally occur between the fifth and sixth decade of life in males. Genetic studies revealed that inactivation of SMARCB1 and epigenetic deregulations of PRC2 are crucial for tumour development. Local recurrence, such as in this case, is consistent with malignant OFMT with the potential for metastasis. As a result of this the patient will undergo a long-term follow-up treatment plan

Reference

Malignant ossifying fibromyxoid tumour of the tongue: case report and review of the literature.
Ohta K, Taki M, Ogawa I, Ono S, Mizuta K, Fujimoto S, Takata T, Kamata N.
HEAD & FACE MEDICINE
2013;9:16.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Adjunctive tranexamic acid does not appear to improve visualisation of the surgical field during sinus surgery
Reviewed by: Laith Tapponi
Sep/Oct 2013 (Vol 22 No 4)
 

Tranexamic acid is an antifibrinolytic that prevents the activation of plasminogen to plasmin. Plasmin is responsible for the degradation of fibrin clots. Bleeding during sinus surgery can hinder surgical progress and has been associated with an increase in complications. Poor visualisation has been associated with worse surgical outcome. This study is a double-blind, randomised, controlled trial of 28 patients with sinusitis with or without polyposis. Exclusion criteria included hypertension (treated or untreated), thrombotic diathesis, vascular disease, colour blindness, renal failure and pregnancy. Outcome measures included the Wormald grading scale to assess the intraoperative surgical field and estimated blood loss based on suction container content with irrigation fluid subtracted. The use of tranexamic acid was not associated with a statistically significant decrease in estimated blood loss (201 versus 231 mL; p = 0.60) or Wormald grading scale (5.84 versus 5.80; p = 0.93). There were no adverse events or complications during the study. Reliable evidence that tranexamic acid reduces blood transfusion in surgical patients has been available for many years. The treatment effect varies somewhat according to the type of surgery. The safety of routine use of tranexamic acid in surgical patients remains uncertain. A need remains for a large pragmatic clinical trial of the effect of use of tranexamic acid in a sinus surgery

Reference

Intravenous tranexamic acid and intraoperative visualization during functional endoscopic sinus surgery: a double-blind randomized controlled trial.
Langille MA, Chiarella A, Côté DWJ, Mulholland G, Sowerby LJ, Dziegielewski PT, Wright ED.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2013;3(4):315-18.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Are your information leaflets fit for purpose?
Reviewed by: Victor Osei-Lah
Sep/Oct 2013 (Vol 22 No 4)
 

Do patients really understand the information leaflets they are inundated with? The authors designed this study to evaluate the effectiveness of the message conveyed by balance appointment patient information leaflets (PILs). Forty participants with neither balance problems nor previous experience of balance tests were recruited. Two PILs (PIL A and PIL B) in current use at an audiovestibular department in an English region were selected. Ten participants were given PIL A, and another 10, PIL B. They were then interviewed to respond ‘yes’, ‘no’ or ‘found with difficulty’ to 11 questions to assess their understanding of the leaflets under four domains: ‘nature and purpose of the leaflet and appointment’, ‘an overview of the anatomy and physiology of the balance system’, ‘information regarding balance assessment tests’ and ‘patient instructions’. The PILs were then revised and reworded to create a single PIL and given to 20 new participants who were then asked the same 11 questions as before. Approximately half of participants had difficulties understanding the information in both leaflets. Although the revised and reformatted leaflets posed some difficulties, this was better received by the participants. The authors conclude that information leaflets do not always convey the intended information and rightly recommend user-testing during leaflet development.

Reference

Balance appointment information leaflets: Employing performance-based user-testing to improve understanding.
Brooke RE, Herbert NC, Isherwood S, Knapp P, Raynor DK.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2:162-8.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Genetic screening in newborns at risk of hearing loss
Reviewed by: Victor Osei-Lah
Sep/Oct 2013 (Vol 22 No 4)
 

Genetic factors are estimated to be responsible for two-thirds of all hearing loss of childhood onset. There are over 500 genetic mutations that have been identified to cause hearing loss, some more complex than others. Not all of these mutations may be of clinical significance. An expert panel came together to discuss the current and future developments in genetic technology and their applicability to hearing loss. The key question they sought to answer was, if the technology were available, ‘could population genetic screening of newborns to detect future hearing loss be an impending possibility?’ The paper gives a brief summary of the genetic causes and inheritance of hearing loss, techniques for mutation analysis (direct sequencing and hybridisation chips), the challenges of population screening of genetic hearing loss and future developments in mutation analysis. The authors considered how the 20-item criteria for genetic screening programmes could guide a screening policy for childhood hearing loss while highlighting the cost / benefit / harm, clinical and laboratory implications. They concluded that until more is known about the clinical significance of identified mutations, ‘genetics cannot be reliably used in a screening capacity for hearing loss’. The authors caution decision-makers to resist the pressure to adopt new technologies. They however support current practice (at least in the UK), that all newborns identified with hearing loss through the newborn hearing screening programme, should be tested for the presently known genetic causes which should include the mitochondrial m.1555A > G mutation

Reference

The future role of genetic screening to detect newborns at risk of childhood hearing loss.
Phillips LL, Bitner-Glindzicz M, Lench N, Steel KP, Langford C, Dawson S, Davis A, Simpson S, Packer C.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:124-33.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Psychological impact of the work environment
Reviewed by: Victor Osei-Lah
Sep/Oct 2013 (Vol 22 No 4)
 

This study was undertaken to assess the psychological effects on Swedish audiologists depending on where they worked. The three practice sectors were public tax-funded, completely private and private but publicly funded. 1032 registered audiologists were recruited to complete a three-part survey. The first part consisted of descriptive demographic and educational data. The second and third parts consisted of the completion of psychometric questionnaires. The second was a control-demand-support questionnaire (DCSQ) to assess the psychological demand, control and social support of work and the third part, the effort-reward imbalance (ERI) questionnaire that assessed perceived demands / effort and rewards of the work of the respondents. The final response rate was 48.5%. Seventy-seven per cent worked in the public tax-funded sector, while 9.9% and 12.2% worked in the completely private and private-public sectors respectively. I must say, I had difficulty understanding how the results were presented and interpreted but to put it simply, low control and high demand meant a stressful work environment and vice-versa. With that in mind, 24% of all respondents did not consider their work environment stressful compared with 29% who reported the opposite, but the differences between the three sectors were small. Overall, 86% of respondents felt rewards did not correspond with the effort they put in and once again the differences between the groups were not significant (83%, 90% and 95% for public, private and private-public respectively). These findings have public health implications

Reference

Psychosocial work environment among Swedish audiologists.
Brännström KJ, Båsjö S, Larsson J, Lood S, Lundå S, Notsten M, Taheri ST.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:151-161.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Reliability of hearing tests in a natural environment
Reviewed by: Victor Osei-Lah
Sep/Oct 2013 (Vol 22 No 4)
 

Traditionally, a soundproof booth has been considered essential in minimising ambience noise during pure-tone audiometry (PTA). An audiometric booth is costly and the mobile booths require frequent calibration. This study compared the PTA thresholds determined in a traditional soundproof booth (audiology clinic) with thresholds determined in a natural environment of a retirement home. The clinical audiometer used was a Type 2 computer-operated KUDUwave 5000. The transducers were embedded in insert earphones, which were covered by circumaural cups. On this cup, there were two microphones that monitored ambience noise in octave bands in real time during testing for quality control. 147 adults (age range 64-94 years) from four retirement homes were enrolled. All subjects were tested twice (first in the retirement home and then at the audiology clinic in a booth) with both air conduction (AC) (8-frequency 250Hz to 8000Hz) and 4-frequency bone conduction (BC). Masking was done as required. The average difference between natural environment and audiometric booth was between -0.6 and 1.1 dB for AC and -0.6 and 1.3 dB for BC. The differences between the two settings across ears and frequencies were within ±5 dB for 95% AC thresholds and 86% BC thresholds. Statistically, there were no significant differences between the two settings for both AC and BC (p > 0.01) except at 8000 Hz for AC in the left ear (p = 0.006). The results have far reaching implications, in an ageing and less mobile population. It also makes financial and economic sense to employ this technology to deliver diagnostic audiology services without audiometric booths, not only in ‘rich countries’ but also particularly in low-middle income countries. The only thing missing in the article is the cost of the KUDUwave audiometer.

Reference

Validity of diagnostic pure-tone audiometry without a sound-treated environment in older adults.
Maclennan-Smith F, Swanepoel DW, Hall III JW.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:66-73.

INTERNATIONAL JOURNAL OF AUDIOLOGY

The upside-down audiogram, ever wondered why?
Reviewed by: Victor Osei-Lah
Sep/Oct (Vol 22 No 4)
 

In most graphs, values in the vertical axis decrease as one moves from top to bottom. Ever wondered why the audiogram is the other way round? This article is a must-read! The author gives a brilliant historical understanding to this apparent ‘anomaly’. If you wish to play the ‘blame game’, then your target would be Fowler (an otolaryngologist), Fletcher (a physicist) and Wegel (a physicist) who collaborated to develop and evaluate the first commercial audiometer in the USA after World War I. The audiometer, which was jointly developed by the two physicists, was evaluated clinically in Fowler’s otology practice. Whereas it was pretty easy to achieve consensus on the horizontal axis representing frequency of sound, the same could not be said for the vertical axis. Fowler and Wegel agreed with scientific tradition at the time to express sound pressure level on a logarithmic scale (small numbers at the bottom and large numbers at the top). The author goes through how ‘sensation units’, ‘thresholds of audibility’ and ‘percentage hearing loss’ were derived by Fowler and Wegel. The latter was plotted on the vertical axis ranging from zero at the bottom to 100% at the top. However, Fletcher disagreed with the ‘percent loss approach’ and argued for a vertical axis representing sound intensity. Not only did he rename the axis ‘hearing loss in sensation units’, he swapped the values round so that the line at the top became ‘zero sensation level’ (0 to 120). Fowler later labelled the vertical axis ‘sensation loss’, then ‘loss in decibels’ after the logarithmic scale was re-adopted. By this time, Fowler’s son was beginning to make a name for himself and he was the first to re-label the axis ‘hearing loss in decibels’ which was later changed to ‘hearing loss in dB’. The author concludes that Fowler’s original idea of ‘percent hearing loss’ was not a bad one as it indicated the ‘amount of retained sensory capacity’ but on the otherhand Fletcher’s objection to Fowler’s concept of ‘threshold of feeling’ was also valid because ‘feeling’ may vary between individuals with and without hearing loss.

Reference

Why the audiogram is upside down.
Jerger J.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:146-50.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Why do some sufferers find tinnitus so distressing?
Reviewed by: Victor Osei-Lah
Sep/Oct 2013 (Vol 22 No 4)
 

Tinnitus is so common and yet a small percentage of sufferers find it so distressing, they frequently seek medical help. What is behind this help-seeking behaviour in patients with tinnitus of recent onset? The objectives of this study were three-fold: predictors of tinnitus catastrophising, how catastrophising contributes to tinnitus of recent onset and the relationship between catastrophising and utilisation of medical services. 270 adults with less than six months’ history of tinnitus were recruited from seven ENT centres, through the internet and via radio and newspaper adverts. Complete data was available for 258 subjects. All participants completed six different questionnaires: tinnitus characteristics, tinnitus catastrophising (TRSS), cognitive and behavioural coping strategies (COPE), depressive symptoms (PHQ-9), tinnitus distress (TQ) and utilisation of medical services. The authors found that catastrophic thinking occurred very early in a subject’s tinnitus experience. They also reported that higher subjective loudness of the tinnitus and greater depressive symptoms were associated with greater tinnitus catastrophising. The converse was true for behavioural coping. Greater catastrophising was associated with greater tinnitus distress and tinnitus-related medical utilisation but it cannot be proven if there is a cause-effect relationship. The authors suggest early intervention in primary care may help in reducing tinnitus catastrophising which in turn may reduce utilisation of medical services. Longitudinal studies may be required to study the complex relationships between all the variables addressed in this particular study.

Reference

The role of catastrophizing in recent onset tinnitus: Its nature and association with tinnitus distress and medical utilization.
Weise C, Hesser H, Andersson G, Nyenhuis N, Zastrutzki S, Kröner-Herwig, Jäger B.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:177–88.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Absence of protocols for treatment of dysphagia after stroke
Reviewed by: Gauri Mankekar
Sep/Oct 2013 (Vol 22 No 4)
 

This study determines speech language therapists’ (SLTs) approaches to direct dysphagia in stroke patients in the UK and Ireland. Dysphagia after stroke is common and leads to adverse outcomes. SLTs use a range of exercises with the aim of restoring swallowing by improving muscle function or through sensory stimulation; but because of paucity of evidence for many of these interventions, there is limited guidance for the clinician regarding the best methods for treating dysphagia. A 24-item questionnaire was delivered in a web-based cross-sectional survey targeting all SLTs working with stroke patients in the UK and Ireland. Respondents’ replies varied to all questions! Despite most respondents having access to an instrumental swallowing assessment, more than half reported never conducting one before recommending exercises. Most SLTs did not use a protocol for systematically progressing patient’s exercises and only 37% reported using standardised outcome measures. This survey highlights the variability in practice in dysphagia therapy and reveals discrepancies between reported approaches and recommendations from existing evidence and clinical guidelines. The authors conclude that the variation in responses indicates a need to develop a consensus statement and further research to guide practice.

Reference

Dysphagia therapy in stroke: a survey of speech and language therapists.
Archer SK, Wellwood I, Smith CH, Newham DJ.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2013;48(3):283-96.

JAMA OTOLARYNGOLOGY HEAD & NECK SURGERY

Health-related quality-of-life scores: something new for predicting survival in head and neck cancer
Reviewed by: Shabbir Akhtar
Sep/Oct 2013 (Vol 22 No 4)
 

Health-related quality of life (HRQOL) has become an important quality improvement tool in oncology during the past decades, interestingly a substantial number of investigations have been published with the aim of assessing its potential use as predictor of survival. The objective of this study was to evaluate the association between pretreatment health-related quality-of-life (HRQOL) scores and survival in patients with newly diagnosed head and neck squamous cell carcinoma (HNSCC). A total of 105 patients were included. Significant survival predictions from all HRQOL sum scores were demonstrated. This relation was independent of adjustment for sex, age, TNM stage, tumour site, alcohol consumption, present smoking status and presence of comorbidities. Several possible explanations for the demonstrated survival prediction from HRQOL scores may exist. Interestingly anxiety and depression have been shown to be predictors of mortality. These findings should be considered of special interest among health care professionals treating and providing surveillance of HNSCC patients because answers to standard health-related quality of life questionnaires may provide unique prognostic information beyond what is recognised today.

Reference

Prediction of survival by pretreatment health-related quality-of-life scores in a prospective cohort of patients with head and neck squamous cell carcinoma.
Østhus AA, Aarstad AK, Olofsson J, Aarstad HJ.
JAMA OTOLARYNGOLOGY HEAD & NECK SURGERY
2013;139(1):14-20.

JAMA OTOLARYNGOLOGY HEAD & NECK SURGERY

Laser assisted cordotomy for bilateral abductor paralysis
Reviewed by: Shabbir Akhtar
Sep/Oct 2013 (Vol 22 No 4)
 

Bilateral vocal cord paralysis is a serious medical condition. Many different techniques have been described to provide an adequate airway without a tracheotomy and to preserve voice quality. Resection of the vocal cord and ventricle, vocal cord lateralisation, external arytenoidectomy and transoral arytenoidectomy usually result in low quality of voice and aspiration. In 1989 the carbon dioxide (CO2) laser endoscopic posterior cordotomy (EPC) technique was described with lower aspiration and tracheotomy rates and higher postoperative vocal quality. In this study from Turkey 66 patients who underwent CO2 laser EPC because of bilateral vocal cord paralysis were studied. The CO2 laser was set to 3W in the continuous pulse and superpulse modes. The follow-up ranged from four to 120 (median, 40) months. Four patients (6%) required a revision procedure because of shortness of breath caused by granulomas on the operated side. In addition, four patients (6%) underwent contralateral posterior cordotomy because of an insufficient airway in a second operation. No serious aspiration problem was observed in any of the patients. The success rate of the one-step operation was 88%, whereas after second surgery in eight patients 100% airway restoration was achieved. Before the operation, 89% had poor exercise tolerance. In the post-operative period, 64% had good and 36% had excellent exercise tolerance. No patients had poor post-operative exercise tolerance. There was no statistically significant difference between the pre-operative and post-operative Voice Handicap Index scores. The authors have concluded that unilateral CO2 laser EPC is a safe, minimally invasive, and effective technique with a short operation time. Bilateral cordotomy should be reserved for patients who have insufficient airway passage with unilateral cordotomy.

Reference

Carbon dioxide laser endoscopic posterior cordotomy technique for bilateral abductor vocal cord paralysis: a 15-year experience.
Ozdemir S, Tuncer U, Tarkan O, Kara K, Sürmelioğlu O.
JAMA OTOLARYNGOLOGY HEAD & NECK SURGERY
2013;139(4):401-4.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Automated ABR in newborn hearing screening
Reviewed by: Stephen Broomfield
Sep/Oct 2013 (Vol 22 No 4)
 

There has been much debate about the best technique for screening the hearing of healthy babies. The advantages of transient evoked otoacoustic emissions (OAE), including it being a simple and quick test procedure, have led to the routine use of this test in some countries. In other regions, the potential for improved diagnostic accuracy has led to the routine use of automated auditory brainstem responses (ABR), the increased cost being offset by a reduced need for potentially expensive onward referral of cases failing OAE. In this study, the authors examine the test time of newborn hearing screening with OAE compared to the latest generation of ABR equipment in a group of 266 healthy infants, excluding any cases failing the screening. Test time for OAE was approximately 14 +/- 9 seconds, and for ABR was 43 +/- 23 seconds. Whilst the OAE test was found to be statistically longer than the ABR test, the authors comment that the new equipment dramatically reduced the time required for ABR when compared to other studies and their own past experience. Interestingly, the test time reported in this study did not include time required for preparation of the infant or test equipment, potentially longer in ABR than OAE tests. Nonetheless, reduced test time, taken with other factors not measured directly in this study (e.g. reduced cost of ABR equipment, ability to detect auditory neuropathy cases, and improved accuracy of ABR) might add to the evidence supporting routine use of ABR as the primary mode of newborn hearing screening.

Reference

Automated auditory brainstem response: a proposal for an initial test for healthy newborn hearing screening with a focus on the test time.
Konukseven O, Dincol I, Genc GA.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2012;8(3):419-425.

JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY

Cholesteatoma risk using bone pate in mastoid surgery
Reviewed by: Stephen Broomfield
Sep/Oct 2013 (Vol 22 No 4)
 

This study is of interest to any otologist using bone pate for reconstruction or obliteration following mastoid surgery. The researchers took samples of bone pate from 32 patients; 16 with cholesteatoma and 16 with non-cholesteatoma middle ear disease. Bone pate was collected separately from the mastoid cortex, the subcortical air cells, and the mastoid antrum region, with saline washes between samples. Each sample was examined by a histopathologist blinded to the middle ear pathology. The presence of squamous epithelium was identified using haematoxylin and eosin staining as well as a monoclonal antibody against epithelial membrane antigen. In the cholesteatoma group, none of the mastoid cortex samples contained squamous epithelium. There were two (12.5%) positive results from the subcortical cells, and four (25%) from the antral region. In the non-cholesteatoma group, none of the samples were positive. Whilst the authors concede that the mere presence of squamous epithelium in bone pate may not necessarily result in cholesteatoma growth, this result nonetheless highlights the importance of careful surgical technique in the harvesting of bone pate in ears with cholesteatoma.

Reference

Is there epithelial tissue in bone pate? A histopathology study.
Yorgancilar E, Firat U, Alabalik U, Gun R, Yildirim M, Bakir S, Kinis V, Topcu I.
JOURNAL OF INTERNATIONAL ADVANCED OTOLOGY
2012;8(3):366-70.

JOURNAL OF VESTIBULAR RESEARCH

Postural and vestibulo-ocular reflex (VOR) changes induced by neck muscle and skull vibration
Reviewed by: Fiona Barker
Sep/Oct 2013 (Vol 22 No 4)
 

Skull vibration induced nystagmus occurs in patients with unilateral vestibular loss and in recent unilateral vestibular loss such vibration has been shown to alter posture. This study looked at the effect of vibration on the skull and neck in patients with chronic unilateral vestibular loss to see whether this would yield clinically useful information. Twelve patients with severe left sided vestibular loss and nine control subjects had vibration applied to various parts of the head and neck. Their eye movements were recorded using videonystagmography (VNG) and postural control was measured with eyes open and eyes closed. All the unilateral vestibular lesion (UVL) patients had a vibration induced nystagmus (VIN) beating toward the healthy side during vertex, mastoid and cervical vibration. None of the control group had any vibration induced nystagmus. The UVL group had some increases in sway path with eyes open with skull vibration but this was too small to be clinically useful. There was no significant difference between the sway of control in UVL patients with eyes closed. The authors recommend using skull vibration induced nystagmus as an adjunct to the caloric test but they found measuring postural sway to be unhelpful clinically in distinguishing patients from healthy controls. How refreshing to see a study that recommends not doing something. Not publishing on non-significant results risks reporting bias. It is good to see that here this is not an issue and that the recommendation that a test is not helpful clinically can be just as useful as one that recommends introducing a new test.

Reference

Clinical interest of postural and vestibulo-ocular reflex changes induced by cervical muscles and skull vibration in compensated unilateral vestibular lesion patients.
Dumas G, Lion A, Gauchard GC, Herpin G, Magnusson M, Perrin PP.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:41-49.

JOURNAL OF VESTIBULAR RESEARCH

Symptoms induced in vestibular patients in optic flow environments
Reviewed by: Fiona Barker
Sep/Oct 2013 (Vol 22 No 4)
 

We have all seen the patient who describes disorientation in complex visual environments such as supermarkets and crowded shopping centres. The purpose of this study was to measure the type and severity of such symptoms in people with vestibular loss during coordinated head and eye movements in a controlled optic flow environment. They compared the results from seven people with vestibular loss to 25 controls in four different optic flow environments across six visits. Participants were asked to perform several eye / head coordination tasks in the optic flow environments and rated their symptoms and dizziness on a number of scales. The participants with vestibular disorders had significantly greater discomfort, oculomotor and disorientation symptoms on performance of gaze and gaze stabilisation tasks in moving visual environments than the control subjects. The reported symptoms increased with each visit, but did not depend on the optic flow condition. People who reported greater dizziness handicap and space and motion discomfort before the trial also had higher levels of symptoms during the experiment. This study confirms that people with vestibular loss do indeed experience a greater degree of disorientation while performing normal head and eye movements in complex visual environments than people without vestibular loss. Those who reported greater disability at the outset experienced higher levels of symptoms. One of the proposed treatments for patients with vertigo provoked by the visual environment is gradual exposure to increasingly complex provocative stimuli. This study emphasises the need for careful, gradual exposure in rehab particularly as the degree of symptoms increased with repeated exposure in this trial.

Reference

Symptoms elicited in persons with vestibular dysfunction while performing gaze movements in optic flow environments.
Whitney SL, Sparto PJ, Cook JR, Redfern MS, Furman JM.
JOURNAL OF VESTIBULAR RESEARCH
2013;23:51-60.

JOURNAL OF VESTIBULAR RESEARCH

Virtual reality for visual vertigo – a pilot study
Reviewed by: Victor Osei-Lah
Sep/Oct 2013 (Vol 22 No 4)
 

A common complication of vestibular dysfunction is visual vertigo (VV), in which exposure to moving scenes exacerbates dizziness but rehabilitation can be challenging. This pilot study assessed the benefits of virtual reality as an adjunct to conventional vestibular rehabilitation in VV patients. The virtual reality environment took place within the ReaCTor™, a form of immersive projection theatre (IPT), generating a virtual crowded street to which the subjects were exposed. Sixteen adults with a history consistent with vestibular neuritis, chronic dizziness and laboratory confirmation of a peripheral vestibular disorder were included in the study. Eleven subjects were exposed to a static virtual reality scene (Group S), five to a dynamic virtual reality scene (Group D) and Group D1 comprised the first five subjects in Group S who later received dynamic virtual reality. All subjects completed six questionnaires to assess the degree of visual vertigo, anxiety, depression and phobia before and after treatment. The virtual reality sessions consisted of twice-weekly 45- minute sessions for four weeks. All subjects continued with their previously instructed Cawthorne-Cooksey exercises at home. The authors found a significant improvement in VV symptoms in groups D and D1 (59% and 28%) compared to group S (1.6%). Virtual reality therapy had no significant impact on anxiety, depression phobia and gait. The authors argued that this finding might be due to the small sample sizes. Whereas virtually reality has been found to improve VV, the current technology is expensive and out of reach. The search for a treatment regime that is applicable in everyday clinical practice for VV patients continues.

Reference

The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study.
Pavlou M, Kanegaonkar RG, Swapp D, Bamiou DE, Slater M, Luxon LM.
JOURNAL OF VESTIBULAR RESEARCH
2012;22:273-81.

NEUROSURGERY

Endoscopic surgery for Cushing's disease
Reviewed by: Showkat Mirza
Sep/Oct 2013 (Vol 22 No 4)
 

This paper looks at the efficacy of endoscopic transphenoidal surgery for Cushing's disease in 61 patients. Overall remission, defined as a post-operative morning serum cortisol of < 5microg/dL or normal or decreased 24 hour urine-free cortisol level, was achieved in 95% of cases by discharge and 84% by one year. There was statistically significant difference in remission rates between microadenomas (93%), pre-operative negative MRI (70%), and macroadenomas (77%); although with a larger series differences may perhaps become apparent. Patients with a history of previous surgery were nine times less likely to achieve remission. In-house cortisol level of < 5.7 microg/dL provided the best prediction of follow-up remission. The microscopic technique has reported remission rates of 70-90%. The endoscopic approach therefore has comparable results. It is interesting to consider that with the advantage of angled endoscopes, the remission rates for the endoscopic technique will in general be superior, particularly for macroadenomas. The authors have described their technique previously but a brief overview would have been of interest

Reference

Endoscopic transsphenoidal surgery for Cushing disease: techniques, outcomes, and predictors of remission.
Starke, RM, Reames DL, Chen C-J, Laws ER, Jane JA.
NEUROSURGERY
2013;72:240-7.

NEUROSURGERY

Medial opticocarotid recess in endoscopic skull base surgery
Reviewed by: Showkat Mirza
Sep/Oct 2013 (Vol 22 No 4)
 

This paper from the renowned Pittsburgh Skull Base Group is a cadaveric anatomical study of the medial opticocarotid recess (MOCR), an important landmark for endoscopic approaches to the cranial base. The MOCR is a teardrop-shaped osseous indentation formed at the medial junction of the paraclinoid carotid canal and the optic canal. It is a key structure to identify when accessing the parasellar and suprasellar areas. The article features some excellent colour photograph illustrations aiding the reader in appreciating the anatomy of this region. In the removal of lesions such as craniopharyngiomas and pituitary macroadenomas with suprasellar and lateral extension, removal of the bone overlying the MOCR allows the safe isolation of the optic carotid cistern during intradural dissection without significant retraction of the tumour medially and hence avoiding injury to the optic nerve and surrounding vessels. The MOCR is also a common place for residual pituitary macroadenomas. A useful paper for the anterior skull base surgeon

Reference

The medial opticocarotid recess: an anatomic study of an endoscopic 'key landmark' for the ventral cranial base.
Labib MA, Prevedello DM, Fernandez-Miranda JC, Sivakanthan S, Benet A, Morera V, Carrau R, Kassam A.
NEUROSURGERY
2013;72:66-76.

NEUROSURGERY CLINICS OF NORTH AMERICA

Cervical spine problems and their management
Reviewed by: Gauri Mankekar
Sep/Oct 2013 (Vol 22 No 4)
 

The flexible cervical spine supports the head and allows the widest possible range of movements relative to the rest of the spine. When normal cervical alignment is disrupted, it leads to a variety of cervical disorders and complications. Occasionally, we as ENT surgeons are faced with patients having vertigo secondary to cervical muscle spasm with loss of cervical lordosis or dysphagia due to cervical osteophytes. This article elaborates on the varying aetiology of cervical deformity, normative data and evaluation and examination of deformity. It also suggests various treatment options for the management of these debilitating conditions and discusses the complications of surgery.

Reference

Assessment and treatment of cervical deformity.
Scheer JK, Ames CP, Deviran V.
NEUROSURGERY CLINICS OF NORTH AMERICA
2013;24(2):249-74

OPERATIVE NEUROSURGERY

Anatomic constraints for auditory brain stem implantation (ABI)
Reviewed by: Ms Gauri Mankekar
Sep/Oct 2013 (Vol 22 No 4)
 

Cochlear implants successfully restore neurological function and hearing for the more peripheral auditory system hearing disorders. However, auditory brain stem implants have not been producing consistent results in cases of hearing loss due to damage to the central hearing pathways. This has been despite use of both surface and penetrating electrodes in auditory brain stem implants. In this study, the authors attempted to determine neuromorphological constraints of the auditory brainstem implant interface which influence the results. After studying 33 human cochlear nuclei in 20 brainstem specimens obtained at autopsy, they concluded that in the absence of appropriate surface landmarks and imaging guidance, to gain access to the human cochlear nucleus with surface and depth electrodes remains a challenge. The small and variable size of the cochlear nucleus, its complex shape and spatial orientation, the location of its ventral portion deep to the surface of the brainstem, the overlap of its ventral and dorsal portion and the close proximity to the facial nerve all contribute to the challenges in establishing a functional electronic interface for ABIs, according to the authors. They suggest that contacts on the penetrating electrode tips for the dorsal cochlear nucleus should not be longer than 1mm but electrodes for direct contact with the upper portion of the ventral cochlear nucleus must be as long as 7mm at least and aimed at a steep angle to leave the facial nerve undamaged. Since no significant side differences were observed, they recommend that the electrode designs can remain bilaterally uniform. This study provides interesting information to those involved in auditory brain stem implantation and is critically important to those involved with the development and innovation of devices

Reference

No easy target: anatomic constraints of electrodes interfacing the human cochlear nucleus.
Rosahl SK, Rosahl S.
OPERATIVE NEUROSURGERY
2013;72:58-65.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Meta-analysis of botulinum toxin for sialorrhoea
Reviewed by: Hannah Blanchford
Sep/Oct 2013 (Vol 22 No 4)
 

This meta-analysis reviewed eight randomised, placebo-controlled trials, evaluating injection of botulinum toxin into salivary glands for patients with sialorrhoea. The trials comprised 181 patients. Four studies used ultrasound guidance for injections and four studies involved children. There was a significant improvement in drooling severity at four weeks post treatment. Only three studies reported drooling severity results at 12 weeks, but these found a sustained improvement. Both antigen types (Botox and Dysport, Myobloc and Neurobloc) produced similarly significant reductions in drooling. The authors concede further studies are necessary to determine the optimal dosage, dose-dependent effects, frequency of injections and long-term outcomes. The meta-analysis was limited by publication bias and lack of long-term follow-up. The authors also suggest development of a universal instrument to report drooling severity and standardise results.

Reference

Botulinum toxin for the treatment of sialorrhoea: a meta-analysis.
Vashishta R, Nguyen SA, White DR, Gillespie MB.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;148:191-6.

OTOLOGY & NEUROTOLOGY

Cochlear implant candidacy in children with auditory neuropathy
Reviewed by: Rebecca Heywood
Sep/Oct 2013 (Vol 22 No 4)
 

Many children with auditory neuropathy (AN) gain little benefit from amplification alone. One option is to offer them cochlear implantation (CI) with a view to stimulating the auditory nerve with a synchronised electrical stimulus. The outcomes are very variable however, possibly because the site of pathology along the auditory pathway varies and possibly because many children with AN also have coexistent cognitive / developmental disorders. This retrospective study compares CI outcomes in children with isolated AN with those with cochlear hearing loss (CoHL). Pre-operative pure tone average (PTA) was significantly better in the AN group, which is not unexpected given the nature of AN, but otherwise the two groups were similar demographically. There were no significant differences in age-appropriate speech perception testing either pre-operatively or up to two years post-operatively. The incidence of prematurity was significantly higher in the AN group (45%) than in the CoHL group (7%). The differences in ventilator dependence (AN 29% vs CoHL 0%), neo-natal intensive care unit (NICU) stay (46% vs 14%) and incidence of hyperbilirubinaemia (40% vs 20%) were quite striking and thought to be clinically significant, though they were not found to be so statistically; this may reflect type II error. Outcomes were then compared between children with isolated AN and AN with a confounding neurologic disorder. There was a significant difference in post-operative mode of communication; 82% of isolated AN children used an oral mode of communication whereas 89% of multiply-involved children used a non-oral one. Speech perception scores were significantly different (isolated AN 72.7% versus 30%). Most multiply-involved AN children were felt to benefit from CI in sound awareness, however. CI offers a valuable form of rehabilitation in children with isolated AN. Coexistent cognitive disorders must be taken in to consideration and the parents counselled about reasonable expectations when determining candidacy. –

Reference

Outcomes of cochlear implantation in children with isolated auditory neuropathy versus cochlear hearing loss.
Budenz CL, Telian SA, Arnedt C, Starr K, Arts HA, El-Kashlan HK, Zwolan TA.
OTOLOGY & NEUROTOLOGY
2013;34:477-83.

OTOLOGY AND NEUROTOLOGY

Bisphosphonate related osteonecrosis of the external auditory canal (EAC)
Reviewed by: Rebecca Heywood
Sep/Oct 2013 (Vol 22 No 4)
 

A case of osteonecrosis (ON) of the external auditory canal (EAC) related to oral bisphosphonate (BP) therapy is reported. ON associated with BP treatment is now a well recognised phenomenon in the jaw and has been reported in other sites. BP use has increased rapidly over the last few years, but the scale of the resultant ON has only recently become apparent due to the time lag of between 18 months and several years between starting treatment and development of symptoms (thought to be 0.09 to 0.34% for oral BP induced ON). In this case report a 79 year old woman, who had taken oral BP for 10 years, presented with persistent otorrhoea, pain and a bony canal wall defect. She used cotton buds for aural toilet on a frequent basis. Malignancy was excluded and she had no risk factors for necrotising otitis externa. Approximately 50% of the defect had re-epithelialised one month after a six week course of intravenous antibiotics, but she was unfortunately lost to follow-up thereafter. The four previously reported cases of ON of the EAC related to BP following intravenous (IV) treatment. The authors highlight BP induced ON as a differential diagnosis in bony erosion of the EAC and the potential for both oral and IV BP to result in complications. They also point out that the incidence is likely to increase with the ever rising number of patients being prescribed BP treatment for osteoporosis and control of bony metastatic disease.

Reference

Osteonecrosis of the external auditory canal associated with oral bisphosphonate therapy: case report and literature review.
Salzman R, Hoza J, Perina V, Starek I.
OTOLOGY & NEUROTOLOGY
2013;34:209-13.

OTOLOGY AND NEUROTOLOGY

Improved electrode impedance after oral steroid therapy
Reviewed by: Rebecca Heywood
Sep/Oct 2013 (Vol 22 No 4)
 

This case study reports a significant deterioration in a cochlear implant (CI) recipient’s performance associated with a change in electrode impedance, which responded to steroids. A 75 year old male received a right Cochlear Nucleus Freedom. Surgery was uneventful. His Hearing in Noise test (HINT) score in quiet improved from 40% binaurally aided pre-operatively to 81% at one week post-activation. He continued to do well until 23 months’ post-activation, when he reported decreased hearing and sound quality. Electrode impedance increased and HINT score fell to 63%. Despite programming changes, HINT continued to decrease to 40%. The implant was replaced with a Nucleus Freedom Contour Advance. Electrode impedances were typical at activation, but just a week later demonstrated abrupt changes across the array. Over the subsequent four months the patient’s performance declined further and stimulation levels increased to those approaching CI voltage compliance limits. The patient ceased using the device for 10 days, following which impedance values decreased and became less erratic, but reverted to previous patterns when use was resumed. At this point the authors hypothesised that a cochlear inflammatory condition may have resulted in the clinical picture and the patient commenced prednisolone 10mg daily, with an immediate and dramatic improvement in impedances. Unfortunately his performance did not mirror this. It is postulated that prolonged cochlear inflammation, in conjunction with a large increase in current amplitude to provide sufficient loudness growth, was detrimental to the auditory neurones. As a result the patient underwent implantation of the contralateral ear. He remained on prednisolone 5mg daily and impedances remained stable for both implants. The authors suggest a period of non-use in cases of increased impedance values, to allow possible cochlear inflammation to subside. When the impedances fall following non-use, a physiological cause is implicated rather than a device-related one and steroids may then be considered.

Reference

Clinical case study review: steroid-responsive change in electrode impedance.
Wolfe J, Baker RS, Wood M.
OTOLOGY & NEUROTOLOGY
2013;34:227-32.

OTOLOGY AND NEUROTOLOGY

Microvascular injury during cochlear implantation
Reviewed by: Rebecca Heywood
Sep/Oct 2013 (Vol 22 No 4)
 

This temporal bone study was carried out to characterise vascular structures at potential risk of injury during cochlear implantation (CI) in an attempt to further understand the aetiology of loss of residual hearing following CI. Study of human cadaveric temporal bones by cross-sectioning and microdissection for examination by light and scanning electron microscopy was performed. The authors describe a venous network within the scala tympani with little or no bony covering which is susceptible to injury. Venules of the lateral wall drain the spiral ligament and stria vascularis, then converge and cross the floor of the scala tympani to join the posterior spiral vein. Venules from the spiral ganglion, osseous spiral lamina and scala vestibuli also drain in to the posterior spiral vein, which in turn eventually unites with the vestibulocochlear vein to become the vein of the cochlear aqueduct. The relevance of this is that interruption of the venous outflow in the basal turn of the scala tympani can have far-reaching effects in other areas of the cochlea, resulting in compromised oxygen delivery with subsequent impairment of strial and spiral ligament function. Injury may occur if the tip of the electrode array strikes a vessel directly, shears past it during insertion or compresses it, and during surgical drilling of a cochleostomy or of the antero-inferior bony overhang of the round window. Extravasation of blood in to the scala tympani following vascular injury may also occur. Injuries of this nature may result in a slow decline or rapid loss of residual cochlear function depending on collateral venous drainage and may contribute to loss of residual hearing

Reference

Vascular trauma during cochlear implantation: a contributor to residual hearing loss?
Wright CG, Roland PS.
OTOLOGY & NEUROTOLOGY
2013;34:402-7.

OTOLOGY AND NEUROTOLOGY

Temporal bone SCC treatment and outcomes
Reviewed by: Hannah Blanchford
Sep/Oct 2013 (Vol 22 No 4)
 

Treatment of SCCs involving the temporal bone has moved away from radical total / subtotal resection due to the associated morbidity and mortality. Lateral temporal bone resection (resection of the cartilaginous and bony external auditory canal) has been the primary intervention in this centre for the past 11 years. This retrospective study of 30 patients provides a review of their current treatment and outcomes. The cohort interestingly grouped 16 patients with primary SCCs of the external auditory canal together with 14 patients with SCCs from adjacent sites demonstrating spread to the temporal bone (such as aggressive cutaneous malignancies). 54% of patients underwent adjuvant radiotherapy but it conferred no increase in disease-free survival. Three patients (10%) with irresectable tumours had non-surgical treatment; the remainder underwent lateral temporal bone resection with or without surgical extension. None of the subjects demonstrated distant metastases at presentation. Eight patients (27%) demonstrated regional nodal disease. Univariate analysis showed advanced (T3 / T4) T stage, facial nerve involvement at presentation, positive surgical margins and post-operative chemoradiotherapy to be associated with reduced disease-free survival. Facial nerve involvement requiring resection or grafting was the only factor to remain a significant predictor of poor survival on multivariate analysis. This paper shows that the surgical treatment and outcomes for both pathologies did not differ significantly (the overall disease free survival was 70%). The authors acknowledge their study was limited by the small sample size and limited follow-up duration (mean 41.9 months)

Reference

Squamous cell carcinoma involving the temporal bone: lateral temporal bone resection as primary intervention.
Lassig AAD, Spector ME, Soliman S, El-Kashlan HK.
OTOLOGY & NEUROTOLOGY
2013;34:141-50.

PEDIATRIC ALLERGY & IMMUNOLOGY

Can family size and farm exposure affect childhood hay fever?
Reviewed by: Evangelia Tsakiropoulou
Sep/Oct 2013 (Vol 22 No 4)
 

It is widely known that exposure to the farming environment and living with a big family can reduce the risk of allergic diseases. However, the combined effect these two parameters on allergic disease and the independence of them was recently investigated in one of the largest population based studies with 79,888 participants aged from six to 12. The so called GABRIELA study was conducted in rural areas of southern Germany, Switzerland, Austria and Poland. According to the study results the prevalence of doctor-diagnosed hayfever and atopy was 12% and 45% respectively among children with no farm exposure and no siblings. On the other hand, farm children with more than two siblings were diagnosed 2% with hay fever   and 20% with atopy. In this paper the investigators do not provide clear evidence of synergy of farm exposure and family size. However, the fact that inverse association of exposure to farming environments with hayfever was found in all family sizes suggests the existence of different underlying biological mechanisms and strengthens the protective role of these factors.

Reference

The combined effects of family size and farm exposure on childhood hay fever and atopy.
Genuneit J, Strachan DP, Büchele G, Weber J, Loss G, Sozanska B, Boznanski A, Horak E, Heederik D, Braun-Fahrländer C, von Mutius E.
PEDIATRIC ALLERGY & IMMUNOLOGY
2013;24:293–8.

RHINOLOGY

Endoscopic endonasal surgery for skull base tumours: technique and preliminary results in a consecutive case series report
Reviewed by: Lakh Pabla
Sep/Oct 2013 (Vol 22 No 4)
 

Acute rhinosinusitis (ARS) is characterised by sudden onset of two or more symptoms of nasal blockage / congestion, nasal discharge, facial pain or pressure and reduction / loss of smell. It can impact upon the quality of life of affected individuals and current recommended treatment includes intranasal steroids and antibiotics. However, there is increasing evidence that phytotherapeutic agents may be useful in the treatment of ARS. This study outlines the authors’ experience with the extended endoscopic endonasal approach (EEA). They discuss clinical and functional findings, results and surgical complications observed in a consecutive series of 40 patients with skull base lesions between January 2007 and January 2012. Three main types of EEAs were performed: anterior skull base, clivus and cavernous sinus. Symptoms, pre- and post-endocrine function, opthalmology and ENT evaluations were recorded. Pre-operative radiological investigations included brain magnetic resonance imaging (MRI) and paranasal sinus computed tomography (CT) scans. All patients underwent post-operative imaging at three months with MRI scans. Total tumour removal (assessed by post-operative MRI scans) occurred in 30 out of 40 patients (75%) but in 10 patients only partial removal was possible. Major complications including CSF leaks were observed in five out of 40 patients (8%). One patient died three months after surgery due to severe systemic sepsis. The authors concluded that the extended endoscopic endonasal approach could be used as a minimally invasive and innovative technique in the removal of selected skull base lesions and that it is sufficiently safe, with the frequency of major complications quite low in expert hands.

Reference

Endoscopic endonasal surgery for skull base tumours: technique and preliminary results in a consecutive case series report.
Ensenat J, Notaris M, Sanchez M, Fernandez C, Ferrer E, Bernal-Sprekelsen M, Alobid I.
RHINOLOGY
2013;51:37-46.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Does intratympanic gentamicin treatment for unilateral Ménière’s disease provide a long-term treatment?
Reviewed by: Madhup K Chaurasia
Sep/Oct 2013 (Vol 22 No 4)
 

Intratympanic injection of gentamicin dates as far back as 1957 when Schucknecht first described this procedure. Several studies have been published since then, but this is probably the first one which has the merit of a 15 year follow-up. A series of 16 patients were treated between November 1991 and February 1995. The regimen adopted was a delivery tube inserted in the middle ear through which 0.65 ml (equivalent to 17.35 mg) of fresh gentamicin was delivered three times a day over four days. The symptoms taken into account were vertigo attacks, tinnitus, aural fullness, fluctuating hearing loss and any major imbalance affecting daily life. The recent follow-up was telephonic in which nine eligible patients could be contacted and included in this latter phase of the study. The follow-up ranged from 15 years and eight months to 18 years and 10 months. Between the two year follow up of these patients by the same author and the present assessment 15 years later, all nine patients were completely free of Ménière’s vertigo attacks. However, all patients continued to suffer hearing loss and tinnitus in the affected ear but they seemed to have adjusted to this without any problems. None developed any associated symptoms of Ménière’s disease in the other ear. Only three of the nine patients developed disequilibrium. In the discussion the authors support a clear correlation between successful vestibular ablation, assessed by absence of caloric response to an ice water stimulus, and complete control of vertigo. However some studies dispute this. The authors also contend that the success is not due to natural periods of remission in view of the long period of this follow-up. The study has limitations, but it is probably the first of its kind and suggests encouraging results with intratympanic gentamicin treatment, which is inexpensive and convenient, compared to more elaborate surgical procedures that have not produced any better results

Reference

Intratympanic gentamicin treatment for unilateral Meniere’s disease: long term follow up of a proven regime.
Wasson J, Upile N, Pfleiderer A.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:20-4.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Safety and cost effectiveness of image guidance functional endoscopic sinus surgery
Reviewed by: Madhup K Chaurasia
Sep/Oct 2013 (Vol 22 No 4)
 

Functional endoscopic sinus surgery (FESS) is now widely performed in the UK. Good results are often restrained by impeding safety factors and lack of completeness of the operation. Whether the armamentarium of image guidance system overcomes these factors is the subject of this study comprising 147 patients over an eight year period. Most of these patients were undergoing revision surgery (60%). Of these patients, four had major complications and 14 required a revision procedure. The success rate claimed in this study is 90% with image guidance system. The results are compared with other studies and literature and considered to be favourable. However, there is a lack of control group in this study and therefore a direct comparison between image guidance surgery and surgery without it is not available. The write-up includes some interesting facts in terms of efficacy and cost effectiveness. Image guidance surgery takes additional time and there is also a learning curve for surgeons, many of whom feel uncomfortable in the initial stages of using the new procedure. The cost effectiveness does not seem to be obvious in the NHS scenario, but it is stated that military air crew who undergo conventional sinus surgery for non polypoid chronic rhinosinusitis need an average of two procedures before returning to work. It is therefore claimed that image guidance surgery certainly helps in this group of patients and therefore reduces the costs in terms of absence from work. The major complication rate of 3% in this study compares equally with a number of studies investigating primary FESS and showing complication rates of 0.3 to 3%.  Technical armamentarium does not always add to skill but certainly has its role in specific circumstances and this needs to be highlighted in future studies on this subject

Reference

Image guided sinus surgery: practical and financial experiences from a UK centre 2001-2009.
Masterson L, Agalato E, Pearson C.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1224-30.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

The significance of senior input in an ENT emergency clinic
Reviewed by: Madhup K Chaurasia
Sep/Oct 2013 (Vol 22 No 4)
 

The brevity of undergraduate exposure in otolaryngology and restriction of practical training, due to the European working time directive, has resulted in inexperienced junior doctors handling emergencies in otolaryngology. This results in more follow-ups, admissions and use of the operating theatre. This study looks at the results of involving senior otolaryngology trainees to actively supervise these clinics. The variables taken into account were the number of complete discharges, admissions, immediate admissions and the use of theatre. These four variables were assessed in a year when there was no direct involvement of senior trainees in open ENT emergency clinics, and in the consecutive year, during which a ‘hot week’ was allotted for a senior trainee to be on site and actively supervise the handling of ENT emergencies. It was observed that direct involvement of a senior trainee resulted in a statistically significant rise in the number of patients completely discharged and a significant reduction in the number of children requiring the operating theatre. No differences were observed in the need for immediate admissions, possibly due to the registrars being consulted in the first year of assessment as well. There was no reduction in the number of admissions between the two years of assessment and this may well be due to good hierarchical culture in the department, where it was very convenient to contact senior colleagues. The authors are aware of the limitations of this study, in that it did not examine the repeat presentations of the discharged patients. There was also a reduction in children requiring the operating theatre and this was attributed to more frequent instances of foreign bodies being removed in the clinic by more experienced doctors. The discussion is worth reading, in that it provides suggestions for improving junior doctor training within the constraints of the European working time directive, through use of modules and workshops. However, special study modules and increasing undergraduate exposure has to be fitted within the rest of the curriculum. There are no simple solutions to these issues

Reference

The ENT emergency clinic: does senior input matter?
Mirza A, McClelland L, Daniel M, Jones N.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:15-19.

WORLD JOURNAL OF SURGICAL ONCOLOGY

Unusual presentation of parathyroid malignancy
Reviewed by: Ms Gauri Mankekar
Sep/Oct 2013 (Vol 22 No 4)
 

This article reports the usual presentation of parathyroid carcinoma in a 30-year-old man. The patient had a six month history of an asymptomatic non-traumatic swelling in the left thigh. Radiography of the left femur showed an osteolytic mid-shaft lesion without any fracture. Laboratory investigations revealed that the patient had elevated levels of adjusted calcium, phosphate and parathyroid hormone. The patient also had a small palpable mass over the left thyroid gland and the Sestamibi scan showed a hot spot localised in the left mid-pole of the thyroid. Computed tomography (CT) scan of the neck showed a hypo-dense lesion in the posterior of the thyroid, without cervical lymphenopathy or local infiltration. After surgery, the patient’s calcium and parathyroid hormone levels normalised, but histology showed parathyroid carcinoma with capsular and vascular invasion. The patient was offered re-operation, but declined and developed recurrent parathyroid carcinoma two years later. The article highlights the challenges faced in diagnosing parathyroid malignancies and the dilemma of re-operation after simple excision

Reference

Parathyroid carcinoma in a 30-year-old man: a diagnostic and management challenge.
Ng S-H, Hung-Hin Lang B.
WORLD JOURNAL OF SURGICAL ONCOLOGY
2013;11:83.

ALLERGY

The art of control in upper airway inflammation
Reviewed by: Laith Tapponi
Jul/Aug 2013 (Vol 22 No 3)
 

This is an initiative taken by the ENT section of the European Academy of Allergology and Clinical Immunology (EAACI), in conjunction with Allergic Rhinitis and its Impact on Asthma (ARIA) and European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) experts who felt the need to provide this comprehensive overview for the group with so-called severe chronic upper airway disease (SCUAD). The diagnosis of allergic rhinitis and chronic rhinosinusitis should be reconsidered in cases of uncontrolled disease. Treatment-related issues of this group are linked with the correct choice of treatment and route of administration, symptom-oriented treatment and the evaluation of the need for immunotherapy in allergic patients.

Reference

Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand?
PW Hellings, WJ Fokkens, C Akdis, C Bachert, C Cingi, D Dietz de Loos, P Gevaert, V Hox, L Kalogjera, V Lund, J Mullol, NG Papadopoulos, G Passalacqua, C Rondón, G Scadding, M Timmermans, E Toskala, N Zhang, J Bousquet.
ALLERGY
2013;68:1-7.

ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY

New concepts in RRP? Injecting laryngeal papilloma with bevacizumab
Reviewed by: Mr Maher El Alami
Jul/Aug 2013 (Vol 22 No 3)
 

Using anti-angiogenesis to treat laryngeal papillomatosis is a relatively new concept in the treatment of this condition in adults. The researchers in this institution have followed their initial research looking at the clinical efficacy with a follow-on study focusing on potential dose related systemic effects. The drug’s initial dosage (Avastin ®) was based on the use of this drug in ophthalmology. Used systemically in high doses in an oncological setting, this drug can potentially cause significant systemic toxicity. In this study the researchers looked at responses to different doses of the locally applied drug. The drug is injected and the site is treated with a photoangiolytic KTP laser. The patients had repeated injection into two or more laryngeal sites in repeated sessions (n = 43, 100 injections) of which 18 had already been included in the previous study to show clinical efficiency. They were followed up and their blood results, ECG and basic vital parameters were monitored. In a dose of up to 88mg of Bevacizumab there were no signs of systemic toxicity while achieving disease control. The authors conclude this is a promising new treatment concept in the treatment of recurrent respiratory papillomatosis (RRP). The concept is interesting; the paper however focuses on recycling data from the previous study which is probably the paper to read.

Reference

Safety and dosing of recurrent respiratory papillomatosis.
Best SR, Friedman AD, Landau-Zemer T, Barbu AM, Burns JA, Freeman MW, Halvorsen Y, Hillman RE, Zeitels SM.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
121(9):587-93.

AUDIOLOGY NEUROTOLOGY

Canal wall up versus canal wall down for cholesteatoma
Reviewed by: Stephen Broomfield
Jul/Aug 2013 (Vol 22 No 3)
 

In this study, the authors admirably aim to combine data from published studies in order to address the longstanding debate between intact canal wall and canal wall down procedures in the treatment of cholesteatoma. In the comparison of single stage surgery, 13 papers were identified. Interestingly, the publication dates ranged from 1973 to 1997; this at least allowed for reasonable, albeit variable, duration of follow-up. Unsurprisingly, canal wall up procedures were associated with a relative risk of recurrent disease of 2.87 (95% confidence interval: 2.45-3.37). The authors acknowledge the lack of randomised controlled trials in this field and the inevitable heterogeneity of results in this type of meta-analysis; for example the inclusion of adults and children in the same study, or the potential bias associated with surgeons applying different techniques according to disease severity. The authors make an interesting comparison of the costs of the two techniques, highlighting the potentially increased financial burden of the multiple operations often associated with the canal wall up approach. Hopefully future studies will include more information on the use of lasers and magnetic resonance imaging (MRI) scans in the management of cholesteatoma, the role of mastoid obliteration, as well as reporting on hearing outcomes and quality of life measures, crucial for any in-depth discussion of this subject. The debate continues.

Reference

Surgical technique and recurrence in cholesteatoma: a meta-analysis.
Tomlin J, Chang D, McCutcheon B, Harris J.
AUDIOLOGY NEUROTOLOGY
2013;18:135-42.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in a child with 3p deletion syndrome and poorly developed mastoids
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2013 (Vol 22 No 3)
 

The authors described a case of cochlear implantation in patients with 3p deletion syndrome (a rare genetic disorder involving the distal end of the short arm of chromosome 3 characterised by low birth weight, psychomotor delay and various phenotypic features). Additionally, this paper reviewed the non-mastoid approaches to the cochlea, potentially used in cases of mastoid abnormalities. A 23-month-old child with 3p deletion syndrome (3pDS), with poorly developed mastoids bilaterally, was successfully implanted using a retro-auricular transmeatal approach. Deafness is commonly encountered in patients with 3pDS and can be improved by cochlear implantation. However, this condition is not associated with abnormal mastoids and this is the first case reported. Therefore an unrelated coincidence cannot be excluded. Nevertheless, all cochlear implant surgeons should be familiar with the techniques that do not involve posterior tympanotomy because cases with mastoid abnormalities may be encountered.

Reference

3p deletion syndrome: Implications for cochlear implantation.  
Coelho D, Taormina Y, Moore J, Dodson K, Sismanis A.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13:248-51.

COCHLEAR IMPLANTS INTERNATIONAL

Consensus on how adult bone anchored hearing aid services should be developed in the United Kingdom
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2013 (Vol 22 No 3)
 

Bone anchored hearing aid services are now available in many centres worldwide. However, there are now guidelines as to how these services should be developed. A multi-disciplinary group of UK clinicians met to review issues relating to bone-anchored hearing-aid (BAHA) development and attempted to reach consensus. A modified Delphi technique was used. Statements were proposed by the lead group and sent out for consultation. Those with 90% agreement were approved without further discussion. Statements with 50-89% agreement were discussed by the lead group to determine whether they should be included in the final document. Any statement with < 50% agreement was removed without discussion. A second consultation was then made, and the process repeated. This led to a final set of consensus statements. Team approach, implementation of minimum assessment standards and service delivery methods, equal provision to minorities or less privileged areas, patient awareness, and the need for better evidence-based research were among the most important consensus issues. An interesting article suggesting that there are several areas for improvement in current BAHA services.

Reference

Adult bone anchored hearing aid services in the United Kingdom: Building a consensus for development.
Hill P, Norman G, Davison T, Andrew R, Shanks M, Johnson I, Burrell S, Reid A,  Archbold S.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13:228-36.

COCHLEAR IMPLANTS INTERNATIONAL

Deaf children with additional disorders. Should we implant them?
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2013 (Vol 22 No 3)
 

In the early days of paediatric cochlear implantation, children with complex needs were not candidates for implantation. However, the situation gradually changed and an increasing number of deaf children with additional disorders have been implanted worldwide. This is a review of the assessment and outcomes of children with complex needs receiving cochlear implants in a single UK centre. The authors assessed 19 children with complex needs pre-implantation and 12 months post-implantation using categories of auditory performance (CAP), meaningful auditory information scale (MAIS), listening progress score (LiP), and meaningful use of speech scale (MUSS). Outcomes were compared with those of 230 children without additional needs. The results revealed that average CAP scores improved from 0.4 to 3.0, compared with 4.2 in the control group. MAIS scores as completed by parents and teachers improved to 62% and 57%, respectively, compared with the control group who achieved 82% and 70% at 12 months. LiP scores improved from 11% to 65% compared with the control which increased from 22% to 81%. MUSS scores as assessed by parent and teacher improved to 35% and 31%, respectively, at 12 months compared with 52% and 51% in the control group. Although, improvement was found across all outcome measures, this was inferior, as expected, to the respective improvement of children without additional needs. The non-users also suggest that selection is very important in this group of children. Finally, the authors discuss the lack of appropriate measures for children with complex needs. Indeed, these children need different assessment outcome measures as their quality of life may not be related to speech, which is not a realistic goal for some of them.

Reference

Cochlear implantation in children with complex needs – outcomes
Rafferty A, Martin J, Strachan D, Raine C.
COCHLEAR IMPLANTS INTERNATIONAL 2013;14(2):61-6.

COCHLEAR IMPLANTS INTERNATIONAL

Music is very important for young implantees and there are methods to encourage it
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2013 (Vol 22 No 3)
 

Almost all cochlear implant (CI) speech processor strategies focus on speech and neglect music perception. However, music is a very important element in everyday life. The authors designed and evaluated a music training programme with a monitoring tool for preschool CI users, for use in family-centred habilitation programmes. The programme included sections on singing; recognising songs, tunes, and timbre; and responding appropriately to music and rhythm. It was implemented over 18 months in 25 paediatric implantees who were split into three groups of varying age, duration of CI use, and ability. The mean total scores were found to increase significantly for all groups. Participation in and enjoyment of musical activities increased for both children and parents. Significant correlations were found between scores and length of CI use. The authors concluded that the training programme effectively enriched implanted children’s musical experience and therefore prelingually deafened CI users should be systematically involved in musical activities to help them acquire skills acquired more easily by hearing peers. It is evident that besides music training programmes, CI speech strategies should include ‘music strategies’ that focus on improved music perception.

Reference

Developing a music programme for preschool children with cochlear implants.
Koşaner J, Kilinc A, Deniz M.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13:237-47.

COCHLEAR IMPLANTS INTERNATIONAL

Should we implant very old deaf patients?
Reviewed by: Thomas Nikolopoulos
Jul/Aug 2013 (Vol 22 No 3)
 

The present study aims to analyse complications and outcomes of cochlear implantation in seniors receiving cochlear implants during a ten year period. The authors assessed a total of 28 patients, of 79 years or older (mean age 81.6 years), and compared them with a younger group of 76 patients who were between 20 and 60 years old (mean age 48.9 years). A retrospective study of the patients’ records was performed. The results revealed no severe peri- or post-operative surgical complications, although longer follow-up is needed to support such a claim. Speech perception improved significantly after surgery. The younger age group showed better results post-operatively for monosyllabic words compared with the older group with no difference seen for bi-syllabic words. In both the groups, there were no significant differences between patients living with or without social support. The authors concluded that cochlear implant surgery for patients of 79 years or older was well tolerated and provided great benefit. Therefore, they suggest that implantation should not be denied in older individuals who are otherwise in good health. Non-use in the elderly was associated with post-operative vertigo and tinnitus, severe disease and limited social support. However, the number of poor users indicates that selection is extremely important in this age group.

Reference

Cochlear implantation in the elderly.  
Lundin K, Näsvall A, Käbler S, Linde G, Rask-Anderse H.
COCHLEAR IMPLANTS INTERNATIONAL
2013;14(2):92-7.

HEARING, BALANCE AND COMMUNICATION

Cognitive processes in vestibular disorders
Reviewed by: Vinaya KC Manchaiah
Jul?Aug 2013 (Vol 22 No 3)
 

Equilibrium of the body is the result of perfect control of the relationship between the body and the environment, which requires functioning of the entire balance system. Although the central nervous system plays an important role in maintaining equilibrium, as it receives and manages signals from various receptors in the human body, it still requires interaction between top-down and bottom-up systems for maintaining the balance function. Clinical investigations and research have suggested that acute lesions, affecting the peripheral receptors or nerves, produce a sudden change in information reaching the balance system, which results in serious symptoms. This may result in various balance disorders, which may have a significant degree of disability and emotional disturbance for patients. This guest editorial provides a comprehensive overview of cognitive processes involved in vestibular disorders with particular emphasis on management of vertigo and other comorbid conditions.

Reference

The role of cognitive disorders in vestibular disorders.
Guidetti G.
HEARING, BALANCE AND COMMUNICATION
2013;11(S1):3-35.

INTERNATIONAL JOURNAL OF AUDIOLOGY

HIV / AIDS and the ear
Reviewed by: Victor Osei-Lah
Jul/Aug 2013 (Vol 22 No 3)
 

Advances in treatment have prolonged the lives of people with HIV / AIDS. As a result other chronic non-life threatening disabilities are becoming more apparent, and the ear is not spared. This study highlights such effects. Two hundred adult HIV-positive patients were enrolled. On the basis of their CD4 counts, these subjects fell within three Centre for Disease Control (CDC) categories. There were 28 patients in Category 1 (CD4 count > 500 cells/uL), 94 in Category 2 (CD4 count 200-499 cells/uL) and 78 in Category 3 (CD4 count < 200 cells/uL). Interviews probed the self-reported symptoms of tinnitus, vertigo and hearing loss, which were rated on a five point severity scale. The patients were asked about otalgia and pruritus. After a clinical examination of the ears, all subjects had tympanometry, distortion product otoacoustic emissions (DPOAE) and a five-frequency pure tone audiometry (PTA) (0.5kHz, 1kHz, 2kHz, 3kHz and 4kHz) in a quiet room. No reasons were given for not doing a full eight-frequency PTA. A control group of HIV-negative adults was used to compare the prevalence of hearing loss. Tinnitus, vertigo and hearing loss were reported by 26%, 25% and 27.5% of patients respectively. Apart from hearing loss, there were no significant differences between disease categories. Hearing loss greater than 25dB was present in 26.5% and the audiometric configuration was dome-shaped (up-sloping in low frequency and down-sloping in the high frequency regions). The majority of the hearing loss (reported and PTA) was in Category 3, i.e. sensorineural hearing loss worsens with disease progression. I agree with the authors’ conclusion that monitoring hearing and balance symptoms should be part of the routine medical care of HIV / AIDS patients.

Reference

Auditory and otological manifestations in adults with HIV/AIDS.
Van der Westhuizen Y, Swanepoel DW, Heinze B, Hofmeyr LM.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:37-43.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Open fit hearing aids and speech recognition in noise
Reviewed by: Victor Osei-Lah
Jul/Aug 2013 (Vol 22 No 3)
 

Open-fit hearing aids are meant to reduce the occlusion effect of the traditional ear mould, thereby enhancing sound quality in users with relatively normal low frequency hearing. To investigate the advantages or otherwise of open-fitting over traditional ear mould fitting, the authors recruited 20 adults with high frequency sensorineural hearing. They had no previous hearing aid experience and were all fitted binaurally with the Phonak Exelia M hearing aid. Three sound processing modes were studied: omnidirectional mode; directional mode; directional mode combined with noise reduction. Unaided speech reception thresholds (SRT) were determined for all subjects at the initial visit. At the second visit, all subjects were fitted binaurally: one set of open-fit and one set of closed ear moulds in turn. SRTs were determined after fitting in the different sound processing modes. However, subjects were sent home with only the open-fit hearing aids with four selectable programmes. At the next visit 4 – 6 weeks later, the subjects completed a subjective benefit questionnaire. The key findings were that open-fitting with omnidirectional microphones did not improve speech recognition significantly over unaided levels but speech recognition in noise was significantly better with directional microphones compared to unaided and omnidirectional microphones. Noise reduction algorithms conferred no extra advantage but rather reduced the effects of directional microphones compared to conventional ear moulds. The authors recommended that directional microphones should be considered in open-fit hearing aids even though the results are only applicable to the hearing aid used in this study.

Reference

Speech recognition in noise using bilateral open-fit hearing aids: The limited benefit of directional microphones and noise reduction.
Magnusson L, Claesson A, Persson M, Tengstrand T.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2013;52:29-36.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Comparision of microphones for amplification of voice
Reviewed by: Ms Gauri Mankekar
Jul/Aug 2013 (Vol 22 No 3)
 

Voice disorders causing reduced loudness may lead to difficulty in communication, socialising and participating in occupational activities. Amplification is often recommended as part of the management strategy to reduce vocal cord load, improve communication and avoid developing maladaptive compensatory behaviours. Different types of microphones and amplifiers have been recommended. The authors of this article investigated and compared the benefits of the fibre optic microphone versus the electret microphone in the amplification of voice for patients with reduced loudness. They found that the fibre optic microphone (1190S) had  better objective acoustic performance than the electret microphone ( M04). It also had better patient subjective satisfaction than the electret microphone.

Reference

Benefits of the fibre optic versus the electret microphone in voice amplification.
Kyriakou K, Fisher HR.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2013;48:115-26.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Do ENT surgeons adhere to the NICE guidelines for surgical management of glue ear?
Reviewed by: Mary-Louise Montague
Jul/Aug 2013 (Vol 22 No 3)
 

The UK National Institute for Health and Care Excellence guidelines on the surgical management of otitis media with effusion (OME) in children younger than 12 years were published in February 2008. By now we should all be well aware that they advise an initial three month period of observation, with repeat audiological assessment at the end of the three month period. At that stage, ventilation tube (VT) insertion should be considered for children with persistent bilateral OME with a hearing level in the better ear of 25-30 dB NHL or worse (referred to as core criteria in this paper). VT insertion can also be considered for children not meeting these audiological criteria but when OME has significant impact on developmental, social or educational status (referred to as exceptional circumstances in this paper). This paper is a multi-centre retrospective case note review from five UK units of 319 children – 173 before and 146 after guideline introduction. Practice was examined over a six month period after publication of the NICE guidance. A six month period at the same time of year before introduction of the guidelines was also studied in order to determine whether they had changed clinical practice. Exclusion criteria were children with Down's syndrome, cleft lip and palate, those having surgery other than VTs alone or VTs with adenoidectomy and those with major comorbidities, special educational needs or other sensory impairment that may affect the decision to list for surgery. There were no significant differences in practice according to the guidelines before and after their introduction, with respect to having two audiograms three months apart, OME persisting at least three months, or fulfilment of the 25dB audiometric criteria. Interestingly practice in accordance with the core criteria fell significantly from 43.9 to 32.2%. However if the exceptional cases were included, there was no significant difference (85.5 vs 87.0%) as the number of exceptional cases rose from 48.3 to 62.2 %.  This study has shown that 87% of children have VTs inserted in accordance with NICE guidelines providing exceptional cases are included. So it would appear that the flexibility afforded by this NICE guidance allows treating clinicians to individualise the treatment provided to each child, focussing on all of their symptoms rather than just hearing level.

Reference

National Institute for Clinical Excellence guidelines on the surgical management of otitis media with effusion: Are they being followed and have they changed practice?
Daniel M, Kamani T, El-Shunnar S, Jaberoo M-C, Harrison A, Yalamanchili S, Harrison L, Cho W-S, Fergie N, Bayston R, Birchall JP.
INTERNATIONAL JOURNAL OF PEDIATRIC
OTORHINOLARYNGOLOGY
2013;77: 54-8.

JOURNAL OF VESTIBULAR RESEARCH

Cognitive processing and visual-vestibular interaction
Reviewed by: Victor Osei-Lah
Jul/Aug 2013 (Vol 22 No 3)
 

It is known that vestibular stimulation can impair ongoing cognitive processing. In this study, the authors assessed the impact of aging on reaction time of subjects, to spatial (frequency discrimination) and non-spatial auditory (left-right lateralisation) tasks while being subjected to simultaneous visual motion and vestibular stimulation of the semicircular canals and otolith organs. There were seven visual, vestibular and visual-vestibular conditions, four of which were in darkness and one, stationary. Twenty-nine older subjects (73 ± 6 years) and 20 younger subjects (24 ± 2.7 years) without neurological, otological, vestibular or ophthalmological abnormalities were recruited. The reaction time at baseline when subjects were stationary in darkness was significantly greater for non-spatial than for spatial tasks (p  < 0.001). The change in reaction time from baseline for the six other conditions was called the ‘task cost’. The authors found that the task cost was greater for otolithic and visual than for semicircular canal stimulation during both spatial and non-spatial tasks. Interestingly, there were no significant differences between the age groups, which the authors argued, might be attributable to the tasks being less demanding. The “task cost for combined visual and semicircular canal stimuli did not exceed that for visual stimulation alone and … the task cost for combined otolithic and semicircular canal stimuli did not exceed that for otolithic stimulation alone”. In summary, otolithic stimulation has a greater effect on cognitive processing than semicircular canal stimulation in both the young and the old. The implication of these findings in vestibular rehabilitation is the subject of further studies.

Reference

Visual-vestibular stimulation influences spatial and non-spatial cognitive processing.
Furman JM, Redfern MS, Fuhrman SI and Richard Jennings J.
JOURNAL OF VESTIBULAR RESEARCH

2012;22:253-9.

NEUROSURGERY

Conservative surgery for jugular foramen schwannomas
Reviewed by: Ms Gauri Mankekar
Jul/Aug 2013 (Vol 22 No 3)
 

The authors review the extensive experience of the senior author in the management of 81 jugular foramen schwannomas. They adopted two strategies for surgical resection: in one group a very aggressive approach to surgical resection was used. However, this approach was associated with a significant incidence of cranial nerve palsies and morbidity. In the second group, a less aggressive resection was performed and attempts were made to preserve the neurovascular structures, including the pars nervosa, cranial nerves and posterior fossa arteries. This resulted in significant reduction in cranial nerve palsies without a statistically significant increase in recurrence rate. The authors recommend near total resection with preservation of pars nervosa and cranial nerves 9/10 which are important for patient quality of life, as any recurrence can be treated subsequently with multi-modality treatment

Reference

Microsurgical management of jugular foramen schwannomas.
Sedney CL, Nonaka Y, Bulsara KR, Fukushima T.
NEUROSURGERY

2013;72:42-6.

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Top ten considerations in paediatric tympanoplasty
Reviewed by: Hannah Blanchford
Jul/Aug 2013 (Vol 22 No 3)
 

In this review article, the authors confront the challenges of achieving successful paediatric tympanoplasty, often in the absence of evidence-based consensus. It serves as a guide in how to approach and make decisions about tympanoplasty in children, and highlights a move away from a strict algorithm approach, given the multitude of biopsychosocial variables for each individual child. A number of contradictory papers are quoted, to highlight the debates, such as the influence of status of the contralateral ear. The article suggests, for example, considering delaying surgery until the upper respiratory system matures and the adenoid pads regress. Another pearl from the experts is the use of a small ‘tab’ of graft brought through an anterior meatal skin incision to anchor the graft, obviating the need for gelatin sponge or hyaluronic acid derivatives in the middle ear cavity. This concise, well-written review, covering patient and surgical factors, maintains that no single technique can reliably provide a good outcome and that the surgeon’s role remains to adapt and decide how and when to employ novel techniques.

Reference

Ten top considerations in pediatric tympanoplasty.
James AL, Papsin BC.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY

2013;147:992-8.

OTOLOGY AND NEUROTOLOGY

Obituary: William F House
Reviewed by: Rebecca Heywood
Jul/Aug 2013 (Vol 22 No 3)
 

It only seems fitting to include an obituary for William F House, who died on 7 December 2012 at the age of 89, as the first article in a special edition of Otology Neurotology dedicated to cochlear implantation in children. Dr House was a dentist originally and hoped to do maxillofacial surgery. However he spent some time observing in his half-brother Howard House’s ENT practice, decided to become an otologist and never looked back. He was noted by the American Academy of Otolaryngology-Head and Neck Surgery Foundation in 1995 to have “developed more new concepts in otology than almost any other single person in history and thus has had a significant impact on otology and neurotology worldwide”. His achievements include introduction of the operating microscope, development of procedures for management of chronic middle ear disease and Menière’s disease, translabyrinthine and middle fossa approaches for removal of acoustic neuromas, the facial recess approach to the middle ear and of course the cochlear implant, which he considered to be his greatest achievement

Reference

In Memoriam: William F. House, D.D.S., M.D., the “Father of Neurotology” 1923-2012. Berliner KI.
OTOLOGY & NEUROTOLOGY

2013;34:386-7.

OTOLOGY AND NEUROTOLOGY

Otosclerosis: how well does CT correlate to histopathology?
Reviewed by: Hannah Blanchford
Jul/Aug 2013 (Vol 22 No 3)
 

Computed tomography (CT) can be used in conjunction with audiological testing and intraoperative findings to diagnose otosclerosis. CT has been shown to have more than 90% sensitivity when the diagnosis is based on clinical and surgical findings.  This paper describes a prospective randomised blinded review of 46 temporal bone specimen CT scans and comparison with histopathology (10 with otosclerosis, 36 controls without otosclerosis).  CT interpretation failed to diagnose two out of 10 specimens with otosclerosis, giving a sensitivity of 80%.  Three false positive CT diagnoses were made in the 36 control specimens ithout histopathological evidence of otosclerosis. These false diagnoses were based on hypodense regions anterior to the stapes footplate which, on histopathological correlation, were areas of increased connective tissue and vasculature.  The authors conclude that clinicians should be mindful not to assume that lucency in this area represents otosclerosis.  The second unblinded part of the study reviewed imaging and histopathology of the otic capsule in 18 temporal bone specimens with otosclerosis. CT interpretation was found to be less sensitive when the focus of pathology occurred in the pericochlear area (nine out of 11 diagnosed correctly) and round window niche (three out of six). However, these areas demonstrated only small foci of otosclerosis. This paper is novel in analysing the sensitivity of high-resolution CT to the ‘gold-standard’ histopathological diagnosis of otosclerosis.  The authors conclude that CT remains sensitive and specific, but that sensitivity varies according to size and location of the otosclerotic focus.

Reference

Correlation of Computed Tomography with Histopathology in Otosclerosis.
Quesnal AM, Moonis G, Appel J, O’Malley JT, McKenna MJ, Curtin HD, Merchant SN.
OTOLOGY & NEUROTOLOGY

2013;34:22-8.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Immunosuppression with transtympanic methotrexate in rats
Reviewed by: Madhup K Chaurasia
Jul/Aug 2013 (Vol 22 No 3)
 

Progressive hearing loss and vestibular problems have often been associated with an autoimmune process. Suppression of autoimmune reaction has been tried with corticosteroids, but these have adverse systemic effects. The use of methotrexate for autoimmune suppression is prevalent in conditions such as rheumatoid arthritis, systemic lupus erythematosus, Sjogren’s syndrome and polyarteritis nodosa and similar conditions. In this study, the authors contemplate whether intratympanic application of methotrexate would be safe in terms of not inducing local and systemic pathology. The study involved 24 male Wistar rats, who received two concentrations of methotrexate intratympanically in the two experimental groups and comparison was made with intratympanic injection of Ringer lactate solution. The experiments were performed under anaesthesia. Auditory brain stem testing was done before and after administration of methotrexate and ringer lactate solutions. Blood samples were taken for analysis of liver enzymes and haemoglobin. Middle ear and liver biopsies were performed after sacrificing the animals. The data was statistically analysed. There was no statistically significant difference in any of the parameters. Liver biopsies did not suggest any form of damage and there was no reaction in the middle ear mucosa. The authors suggest methotrexate is safe, unlike other drugs such as cyclophosphamide and corticosteroids. Comparisons from the literature have been made with the use of etanercept. The study has limitations in that just a day was allowed to test post administration status in terms of liver damage and middle ear mucosal reaction and there would be wide gaps between animal experimentation and actual clinical benefits in a patient, but the study does do some fact finding.

Reference

Local and systemic effects of low-dose transtympanic methotrexate: in vivo animal study.
Sozen E, Erol SB, Yildrim O, Coskin BU, Basak T, Kayhan FT, Dadas B.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

2013;127:148-52.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Quality of life after adenotonsillectomy for obstructive sleep apnoea syndrome
Reviewed by: Madhup K Chaurasia
Jul/Aug 2013 (Vol 22 No 3)
 

Children with large tonsils and adenoids often present with sleep disordered breathing. This affects quality of life and in the long term may detriment health in terms of pulmonary hypertension, growth retardation and cognition. Several studies have been quoted which describe a number of changes in the child’s well being, education input and behaviour regulation. Emotional fragility is another factor associated with obstructive sleep apnoea syndrome (OSAS) in various studies. In this study the authors selected 39 children under three years of age who were suffering from OSAS as diagnosed by pulse oxymetry showing oxygen desaturation dips of greater than 4% and / or repetitive episodes exceeding 10 fluctuations per hour. 77% of patients were male and 23% female. The assessment was made by a questionnaire covering six domains, namely physical suffering, sleep disturbance, speech or swallowing problems, emotional distress, activity limitations and care giver concerns. Improvements in these domains were rated from zero (“none”) to six (“couldn’t be more”). The distribution of improvement scores showed the highest score to be for physical suffering, sleep disturbance and care-giver concern and the same was true of the mean improvement scores in these domains. For speech and swallowing problems and activity limitations, the improvement was minimal but no respondents said there was no improvement in any of these domains. The study therefore affirms that adenotonsillectomy results in considerable improvement in quality of life. This study has limitations, in that it depends on the response of parents from memory and a comparison between pre- and post-operative assessment of these domains would have been more meaningful.

Reference

Quality of life assessment following adenotonsillectomy for obstructive sleep apnoea in children under three years of age.
Mandavia R, Dhar V, Kapoor K, Rachmanidou A.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1241-6.

WORLD JOURNAL OF SURGICAL ONCOLOGY

Induction chemotherapy – benefits
Reviewed by: Ms Gauri Mankekar
Jul/Aug 2013 (Vol 22 No 3)
 

This is a retrospective study of fourteen randomised trials performed between 1965 and 2011, on the impact of induction chemotherapy on survival, disease control and toxicity in patients with resectable advanced disease. The authors found that there was no significant difference in overall survival, disease free survival, or loco-regional recurrence between the patients treated with and without induction chemotherapy. But patients treated with induction chemotherapy had an 8% lower rate of distant metastasis, compared to those treated without induction chemotherapy. The incidence of induction chemotherapy-associated death was 0%–5%. The authors conclude that there is a significant benefit of induction chemotherapy on decreasing the incidence of distant metastasis in patients with resectable head and neck squamous cell carcinoma. Also, in patients with laryngeal cancer, induction chemotherapy provides larynx preservation in those patients who respond to induction chemotherapy.

Reference

Induction chemotherapy in patients with resectable head and neck squamous cell carcinoma: a meta-analysis.
Ma J, Liu Y, Yang X, Zhang C-P, Zhang Z-Y, Zhong L-P.
WORLD JOURNAL OF SURGICAL ONCOLOGY

2013;11:67.

ACTA OTOLARYNGOLOGICA

Different outcomes for idiopathic versus traumatic BPPV
Reviewed by: Victoria Possamai
May/Jun 2013 (Vol 22 No 2)
 

This group from China reviewed their Benign paroxysmal positioal vertigo patients between 2004 and 2011, assessing  40 patients with traumatic, and 46 with idiopathic BPPV (iBPPV). It was not clear whether these represented all patients with these diagnoses seen during this period, or a selected cohort. The definition of traumatic BPPV (tBPPV) was made by the onset of vertigo within three months of well-documented head injury. Patients with history of any other identifiable aetiology were excluded. Patients were examined and underwent the appropriate particle repositioning manoeuvre (PRM), following Hallpike-Dix and rollover test.  Patients were reviewed at one week when, if needed, PRM was repeated, then, once negative for vertigo, after three, six and 12 months. The follow- up revealed stark differences in outcomes for the two groups – 55% of tBPPV patients had involvement of two or more semicircular canals, vs 6.5% in iBPPV group, 25% of the tBPPV group had bilateral SCC involvement vs 2% in iBPPV. After a single PRM, 84% of iBPPV patients were asymptomatic vs only 35% of tBPPV group. Recurrence of symptoms was much greater (67%) in tBPPV vs iBPPV (12%) groups within 12 months. The paper discusses the pathological inner ear changes which may be caused by trauma, to explain the different outcome.  Awareness of the marked difference between the two groups is useful to know to provide prognostic information for patients.

Reference

Presentation and outcome of post-traumatic benign paroxysmal positional vertigo.
Liu H.
ACTA OTOLARYNGOLOGICA
2012;132:803-6.

ALLERGY

Uncontrolled allergic rhinitis: is there any way to control it?
Reviewed by: Evangelia Tsakiropoulou
May/Jun 2013 (Vol 22 No 2)
 

This is an interesting review dealing with allergic rhinitis and chronic rhinosinusitis patients, who do not improve after guideline-based treatment. The authors provide an overview of how control of the disease is currently defined. Regarding chronic rhinosinusitis, the criteria proposed in the 2012 update of the European Position Paper on Rhinosinositis and Nasal Polyps document combined evaluation of the severity of sinonasal symptoms by the patients, clinical evaluation of the mucosa and need for systemic treatment over the course of the last month. For evaluation of control in allergic rhinitis, visual analogue scale score for total nasal symptoms turned out to be a convenient tool. However, further evaluation for both disorders is needed. The uncontrolled cases are described by the term severe chronic upper airway disease and represent a therapeutic challenge for all clinicians. Both allergic rhinitis and chronic rhinosinusitis are multi-factorial diseases involving anatomic, humoral, environmental, endogenous and even iatrogenic factors. So, the lack of symptom improvement could implicate parameters related to the pathophysiology of the disease, the diagnosis, the treatment modalities and patients’ perceptions of the treatment, as well as compliance. The authors underline the need for a better insight into the different factors responsible for the lack of symptom control.

Reference

Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand today?
Hellings PW, Fokkens WJ, Akdis C, Bachert C, Cingi C, Dietz de Loos D, Gevaert P, Hox V, Kalogjera L, Lund V, Mullol J, Papadopoulos NG, Passalacqua G, Rondón C, Scadding G, Timmermans M, Toskala E, Zhang N, Bousquet J.
ALLERGY
2013;68:1–7.

B-ENT

Risk factors for laryngeal cancer: not only smoking and alcohol?
Reviewed by: Iordanis Konstantinidis
May/Jun 2013 (Vol 22 No 2)
 

This paper investigates the role of smoking, alcohol, coffee consumption, demographic factors, toxic agents and occupation in laryngeal carcinogenesis. In this case-control study, 70 patients with histologically confirmed laryngeal cancer were compared with 70 controls, who had non-neoplastic conditions unrelated to the assessed factors. Relative risk, odds ratio (OR) and 95% confidence intervals were estimated using multiple logistic regression. The study confirmed the already known relationship between smoking and laryngeal cancer. In addition the respective OR for alcohol consumption was 3.94 (p = 0.006). While the risk increased for heavy drinkers, there was no difference in terms of duration of alcohol consumption. However, what is interesting in this study is a strong and consistent relationship between laryngeal cancer and the consumption of Greek / Turkish cups of coffee / day (p = 0.002, OR = 1.77). This is not in agreement with the current literature, which suggests coffee has a protective role in oral and pharyngeal cancer and no role in laryngeal cancer. Further studies are needed to clarify the role of coffee, comparing different forms of it. Finally the authors suggest that diesel exhaust fumes also seemed to increase the risk of laryngeal cancer, however the association found was not significant after logistic regression analysis.

Reference

Laryngeal cancer: smoking is not the only risk factor.
Vassileiou A, Vlastarakos PV, Kandiloros D, Delicha E, Ferekidis E, Tzagaroulakis A, Nikolopoulos TP.
B-ENT
2012;8:273-78.

BMC EAR, NOSE AND THROAT DISORDERS

Review of ENT injuries at a medical centre in Tanzania
Reviewed by: Gauri Mankekar
May/Jun 2013 (Vol 22 No 2)
 

This prospective study reviews 456 cases of ear, nose and throat injuries over a five year period at the Bugando Medical Centre in north-western Tanzania. The study found that the commonest cause of injury was foreign bodies, followed by road traffic accidents. The ear was the most common part of the body to be injured and foreign body removal and surgical wound debridement were the most common procedures. The majority of patients were treated on an outpatient basis. The authors conclude that the majority of the injuries could be prevented through public awareness campaigns.

Reference

Ear, nose and throat injuries at Bugando Medical Centre in northwestern Tanzania: a five-year prospective review of 456 cases.
Gilyoma JM, Chalya PL.
BMC EAR, NOSE AND THROAT DISORDERS
2013;13:4.

COCHLEAR IMPLANTS INTERNATIONAL

A test battery for the assessment of pitch perception in speech
Reviewed by: Thomas Nikolopoulos
May/Jun 2013 (Vol 22 No 2)
 

The need for such tests arises from the increased awareness of the importance of prosody in clinical practice, and the development of methods for improving pitch perception in listeners with profound hearing loss. The auditory speech sounds evaluation 2009 test battery developed by the authors aims to assess speech pitch perception. It was designed to (a) assess perception of pitch in linguistic contexts without the confounds of secondary acoustic cues, (b) be usable with listeners from different language backgrounds, and (c) be suitable for use in a clinical setting. Identification and discrimination tasks based on linguistic contexts were developed to establish listeners' just noticeable differences (JNDs) for pitch changes. Stimuli were pseudosentences and pseudowords based on speech from a female speaker, overlain with stylised pitch contours. Target pitch excursions were varied from the 200 Hz baseline to a maximum of 349 Hz. Ninety normal-hearing listeners participated in test validation. The JNDs on non-linguistic, control tasks were lower than on linguistic ones, showing that non-linguistic tasks may overestimate pitch perception in speech. Listeners from different language backgrounds scored comparably on most linguistic tasks, and test/retest differences were non-significant. The authors concluded that test usability as evidenced by task duration and subject experience seems satisfactory for clinical use. It remains to be seen how useful this test will be found in current practice.

Reference

Development of the A&E test battery for the assessment of pitch perception in speech.
Heeren W, Coene M, Vaerenberg B, Avram A, Cardinaletti A, del Bo L, Pascu A, Volpato F, Govaerts PJ.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13:206-19.

COCHLEAR IMPLANTS INTERNATIONAL

Is pneumococcal vaccination in paediatric cochlear implantees optimum?
Reviewed by: Thomas Nikolopoulos
May/Jun 2013 (Vol 22 No 2)
 

It is well known, at least in the UK cochlear implant programmes, that pneumococcal vaccination is mandatory in all candidates for paediatric cochlear implantation. Therefore, it is routine practice to check that pneumococcal vaccinations have been received prior to surgery. Recent changes in United Kingdom national guidelines mean that children who were previously thought to be fully immunised may in fact not be optimally protected. This paper aimed to assess the current situation with regard to pneumococcal vaccination in paediatric cochlear implantees. The authors investigated the pneumococcal immunisation status of 63 paediatric cochlear implant recipients, using a unique and comprehensive flowchart-style audit tool. The data collected included age at implantation, details of previous immunisation, and whether or not further vaccinations were required. It was very interesting to find that 54% of children were not optimally immunised prior to implantation and 70% required further vaccinations following surgery. The commonest reason for an incomplete immunisation history was failure to administer the 23-valent vaccine after the second birthday. The alarming results of this study suggest that pneumococcal vaccination should be standardised across the UK and carefully monitored, especially in high-risk populations such as paediatric cochlear implant recipients. I do not dare to think what the situation is in other countries where a National Health System does not exist.

Reference

Optimising pneumococcal vaccination for paediatric cochlear implant recipients using the cochlear implant pneumococcal vaccination flowchart.
Moore A, Harris R, Selvadurai D.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13:193-6.

COCHLEAR IMPLANTS INTERNATIONAL

Programming balanced bilateral cochlear implant stimulation levels in children
Reviewed by: Thomas Nikolopoulos
May/Jun 2013 (Vol 22 No 2)
 

Device tuning may be very challenging in young implantees. Bilateral cochlear implantation added another factor to the already difficult equation. This study aimed to assess the differences in stimulation levels between bilateral cochlear implants (CIs) in children and compared these to previously recorded measures of balanced input. Participants were 19 children who received bilateral CIs sequentially. Behaviourally determined minimum and maximum stimulation levels from the first (CI-1) and second (CI-2) CIs at an apical electrode (#20) were compared with thresholds of the electrically evoked compound action potential (ECAP) of the auditory nerve and electrically evoked stapedius reflex (ESR). The results revealed that all four measures were greater when evoked from CI-1 than CI-2 and the dynamic range between behavioural measures was reduced in CI-2 relative to CI-1. Significant correlations were found between differences in behavioural and objective measures; as differences in threshold-levels between CI-1 and CI-2 increased, so did the differences in ECAP thresholds and a similarly positive relationship was found between C-level differences and ESR threshold differences. Differences in ECAP thresholds between CI-1 and CI-2 were significantly correlated with balanced bilateral levels. The authors concluded that although lower levels were needed on the side more recently implanted with newer technology, the dynamic range of input provided on the second side was reduced relative to the more experienced side. In addition, differences in behavioural measures between CI-1 and CI-2 could be partially predicted by objective measures. The authors finally claim that ECAP thresholds show the best promise for helping to provide balanced bilateral CI input in children. However the outliers in the statistical graphs of this study indicate that there are cases that may not follow these correlations and tuning may be very difficult.

Reference

Toward a method for programming balanced bilateral cochlear implant stimulation levels in children.
Gordon KA, Chaiko, MH, Salloum C, Goulding G, Papsin B.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13:220-7.

COCHLEAR IMPLANTS INTERNATIONAL

The transition from the paediatric to adult cochlear implant setting remains challenging for implantees and cochlear implant professionals
Reviewed by: Thomas Nikolopoulos
May/Jun 2013 (Vol 22 No 2)
 

Most cochlear implant (CI) centres have two different settings; paediatric and adult, each of which may have completely different professionals and philosophy. The transition from the paediatric to the adult setting may have various implications in the quality of life of implantees. This issue of transition is not unique to CI services and research in other chronic health conditions has documented a variety of challenges for youth and health care providers. The aims of this study were to identify factors important in the transition from paediatric to adult CI services, from the perspective of service providers and to make recommendations to improve transition practices in the future. Qualitative research methodology was used to identify key themes. Data extracted from patient files allowed comparison of paediatric and adult CI recipients. The results showed that youths who had received CIs in the paediatric setting differed from other adult patients in the incidence of prelingual hearing losses, and age at CI surgery. Key focus group themes were related to service delivery models, communication between settings, and skills needed by the patients to effectively meet their own health needs. The main recommendations include: formal and adequate communication between the two settings, designation of a key person responsible for this communication, systematic transfer of information, involvement of parents and community services, awareness of the special needs of teenagers, implementation of audits and tools to assess the effectiveness of the transition, etc. A very interesting study reminding us that implantees have individual needs that have to be met, especially when moving to a different setting.

Reference

Facilitating the transition from the pediatric to adult cochlear implant setting: perspectives of CI professionals.
Olds J, Fitzpatrick E, Séguin Ch, Moran L, Whittingham, J, Schramm D.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13:197-205.

EUROPEAN JOURNAL OF ONCOLOGY NURSING

Education at discharge for head and neck cancer patients
Reviewed by: Angela Griggs
May/Jun 2013 (Vol 22 No 2)
 

The information needs of head and neck cancer patients are a key issue for nurses. Head and neck treatment often causes life changes that continue after discharge home. To prepare the patient for discharge, they require adequate information on their treatment and future health and life issues. The authors of this paper identified that information needs were required, but that they were unable to find effective education interventions in the literature. This paper looks at the development of a nurse-led education intervention and then determines the effect of this intervention on the information needs and satisfaction with the information provided to head and neck cancer patients. The study used a quasi-experimental method with 48 participants. The control group (26) received the current standard of information, given via a short interview talking through the discharge letter. The intervention group (27) received the education intervention. This consisted of a discharge interview, using a checklist to inform patients about general information, wound care, physical-social problems, work and finances. The effects were measured using the Patient Information Need Questionnaire (PINQ) and the Satisfaction with Cancer Information profile. Telephone interviews were carried out five days after discharge. The results found that patients and nurses liked the structured interview. The study found no significant effect on information needs or level of satisfaction between the two groups. The authors highlight that this result may have been because patients review information across all of their stay, rather than just the information at discharge. This is an interesting paper which reviews the information needs of head and neck cancer patients. Although they found no difference with the education intervention, they have highlighted the usefulness of the tools, and nurses and doctors would find this paper useful when thinking about how to plan what information to give out.

Reference

Educational intervention for patients with head and neck cancer in the discharge phase.
van der Meulen I, de Leeuw J, Gamel C, Hafsteinsdóttir T.
EUROPEAN JOURNAL OF ONCOLOGY NURSING
2013;17:220-7.

HEAD & FACE MEDICINE

Cavernous sinus thrombosis caused by contralateral sphenoid sinusitis
Reviewed by: Bilal Gani
May/Jun 2013 (Vol 22 No 2)
 

This report is based on the case of a 33 year old female, who presented with right-sided, temporal headache, chemosis and proptosis in the left eye. Physical examination further revealed pyrexia, periorbital edema and left abducent nerve paresis. Contrast enhanced computerised tomography (CT) showed left superior ophthalmic vein enlargement and congested right sided paranasal sinuses. A T1 weighted multi-resonance imaging (MRI) scan agreed with the CT findings and showed enlargement of the left cavernous sinus. It was also noted that the right sphenoid sinus was much larger than the left. The patient was treated surgically with right endoscopic drainage of the sphenoid sinus, which resulted in a marked improvement in symptoms and signs. A prolonged course of antibiotics was also administered together with beclametasone, heparin and, more latterly, warfarin. This rare case of cavernous sinus thrombosis (CST) is thought to have arisen from the infected dominant contralateral sphenoid sinus. Although the cavernous sinus drains several areas, including the face, tonsils and soft palate, the advent of antibiotic therapy has led to the sphenoid sinus emerging as the most common source of infection. In this case CT imaging showed that the right sphenoid sinus was dominant, lying in contact with both cavernous sinuses, which may explain the spread of infection. In summary, sphenoid sinusitis is difficult to diagnose and may explain why this is associated with a poor prognosis of CST. Based on this report one should not rule out contralateral infection as a cause of CST.

Reference

Cavernous sinus thrombosis caused by contralateral sphenoid sinusitis: a case report.
Komatsu H, Matsumoto F, Kasai M, Kurano K, Sasaki D, Ikeda K.
HEAD & FACE MEDICINE
2013;9:9. http://www.head-face-med.com/content/9/1/9/abstract 

HEARING, BALANCE AND COMMUNICATION

Defining hearing loss and its consequences
Reviewed by: Dr Vinaya KC Manchaiah
May/Jun 2013 (Vol 22 No 2)
 

Hearing is a complex function that has both cognitive and emotional aspects. A person with hearing loss may have other symptoms in the physical, mental and social domains. Hearing loss in the context of clinical audiology is currently defined based on type of pathology and severity. However, evidence from both clinical findings and research suggests that this may not cover all the aspects of ‘hearing loss’ as a disability. This discussion paper highlights various factors that may be important in defining hearing loss and its consequences, and also presents different perspectives based on various models of disability, with particular emphasis on the biopsychosocial model. It is suggested that defining and describing hearing loss and its consequences with a holistic approach has some clinical value, particularly in the context of audiological enablement / rehabilitation. The authors argue that it is time to rethink how we define hearing loss, which may have significant implications on how we manage it. These arguments are supported by relevant literature and supplemented with brief discussion about the recent development of the International Classification of Functioning, Disability and Health (ICF) core sets for hearing loss.

Reference

Perspectives in defining ‘hearing loss’ and its consequences.
Manchaiah VKC, Stephens D.
HEARING, BALANCE AND COMMUNICATION
2013;11:6-16.

INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY

Of smell and pituitary surgery – again!
Reviewed by: Christos Georgalas
May/Jun 2013 (Vol 22 No 2)
 

As the endoscopic approaches to skull base gain in popularity, there comes a time for assessing our results, not only in terms of oncological success, but also in terms of sinonasal outcomes. More extended approaches have been made feasible through the use of improved reconstruction techniques, however, these have been associated with worse olfactory scores. In this study, the authors assessed the olfactory function of 22 patients all of whom underwent transphenoid endoscopic surgery, 20 for pituitary adenomas and two for Rathke cysts. They used the University of Pennsylvania Smell Identification Test (UPSIT) as well as an abbreviated eight question form of the sinonasal outcome test. After an average follow- up of two months, the authors noticed no significant difference in the eight SNOT 22 questions nor in overall olfactory scores. Although the results would appear encouraging to anyone doing this type of surgery, they come as no surprise. The authors assessed a small number of patients undergoing almost exclusively pituitary surgery and their decision to reduce SNOT 22 to eight items would appear methodologically problematic, to anyone familiar with quality of life instruments. Healing takes a few months in endoscopic skull base surgery, and hence the follow-up of only 60 days is not long enough for assessing QOL outcomes. The patients they assessed did not undergo complex extended approaches, which require reconstruction with nasoseptal flaps, and hence would have been unlikely to suffer negative nasal symptoms. Indeed, it has been shown for more than 10 years, that simple endoscopic pituitary surgery has better nasal outcomes than the microscopic approaches. The authors have confirmed this with their study – however, we are still awaiting similar studies that would replicate their results in more extended approaches.

Reference

Olfactory and sinonasal outcomes in endoscopic transsphenoidal skull-base surgery.
Sowerby LJ, Gross M, Broad R, Wright ED.
INTERNATIONAL FORUM OF ALLERGY AND RHINOLOGY
2012; [Epub ahead of print] doi: 10.1002/alr.21103.

INTERNATIONAL JOURNAL OF AUDIOLOGY

Behavioural versus electrophysiological measures
Reviewed by: Diego Zanetti
May/Jun 2013 (Vol 22 No 2)
 

The auditory discrimination abilities of adult listeners are usually tested with psychophysical methods. Conversely, electrophysiological tests are necessarily applied in children and non-cooperative subjects. The N1-P2 acoustic change complex (ACC) (Ostroff et al., 1998) is an objective method of detection of sound changes, i.e. recording of the cortical response modification determined by changes in continuous or long standing stimuli. It can be obtained by varying the frequency or the intensity of a pure tone or noise stimulus, or by introducing a silent gap. Despite the morphologic similarity with the slow vertex responses (SVR) to brief stimuli (tone pips, clicks, short speech tokens), the ACC are exclusively elicited by changes in continuous sounds. Interestingly, it can be recorded not only in normal hearing listeners, but also in patients with sensorineural hearing loss, cochlear implants, auditory spectrum disorders and children as young as six years of age. The authors compared the behavioural thresholds of detection of the amplitude and spectrum change and temporal gap with those of the recordings of ACC. They observed a good correlation between the amplitude changes and the behavioural thresholds, but not with frequency changes or gap detection. In particular, the ACC amplitude increased proportionally to the increment of acoustic change of intensity. This study represents another step forward in the search for a reliable method of assessment of the auditory discrimination abilities in children.

Reference

Auditory discrimination: the relationship between psychophysical and electrophysiological measures.
He S, Grose JH, Buchman CA.
INTERNATIONAL JOURNAL OF AUDIOLOGY
2012;51:771-82.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Classification systems for children with speech and sound disorders
Reviewed by: Gauri Mankekar
May/Jun 2013 (Vol 22 No 2)
 

This is an excellent review article on the difficulties faced in classifying and in the management of children with speech and sound disorders (SSD). One of the greatest difficulties faced is that there is no universal agreed-upon classification system for SSD, although children with SSD form more that 70% of the clinician’s case load. There is considerable support for classifying speech disorders into those with a known aetiological factor versus unknown or ‘functional’ speech disorders. However there is controversy regarding the further classification of the large heterogenous group of unknown or ‘functional’ speech disorders. In this article the authors describe classification systems, review existing empirical evidence and evaluate the major classification system against five criteria. They strongly recommend a universally agreed upon classification system that would be useful for clinicians as well as researchers.

Reference

How should children with speech and sound disorders be classified? A review and critical evaluation of current classification systems.
Waring R, Knight R.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2013;48:25-40.

INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY

Foreign body aspiration - what do mothers know?
Reviewed by: Mary-Louise Montague
May/Jun 2013 (Vol 22 No 2)
 

Foreign body aspiration is a common cause of respiratory emergencies in young children and it can be life threatening. There have been significant advances in airway management and endoscopic technology. Despite this, the incidence of foreign body aspiration has not changed significantly. This Japanese study involved the development of a questionnaire assessing the knowledge of parents regarding foreign body aspiration. It was distributed for completion at regular check-ups for children under two years of age. The authors also tried to ascertain what factors are associated with lack of parental knowledge regarding foreign body aspiration. Out of 1766 questionnaires distributed, 1603 were recovered. Most of them (1539) were answered by mothers. Only 4.3% of mothers did not recognise a small toy as a cause of foreign body aspiration. 20.2% were unaware that peanuts and other nuts can cause foreign body aspiration. 48% did not realise that they should not give nuts to a child under three years of age. With respect to clinical signs, 27.7% and 41.8% of mothers did not know that sudden choking and sudden coughing respectively were symptoms suggestive of foreign body aspiration. Being a mother with a child younger than 12 months and being a mother with a first child were independent risk factors for lack of knowledge about foreign body aspiration. The age of the mother was not. There are some limitations of the study – namely the questionnaire used was not validated, it did not assess other caregivers' knowledge, and confounding factors such as educational level, economic status and family size were not accounted for. Nonetheless, from this data it would appear that a substantial number of mothers lack knowledge about foreign body aspiration. This knowledge gap could be targeted easily by health visitors, paediatricians and public health providers, providing an individualised educational programme for mothers of children under 12 months and mothers with first children, irrespective of mothers' age.

Reference

Mothers' knowledge about foreign body aspiration in young children.
Higuchi O, Adachi Y, Adachi YS, Taneichi H, Ichimaru T, Kawasaki K.
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2013;77:41-4.

JOURNAL OF HEAD TRAUMA REHABILITATION

Post concussive symptom reporting
Reviewed by: Susan A Douglas
May/Jun 2013 (Vol 22 No 2)
 

This is a well-written article, which examines health assessments in combat veterans. It examines the association between post-concussive symptoms (PCS) and mild traumatic brain injury (MTBI), while adjusting for depression and post-traumatic stress disorder (PTSD). The incidence of concussion or MTBI has increased in combat veterans because of the predominance of injuries due to blast weaponry. Coupled with the improvements in body armour and field medical care, this has resulted in a greater survivability rate. Combat veterans therefore survive their wounds but often face adverse post injury health sequelae. The study population consisted of 334 service members with MTBI and 658 with non-head injuries. When compared to those with non-head injury, those with MTBI were more likely to be male, younger, junior enlisted and marines. Blast injuries accounted for more than twice as many MTBIs as non-head injuries. After adjustment for PTSD and depression, those with MTBI were more likely to complain of headache, back pain, memory problems, tinnitus and dizziness, than those with non-head injury. Patients with MTBI were more likely to report PCS symptoms than those with non-head injury. MTBI is associated with reports of negative health consequences in combat veterans, even when the co-occurring psychological morbidity is accounted for. These post-concussive symptoms are associated with declines in veterans’ self-related health and this may be important in targeting and prioritising clinical interventions.

Reference

Post concussive symptom reporting among US combat veterans with mild traumatic brain injury from operation Iraqi freedom.
MacGregor AJ, Dougherty AL, Tang JJ, Galarneau MS.
JOURNAL OF HEAD TRAUMA REHABILITATION  
2013;28(1):59-67.

JOURNAL OF MEDICAL CASE REPORTS

Burkitt’s lymphoma originating from the nasal septum
Reviewed by: Bilal Gani
May/Jun 2013 (Vol 22 No 2)
 

This case report describes a very unusual presentation of sporadic (non-cleaved) Burkitt’s lymphoma (BL). The 78 year old non-smoking Caucasian male presented with complaint of left sided nasal obstruction. Physical examination revealed a smooth mass occluding his left nasal orifice with rightward deviation of his nasal septum. Paranasal computerised tomography (CT) revealed it originated from his anterior septum. Histopathological and immunohistochemical evaluation derived from a punch biopsy allowed a diagnosis of BL to be made. Titres testing for the human immune-deficiency virus (HIV) and Epstein-Barr virus (EBV) were both negative. Eight cycles of chemotherapy and no radiotherapy resulted in a loss of tumour mass and no nasal obstruction. The sporadic form of BL accounts for 1-2% of adult lymphomas in Western Europe and the United States. Although BL is histologically the same as the one that occurs in endemic areas, it presents differently. It is most commonly found in lymphoid tissues of the gut and the upper respiratory tract. This is the first described case of BL originating from the anterior septum. As a result of the short intensive chemotherapy regimen followed ± radiotherapy there is a 92% two year event-free survival rate for children and adults with small non-cleaved lymphoma. The combination of chemotherapy and radiotherapy has resulted in a complete cure of this patient. However, it should be noted that negative EBV titres are associated with a good prognostic outcome.

Reference

Unusual presentation of sporadic Burkitt’s lymphoma originating from the nasal septum: a case report.
Aslan G.
JOURNAL OF MEDICAL CASE REPORTS
2013;7:60.
http://www.jmedicalcasereports.com/content/7/1/60

JOURNAL OF THE ASSOCIATION FOR RESEARCH IN OTOLARYNGOLOGY

Inner hair cell dysfunction induces tinnitus?
Reviewed by: Iordanis Konstantinidis
May/Jun 2013 (Vol 22 No 2)
 

This is a nice paper dealing with an old question regarding the correlation of tinnitus with the presence of damaged hearing – why does tinnitus affect only some, and not all, hearing loss patients? The authors suggest that tinnitus patients have specific inner ear damage that triggers tinnitus. In this study, differences in cochlear function inferred from psychophysical measures were measured between hearing-impaired listeners with tinnitus and hearing-impaired listeners without tinnitus. The main finding of the study was that tinnitus patients had better frequency selectivity and compression than those without tinnitus, although both groups had similar hearing loss. The results suggest that the presence of subjective tinnitus may not be strongly associated to outer hair cell impairment, at least where hearing impairment is evident. In addition the results show a different pattern of hearing impairment amongst the tinnitus patients, a fact in agreement with the suggestion that inner hair cell dysfunction with reduced auditory innervation could be a possible trigger of tinnitus.

Reference

Tinnitus and patterns of hearing loss.
Tan CM,  Lecluyse W,  McFerran D,  Meddis R.
JOURNAL OF THE ASSOCIATION FOR RESEARCH IN OTOLARYNGOLOGY
2013;14: 275-82. 

JOURNAL OF VESTIBULAR RESEARCH

Vestibular rehabilitation for bilateral vestibular failure – the evidence
Reviewed by: Victor Y. Osei-Lah
May/Jun 2013 (Vol 22 No 2)
 

The effectiveness of vestibular rehabilitation (VR) in unilateral peripheral vestibular hypofunction is well documented. However, the same cannot be said about bilateral vestibular hypofunction / failure (BVF). The two modalities of VR interventions that were assessed were exercise-based programmes and sensory prosthetics. This systematic review examined the evidence of VR outcomes in BVF using the WHO International Classification of Functioning, Disability and Health (ICF) framework. Under this framework, the effect of VR on BVF patients was assessed in three domains: body functions and structure, activity and participation. Fourteen studies met the authors’ strict inclusion criteria. There were several studies reporting outcome measures on the effect of exercise-based programmes on body functions, i.e. gaze and postural stability; with the level of evidence classified as moderate by the authors. Due to the limited number of studies, there was insufficient evidence to support VR in improving activity and participation in patients with BVF. Sensory prosthetics are in the early stages of development and this may explain why there was no evidence to support its effectiveness in BVF.

Reference

The effect of vestibular rehabilitation on adults with bilateral vestibular hypofunction: A systematic review.
Porciuncula F, Johnson CC and Glickman LB.
JOURNAL OF VESTIBULAR RESEARCH
2012;22:283–98.

NEUROSURGERY

Management of facial paresis / paralysis following vestibular schwannoma surgery
Reviewed by: Gauri Mankekar
May/Jun 2013 (Vol 22 No 2)
 

In this retrospective study the authors evaluated the facial nerve functional outcome in patients with an electrically unresponsive but anatomically intact facial nerve after microsurgical vestibular schwannoma removal. They tried to determine whether facial nerve repair during the same surgical procedure should be considered. Eleven patients met their inclusion criteria. The median preoperative and definitive postoperative scores were House-Brackmann grades 1 and 3 respectively and the median time for definitive facial nerve recovery was 9.4 months. From their data the authors concluded that modern prognostic testing strategies are incapable of reliably predicting poor outcomes. Therefore if facial nerve continuity is maintained then facial nerve repair should not be pursued during the same procedure. The best option seems to be to observe facial nerve recovery closely, both clinically and electrophysiologically and if the facial palsy persists for 10 - 12 months, then to consider facial reanimation procedures.

Reference

The anatomically intact but electrically unresponsive facial nerve in vestibular schwannoma surgery.
Carlson ML, Van Abel KM, Schmitt WR, Driscoll CL, Neff BA, Link MJ.
NEUROSURGERY
2012;71:1125-30.

NEUROSURGERY

Middle clinoid anatomy for extended endonasal surgery
Reviewed by: Gauri Mankekar
May/Jun 2013 (Vol 22 No 2)
 

This article describes in detail the anatomy of the middle clinoid region and is accompanied by high quality images and video. The authors examined fine-cut CT angiogram scans of 100 patients and 50 anatomic specimens for middle clinoid anatomy and variations. Ten coloured silicon injected specimens were used to study the surgical anatomy for endonasal middle clinoidectomy. The middle clinoid was identifiable in 60% of the scans and 20% had at least one caroticoclinoidal ring. The authors conclude that recognition of the middle clinoid and caroticoclinoid ring on preoperative imaging is critical for surgical planning and middle clinoid removal in endonasal surgery. This article will be of interest to those surgeons who perform endonasal extended transsphenoidal surgery.

Reference

Endoscopic endonasal middle clinoidectomy: anatomic, radiological and technical note.
Fernandez-Miranda JC, Tormenti M, Latorre F, Gardner P, Snyderman C.
NEUROSURGERY
2012;71:233-9.

NEUROSURGERY CLINICS OF NORTH AMERICA

Pituitary tumour removal via the endoscopic approach
Reviewed by: Gauri Mankekar
May/Jun 2013 (Vol 22 No 2)
 

In this article, the authors describe the history of endoscopic transphenoidal pituitary surgery, compare it with the microsurgical approach, and describe in detail the equipment and surgical instrumentation, as well as the pre-operative assessment. They also discuss technique, complications and recommend post-operative care. The authors state that endoscopic transphenoidal pituitary surgery has proven to have similar or even better results compared to traditional microsurgical techniques, with equal or reduced incidence of complications. The approach provides the surgeon with improved visualisation, illumination and surgical mobility. The technical details of the procedure as described by the authors is a ‘must read’ for all potential endoscopic pituitary surgeons.

Reference

Endoscopic surgery for pituitary tumors.
Lucas JW, Zada G.
NEUROSURGERY CLINICS OF NORTH AMERICA
2012:23;555-69.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY

Electrophysiological investigations in facial nerve paresis or paralysis
Reviewed by: Susan A Douglas
May/Jun 2013 (Vol 22 No 2)
 

This is a well-written article describing electrophysiological testing after facial nerve injury. The article describes the classification of facial nerve injury, as well as the electroneuronography (ENOG) and electromyography (EMG), which are the most commonly used objective measures of facial nerve function. Facial nerve paresis and paralysis have been shown to have a significant impact on a patient’s quality of life. Seddon classified peripheral nerve injury into three types (1) neuropraxia (2) axonotmesis and (3) neuronotmesis. Sunderland expanded on this classification and sub classified neuronotmesis to give five grades of injury. The article describes the grades of injury based on Seddon’s and Sunderland’s work. Electroneurography (ENOG) is more accurately described as evoked EMG or facial nerve conduction evaluation. The goal of the test is to measure the amount of neural degradation distal to the site of injury, by measuring the muscle response to an electrical stimulus. The method of performing the ENOG is described. The main purpose of ENOG is to determine the long-term prognosis of facial function. Patients with greater than 90% degradation on the affected side (compared with the unaffected side) have a positive test (therefore need some intervention). Patients with facial nerve paresis with a normal ENOG are likely to have a conduction block and therefore should recovery satisfactorily. ENOG cannot differentiate second to fifth degree injuries but the timing of the ENOG can be helpful as the velocity of complete denervation is proportional to the severity of the injury. Wallerian degeneration is complete 5–7 days after complete transection of the nerve but in axonotmesis this process takes 14–21 days. ENOG has been found to be 88% accurate in predicting incomplete recovery when denervation is greater than 75%. The positive predictive value rose to 91% in those with greater than 90% reduction in function. Electromyography (EMG) is the recording of spikes in electrical activity which are generated when a motor unit fires. The motor unit consists of the motor neuron and the corresponding muscle fibres innervated by the neuron. The technique of performing EMG is described; the testing is done at rest and during attempts at volitional movement. One study has demonstrated that assessing for volitional EMG is 75% accurate in predicting a poor outcome and 62% accurate in predicting a favourable outcome. The article describes the timing consideration when using ENOG and EMG – for example ENOG should only be performed from three days after the injury because the test assesses Wallerian degeneration, which takes a minimum of 72 hours to occur. EMG can be performed at any time. The authors use these tests as a guide to the decision making process. Primary facial nerve repair is indicated in a fifth degree injury with signs of early Wallerian degeneration. Decompression should be considered where there is greater than 90% denervation on ENOG. This would be supported by complete absence of volitional EMG. Surgeons can then explore the nerve and decompress or graft the nerve if needed. Observation or medical management is reserved for those with a negative ENOG (less than 90% denervation). This is a well–written article describing the electrophysiological testing in facial nerve paresis or paralysis. 

Reference

Electrophysiological measures in facial paresis and paralysis.
Mannarelli G, Griffin GR, Kilney P, Edwards P.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY


OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Survivorship following chemoradiation
Reviewed by: Hannah Blanchford
May/Jun 2013 (Vol 22 No 2)
 

In the advent of debate surrounding survivorship in head and neck cancer, this study, written by surgeons, highlights some longer term functional problems faced by patients following chemoradiation. This retrospective review investigated tracheostomy and feeding tube dependence in 243 patients treated with chemotherapy and intensity-modulated radiation therapy (IMRT) for HNSCC between 2002 and 2008 in a tertiary referral centre in Arkansas. 144 patients (59.25%) received a percutaneous gastrostomy tube (PEG), most of which were placed prior to radiotherapy. 116 patients retained their PEGs for longer than 6 months and dependence was most frequent in patients with base of tongue and laryngeal primaries and advanced T-stage disease. Median PEG duration was 9 months. Despite cricopharyngeus-sparing IMRT to preserve function, 32 patients underwent oesophageal dilatation (an average of 1.8 times) at an average of 24 months’ post-treatment.  This reflects post-radiotherapy fibrosis that may continue years after treatment finishes. 25 patients (10.28%) received a tracheostomy and average duration of dependence was 11 months. Despite improvement in locoregional control rates, dysphagia remains a significant and persistent problem for patients receiving chemoradiation for HNSCC. This study demonstrated that almost 50% of patients were rendered PEG dependent for more than six months, illustrating the well documented observation that organ preservation does not necessarily equate to preservation of function. The authors acknowledge that, like most studies investigating these outcomes, it is limited by its retrospective nature and further prospective studies are needed to evaluate the long-term toxicity of chemoradiation.

Reference

Functional outcomes of chemoradiation in patients with head and neck cancer.
Tulunay-Ugur OE, McClinton C, Young Z, Penagaricano JA, Maddox A-M, Vural E.
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2013;148:64-8.

OTOLOGY AND NEUROTOLOGY

Are BAHA anchors stable to load at four weeks?
Reviewed by: Hannah Blanchford
May/Jun 2013 (Vol 22 No 2)
 

Resonance frequency analysis (RFA) has historically been used as a quantitative measure of implant stability in dental surgery. Following bone anchored hearing aid (BAHA) surgery, many clinicians wait at least six to eight weeks for adequate osseointegration before loading the sound processor. Using RFA, this prospective study of 68 patients assessed the implant stability quotient (ISQ) of the BAHA B1300 intraoperatively and at one, four and 16 weeks post-operatively. The implant’s features; a wider screw diameter, smaller threads and roughened surface, are said to promote osseointegration. At each time point measured, the mean ISQs exceeded the recommended 60 unit threshold quoted in dental implant studies.  Literature regarding the optimal ISQ in the human temporal bone is currently limited. It is suggested that ISQ trend over time is more clinically relevant than absolute values. All patients, bar one, had ISQs over 60 units at four weeks and were loaded with sound processors. There were no failed implants. The change in the ISQ value from the intraoperative baseline value was measured. The average change in ISQ demonstrated an increase in stability over time (delta 1.21 at four weeks and delta 1.60 at 16 weeks).  The data did however demonstrate a small dip at one week post-operatively (delta -0.10), which is supported by research demonstrating reduced stability during the early phase of healing. The authors acknowledge that this paper did not seek to find the optimal ISQ value. They conclude that these results support the safe and early loading of processors at four weeks and that RFA may be used to reliably assess implant stability.

Reference

Evidence for early loading of osseointegrated implants for bone conduction at four weeks.
McLarnon CM, Johnson I, Davison T, Hill J, Henderson B, Leese D, Marley S.
OTOLOGY & NEUROTOLOGY
2012;33:1578-82.

OTOLOGY AND NEUROTOLOGY

Ocular VEMP responses most valuable test for diagnosing superior semicircular canal dehiscence
Reviewed by: Rebecca Heywood
May/Jun 2013 (Vol 22 No 2)
 

Patients with superior canal dehiscence syndrome (SCDS) may not display clinical signs characteristic of the condition and it is well recognised that CT scanning can overestimate the size and prevalence of superior semicircular canal dehiscence. Additional confirmation of the diagnosis is therefore valuable before proceeding to surgical intervention. In this study preoperative ocular and cervical VEMP (o- and cVEMP) responses of 11 patients with surgically confirmed SCDS in response to air and bone conduction were compared to those of age-matched controls with no hearing or vestibular deficits. Click and 500Hz tone burst air conduction and midline reflex hammer and 'mini-tap' bone conduction stimuli were delivered to elicit o- and cVEMPs. Overall air conduction stimuli produced greater increases in o- and cVEMP amplitudes than bone conduction stimuli. Ocular veMp amplitudes were higher overall in the surgically confirmed cases than cVEMP amplitudes. Ocular veMp amplitudes in response to air conduction stimuli produced no overlap at all between surgically confirmed SCDS cases and control subjects. There was no correlation between o- or c-VEMP amplitudes and presence or absence of tone-evoked nystagmus, Dizziness Handicap Inventory scores, surgically measured dehiscence area or average air-bone gap. Therefore as a single step suprathreshold test for SCDS this study demonstrates that oVEMPs in response to air conduction stimuli are the most valuable.

Reference

Air-conducted oVEMPS provide the best separation between intact and superior canal dehiscent labyrinths.
Janky KL, Nguyen KD, Welgampola M, Zuniga MG, Carey JP.
OTOLOGY & NEUROTOLOGY
2012;34:127-34.

RHINOLOGY

Paranasal sinus osteoma: is there any association with anatomical variations?
Reviewed by: Lakhbinder Pabla
May/Jun 2013 (Vol 22 No 2)
 

Paranasal sinus osteomas are benign osteogenic lesions, often diagnosed as an incidental radiological finding. Although the majority are asymptomatic, their clinical importance lies in the possibility of them causing various complications. The aetiology of osteomas is unclear and developmental disturbances of the paranasal sinuses have been proposed as a potential cause. This retrospective study evaluated demographic and CT characteristics of osteomas. Associated pathological findings and anatomical variations were evaluated for patients with diagnosed osteoma compared to a control group. The prevalence was found to be 3.69%, with a male-to-female ratio of 1.08:1. The frontal sinus was most commonly found to be affected. They also found that the presence of anatomical variations was more frequent in patients with osteomas than in the control group, with significant differences in the sphenomaxillary plate, infraorbital cell and crista galli pneumatisation. The authors propose that the higher prevalence of anatomical variations in patients with osteomas could be explained by the stronger influence of genetic and / or environmental factors on the development of the paranasal sinuses.

Reference

Paranasal sinus osteomas: is there any association with anatomical variations?
Janovic A, Antic S, Rakocevic Z, Djuric M.
RHINOLOGY
2013;51:54-60.

SEMINARS IN HEARING

Fitting hearing aids to babies
Reviewed by: Vinaya KC Manchaiah
May/Jun 2013 (Vol 22 No 2)
 

Fitting hearing aids to infants is a challenging process, which requires special considerations and careful attention at every stage. In the first instance, it is important to use both behavioural and electrophysiological assessment to get accurate estimations of babies’ hearing. It is also important to consider ear canal acoustics and use hearing aid selection and verification measures to make sure the fitting is appropriate. Finally it is important to evaluate the effectiveness of hearing aid fitting in terms of outcome. Overall, this article details the three main stages of the hearing aid fitting process to infants, which may serve as a valuable resource to clinicians working in this area.

Reference

The essentials of fitting hearing aids to babies.
Bagatto MP.
SEMINARS IN HEARING
2013;34:19-26. 

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Is incision and drainage adequate in a subperiosteal mastoid abscess in children?
Reviewed by: Madhup K Chaurasia
May/Jun 2013 (Vol 22 No 2)
 

A subperiosteal abscess often complicates acute mastoiditis in children. Theoretically one can adopt a more conservative management plan, such as incision and drainage of the abscess and myringotomy, or resort to a cortical mastoidectomy and myringotomy. In this study the authors compare the efficacy of both methods, as applied to children with subperiosteal mastoid abscess. This is a retrospective study which looked at records of 164 children with acute mastoiditis, of whom 34 had subperiosteal abscess. All were given intravenous antibiotics. 13 underwent simple mastoidectomy, of whom all were cured. 21 children had abscess drainage and myringotomy as an initial procedure. After three to five days 43% of these needed a simple mastoidectomy. It appears from the study that all children received general anaesthesia. It was noted that children who underwent mastoidectomy with myringotomy and the 57% of children who were cured with myringotomy and incision and drainage had the shortest stay in the hospital, whereas those in whom mastoidectomy was required as a second stage treatment stayed much longer. Of course the conservative management was not applied to children with further complications of mastoid abscess such as extradural collection of pus. The inspiration / incision and drainage procedure with myringotomy has been described in various studies, with results of varying degrees of success. The authors contend that simple mastoidectomy with myringotomy is a more effective procedure for treating mastoid subperiosteal abscess. It is also suggested that non-responding patients should be treated with simple mastoidectomy within five days. The article however does not lend credence to the lesser procedure and therefore its reliability in the treatment of subperiosteal abscess should not be presumed.

Reference

A mastoid subperiosteal abscess in children: drainage or mastoidectomy?
Psarommatis I, Giannakopoulos V, Theodorou E, Voudouris C, Carabios C, Tsakalikos M.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1204-8.

THE JOURNAL OF LARYNGOLOGY AND OTOLOGY

Question tests, not the patient
Reviewed by: Madhup K Chaurasia
May/Jun 2013 (Vol 22 No 2)
 

Advances in technology have facilitated a wide variety of tests in otology which lead us to presume that, if these are normal, the patient has no problem, despite repeated and definitive expression of symptoms. In this revealing article, the author elaborates how despite being ‘normal’ or ‘not significant’, the battery of tests available to the otologist does not necessarily exclude a disease. The author starts with simple tuning fork tests, which do not cover all degrees of conductive loss, and the limits of audiometry, which may not test all frequencies that the human ear can distinguish between one octave and the next. The tests have been likened to a ‘Swiss cheese’ with more holes than substance. Similar inadequacies have been pointed out for speech tests and the caloric vestibular test, which is like “testing vision with lightning and hearing with thunder”! The article conveys a deep and righteous philosophy and exposes the clincian’s tendency to fit the patient into tests rather than otherwise. It will help to avoid unreasonable conclusions even though the tests may be normal or 'not significant'. The message is that if tests are normal we should question not the patient, but the tests. An interesting and a very sharp example has been quoted from Greek mythology and I feel we are not very far from doing the same frightening act for our patients as Procustus did! 

Reference

Abnormal patient, normal test: the otologist’s dilemma.
Jahn, AF.
THE JOURNAL OF LARYNGOLOGY AND OTOLOGY
2013;127:111-13.

WORLD JOURNAL OF SURGICAL ONCOLOGY

Risk factors for thyroid malignancy
Reviewed by: Gauri Mankekar
May/Jun 2013 (Vol 22 No 2)
 

In this study the authors attempted to confirm whether clinical and biochemical parameters of Hashimoto’s Thyroiditis (HT) could predict the risks of malignancy amongst patients who underwent thyroidectomy and to determine the influence of HT on the biological behaviour of papillary thyroid cancer (PTC). They found that the risk of thyroid malignancy increases with the presence of HT and microcalcification, as evaluated by ultrasonography. Raised thyroid stimulating hormone (TSH) levels within the normal range are also independently associated with the likelihood of thyroid malignancy. Coexisting HT in PTC does not have a significant effect on the biologic behaviour of PTC. Based on their findings, the authors do not recommend a more aggressive surgical intervention for patients with HT, microcalcification, or even high TSH levels.

Reference

Hashimoto's Thyroiditis, microcalcification and raised thyrotropin levels within normal range are associated with thyroid cancer.
Ye Z, Gu D, Hu H,  Zhou YH , Hu X , Zhang X.
WORLD JOURNAL OF SURGICAL ONCOLOGY
2013:11;56.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Douching devices: the need to keep them clean
Reviewed by: Edward W Fisher
Mar/Apr 2013 (Vol 22 No 1)
 

The resurrection of douching in recent decades has been accompanied by a commensurate increase in the number of devices and commercial preparations to use. The contamination of irrigation devices by potentially troublesome organisms has been well described and this review looks at the evidence so far as to how big the problem of 'dirty' devices is and what we as physicians can do to help the situation. Patients do not seem to be cleaning the devices after each use, nor are they replacing them after 3 months, both of which are advisable. We as ENT doctors should perhaps be taking this more seriously and offering advice on this aspect of a patient's management of their condition. Whether the contamination matters much (i.e. whether it causes infection in the nose and sinuses) is open to doubt and the review poses as many questions as it answers.

Reference

Contamination of sinus irrigation devices: a review of the evidence and clinical relevance.
Psaltis AJ, Foreman A, Wormald P-J, Schlosser RJ.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26:201-3.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

The overall effect of rhinitis on the pregnant woman.
Reviewed by: Edward W Fisher
Mar/Apr 2013 (Vol 22 No 1)
 

This study uses the SNOT-22 questionnaire to evaluate the quality of life of pregnant women in the second and third trimesters (32 and 44 weeks respectively). The findings were that the women had more problems with quality of life in the third than in the second trimester. The first trimester was not assessed. The second trimester women (surprisingly) had scores that were no different from ‘non-rhinosinusitis’ patients. Sleep disturbance was an important aspect of the quality of life deterioration, and women with pre-existing rhinitis did worse than those who gave no history of rhinitis prior to the pregnancy. The article gives some guidelines for managing rhinitis in pregnancy.

Reference

Rhinosinusitis-related quality of life during pregnancy.
Gilbey P, McGruthers L, Morency A-M, Shrim A.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26:283-6.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Young’s procedure for the difficult HHT case.
Reviewed by: Edward W Fisher
Mar/Apr 2013 (Vol 22 No 1)
 

This is a large series of patients with HHT who underwent closure of the nostrils for this difficult to manage condition. Out of 43 patients, 83% had a complete cessation of bleeds and a mean increase in haemoglobin of 4.68 g/dl. Interestingly, no patient requested reversal of this procedure, despite the loss of smell / taste and obligate mouth breathing (with consequent dry mouth) which results. This series was accumulated over just a 6 year period. I can think of no UK department who could accumulate such a large series over such a short period of time. An average Glasgow Benefit Inventory score of over 43 is a testament to the efficacy of this procedure. The article describes the technique in detail.

Reference

The Young’s procedure for severe epistaxis from hereditary hemorrhagic telangiectasiab.
Richer SL, Geisthoff UW, Livada N, Ward PD, Johnson L, Mainka A, Henderson KJ, Maune S, White RI, Ross DA.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26:401-4.

AUDIOLOGICAL MEDICINE

Listening with a single ear
Reviewed by: Diego Zanetti
Mar/Apr 2013
 

Subjects with unilateral sensorineural hearing loss (USNHL) experience challenges in difficult listening conditions such as understanding speech coming from the affected side, perceiving speech in noisy environments and localizing sound sources. The authors investigated the degree of social disability  in a population of 98 USNHL compared with 89 normally hearing subjects according to age, gender, side affected, duration and cause of hearing loss and progressive vs sudden onset, by means of the Speech, Spatial and Qualities of Hearing Scale (SSQ) questionnaire. All ratings in the three SSQ sections were higher in the reference group compared to those of the USNHL group. Speech in difficult situations and localization were the factors most affected by USNHL. In particular, the estimation of distance from sound sources was rated worse by the USNHL group. The scientific value of this article stands in support of current rehabilitation methods for single sided deafness, including BAHAs and, possibly, cochlear implants.

Reference

Self-reported hearing performance among subjects with unilateral sensorineural hearing loss.
Olsen SO, Hernvig LH, Nielsen LH.
AUDIOLOGICAL MEDICINE
2012;10:83-92.

AUDIOLOGICAL MEDICINE

Medical therapy in Ménière’s disease.
Reviewed by: Vinaya KC Manchaiah
Mar/Apr 2013 (Vol 22 No 1)
 

Ménière’s disease is an idiopathic disorder of the inner ear due to endolymphatic hydrops that causes recurrent acute vertigo, sensation of fullness of the ear and fluctuating sensorineural hearing loss. It is not easy to diagnose this condition and due to its nature there is no universally agreed treatment. This article is aimed at describing the current clinical treatment approaches for Ménière’s disease. The study design focussed on acute and chronic current pharmacological treatments in Ménière’s disease by reviewing the literature. The results suggest medical management includes sodium restriction and the avoidance of caffeine, alcohol and nicotine. In addition, all treatments are focused on treating the symptoms and intend to prevent further attacks. Moreover, there is still a lack of evidence base for the management of this condition and also the outcome of treatment is difficult to assess. In general, the medical management of Ménière’s disease is still empiric and based on lifestyle changes. Pharmacotherapy remains the primary therapy in definite Ménière’s disease and other treatment options such as transtympanic therapies are used as a second choice. 

Reference

Medical therapy in Ménière’s disease.
Sammartano AM, Cassandro C, Giordano P, Canale A, Albera R .
AUDIOLOGICAL MEDICINE.
2012;10:171-7. 

BIOMED CENTRAL EAR, NOSE AND THROAT DISORDERS

Temporomandibular joint disorders and extended computer usage
Reviewed by: Gauri Mankekar
Mar/Apr 2013 (Vol 22 No 1)
 

For this study the authors assessed 1969 employees of the same Japanese company using a questionnaire that covered both temporomandibular joint disorders related symptoms (TRS) and the work environment. TRS was measured from four items on the questionnaire while the work environment factors recorded were the mean daily duration of computer use, driving, precise work, commuting, time spent at home before going to bed, sleeping, attending business meetings and performing physical labour. The study showed that female gender and extended periods of computer use were significant contributors to the manifestation of TRS. The authors propose that computer usage indirectly influences TRS due to increased incidences of habitual behaviour such as 'tooth contacting habit' that are more often performed during computer use. They recommend evaluation of ergonomics for patients with temporomandibular joint dysfunctions.

Reference

A survey of influence of work environment on temporomandibular disorder related symptoms in Japan.
Nishiyama A, Kino K, Sugisaki M, Tsukagoshi K.
BIOMED CENTRAL EAR, NOSE AND THROAT DISORDERS
2012;8:24.

BRITISH MEDICAL JOURNAL

Rudolph’s red nose mystery solved?
Reviewed by: Ananth Vijendren
Mar/Apr 2013 (Vol 22 No 1)
 

The authors from Tromso, Norway (near the North Pole) and Amsterdam, Netherlands set out to solve the age old mystery of why Santa Claus’s most famous reindeer has a red nose. An observational study involving five healthy human volunteers, two adult reindeers and a patient with grade 3 nasal polyposis was carried out with the aim of characterising the functional morphology of the nasal microcirculation in adult humans as opposed to that in reindeers. A handheld intravital video microscope was used to image the nasal microcirculation in the reindeers (under sedation) at 18°C and subsequently in the human volunteers at 22°C. Post-analysis, using a semi-automated microvascular imaging software, the authors found that the microcirculation of the nasal mucosa in reindeer is 25% denser and more vascularised compared to adult humans. The microvasculature of the patient with polyposis was irregular and lacked the characteristic features usually present in normal humans. The authors postulate that Rudolph’s red nose is physiologically richer in blood supply to help protect it during freezing sleigh rides. This, however, does not explain why the ‘red nose’ connotation has only been historically associated with Rudolph and not the rest of Santa Claus’s reindeers! 

Reference

Why Rudolph’s nose is red:observational study.
BRITISH MEDICAL JOURNAL
Ince C, van Kuijen A, Milstein DM, Yuruk K, Folkow LP, Fokkens W and Blix AS.
2012;345:e8311

COCHLEAR IMPLANTS INTERNATIONAL

A new surgical technique for the Nucleus 5 cochlear implant
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

It was rather interesting to see a study describing a new surgical technique and early clinical results for a device that has been recalled by its company and caused a significant number of re-implantation word-wide. The study aimed to demonstrate that the new design could facilitate a minimally invasive surgical approach, without the need for tie-down sutures and without a seat drilled for the receiver-stimulator package. The surgical technique involved placing the device directly on the surface of the bone in a secure sub-periosteal pocket with a channel drilled for the lead. A well or ramped seat was not drilled and tie-down sutures were not used. Measurements were taken from the transmitting coil to the tragus and the coil to the lobule immediately after implantation, and serially thereafter to document implant position. The results revealed that 8% showed a measurement change of greater than 1 cm whereas 4.4% demonstrated a clinically evident movement. None had any complications relating to migration and none required repositioning of the device. The authors concluded that Nucleus 5 can safely be inserted without drilling a well for the receiver-stimulator package as any early post-operative movement of the package had caused no clinical impact. Moreover, they claim that this modified surgical technique reduces the risk of intracranial complications and reduces operating time. However, the last claims are not supported by any direct evidence. Nevertheless, the whole study seems rather odd after the device recall.

Reference

The new Nucleus 5 model cochlear implant: a new surgical technique and early clinical results. 
Monksfield P, Husseman J, Cowan RSC, O'Leary SJ; Briggs RJS.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(3):142-7.

COCHLEAR IMPLANTS INTERNATIONAL

Auditory dys-synchrony secondary to Charcot-Marie-Tooth disease and cochlear implantation
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

Auditory neuropathy (dys-synchrony) has been associated with many factors such as prematurity or neurological diseases. Charcot-Marie-Tooth (CMT) disease is the most common hereditary motor and sensory neuropathy and may result in hearing loss. This study investigates whether the reintroduction of auditory synchrony by means of cochlear implantation would improve speech perception in patients with auditory dys-synchrony associated to CMT. The authors described the case of a 67-year-old male presented with a gradual but significant decrease in his hearing attributed to a slowly progressing demyelinating peripheral neuropathy. On aided open-set speech discrimination he scored 0% although pure tone audiogram was in the range of moderate to severe hearing loss. The diagnosis of auditory dys-synchrony was strengthened by the presence of TEOAEs in one ear. Twenty-one months following cochlear implantation, the open-set speech discrimination score reached 54%. It seems that there was a significant benefit from cochlear implantation, although this may be considered poorer in comparison to the average implantee.

Reference

Cochlear implantation in a patient with sensori-neural deafness secondary to Charcot-Marie-Tooth disease.
Goswamy J, Bruce IA, Green KMJ, O'Driscoll MP.
COCHLEAR IMPLANTS INTERNATIONAL 
2012;13(3):184-7.

COCHLEAR IMPLANTS INTERNATIONAL

Chronic infantile neurological cutaneous and articular syndrome in combination with enlarged cochlear aqueducts and cochlear implantation
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

Gene research and genetic evaluation of deafness has helped us analyse a plethora of syndromes. Chronic infantile neurological cutaneous and articular (CINCA) syndrome is a severe auto-inflammatory disease, due to mutation of the CIAS1 gene. This syndrome should be considered the most severe of a spectrum of three disorders all due to mutation of the CIAS1 gene. CINCA syndrome produces a triad of symptoms of neonatal onset: maculopapular urticarial rash, chronic meningitis and chronic non-inflammatory arthropathy with recurrent fever. CINCA syndrome is also associated with sensory organ damage, especially progressive hearing loss and loss of vision. In this case report, the authors presented a case of cochlear implantation in a 13-year-old child with CINCA syndrome and large vestibular aqueducts. Cochlear implantation was successful and the child continued mainstream education, with her academic performance and speech discrimination showing marked improvement. Therefore, the authors suggested that cochlear implantation is the modality of choice in rehabilitating severe-to-profound hearing loss in children suffering from CINCA syndrome and deafness not responsive to medical treatment with anakinra. However, it remains to be seen if the long-term sequel of the syndrome could affect cochlear implantation.

Reference

Cochlear implantation in a child with CINCA syndrome who also has wide vestibular aqueducts. 
Bates JEHM, Bruce IA, Henderson L, Melling  C, Green KMJ.
COCHLEAR IMPLANTS INTERNATIONAL 
2012;13(3):173-76.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation in syndromic children
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

In this study, the authors reported their surgical results and outcomes of cochlear implantation in a large series of syndromic children. Over a 10 year period, a total of 88 cochleas in 67 children with syndromes were implanted in the authors' centre. The common syndromes implanted were Usher's syndrome (23 patients, 33 cochleas), Wardenburg's syndrome (8 patients, 9 cochleas), Pendred's syndrome (4 patients, 4 cochleas), Jervell-Lange-Neilsen syndrome (3 patients, 4 cochleas), enlarged vestibular aqueduct syndrome (4 patients, 7 cochleas), Cogan's syndrome (3 patients, 4 cochleas), CHARGE (5 patients, 6 cochleas) and Branchio Oto Renal syndrome (3 patients, 4 cochleas). Pre-operative radiological inner ear anatomy was found to be abnormal in 28.4% (25/88) cochleas in this study group. Full insertion of the electrode was achieved in 93.1% (82/88) of cochleas, partial insertion in three cochleas and insertion was abandoned in three cochleas. Early complications were seen in 7% (6/88) of implantations. All the 64/67 children were using the implant at the time of the study. It is well known that surgery, tuning and (re)habilitation may be very challenging in children with syndromes. Experience accumulated contributes to better parental counselling and planning.

Reference

Surgical aspects of cochlear implantation in syndromic children. 
Bajaj Y, Gibbins N, Fawkes K, Hartley B, Jephson C, Jonas N, Albert D, Bailey M, Wyatt M, Cochrane L.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(3):163-7.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear Implantation surgery and benign paroxysmal positional vertigo in children
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

It has been reported, in adults, that cochlear implantation can be associated with benign paroxysmal positional vertigo (BPPV), as a complication of surgery although the exact pathophysiologic mechanism has not yet been fully explained. However, the literature is very poor regarding benign paroxysmal positional vertigo in children who have undergone cochlear implant surgery. The author in this study presented a 13-year-old girl who underwent the insertion of a cochlear implant and developed benign paroxysmal positional vertigo BPPV as a result of visiting fairground rides approximately 2 years after surgery. The author performed a right Epley's manoeuvre and advised the child to do Brandt-Daroff exercises for 6 weeks. The child became symptom free within a few weeks of doing vestibular rehabilitation exercises. However, vestibular rehabilitation lasted for 6 weeks. The author suggested that the labyrinth became vulnerable during cochlear implantation surgery and this helped the fairground ride to cause BPPV. However, it is very likely that there was no causative association between surgery and BPPV.

Reference

Benign paroxysmal positional vertigo in a child: an infrequent complication following a fairground ride and post-cochlear implant surgery. 
Shetye A.
COCHLEAR IMPLANTS INTERNATIONAL 
2012;13(3):177-80.

COCHLEAR IMPLANTS INTERNATIONAL

How much intracochlear trauma can be caused by the insertion of a new straight research array?
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

Patients with serviceable hearing in the low frequencies may gain significant benefit by electroacoustic stimulation (EAS) that enables recipients to benefit from cochlear implantation while retaining their natural low-frequency hearing. A disadvantage of short EAS electrodes is that short electrodes provide limited low-frequency stimulation. Thus, loss of the residual hearing may require reimplantation with a longer electrode. To solve this problem, the slim diameter (SRA) with increased length (20-25 mm) has been designed to provide a deeper, yet non-traumatic insertion. The authors assessed the degree of intracochlear trauma using the Cochlear Straight Research Array (SRA). Two insertion studies into temporal bones were undertaken. The first involved dissection of the cochlea to gain a view into the scala vestibuli and insertion of the SRA and control electrodes with a microactuator for a surgeon-independent yet controlled insertion. High-speed photography was used to record data. The second study involved a high-resolution X-ray microcomputed tomography (microCT) study to assess electrode placement and tissue preservation in surgeon-implanted bones. The results revealed that the SRA had a smooth insertion trajectory. The average angular insertion depth was 383° when inserted until resistance was encountered, and 355° if inserted to a predetermined mark for EAS use. In addition, microCT data showed that this caused no significant trauma or distortion of the basilar membrane up to 20 mm depth. The conclusion that the SRA appears to cause no intracochlear trauma if used as an EAS electrode up to 20 mm depth of insertion appears very promising. However, temporal bone studies do not always reflect the reality of real patients and direct trauma may not be the only factor that affects residual hearing following implantation.

Reference

Assessment of intracochlear trauma caused by the insertion of a new straight research array.
Mukherjee P, Uzun-Coruhlu, H, Wong CC, Curthoys IS, Jones AS, Gibson WPR. 
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(3):156-62.

COCHLEAR IMPLANTS INTERNATIONAL

Hybrid implants. What happens if the residual hearing is lost?
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

Inserting a hybrid implant has always been a major risk. If the residual hearing is lost then the implant is inadequate to cover the implantee's hearing needs. Therefore, revision surgery using a conventional length cochlear implant electrode is supposed to provide improved speech perception in patients that initially underwent hybrid electrode implantation and experienced post-operative loss of residual hearing and performance deterioration. The authors presented their experience of four patients who had delayed post-operative hearing loss following implantation with the Nucleus Hybrid S8 device and underwent reimplantation with the Nucleus Freedom or Nucleus 5 device using the Contour Advance array. Pure-tone thresholds and speech perception data were retrospectively reviewed. The results revealed that the comparison of pre-revision performance to the most recent post-revision performance demonstrated improved speech perception performance in all subjects following reimplantation. The authors concluded that revision surgery with a conventional length electrode should be considered in 'short electrode' recipients who experience performance deterioration following loss of residual hearing. Of course any statistics performed in four patients are rather weak. Moreover, the difference observed between the 6-month post-hybrid and the post-revision best aided condition in favour of the post-revision condition questions the initial decision for a hybrid implant.

Reference

Reimplantation with a conventional length electrode following residual hearing loss in four hybrid implant recipients. 
Carlson M, Archibald DJ, Gifford RH, Driscoll CLW, Beatty CW.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(3):148-55.

COCHLEAR IMPLANTS INTERNATIONAL

Jervell Lange-Nielsen syndrome. The fear of surgeons and anaesthetists
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

Congenital profound deafness may be associated with the Jervell Lange-Nielsen (JLN) syndrome that has a characteristic prolonged QT interval on the electrocardiogram. Children presenting for cochlear implantation with this condition may be asymptomatic but are at risk of sudden death. In this study, the authors presented their experience of cochlear implantation in four children with JLN syndrome, including two who died unexpectedly, and suggested a protocol for management of such cases. None of the four cases had any previous cardiological family history. Two were diagnosed pre-operatively but, despite appropriate management under a cardiologist, died from cardiac arrest; the first in the perioperative period following reimplantation for infection, and the second unrelated to his cochlear implant surgery. The other two patients were diagnosed only subsequent to their implantation and continued to use their implants successfully. These cases highlight the variation in presentation of JLN syndrome, and the spectrum of disease severity that exists. Careful assessment and counselling of parents by an experienced implant team are of utmost importance. In addition, the fact that two of the four implanted children died despite proper diagnosis and cardiologic management, highlights the severity of the syndrome.

Reference

Cochlear implantation in children with Jervell and Lange-Nielsen syndrome - a cautionary tale.
Broomfield SJ, Bruce IA, Henderson Lise, Ramsden RT, Green KM. 
COCHLEAR IMPLANTS INTERNATIONAL 
2012;13(3):168-72.

COCHLEAR IMPLANTS INTERNATIONAL

Pneumocoele as a rare complication of cochlear implantation
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

The authors described four cases of post-operative (short and long-term) scalp pneumocoele. Three of the four cases, consisting of two adults (aged 53 and 81 years) and one child (aged 26 months), developed the scalp pneumocoeles within the first 3 months of implantation. Another child (aged 10) developed pneumocoele 7 years after surgery. The common diagnostic features included a soft, non-tender, fluctuant swelling over the receiver / stimulator package. In all cases, according to history, pneumocoeles were triggered by Valsalva's or Toynbee's manoeuvres. Complications included infection (case one) and reduction in cochlear implant (CI) function (cases three and four), secondary to displacement of the receiver / stimulator package or electrode displacement. Four such cases from a single centre is a very large number as this complication is very rare. Aspiration of air or radiologic evidence could be the pathognomonic signs of pneumocoele. However, some of the described cases did not have these signs and the electrode displacement in one case could be coincidental. Nevertheless, pneumocoele is a complication that may become very serious (various further complications have been described in the literature) and otologists should be aware of the possible consequences.

Reference

Pneumocoele after cochlear implantation.
Qiu S, Gray RF, Kumar S, Axon P.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(3):187-92.

COCHLEAR IMPLANTS INTERNATIONAL

The ultrasonication technique used to identify staphylococcus aureus biofilm formation on an explanted cochlear implant device
Reviewed by: Thomas Nikolopoulos
Mar/Apr 2013 (Vol 22 No 1)
 

A growing number of articles in the literature have implicated biofilms as the cause of persistent infections, especially when medical devices and foreign bodies are involved. The current definitive technique for confirming biofilm formation is the use of scanning electron microscopy. However, very few centres offer this facility. The authors described a case of a persistently infected cochlear implant that was finally explanted. At operation it was surrounded by a fibrous capsule containing a glue-like substance, characteristic of biofilm formation that yielded Staphylococcus aureus after ultrasonication of the cochlear implant. It was placed in a nutrient broth in an ultrasonic water bath and then ultrasonicated for 5 minutes and the broth cultured on blood agar, incubated aerobically and anaerobically for 48 hours, and then incubated in air on MaConkey agar for 24 hours. This produced a heavy, confluent growth of S. aureus, in contrast to previous aspirates from a blister that lay over the infected implant that grew a coliform organism and Pseudomonas sp. The authors claim that this technique, being widely available and relatively inexpensive, can be used to improve the recovery of biofilm-associated organisms from explanted cochlear implants. However, comparative studies, with a significant number of devices, using electron microscopy as the gold standard, are needed to confirm these claims.

Reference

Case report: Staphylococcus aureus biofilm formation on an explanted cochlear implant demonstrated using an ultrasonication technique.
Fishpool SJC, Osborne JE, Looker N. 
COCHLEAR IMPLANTS INTERNATIONAL 
2012;13(3):181-3.

EAR AND HEARING

Generational difference in reporting tinnitus.
Reviewed by: Vinaya KC Manchaiah
Mar/Apr 2013 (Vol 22 No 1)
 

Tinnitus is one of the most frequent symptoms associated with hearing impairment. Considering that hearing impairment is declining among older adults compared with earlier generations of the same age, one might hypothesize that the prevalence of tinnitus is declining in a similar manner. The current study was aimed at examining whether the prevalence of tinnitus is declining among more recent generations with the use of multigenerational data with repeated measures. Using the epidemiological data authors examined birth cohort patterns in the report of tinnitus for adults aged 45 years and older (n = 12,689). Participants were classified as having tin­nitus if they reported tinnitus in the past year of at least moderate severity or that caused difficulty falling asleep. A low-frequency and high-frequency PTA from the worse ear was used to summarize hearing status. Other potential risk factors for tinnitus were also explored to determine if changes in the prevalence of these factors over time could explain any observed birth cohort differences in the prevalence of tinnitus. Using the alternating logistic regression models, birth cohort effects were modelled. The results suggest that the report of tinnitus tended to increase with more recent birth cohorts compared with earlier birth cohorts. These increased reports of tinnitus may reflect increased preva­lence of symptoms, increased awareness of symptoms, or higher health expectations among more recent generations of adults. Nevertheless, more importantly the increasing prevalence of tinnitus suggests that health care providers may see an increased number of patients bothered by this common but little understood symptom. 

Reference

Generational differences in the reporting of tinnitus.
Nondahl DM, Cruickshanks KJ, Huang G-H, Klein BEK, Klein R, Tweed, TS, Zhan W.
EAR AND HEARING.
2012; 33:640-44. 

EAR AND HEARING

Monitoring postnatal hearing loss
Reviewed by: Vinaya KC Manchaiah
Mar/Apr 2013 (Vol 22 No 1)
 

It is suggested that as many as 3 in every 1000 children develop hearing loss subsequent to screening at birth (postnatal) due to various causes. This systematic literature review was aimed at reviewing whether there was evidence-based support for targeted surveillance programs using a risk-factor registry to detect postnatal hearing loss and to look at other models to address postnatal hearing loss. The authors reviewed 40 articles which met the inclusion criteria. Even though, in general, the outcomes drawn from these studies were inconclusive (as they were based on small sample sizes and largely from single sites only), a number of useful observations were made. These include: (1) gestational age, low-birth weight, toxoplasmosis, other infections, rubella, cytomegalovirus (CMV), herpes simplex virus infections, craniofacial anomalies, respirator support, and the administration of aminoglycosides were the more commonly reported risk factors in programmes; (2) referral frequency for monitoring appointments was approximately 3%; and (3) CMV, extracorporeal membrane oxygenation, congenital diaphragmatic hernia and persistent pulmonary hypertension of the newborn were associated with postnatal hearing loss, whereas, preauricular skin tags and ear pits, low birth weight, and toxoplasmosis were not. The findings in this review also make a strong case for exploring other models such as second-phase universal screening programs, CMV screening and genetic screening as potential additions or alternatives to targeted surveillance using risk factors. Furthermore, the review highlights the need for large-scale, population-based research on available programmes for the detection of postnatal hearing loss, to assist with the development of evidence-based guidelines for hearing monitoring.

Reference

Monitoring for postnatal hearing loss using risk factors: a systematic literature review.
Beswick R, Driscoll C, Kei J. 
EAR AND HEARING.
2012;33:745-56.

EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK

Thyroid incidentalomas on FDG-PET/CT
Reviewed by: Ian Coulter
Mar/Apr 2013 (Vol 22 No 1)
 

Bonabi et al. studied 3,062 PET scans over a 3 year period to evaluate the prevalence of thyroid FDG-PET/CT incidentalomas and the risk of malignancy in focal findings. They analysed the prevalence of thyroid incidentalomas, risk of malignancy and correlation between standard uptake value (SUV) and cancer risk. They observed an overall prevalence of 2.4%. Of these 71% had a focal and 29% had a diffuse uptake. Of those with focal uptake, 79% went on to receive cytology / histological clarification. A malignant lesion was identified in 23.8% of patients with a focal uptake. Diffuse uptake was largely associated with autoimmune thyroiditis. No statistically significant difference in the SUVmax between benign and malignant focal lesions was observed. The findings suggest patients with incidental focal uptake in the thyroid on FDG-PET / CT harbour a significant risk of malignancy and the authors go on to recommend further evaluation with fine needle aspiration cytology in such cases.

Reference

Thyroid incidentalomas in FDG-PET/CT: prevalence and clinical impact.
Bonabi S, Schmidt F, Broglie MA, Haile SR, Stoeckli SJ.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269:2555-60.

HEAD & NECK ONCOLOGY

Tips and Tricks on Thyroid Surgery.
Reviewed by: Ananth Vijendren
Mar/Apr 2013 (Vol 22 No 1)
 

Thyroid surgery is a shared discipline between General and ENT surgeons. Although well established and treated primarily with surgical excision, there is not much information in the literature on how to deal with difficult thyroid cancers. The authors have attempted to rectify this by describing a hemi-thyroidectomy through a multi-disciplinary team approach. Pre-operatively, patients are optimised by maintaining a euthyroid state, adequate nutrition and recent voice assessment, imaging and cytological results. At the beginning of surgery, a WHO peri-operative checklist is undertaken to ensure the desired equipments are available. Nerve monitors are attached and 8mg of IV dexamethasone given to reduce the incidence of neuropraxia. The patient is preferably anaesthetised but not paralysed under physiological appropriate hypotension. The authors have found the use of dilute infusions of methylene blue helpful to delineate thyroid and parathyroid tissue. After identifying the superior and recurrent laryngeal nerves, the gland is dissected free using a harmonic scalpel. Haemostasis is achieved via adrenaline soaked swabs first followed by diathermy or liga-clips and confirmed in the head down position and anaesthetic-induced Vasalva. The methods used by the authors have been described in great detail for general applicability to all forms of thyroid surgery with strong emphasis on frequent and clear communication between the surgeons, scrub nurse and anaesthetist. It would be interesting to ascertain the length of surgery, total amount of blood loss and post-operative morbidity of these patients. 

Reference

How to do it: the difficult thyroid.
Upile T, Jerjes W, Mahil J, Tailor H, Balakumar R, Rao A , Qureshi Y, Bowman I and Mukhopadhyay S.
HEAD & NECK ONCOLOGY
2011;3: doi:10.1186/1758-3284-3-54

 

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

An absorbable steroid-eluting ethmoid stent improves healing post-ESS
Reviewed by: Joanne Rimmer
Mar/Apr 2013
 

Healing following endoscopic sinus surgery is recognised to be a variable beast, with inflammation, crusts and synechiae all potentially affecting the long-term outcome. This meta-analysis looks at two prospective, multicentre, randomised, double-blind, controlled trials of a bioabsorbable steroid-releasing sinus implant that release a corticosteroid directly to the ethmoid mucosa over 30 days postoperatively. The implants were successfully placed in all 286 ethmoid sinuses included in the studies. Three experienced otolaryngologists assessed the patients postoperatively, and reported that the stents reduced the need for postoperative intervention by 35%, adhesion formation by 51% and the need for oral steroid treatment by 40%. There was also a significant reduction in frank polyposis seen post-operatively, albeit with a follow-up of only 30 days. The authors conclude that post-operative healing is improved with placement of a steroid-eluting stent in the ethmoid sinuses at the time of surgery, although as follow-up is only 30 days it is not clear how this will impact on the long-term outcome for these patients.

Reference

Effect of steroid-releasing sinus implants on postoperative medical and surgical interventions: an efficacy meta-analysis.
Han JK, Marple BF, Smith TL, Murr AH, Lanier BJ, Stambaugh JW, Mugglin AS.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2012;2(4):271-9.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

How to approach the sphenoid sinus
Reviewed by: Joanne Rimmer
Mar/Apr 2013 (Vol 22 No 1)
 

There are two standard approaches to the sphenoid sinus during endoscopic sinus surgery: the transethmoid approach or the transnasal or trans-sphenoethmoidal approach via the natural ostium. The safest technique is obviously preferable, given the potential risks of sphenoid sinus surgery, but this may vary with individual patient anatomy. The senior author has previously described a grading system to classify the attachment of the superior turbinate (ST) to the face of the sphenoid, in an attempt to try and improve the safety of the planned approach to sphenoidotomy. This classified the ST attachment as type A if it was attached via its medial one-third, type B if within its middle one-third, type C if within the lateral one-third and type D if the ST was attached directly to the orbit. Using single-slice CT scans and ten experienced sinus surgeons, this paper showed that the four grade system has a very low mean accuracy (63%). A two grade system was therefore proposed, combining types A and B into type I, and types C and D into type II, with an accuracy of 91%. A transethmoidal approach would be advised for a type I ST attachment and a transnasal approach for a type II. If this makes sphenoidotomy safer then it should be encouraged.

Reference

Validation of a grading system for the attachment of the superior turbinate to the sphenoid face.
Sunkareneni VS, Qian H, Wong H, Javer A.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2012;2(5):411-4.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Nasoseptal flaps work without CSF diversion
Reviewed by: Joanne Rimmer
Mar/Apr 2013 (Vol 22 No 1)
 

Pedicled nasoseptal flaps (PNSFs) have been in use for decades with good success rates for closure of CSF leaks following endoscopic skull base surgery. This study looks specifically at the success rate of PNSF closures of high-flow CSF leaks without post-operative CSF diversion. They classify a high-flow leak as one with a "brisk" CSF flow through a skull base defect seen without an intraoperative Valsalva manoeuvre, so this is perhaps rather subjective. Their series of 59 patients had a 100% success rate for closure with a PNSF as part of a multilayer closure. The authors discuss the literature on the subject as well as their technique, and conclude that a meticulous multilayer watertight closure is key to repairing a skull base defect. The risks associated with a lumbar drain may be avoided if a PNSF is used.

Reference

 

Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks.
Eloy JA, Kuperan AB, Choudhry OJ, Harirchian S, Liu JK.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2012;2(5):397-401.

Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks.
Eloy JA, Kuperan AB, Choudhry OJ, Harirchian S, Liu JK.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2012;2(5):397-401.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Association of sensorineural hearing loss with enlarged vestibular aqueduct
Reviewed by: Madhup K Chaurasia
Mar/Apr 2013 (Vol 22 No 1)
 

The endolymphatic duct forms an important part of the vestibular aqueduct and variations in the size of the latter can affect inner ear mechanisms associated with sensorineural hearing loss and Meniere's disease. In this meta-analysis of a large case series and a review of literature, a correlation was sought between the diameter of the vestibular aqueduct at its external aperture of the midpoint and the respective pure tone average of 0.5, 1 and 2 KHz, or the raw data at these frequencies. Three articles were included in the review, totalling 61 patients with vestibular aqueduct diameters and pure tone averages. One of these studies involved patients with unilateral sudden sensorineural hearing loss with 47 control subjects, the second investigated the effect of corticosteroids on audiograms of patients with large vestibular aqueduct and the third had a series of patients with large vestibular aqueducts and sensorineural hearing loss. This meta-analysis resulted in finding a highly statistically significant linear relationship between pure tone average and the dimension of the vestibular aqueduct diameter at its midpoint and external aperture. The authors explain the correlation at both sides by Poiseuille's law, in that the flow or change of pressure is proportional to the fourth power of the radius of a cylindrical pipe and thus the diameter of the cochlear aqueduct can affect inner ear flow mechanisms. This study claims to be unique in formulating an indeterminate 'unit' of vestibular aqueduct diameter which proved to have an important association with pure tone average.

Reference

The relationship between vestibular aqueduct diameter and sensorineural hearing loss is linear: a review and meta-analysis of large case series.
Spencer CR.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1086-90.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Can transtympanic balloon dilatation of the Eustachian tube be as an adjunct to mastoid surgery?
Reviewed by: Madhup K Chaurasia
Mar/Apr 2013 (Vol 22 No 1)
 

Eustachian tube dysfunction often results in failure of mastoid surgery. Repeated operations may be required and cholesteatoma can recur if the Eustachian tube dysfunction is significant. Various methods have been tried to dilate the Eustachian tube varying from drilling and stenting to laser dilatation. Most of these procedures have been applied through the transnasal approach. It is easy to speculate that adding a procedure of transtympanic Eustachian tube dilatation to mastoid surgery would be an easy and safe technique to ensure good results. This study was truly experimental and used cadaveric heads in which transtympanic dilatation was carried out through the lateral end of the Eustachian tube by using Lacricath catheters, based on the analogy of balloon dilatation of paranasal sinuses. A 2-mm Lacricath balloon dilatator catheter was inserted into the tympanic opening of the Eustachian tube through an anterior tympanotomy approach in 10 ears. It was necessary to drill the posterior external auditory canal in six out of 10 ears to achieve a favourable angle which also meant exposing mastoid air cells. After placement of the balloon dilatators the cadaver heads were transported to a radiology unit where a pre- and post-dilatation CT scan was done. Only one side was dilated for comparison with the other side and the investigator studying the pre- and post-dilatation dimensions of the Eustachian tube was blinded to the procedure. In one cadaver the placement was inadequate on one side as the catheter tip did not extend beyond the bony isthmus. In the other cadaveric head the right catheter entered the petrous carotid canal. In another, both catheter balloons entered the vidian canal. From these observations the authors conclude that transtympanic balloon catheterisation of the Eustachian tube is highly likely to be associated with surgical misadventure. The progress of the catheter in the introduction process appeared unimpeded, probably because they were tracking down the vidian and carotid canals. The study failed to show that the catheter balloon actually dilated the bony isthmus. The cadaveric heads used did not have the pathology that we expect to treat, in which case the opening of the Eustachian tube may be even narrower and hence the procedure more difficult. The study therefore suggests that this desired supplement to mastoid surgery is highly dangerous. This is a useful study because even in its negativity, it warns against a disastrous misadventure which is more likely, rather than any useful gain from such an innovation.

Reference

Transtympanic balloon dilatation of the Eustachian tube: a human cadaver pilot study. 
Kepchar A, Acevedo J, Schroeder J, Littlefield E.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1102-07.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Guillotine tonsillectomy revisited
Reviewed by: Madhup K Chaurasia
Mar/Apr 2013 (Vol 22 No 1)
 

Tonsillectomy is one of the commonest procedures in otolaryngology and factors that control its efficiency are the ease of performance, minimal pain during recovery and low costs in terms of equipment required and early discharge from the hospital. In this article the authors compare guillotine tonsillectomy with cold steel dissection of the tonsils in terms of operative blood loss, haemostasis and post-operative control of pain. The two procedures were applied in the same patient and the selection as to which side was operated by guillotine or dissection was randomised. 100 children between the ages of 3 and 12 years were recruited into the study.  Guillotine was performed by engaging the tonsil in the crushing blade and then cutting out with the other blade. The dissection technique was performed in the standard manner. The two procedures were strictly sequential allowing record of the operating time for each. The blood loss was measured by weighing the swabs pre and post-operatively and measuring the volume of blood collected in the suction apparatus. The post-operative pain was assessed by allocating pain scores in the recovery room, two and five hours post-operatively, first post-operative day and finally on the seventh post-operative day by a telephone questionnaire. It was observed that the operative time for guillotine tonsillectomy as expected was substantially less. This was also true for post-operative pain. The blood loss was significantly less for guillotine tonsillectomy and this procedure required less extensive haemostasis. In terms of blood loss this study agrees with previous publications. There are varying reports for returns to the theatre in comparing guillotine with dissection tonsillectomy. The authors contend that there is a place for guillotine tonsillectomy and justify its more frequent usage. However, in the setting that now prevails with widespread use of dissection tonsillectomy, re-introducing this technique would have problems particularly in finding trainers for this rather artful exercise.

Reference

Guillotine versus dissection tonsillectomy: randomised control trial.
Frampton SJ, Ward MJA, Sunkaraneni VS, Ismailkoch H, Shepherd ZA, Salib RJ, Jain EK.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1142-49.

NEUROSURGERY

Management of facial paresis / paralysis following vestibular schwannoma surgery.
Reviewed by: Gauri Mankekar
Mar/Apr 2013 (Vol 22 No 1)
 

In this retrospective study the authors evaluated the facial nerve functional outcome in patients with an electrically unresponsive but anatomically intact facial nerve after microsurgical vestibular schwannoma removal. They tried to determine whether facial nerve repair during the same surgical procedure should be considered. Eleven patients met their inclusion criteria. The median preoperative and definitive postoperative scores were House-Brackmann grades 1 and 3 respectively and the median time for definitive facial nerve recovery was 9.4 months. From their data the authors concluded that modern prognostic testing strategies are incapable of reliably predicting poor outcomes. Therefore if facial nerve continuity is maintained then facial nerve repair should not be pursued during the same procedure. The best option seems to be to observe facial nerve recovery closely, both clinically and electrophysiologically and if the facial palsy persists for 10 - 12 months, then to consider facial reanimation procedures.

Reference

The anatomically intact but electrically unresponsive facial nerve in vestibular schwannoma surgery.
Carlson ML, Van Abel KM, Schmitt WR, Driscoll CL, Neff BA, Link MJ.
NEUROSURGERY
2012;71:1125-30.

NEUROSURGERY

Middle clinoid anatomy for extended endonasal surgery.
Reviewed by: Gauri Mankekar
Mar/Apr 2013 (Vol 22 No 1)
 

This article describes in detail the anatomy of the middle clinoid region and is accompanied by high quality images and video. The authors examined fine-cut CT angiogram scans of 100 patients and 50 anatomic specimens for middle clinoid anatomy and variations. Ten colored silicon injected specimens were used to study the surgical anatomy for endonasal middle clinoidectomy. The middle clinoid was identifiable in 60% of the scans and 20% had at least one caroticoclinoidal ring. The authors conclude that recognition of the middle clinoid and caroticoclinoid ring on pre-operative imaging is critical for surgical planning and middle clinoid removal in endonasal surgery. This article will be of interest to those surgeons who perform endonasal extended transsphenoidal surgery.

Reference

Endoscopic endonasal middle clinoidectomy: anatomic, radiological and technical note.
Fernandez-Miranda JC, Tormenti M, Latorre F, Gardner P, Snyderman C.
NEUROSURGERY
2012;71:233-9. 

NEUROSURGERY

Rathke cleft cyst
Reviewed by: Showkat Mirza
Mar/Apr 2013 (Vol 22 No 1)
 

This paper reviews the results of 73 patients who underwent a transphenoidal microscopic drainage of Rathke Cleft Cyst (RCC) during a 13 year period. Many RCCs were felt to be incidental and only 10% of cases underwent an operation. Presenting symptoms included headache, visual disturbance and polyuria. The surgical technique involved an inverted T-shaped dural incision and then the cyst contents were removed. A 70 degree endoscope confirmed the total removal of cyst contents. The cyst cavity was then packed with fat and more recently synthetic material was employed. After transphenoidal surgery, 75% of polyuria and 96% of visual field defects were resolved and pituitary function improved in 42% of patients. Twenty-nine patients had a minimal intraoperative CSF leak and two had a post-operative CSF leak requiring surgical closure. Twelve of the 73 cases had a recollected cyst but none required a further operation. The mean duration of recollection was 32 months. In the past RCCs were treated by aggressive cyst wall resection but this is considered to have a higher rate of iatrogenic hypopituitarism and other complications. This paper advocates more conservative surgery with reasonable results and careful follow-up of recurrent cysts rather than hasty revision surgery. We tend to make a large cyst opening with marsupialisation to prevent recurrence. Avoiding packing of the cavity may also reduce subsequent pituitary dysfunction.

Reference

Optimal surgical approaches for rathke cleft cyst with consideration of endocrine function.
Park JK, Lee EJ, Kim SH.
NEUROSURGERY
2012;70():250-8.

NEUROSURGERY

Skull base chordomas
Reviewed by: Showkat Mirza
Mar/Apr 2013 (Vol 22 No 1)
 

Chordomas of the skull base are locally aggressive neoplasms for which maximal surgical resection confers prolonged survival. This paper presents the largest consecutive surgical series of cranial base chordomas to date, featuring 95 patients over a period of 23 years. A variety of cranial base approaches were employed including the extended subfrontal, frontotemporal orbitozygomatic transcavernous and Le Fort I transmaxillary approach. Only one patient underwent a purely endoscopic surgical resection. Patients with residual tumour were given post-operative radiation therapy but over the last 6 years all patients received post-operative radiation therapy. The mean overall survival and recurrence free survival was 74%+/-6% and 56%+/-8%, respectively. The use of vascularised tissue flaps such as temporalis muscle dramatically reduced the incidence of post-operative CSF leakage. The authors also found that ultrasonic cavitation devices for bone use (Sonopet) increased the safety of aggressively removing tumour infiltrated bone without the risks associated with spinning microdrills. A learning curve was observed with cranial nerve and vascular injuries decreasing over time. There were three surgical mortalities from 1988-1999 and none from 2000-2011. The five year overall survival was higher during the 2000-2011 era and was felt to be due to the more liberal use and improved techniques of adjunctive radiation therapy. The authors acknowledge the trend to treat such lesions endoscopically now in order to avoid the morbidity of more extended approaches and feel this paper can be used as a more accurate 'yardstick' for the comparison of outcomes.

Reference

Current surgical outcomes for cranial base chordomas: cohort study of 95 patients.
Maio SD, Rostomily R, Sekhar LN.
NEUROSURGERY
2012;70:1355-60.

OPERATIVE NEUROSURGERY

Mapping line for the inferior limit of the cranio-vertebral junction via the endonasal endoscopic approach.
Reviewed by: Gauri Mankekar
Mar/Apr 2013 (Vol 22 No 1)
 

An emerging route via the endoscopic endonasal approach is for the decompression of the craniovertebral junction (CVJ). The authors of this article used the naso-axial line (NAxL) to compare its predictability in determining the inferior limit of the endoscopic endonasal approach with the CVJ. The authors performed pre- and post-dissection computerized tomographic scans of nine cadaver heads to delineate the naso-axial line. They compared this with the previously described naso-palatine line (NPL) or the Kassam line. They found that the naso-axial line more accurately predicts the inferior limit of endoscopic endonasal approach as compared to the NPL. This referring naso-axial line can be easily used on pre-operative sagittal scans, provides better accuracy in predicting the surgical areas to be accessed and can help surgeons to address caudal CVJ pathology. For the ever widening frontiers of endonasal endoscopic surgery this is an important mapping tool. 

Reference

The Naso-Axial line : a new method of accurately predicting the inferior limit of the endoscopic approach to the craniovertebral junction.
Aldana PR, Naseri I, La Corte E.
OPERATIVE NEUROSURGERY
2012;71:e308-14. 

OPERATIVE NEUROSURGERY

Radial forearm free flap for closure of recalcitrant CSF leaks.
Reviewed by: Gauri Mankekar
Mar/Apr 2013 (Vol 22 No 1)
 

Transnasal endoscopic repair of CSF leaks with nasal and septal flaps has revolutionized the management of CSF leaks. However in rare cases, there may be a recalcitrant leak after skull base tumour resection or major head trauma often complicated by lack of local vascularized tissue in a scarred radiated field. The authors describe a novel extracranial approach to manage recalcitrant leaks in five of their patients with a radial forearm free flap. The vascularized free flap was channeled from the neck to the anterior skull base, avoiding a craniotomy. It is a repair worth considering in patients with recalcitrant leaks especially in the setting of previously operated or irradiated fields

Reference

Extracranial radial forearm free flap closure of refractory cerebrospinal fluid leaks: a novel hybrid transantral-endoscopic approach.
Sinha P, Desai SC, Ha DH, Chicoine MR, Haughey BH.
OPERATIVE NEUROSURGERY
2012;71:e219-26. 

OTOLOGY AND NEUROTOLOGY

Malleus replacement prosthesis to provide TORP/PORP stability
Reviewed by: Rebecca Heywood
Mar/Apr 2013 (Vol 22 No 1)
 

Ossiculoplasty results using a TORP are notoriously poor due to the poor stability of the prosthesis. This study from the Causse Clinic describes a new titanium malleus replacement prosthesis (MRP) to be used when both the malleus and stapes superstructure are absent in an attempt to prevent displacement of a TORP. Its 2 titanium posts are inserted into 2 holes drilled in to the bony rim of the external auditory canal. The handle of the prosthesis is malleable and can thus be moved to the appropriate position to stabilise the TORP. The vibratory properties of the MRP were tested when implanted in human cadaveric temporal bones using laser Doppler vibrometry. The MRP was found to have good vibratory properties when sounds of 0.5 to 4kHz were transmitted to it via direct contact with the tympanic membrane. Clinically two groups of patients were then compared: 34 patients who had a TORP positioned from the stapes footplate to the tympanic membrane (TM) and 58 cases in whom the TORP was positioned between the stapes footplate and MRP. At 1 year the mean ABG was 22.5dB in the TM to footplate group and 12.9dB in the MRP to footplate group. The postoperative ABG was less than 10dB in 15.4% and less than 20dB in 53.8% of the TM to footplate group compared to 52.6% and 84.2% respectively in the MRP to footplate group. The failure rate was 51.9% in the TM to footplate group and 23.2% in the MRP to footplate group. Prosthesis displacement was the most common cause of failure in the TM to footplate group; there were no identified cases of prosthesis displacement in the MRP to footplate group. The results are very impressive; hopefully others are able to repeat them!

Reference

Ossiculoplasty in Missing Malleus and Stapes Patients: Experimental and Preliminary Clinical Results With a New Malleus Replacement Prosthesis With the Otology-Neurotology Database
Vincent R, Bittermann AJN, Wenzel G, Oates J, Sperling N, Lenarz T, Grolman W.
OTOLOGY & NEUROTOLOGY
2012;34:83-90.

OTOLOGY AND NEUROTOLOGY

Are BAHA anchors stable to load at 4 weeks?
Reviewed by: Hannah Blanchford
Mar/Apr 2013 (Vol 22 No 1)
 

Resonance frequency analysis (RFA) has historically been used as a quantitative measure of implant stability in dental surgery. Following BAHA surgery, many clinicians wait at least 6 to 8 weeks for adequate osseointegration before loading the sound processor. Using RFA, this prospective study of 68 patients assessed the implant stability quotient (ISQ) of the BAHA B1300 intraoperatively and at 1, 4 and 16 weeks post-operatively. The implant’s features; a wider screw diameter, smaller threads and roughened surface, are said to promote osseointegration. At each time point measured, the mean ISQs exceeded the recommended 60 unit threshold quoted in dental implant studies. Literature regarding the optimal ISQ in the human temporal bone is currently limited. It is suggested that ISQ trend over time is more clinically relevant than absolute values. All patients, bar one, had ISQs over 60 units at 4 weeks and were loaded with sound processors. There were no failed implants. The change in the ISQ value from the intraoperative baseline value was measured. The average change in ISQ demonstrated an increase in stability over time (delta 1.21 at 4 weeks and delta 1.60 at 16 weeks). The data did however demonstrate a small dip at 1 week post-operatively (delta -0.10), which is supported by research demonstrating reduced stability during the early phase of healing. The authors acknowledge that this paper did not seek to find the optimal ISQ value. They conclude that these results support the safe and early loading of processors at 4 weeks and that RFA may be used to reliably assess implant stability.

Reference

Evidence for Early Loading of Osseointegrated Implants for Bone Conduction at 4 Weeks,
McLarnon CM, Johnson I, Davison T, Hill J, Henderson B, Leese D, Marley S.
OTOLOGY & NEUROTOLOGY
2012;33:1578-82.

OTOLOGY AND NEUROTOLOGY

Cochlear implants: Is round window insertion best?
Reviewed by: Hannah Blanchford
Mar/Apr 2013 (Vol 22 No 1)
 

The most reliable technique for placing cochlear implant electrodes remains controversial. Round window insertion (RWI) has fallen out of favour in recent times, due to concerns that multichannel electrodes may buckle and traumatise the cochlear. Instead, many surgeons have adopted the use of a cochleostomy, just antero-inferior to the round window membrane. This single centre retrospective case review of 130 cochlear implant procedures assessed post-operative complications and audiometric performance after these two techniques. RWI was performed in 111 (85.4%) cases through a facial recess approach. Standard cochleostomy was performed in 19 (14.6%) cases when anatomical variation of the facial nerve or jugular bulb rendered RWI unsafe. The patients’ best postoperative audiometric performance in 3 tests (Hearing in Noise test, Consonant-Nucleus-Consonant test and Arizona Biomedical Sentences test) was used for comparison and follow up was performed at 1, 2, 3, 6 and 12-months. There was no incidence of facial nerve paralysis, CSF leak or significant infection. Results demonstrated no significant difference in the rate of vestibular symptoms or in the post-operative audiometric performance of the two groups. The authors conclude that clinically significant cochlear trauma is comparable in the two techniques assessed. The authors suggest that RWI may prove to be the ‘cochleostomy’ of choice now that modern multichannel electrodes are relatively thin and flexible. They do however acknowledge that longer follow-up and multicentre analysis in a larger cohort of patients is necessary to conclusively verify these results

Reference

The Round Window: Is it the”Cochleostomy” of Choice? Experience in 130 Consecutive Cochlear Implants.
Gudis DA, Montes M, Bigelow DC, Ruckenstein MJ.
OTOLOGY & NEUROTOLOGY
2012;33:1497-501.

OTOLOGY AND NEUROTOLOGY

Ocular VEMP responses most valuable test for diagnosing superior semicicular canal dehiscence
Reviewed by: Rebecca Heywood
Mar/Apr 2013 (Vol 22 No 1)
 

Patients with superior canal dehiscence syndrome (SCDS) may not display clinical signs characteristic of the condition and it is well recognised that CT scanning can overestimate the size and incidence of superior semicircular canal dehiscence. Additional confirmation of the diagnosis is therefore valuable before proceeding to surgical intervention. In this study preoperative ocular and cervical VEMP (o- and cVEMP) responses of 11 patients with surgically confirmed SCDS in response to air and bone conduction were compared to those of age-matched controls with no hearing or vestibular deficits. Click and 500Hz tone burst air conduction and midline reflex hammer and 'mini-tap' bone conduction stimuli were delivered to elicit o- and cVEMPs. Overall air conduction stimuli produced greater increases in o- and cVEMP amplitudes than bone conduction stimuli. OVEMP amplitudes were higher overall in the surgically confirmed cases than cVEMP amplitudes. OVEMP amplitudes in response  to air conduction stimuli produced no overlap at all between surgically confirmed SCDS cases and control subjects. There was no correlation between o- or c-VEMP amplitudes and presence or absence of tone-evoked nystagmus, Dizziness Handicap Inventory scores, surgically measured dehiscence area or average air-bone gap. Therefore as a single step suprathreshold test for SCDS this study demonstrates that oVEMPs in response to air conduction stimuli are the most valuable. 

Reference

Air-Conducted oVEMPS Provide the Best Separation Between Intact and Superior Canal Dehiscent Labyrinths
Janky KL, Nguyen KD, Welgampola M, Zuniga MG, Carey JP.
OTOLOGY & NEUROTOLOGY
2012;34:127-34.

THE CLEFT PALATE-CRANIOFACIAL JOURNAL

Psychological factors associated with parental adaptation to having a cleft lip and / or palate child
Reviewed by: Bilal Gani
Mar/Apr 2013 (Vol 22 No 1)
 

Becoming a parent is one of the most difficult life transitions one has to encounter. This can be confounded by the unexpected diagnosis of a cleft lip and / or palate. Parents often draw from their own childhood experiences. Those parents who were born with cleft lips and / or palates often re-experience their imperfections through their children. Although some research on parental adaptation to having a child with the condition has been carried out, the findings are inconclusive. Hence using a series of qualitative and quantitative scales and questionnaires this study aimed to provide an insight into the factors associated with parenting children born with cleft lip and palates. Furthermore, the study applied these analyses to two cohorts of parents; 27 parents born with a cleft lip and / or palate and 27 parents born without a cleft lip and / or palate. Differences were elicited between the two groups. Those parents who had had a cleft lip and / or palate experienced higher afflictions of guilt and tended to draw memories from their own childhood experiences in order to adjust to having a child with a cleft lip and / or palate. Meanwhile those parents with no past history of a cleft lip and / or palate tended to suffer from higher levels of anxiety and highlighted the importance of accurate information and positive interactions with clinicians in facilitating adjustment to their situation.

Reference

Factors associated with parental adaptation to having a child with a cleft lip and / or palate: the impact of parental diagnosis.
O'Hanlon K, Camic PM, Shearer J.
THE CLEFT PALATE-CRANIOFACIAL JOURNAL 
2012;49(6):718-29.

AUDIOLOGICAL MEDICINE

Auditory cortical response in noise
Reviewed by: Diego Zanetti
Jan/Feb 13 (Vol 21 No 6)
 

The perception, segregation and identification of a significant sound pattern in background noise relies upon the integrity of the cochlea and on the processing  of the incoming signal at various levels in the central auditory nervous system (CANS). Its interpretation is then  performed by the auditory cortical areas, which are usually studied by electrophysiological methods such as the late auditory evoked potentials, or slow vertex responses. To date, there is little knowledge of the effects of background noise on these auditory cortical potentials. The authors conducted a clinical trial on 20 normal hearing young subjects: they evoked the cortical potentials with a standard oddball paradigm with binaural stimulation  and competitive noise at different signal-to-noise ratios (SNRs) (quiet, +20,  +10, 0 dB). The amplitude and latency of the N1, P2, and P3 waves were measured for each SNR. As expected, no significant differences in the morphology or the parameters of the responses were observed between the quiet and +20 SNR condition; when the noise level increased, significant latency shifts and amplitude of the N1, P2 and P3 waves were detected. The results indicate a significant change in the activity of higher-order neurons in the auditory area when challenged with concurrent sound and noise. These normative data constitute the basis for further clinical studies that could shed light on the mechanisms of central processing of relevant sound, such as speech, in a noisy environment. The consequences would be an improvement of the strategies applied in auditory rehabilitation methods and technological advances by the hearing aid and cochlear implant manufacturers

Reference

Auditory Cortical Processing in Noise in Normal-Hearing Young Adults.
McCullagh J, Musiek FE, Shinn JB.
AUDIOLOGICAL MEDICINE
2012;10(3):114-21.

AUDIOLOGICAL MEDICINE

Diabetes and hearing loss
Reviewed by: Diego Zanetti
Jan/Feb 13 (Vol 21 No 6)
 

Diabetes mellitus is a chronic metabolic disorder characterized, in the long run, by vascular and neurological complications such as microangiopathies and neuropathies. It affects 9.6% of the population in the USA and 4.8% of Italian adults. The prevalence of hearing loss is more than double among people with diabetes than those without it. Given the respective prevalence of sensorineural hearing loss and diabetes, it is easily acceptable that the inner ear and the retrocochlear auditory pathways are among the targets of the latter, although the pathophysiological relationship between these two conditions is still unclear. The authors conducted a systematic review through Medline search in order to examine the relationship between diabetes mellitus and sensorineural hearing loss. In the literature, angiopathy (thickening and parvicellular infiltrates) has been observed in capillaries of the stria vascularis, of the modiolus and of vasa nervorum. They are more evident in type I (insulin dependent), long-standing diabetic patients. Despite many experimental studies confirming the pathological findings, definite evidence in humans is lacking. While waiting for large cohort studies to enlighten the issue, a systematic audiological screening for diabetic patients is recommended.

Reference

Hearing loss and diabetes mellitus: Evidences of cochlear microangiopathy?
Ciorba A, Aimoni C, Bovo R.
AUDIOLOGICAL MEDICINE
2012;10:105–8.

BIOMED CENTRAL EAR, NOSE AND THROAT DISORDERS

Methylene blue for safe thyroidectomy
Reviewed by: Ms Gauri Mankekar
Jan/Feb 13 (Vol 21 No 6)
 

In this prospective study, the authors describe a novel technique of identifying recurrent laryngeal nerves, parathyroid glands and thyroid arteries during thyroidectomy. After superior pole ligation but before ligation of inferior pole, 0.5 ml of methylene blue was sprayed over the thyroid lobe and perilobular areas in 56 patients undergoing primary (not recurrent) thyroidectomy. The arteries and nerves were not stained and remained white at all times. The stain was washed out over the parathyroid glands within 3 minutes and they regained their original yellow colour. The wash out time for thyroid tissue was more than 15 minutes but less than 25 minutes. All patients underwent total thyroidectomy. The authors conclude that their technique ensures not only identification of parathyroid glands within 3 minutes but also identification of the recurrent laryngeal nerve and thyroid arteries. The authors recommend this technique for safe thyroid surgery.

Reference

Safe thyroidectomy with intra-operative methylene blue spraying.
Sari S, Aysan E, Muslumanoglu M, Ersoy YE, Bektasoglu H, Yardim E.
BIOMED CENTRAL EAR, NOSE AND THROAT DISORDERS
2012;5:15.

BIOMED CENTRAL EAR, NOSE AND THROAT DISORDERS

Osteoporosis and superior semicircular canal dehiscence
Reviewed by: Ms Gauri Mankekar
Jan/Feb 13 (Vol 21 No 6)
 

This is a retrospective study of 496 East Asian patients with giddiness attending a neurology community health centre in Boston. Superior semicircular canal dehiscence (SSCD) was confirmed in 5 of these patients by a multi-detector, high resolution CT of the temporal bone and osteoporosis was documented by bone marrow density (BMD) scans in these patients. The authors describe an atypical presentation of SSCD without Tullio phenomenon or Hennebert sign in these patients. They conclude that there may be an association between SSCD and osteoporosis in this susceptible population, although they recommend further research to determine the incidence and prevalence of this disorder as well as the relationship of age, race, osteoporosis risk and the development of SSCD.

Reference

Superior semicircular canal dehiscence in East Asian women with osteoporosis.
Yu A, Teich DL, Moonis G, Wong ET.
BIOMED CENTRAL EAR, NOSE AND THROAT DISORDERS
2012;12:8.
Superior semicircular canal dehiscence in East Asian women with osteoporosis.
Yu A, Teich DL, Moonis G, Wong ET.
BIOMED CENTRAL EAR, NOSE AND THROAT DISORDERS
2012;12:8.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Complications following Oral laser surgery
Reviewed by: Sunil Kumar Bhatia
Jan/Feb 13 (Vol 21 No 6)
 

Carbon dioxide laser therapy is a preferred treatment of precancerous lesions. The laser allows for rapid and accurate dissection with reduced intra-operative bleeding and post-operative pain and scarring.  When used to dissect, a histological specimen can be obtained. This paper looks at 82 patients treated by the same surgeon and worked to a standardised protocol for intraoral pre-cancer and cancer. Oral resections were done under general or local anaesthetic. The authors set out to study the post operative complications. Most of the patients had at least one complication; while they varied in severity most were an inevitable consequence of intraoral resection. Commonest complication was pain, followed by obstructive swelling of the submandibular glands, then lingual paresthesia. Other complications were bleeding, difficulties with speech and swallowing and tethering. As there are no papers comparing laser and conventional surgical excisions, this paper helps to inform preoperative counsel and  patients consent.

Reference

Complications following interventional laser surgery for oral cancer and precancerous lesions.
Goodson ML, Sugden K, Kometa  S , Thomson PJ.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2012;50(7):597-600.
Complications following interventional laser surgery for oral cancer and precancerous lesions.
Goodson ML, Sugden K, Kometa  S , Thomson PJ.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2012;50(7):597-600.

BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY

Pre-operative assessment of appropriate post operative method of feeding
Reviewed by: Sunil Kumar Bhatia
Jan/Feb 13 (Vol 21 No 6)
 

This paper is from a tertiary maxillofacial  referral  unit in the UK. Following ablative oral / head and neck surgery and reconstruction, feeding is of paramount importance and yet oral intake may not be appropriate.  Pre-operatively between 35% and 60% of patients with head and neck malignancies are malnourished and so need optimal nutritional support. Traditional methods are nasogastric feeding or feeding via percutaneous gastrostomy tube. Selection of the appropriate method can be difficult as both methods carry morbidity. The authors reviewed 144 patients that underwent oral cancer resection and reconstruction and developed a scoring system to aid selection of appropriate feeding method; The Key to Appropriate Replacement Enteral Nutrition (KAREN). this takes into account the ASA, tumour stage, site and reconstruction and assigns a score. 0-3 can have NG feeding and at greater than 4 a PEG is suggested. With a 92% accuracy to predict the best feeding method, I think this is a good tool to help clinicians assess and plan enteral support post-operatively. This is a retrospective study and thus requires prospective validation but, as mentioned, could be a useful tool to help clinicians’ treatment plan.

Reference

A review of post-operative feeding in patients undergoing resection and reconstruction for oral malignancy and presentation of a pre-operative scoring system. 
Eley KA, Shah R, Bond SE, Watt-Smith SR.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2012;50(7):601-605.
A review of post-operative feeding in patients undergoing resection and reconstruction for oral malignancy and presentation of a pre-operative scoring system. 
Eley KA, Shah R, Bond SE, Watt-Smith SR.
BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY
2012;50(7):601-605.

COCHLEAR IMPLANTS INTERNATIONAL

Do children with moderately severe / severe hearing loss and hearing aids outperform children with severe to profound deafness and cochlear implants?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 13 (Vol 21 No 6)
 

This is a very interesting question. The authors assessed 41 children with bilateral sensorineural hearing impairment, aged 6-18 years. Twenty children had moderately severe / severe hearing loss and used hearing aids, and 21 had severe to profound hearing loss and used cochlear implants. Comparisons of the two groups revealed that they did not differ in their open-set speech recognition abilities or speech production skills. However, children with hearing aids obtained higher scores than their peers with cochlear implants in the domains of receptive vocabulary, language, phonological memory, and reading comprehension. It was also very interesting to find that children with moderately severe or severe hearing loss can develop spoken language skills that are within the range expected for normal hearing children. Although such comparisons are always welcome as the audiological cut-off criterion for a child to be a candidate for cochlear implantation remains controversial, the study design should be more robust as factors such as the small numbers and the different age at assessment weaken the conclusions.

Reference

Comparison of outcomes in children with hearing aids and cochlear implants.
Fitzpatrick E, Olds J, Gaboury I, McCrae R, Schramm D, Durieux-Smith A.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):5-15.
Comparison of outcomes in children with hearing aids and cochlear implants.
Fitzpatrick E, Olds J, Gaboury I, McCrae R, Schramm D, Durieux-Smith A.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):5-15.

COCHLEAR IMPLANTS INTERNATIONAL

MRI or CT-scan or both for pre-operative imaging for cochlear implantation?
Reviewed by: Thomas Nikolopoulos
Jan/Feb 13 (Vol 21 No 6)
 

The authors correctly claim that previous studies of computed tomography (CT) and magnetic resonance imaging (MRI) before cochlear implantation have been of limited sample size, lacked statistical analysis and been inconsistent in their conclusions. Their aim was to quantify the utility of CT, MRI, and their combination in order to rationalize their selection. Clinical records and radiological findings were correlated retrospectively in 158 adults and children. All underwent both CT and MRI. The results revealed that a total of 28% of patients had a significant radiological abnormality, but these were considered critical to subsequent management in only 13%. All these were detected by MRI. They were missed by CT in 6.3%. In all, 6.3% also had non-critical abnormalities that were reported only on CT. The authors concluded that while CT may be better at defining some abnormalities, MRI appears to be able to detect all abnormalities that are critical to patient management. Therefore, they recommend MRI as the initial method imaging and CT could be added in cases with a history of severe middle ear disease, meningitis, or dysmorphic syndromes. An interesting study; however it is retrospective and cases who were not implanted, for whatever reasons, were not included in the study.

Reference

Pre-operative imaging for cochlear implantation: magnetic resonance imaging, computed tomography, or both? 
Mackeith S, Rajive J, Robinson P, Hajioff D. 
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(3):133-6.

COCHLEAR IMPLANTS INTERNATIONAL

Simultaneous cochlear implantation in children: the Great Ormond Street experience
Reviewed by: Thomas Nikolopoulos
Jan/Feb 13 (Vol 21 No 6)
 

The authors aimed to analyse the surgical aspects and safety of bilateral simultaneous cochlear implantation in children. They conducted a retrospective case series at their tertiary paediatric centre in the United Kingdom. Surgical times, analgesia and antiemetic use and complications were analysed for the first 25 bilateral simultaneous cochlear implants performed at their hospital. These were compared with a consecutive group of sequentially implanted children. The results revealed that total time for simultaneous implantation was significantly less than the cumulative time required for sequential implantation. In addition, the number of paracetamol, non-steroidal anti-inflammatory and antiemetic doses was significantly less for simultaneous implantation than for sequential implantation. Finally, the number of doses of analgesia and antiemetic required for simultaneous implantation were no higher than for single-side surgery and no difference in complication rates was seen between the groups. However, the numbers in this study were rather small and the follow-up period very small to assess complications.

Reference

Simultaneous cochlear implantation in children: the Great Ormond Street experience. 
Grainger J, Jonas NE, Cochrane LA.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(3):137-41.
Simultaneous cochlear implantation in children: the Great Ormond Street experience. 
Grainger J, Jonas NE, Cochrane LA.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(3):137-41.

EAR NOSE & THROAT JOURNAL

Laryngeal hyposensitivity in COPD patients
Reviewed by: Mr Jahangir Ahmed
Jan/Feb 13 (Vol 21 No 6)
 

Various studies have reported a relatively high prevalence of aspiration in association with impaired swallow in patients suffering with COPD. In the absence of a mechanical block, little is known about the mechanism(s) responsible for this. Here the primary hypothesis was that an impairment in laryngeal sensitivity may at least contribute (to the dysphagia) or indeed be directly responsible for silent aspiration. Certainly in stroke patients the risk of aspiration has been related to the extent of laryngopharyngeal hyposensitivity. The authors used a reproducible sensory discrimination test based on the threshold pressure of a puff of air applied to the arytenoid eminence on one side of the laryngeal inlet (via a flexible nasendoscope) required to elicit the laryngeal adductor reflex.  Twenty adult patients met the rigorous inclusion and exclusion criteria and were compared with 11 age matched healthy controls. These numbers were based on a power calculation using data obtained from a prior pilot study. The assessor however was not blinded to the diagnosis of COPD; a potential source of bias. There was a statistically significant reduction in laryngeal sensitivity in patients with COPD. This association may be an important contributor to COPD exacerbations, many of which occur due to lower respiratory tract infections; although the latter was not looked at specifically. Laryngeal hyposensitivity has been associated with impaired strength of pharyngeal musculature and would warrant investigation in this population. Nevertheless the current study is novel and does pose some important clinically relevant mechanistic questions in a relatively large population at risk of aspiration. The cause of sensory impairment may be manifold in this context, for example chronic inhaled steroid use and /or active smoking and chronic cough (causing laryngeal oedema).

Reference

The effect of chronic obstructive pulmonary disease on laryngopharyngeal sensitivity.
Clayton NA, Carnaby-Mann GD, Peters MJ, Ing AJ.
EAR NOSE & THROAT JOURNAL
2012;91(9):370-82.
The effect of chronic obstructive pulmonary disease on laryngopharyngeal sensitivity.
Clayton NA, Carnaby-Mann GD, Peters MJ, Ing AJ.
EAR NOSE & THROAT JOURNAL
2012;91(9):370-82.

EAR NOSE & THROAT JOURNAL

Puffing out the cheeks improves the diagnostic accuracy of CT scans of oral cavity carcinomas
Reviewed by: Mr Jahangir Ahmed
Jan/Feb 13 (Vol 21 No 6)
 

The gold standard for diagnosing carcinomas of the oral cavity is by direct visualisation and pathological scrutiny of a biopsy specimen. Imaging (CT) plays an important role in staging of disease as well as guiding the extent of putative surgical resection. This study looked at the quality of the latter and in particular whether puffing out the cheeks improves diagnostic evaluation. Here, 11 patients with primary squamous carcinoma of the oral cavity located in the floor of mouth, buccal mucosa and / or the retromolartrigone had a conventional contrast enhanced CT and another one obtained when their cheeks were puffed out against pursed lips whilst holding their breath. Obviously there will be a limit to how long head and neck cancer patients (many with concomitant respiratory problems) will be able to do this, but a CT scan is usually a fairly rapid affair. All lesions were able to be accurately and confidently evaluated in terms of location and size in “puffed cheek” mode. Worryingly three lesions were not picked up at all on conventional CT whilst for the other eight, conventional CT despite revealing a mass was unable to delineate it from the normal mucosal surface. It is unclear whether the CTs were examined independently by more than one radiologist, which ought to be the standard in a study like this. Nevertheless the theory behind the manoeuvre is sound, i.e. air separates the closely apposed mucosal surfaces in the oral cavity, enabling better localisation and demarcation. For the same reason the tongue may be elevated from the floor of mouth if a tumour is suspected in this region. If a patient is able to hold their breath and puff their cheeks out, this manoeuvre may be beneficial in aiding the radiologist to evaluate small oral cavity tumours on CT.

Reference

Puffed-cheek computed tomography: a dynamic manoeuvre for imaging oral cavity tumours.
Erdogan N, Bulbul E, Songu M, Uluc E, Onal K,Apaydin M, Katilmis H
EAR NOSE & THROAT JOURNAL
2012;91(9):383-86.
Puffed-cheek computed tomography: a dynamic manoeuvre for imaging oral cavity tumours.
Erdogan N, Bulbul E, Songu M, Uluc E, Onal K,Apaydin M, Katilmis H
EAR NOSE & THROAT JOURNAL
2012;91(9):383-86.

EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK

A blood marker for chronic rhinosinusitis
Reviewed by: Ian Coulter
Jan/Feb 13 (Vol 21 No 6)
 

The chemokines eotaxin and RANTES (regulated upon activation normal T expressed and presumably secreted) encourage eosinophil recruitment into the lamina propria of nasal polyps.  In this study, Chao et al. have investigated whether plasma levels of eotaxin and RANTES correlate with the severity of chronic rhinosinusitis and nasal polyposis.  They compared plasma levels of both chemokines in 20 Taiwanese patients with chronic rhinosinusitis and nasal polyps to 20 healthy controls.  They utilised ELISA to measure plasma chemokine levels and CT scanning to grade disease severity. Patients with nasal polyps were found to have significantly elevated plasma levels of eotaxin and RANTES and increased peripheral blood eosinophils (p < 0.001).  Eotaxin levels were found to correlate more significantly with disease severity than RANTES.  The researchers acknowledge that the study was limited by its size and that only Taiwanese patients with severe disease were included.  Nevertheless the findings may warrant further investigation into the potential utility of employing such markers in clinical practice.

Reference

Plasma RANTES and eotaxin levels are correlated with the severity of chronic rhinosinusitis.
Chao PZ, Chou CM, Chen CH.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269:2343-48.
Plasma RANTES and eotaxin levels are correlated with the severity of chronic rhinosinusitis.
Chao PZ, Chou CM, Chen CH.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269:2343-48.

EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK

The pain of intratympanic injections
Reviewed by: Ian Coulter
Jan/Feb 13 (Vol 21 No 6)
 

The investigators conducted a prospective randomised study to elucidate the pain levels associated with three methods of intratympanic (IT) injections, namely: EMLA cream applied to the tympanic membrane 60 minutes prior to the procedure, subcutaneous injection of lidocaine 1% with 1:100,000 epinephrine in the external auditory canal and an IT injection without anaesthesia. 39 patients with Ménière’s disease and 30 patients with sudden sensorineural hearing loss were included and received methylprednisolone and / or gentamicin. Patients received one injection per week for a total of 3 weeks and were asked to comment on their pain intensity using four different pain rating scales 5 minutes and 45 minutes following injection.There was no difference in pain intensity observed between the three methods of IT injection, with 45.8% of patients preferring the IT injection without anaesthesia.  Injecting without anaesthesia may therefore be the most appropriate method, which will avoid exposing the patient to the potential disadvantages of the anaesthesia.

Reference

Pain assessment of the intratympanic injections: a prospective comparative study.
Belhassen S, Saliba Issam
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269:2467-73.
Pain assessment of the intratympanic injections: a prospective comparative study.
Belhassen S, Saliba Issam
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269:2467-73.

INTERNATIONAL ARCHIVES OF ALLERGY AND IMMUNOLOGY

Comparing Allergic Sensitization with Allergic Rhinitis symptoms
Reviewed by: Laith Tapponi
Jan/Feb 13 (Vol 21 No 6)
 

Allergic Rhinitis poses a considerable burden on public health because of its prevalence, impact on the quality of life and productivity, economic costs and asthma co-morbidity. It is to be expected that in the next decades, when this generation grows older, the general Allergic Rhinitis prevalence will further increase. This study found that the increase in allergy at a young age reached a maximum in the third and fourth decades and then decreased in later life. A large review of the available literature about the epidemiology of Allergic Rhinitis showed that its prevalence has increased over the last decades, in particular in countries with a low prevalence. The interaction between genetic and environmental factors seems to be crucial. However, lifestyle changes such as Westernization, urbanization and affluence recently received more attention. Consequently, it is to be expected that the worldwide prevalence of atopy and Allergic Rhinitis will grow further. On the other hand, the increase in the number of Allergic Rhinitis patients seems to recede in countries with a high prevalence. In Western countries, we still might expect an increase in the general Allergic Rhinitis prevalence, because the present 20- to 40-year-old generation will grow older in the next decades, while a substantial proportion (but probably no longer or only restrictedly growing) of young children will have Allergic Rhinitis. We observed a higher prevalence of house dust mites sensitization in men. Women with a positive skin prick testing for grass pollen or house dust mites were significantly more prone to experience symptoms than were men. skin prick testing is the standard of care in diagnosing IgE-mediated allergy. However, not all rhinitis patients have a positive Skin prick testing, and not all patients with a positive skin prick testing perceive allergic symptoms

Reference

Prevalence of allergic sensitisation versus Allergic Rhinitis symptoms in an unselected population.
Blomme K, Tomassen P, Lapeere H, Huvenne W, Bonny M, Acke F, Bachert C, Gevaert C. 
INTERNATIONAL ARCHIVES OF ALLERGY AND IMMUNOLOGY
2013;160:200-7.
Prevalence of allergic sensitisation versus Allergic Rhinitis symptoms in an unselected population.
Blomme K, Tomassen P, Lapeere H, Huvenne W, Bonny M, Acke F, Bachert C, Gevaert C. 
INTERNATIONAL ARCHIVES OF ALLERGY AND IMMUNOLOGY
2013;160:200-7.

INTERNATIONAL ARCHIVES OF ALLERGY AND IMMUNOLOGY

The effects of neuro-allergic mechanism on non Allergic Rhinitis
Reviewed by: Laith Tapponi
Jan/Feb 13 (Vol 21 No 6)
 

This study aimed to explore the contribution of neuro-allergic mechanisms to the pathogenesis of Non Allergic Rhinitis. It concludes that the neurogenic way seems to play a major role in Non Allergic Rhinitis, with the main symptoms being rhinorrhea and a high expression of substance p in the nasal mucosa, whereas positivity to nasal provocation test with allergen, increased ratios of tryptase levels in the nasal lavage, similar to the inflammatory cell profile of Allergic Rhinitis, and IgE expression in the nasal tissue may be an indicator of localized IgE-mediated allergy in almost half of the Non Allergic Rhinitis patients. In summary, it indicates the existence of a common neuro-allergic mechanism in Non Allergic Rhinitis, just like in Allergic Rhinitis, but with different contributions. The difference in dominance of these ways might determine the major phenotype of rhinitis. The limitations of this study included the small size of the study group, and the fact that it was conducted as a nasal provocation test only with house dust mites, which might leave other entopic sensitizations undetected. The authors chose rhinitis patients only with perennial symptoms because house dust mites are the most common allergens responsible for perennial symptoms, whereas there are too many pollen types that could trigger seasonal rhinitis symptoms. They did not assess late allergic response, reported to be present in low ratios in Allergic Rhinitis as well as in Non Allergic Rhinitis, but only if it was accompanied by early response. Furthermore, the neurogenic way was shown to only evoke early nasal reaction, and substance p was found to be released early after the challenge.

Reference

Contribution of neurogenic and allergic ways to the pathophysiology of Nonallergic Rhinitis.
Kavut AB, Kalpaklıoğlu F, Atasoy P.
INTERNATIONAL ARCHIVES OF ALLERGY AND IMMUNOLOGY
2013;160:184-91.
Contribution of neurogenic and allergic ways to the pathophysiology of Nonallergic Rhinitis.
Kavut AB, Kalpaklıoğlu F, Atasoy P.
INTERNATIONAL ARCHIVES OF ALLERGY AND IMMUNOLOGY
2013;160:184-91.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Eosinophils and the sinuses
Reviewed by: Jo Rimmer
Jan/Feb 13 (Vol 21 No 6)
 

Chronic rhinosinusitis (CRS) may be subdivided into CRS with (wNP) or without (sNP) nasal polyps. CRS with fungal involvement is often known as allergic fungal sinusitis (AFS), but it is also known as eosinophilic fungal CRS (ECRS) due to the inflammatory profile seen, with a high serum eosinophilia. ERCS appears to have a worse prognosis, with higher symptom scores, worse olfactory dysfunction and poorer outcome overall. However, this diagnosis is currently based on symptoms and blood tests rather than histopathology. This cross-sectional study aimed to determine the associations between histopathology, serology and the clinical phenotype of patients with presumed ERCS. In a sample of 51 patients, high tissue eosinophilia was seen in 84% of those with polyps but also seen in 19% of those without. Surprisingly, asthma was not associated with high tissue eosinophilia, which was seen in 42% of non-asthmatic patients. Serum eosinophilia was highly predictive of high tissue eosinophilia, but a high serum IgE was not. ERCS appears to have a worse prognosis, with more severe endoscopic and CT scores, but surprisingly the SNOT-22 scores were not significantly different from those with CRS without eosinophilia.  Based on this study, the authors suggest that histopathological assessment of tissue eosinophilia should be part of a standard structured pathology assessment in clinical practice, as the severity and prognosis of ECRS is significantly different to that of non-ECRS CRS. Perhaps we should all start requesting eosinophil levels on our polyp histology forms?

Reference

Structured histopathology profiling of chronic rhinosinusitis in routine practice.
Snidvongs K, Lam M, Sacks R, Earls P, Kalish L, Phillips PS, Pratt E, Harvey RJ.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2012;2(5):376-85.
Structured histopathology profiling of chronic rhinosinusitis in routine practice.
Snidvongs K, Lam M, Sacks R, Earls P, Kalish L, Phillips PS, Pratt E, Harvey RJ.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2012;2(5):376-85.

INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY

Sinus surgery on the rise
Reviewed by: Jo Rimmer
Jan/Feb 13 (Vol 21 No 6)
 

The authors used an american database to obtain health insurance claims for certain procedure codes over the 2 year period, specifically those for septoplasty, inferior turbinate surgery and endoscopic sinus surgery (ESS). They subdivided the ESS codes into “basic” procedures such as “maxillary antrostomy without tissue removal” and “advanced” procedures, which included frontal and sphenoid sinus work. There was a significant increase in the absolute number of all these procedures over the two-year period, as well as a significant percentage increase (23% for ESS and 21% for septoplasty and turbinate surgery). Interestingly, this increase was much higher than that seen for tonsillectomy (only 6.1%), so this is not just due to more surgery overall. Whilst “basic” ESS procedures showed only a small increase (8%), the number of “advanced” procedures, particularly frontal and sphenoid sinusotomy, rose dramatically (by 76%). The authors suggest that this may be due to the advent of balloon sinuplasty techniques as well as the increased availability and use of image guidance techniques, both giving surgeons more confidence in those more difficult anatomical areas.  The prevalence of chronic rhinosinusitis does not appear to have increased, and the rate of sinus imaging has if anything reduced over that time period, so these would not appear to be contributing factors. The authors discuss other potential explanations for the significant rise, including a change in surgical philosophy and socioeconomic factors. It would be interesting to see whether these rises continue once the use of sinus balloons has stabilised, and whether the recent economic downturn may have affected rates since 2009.

Reference

Changing trends in sinus and septal surgery, 2007 to 2009.
Psaltis AJ, Soler ZM, Nguyen SA, Schlosser RJ.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2012;2(5):357-61.
Changing trends in sinus and septal surgery, 2007 to 2009.
Psaltis AJ, Soler ZM, Nguyen SA, Schlosser RJ.
INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY
2012;2(5):357-61.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Objective kinematic analyses of speech in Parkinson’s disease
Reviewed by: Ms Gauri Mankekar
Jan/Feb 13 (Vol 21 No 6)
 

Motor speech disorders are usually assessed with rapid syllable repetition tasks. Studies so far on rapid syllable repetition in Parkinson’s disease (PD) were based on perceptual and acoustic analyses rather than objective kinematic investigations and suggested that articulatory dysfunction in PD are the outcome of a restricted range of movement of articulatory muscles. The findings of this paper are however to the contrary. The authors investigated and compared lingual kinematics during rapid syllable repetition in dysarthric speakers with PD, non-dysarthric speakers with PD and a group of healthy controls. They used electromagnetic articulography to record tongue tip and tongue back movement in participants during rapid repetition of syllables and compared with healthy controls. They found that both dysarthric and non-dysarthric speakers with PD had an increased range, duration and speed of lingual movement during production of rapid repetitions compared with healthy controls plausibly due to increased range of lingual movement rather than slowness of lingual movement.

Reference

Lingual kinetics during rapid syllable repetition in Parkinson’s disease.
Wong MN, Murdoch BE, Whelan BM.
INTERNATIONAL JOURNAL OF LANGUAGE AND 
COMMUNICATION DISORDERS
2012;47(5):578-88.
Lingual kinetics during rapid syllable repetition in Parkinson’s disease.
Wong MN, Murdoch BE, Whelan BM.
INTERNATIONAL JOURNAL OF LANGUAGE AND 
COMMUNICATION DISORDERS
2012;47(5):578-88.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Triage 10 words to identify phonological delay and disorders in young children
Reviewed by: Ms Gauri Mankekar
Jan/Feb 13 (Vol 21 No 6)
 

Speech language therapists typically use speech sound assessment samples to judge whether a child’s speech is developing, delayed or disordered through phonemic and phonetic inventory analysis. Ideally single words used in sampling should be spontaneously produced rather than imitated by children. The authors of this study attempted to identify this short word list based on word complexity that could be spontaneously produced by 150 nursery children between ages of 3 and 5.5 years. Words from published speech assessment were modified and extended to include a range of phonemic targets in different word positions in 78 monosyllabic and polysyllabic words. These 78 words were also ranked by phonemic / phonetic complexity and by ease of speech production. The ten most complex words – called Triage 10 – were spontaneously produced by 90% of the participating children. The Triage 10 words reliably differentiated children with typically developing speech from those with delayed or disordered speech patterns. The authors conclude that Triage 10 words can be used as a screening tool for general assessment and has the potential to monitor progress during speech language therapy.

Reference

Measuring word complexity in speech screening: a single word sampling to identify phonological delay/disorder in preschool children.
Anderson C, Cohen W.
INTERNATIONAL JOURNAL OF LANGUAGE AND 
COMMUNICATION DISORDERS
2012;47(5):534-41.
Measuring word complexity in speech screening: a single word sampling to identify phonological delay/disorder in preschool children.
Anderson C, Cohen W.
INTERNATIONAL JOURNAL OF LANGUAGE AND 
COMMUNICATION DISORDERS
2012;47(5):534-41.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Better assessment of benefit with grommet insertion
Reviewed by: Madhup Chaurasia
Jan/Feb 13 (Vol 21 No 6)
 

The funding of procedures with limited benefits has come under pressure in efforts to enhance cost effectiveness. Studies have suggested that hearing improvement with insertion of grommets is nine decibels which falls down to six decibels after 12 months. On the contrary many parents report dramatic improvement in the child’s hearing and speech after insertion of grommets. This leads one to think that pure tone audiometry is not the best method to evaluate the benefits of grommet insertion. In this study the authors have used speech and noise testing as an experiment to evaluate the pre- and post-operative hearing status of 12 children undergoing insertion of grommets. Arthur Boothroyd word lists were used for hearing testing delivered through one channel.  Through another channel a babble noise at intensities of 50, 60 and 70 decibels was produced to test speech in noise in different signal to noise ratios. These tests were carried out three weeks and six to eleven weeks after the insertion of grommets. It was noted that there was a marked improvement in speech testing in quiet conditions. This improvement was also sustained in the post-operative testing with background noise. All these results were statistically significant except for testing in 60 decibel background noise. However this does not show any correlation with improvement in pure tone thresholds which were measured simultaneously. The authors are aware of the limited numbers and short-term follow-ups in this study but do make a case for speech and noise testing before and after insertion of grommets, being aware that although this kind of a test may initially require more time, this can be improved upon to compare with the time taken for a pure tone audiogram for the same purpose. The main issue in these children is educational advantage and it is heartening to see one such study which feeds from theoretical to practical benefits.

Reference

Speech and noise testing before and after grommet insertion.
Possamai V, Kirk G, Scott A, Skinner D.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1010-15.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Is hearing a fourth dimension maintenance of balance?
Reviewed by: Madhup Chaurasia
Jan/Feb 13 (Vol 21 No 6)
 

Inputs from vision, proprioception and the peripheral vestibular system are normally known to control human balance. Whether hearing provides additional contribution is not well understood. In this simple pilot study the authors have assessed the role of hearing maintenance of balance in normal subjects. Twenty-one volunteers aged between 23 and 44 years were recruited into this pilot study. None of them had any hearing loss or balance problems. The method used was sway measurements recorded as an area of ellipse depicting the centre of gravity and the equipment used was a Nintendo Wii gaming console and balance board. The tests were performed in the normal environment of a clinic room and then in a sound proof room. The tests were carried out with eyes open and closed on normal surface and then standing on foam, this being repeated with or without ear defenders, then with eyes open or closed with ear defenders and standing on foam, thus constituting eight different scenarios. It was noted that in the normal room, increase in the postural sway measurements was found in subjects standing on foam with eyes closed and also when wearing ear defenders which obliterated auditory input. In the sound proof room, an increase in postural sway measurements was noted when subjects wore ear defenders. The study therefore suggests that the static postural control is adversely affected with the hearing facility impeded; in this scenario with the use of ear defenders and a sound proof room. The authors claim that normal balance templates include auditory information and losing this facility adversely affects postural control. It is further stated that there is a higher risk of falls in elderly individuals who have poor hearing and therefore hearing should be optimised to promote balance. In this scenario the use of bilateral hearing aids is advised. The study is interesting, but a rather simple way of addressing the complexities of balance control and further research is required to substantiate these findings.

Reference

The contribution of hearing to normal balance.
Kanegaonkar RG, Clarke M.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:984-88.
The contribution of hearing to normal balance.
Kanegaonkar RG, Clarke M.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:984-88.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Laryngeal lesions in pemphigus vulgaris
Reviewed by: Madhup Chaurasia
Jan/Feb 13 (Vol 21 No 6)
 

Pemphigus vulgaris is an autoimmune bullous disease but has a very rare incidence of 0.7 patients per 100,000. It exists in various forms, which include drug induced and paraneoplastic pemphigus. In this prospective study, 40 sequentially treated patients with pemphigus vulgaris underwent endoscopic ENT examination with either a flexible nasopharyngolaryngeal endoscope or a rigid 70° laryngeal telescope. Laryngeal biopsy however was not done and an association with a positive oral mucosal biopsy was presumed. Lesions were classified as follows: grade 1 – involving the epiglottis, grade 2 – involving the supraglottic, grade 3 – involving the piriform fossae and grade 4 – involving the vocal cords and the glottis.  Subglottic lesions were not seen.  95% of these patients had active lesions due to pemphigus vulgaris and most of these involved the epiglottis. Patients in grades were equally distributed. Varying prevalence of laryngeal lesions in other studies has been described. The authors contend that classification is important because it guides the corticosteroid dose that should be given to these patients. The study generates useful awareness of laryngeal lesions in pemphigus vulgaris patients with associated symptoms. To this can be added a case from personal experience which needed a tracheotomy for glottic obstruction caused by pemphigus vulgaris lesions.

Reference

The laryngeal involvement in pemphigus vulgaris: a proposed classification.
Mohmoud A, Miziara ID, Costa KC, Santi CG, Maruta CW, Aoki V.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1041-44.
The laryngeal involvement in pemphigus vulgaris: a proposed classification.
Mohmoud A, Miziara ID, Costa KC, Santi CG, Maruta CW, Aoki V.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1041-44.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Surgical treatment for chronic obliterative otitis externa
Reviewed by: Madhup Chaurasia
Jan/Feb 13 (Vol 21 No 6)
 

Obliteration of the external auditory canal by development of fibrous tissue is a rare condition occurring in 0.6 per 100,000 of the population. The treatment of this however is difficult and recurrence is common. In this article the authors have described the procedure of canaloplasty applied to 14 patients, with outcome measures based on Glasgow benefit inventory and pure tone audiology. The surgical approach was made through a post auricular incision. The fibrous tissue was dissected from lateral to medial direction and this was very carefully removed with preservation of the tympanic membrane. The bare bone was covered with temporalis fascia and 0.5 mm thick split skin graft which was harvested from the upper arm. Strips of these were longitudinally placed with a paraffin gauze superficial to the skin graft. The authors describe a very long follow-up of about 15 visits which was carried out mainly through aural care by the nursing staff, who ensured appropriate treatment of granulation tissue, infection or fibrosis with local medication. The Glasgow benefit inventory scores were obtained through telephone interviews. Three months after surgery the patients’ pure tone average hearing threshold improved by a mean of 13.9 decibels and in complete stenosis this improvement was 20.2 decibels. There was only one case of re-stenosis. The authors present results of other studies in literature and emphasize the finer points of surgery, which makes this useful reading

Reference

Outcomes of canalplasty for chronic obliterative otitis externa.  
Potter CPS, Bottrill ID.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1016-21.
Outcomes of canalplasty for chronic obliterative otitis externa.  
Potter CPS, Bottrill ID.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:1016-21.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

The effect of prophylactic antibiotics, tympanostomy tubes and adenoidectomy on the course of recurrent acute otitis media in children
Reviewed by: Madhup Chaurasia
Jan/Feb 13 (Vol 21 No 6)
 

This is a systematic review of publications which tried the effects of the three modalities (namely prophylactic antibiotics, insertion of tympanostomy tubes and adenoidectomy) used in the management of recurrent otitis media in children. Eighteen publications were identified which had the inclusion criteria of randomized controlled trials, a population of more than 40 children of less than 15 years and contained these avenues of treatment with the use of antibiotics being over a month.  The outcomes were measured in terms of recurrence of otitis media, the frequency of recurrence and the length of time for which the recurrence occurred. It was noted that prophylactic antibiotics were effective in reducing the recurrence, the frequency of recurrence and the total length of time for which acute otitis media occurred in these children. Tympanostomy was less effective because it did not reduce the prevalence but did affect the frequency of recurrence and the total length of disease. Adenoidectomy however, proved the least effective in reducing prevalence but other outcomes were not clearly affected. It had no benefit in the treatment of children under two years of age.   The role of various other factors such as Down’s syndrome, cleft palate and impaired eustachian tube function has been mentioned. Immune deficiency can also affect results and the follow-up times have been quite variable in these studies. Therefore the frequency of recurrence may not have been accurately recorded. It is suggested that these studies would be more valid if a standard treatment protocol and a standard follow-up method is adopted.  This would be a rather difficult task but if possible would help standardise treatment and possibly reduce costs for this highly prevalent condition.

Reference

Management of recurrent acute otitis media in children: systemic review of the effective different interventions on otitis media recurrence, recurrence frequency and total recurrence time.
Cheong KH, Hussain SSM.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:874-85.
Management of recurrent acute otitis media in children: systemic review of the effective different interventions on otitis media recurrence, recurrence frequency and total recurrence time.
Cheong KH, Hussain SSM.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126:874-85.

NEUROSURGERY

Microvascular decompression with dural flap in Hemifacial spasm
Reviewed by: Ms Gauri Mankekar
Jan/Feb 13 (Vol 21 No 6)
 

Microvascular decompression for hemifacial spasm is commonly achieved using a sling made of autologous free graft or synthetic material that is attached to the tentorium or petrous dura. The authors propose a novel transposition technique to achieve a definite and durable decompression based on their preliminary work in seven patients. They fashioned a local pedicled dural flap from the petrous posterior surface to retract the offending blood vessel from the root exit zone of the facial nerve in hemifacial spasm cases. The advantages of this technique are that it is fairly simple, does not require any special equipment and uses autologous material. The authors state that the dural pedicle is much softer, less space consuming and more flexible for manipulation compared to other materials. According to the authors the main disadvantage of this technique is that it cannot be used in all cases such as for venous decompression or in cases with short perforating arteries that make transposition of the artery from the nerve too dangerous and also in cases in which the artery transects the seventh cranial nerve. This novel work aims to improve existing conventional operating techniques for hemifacial spasm.

Reference

A ‘sling swing transposition’ technique with pedicled dural flap for microvascular decompression in hemifacial spasm.
Ming KH, Yoshimine T, Taki T.
NEUROSURGERY
2012;71(3):ONS 25-31.
A ‘sling swing transposition’ technique with pedicled dural flap for microvascular decompression in hemifacial spasm.
Ming KH, Yoshimine T, Taki T.
NEUROSURGERY
2012;71(3):ONS 25-31.

NEUROSURGERY

Optic canal decompression during endonasal endoscopic transsphenoidal approach to anterior skull base
Reviewed by: Ms Gauri Mankekar
Jan/Feb 13 (Vol 21 No 6)
 

Endonasal endoscopic transsphenoidal approach is being increasingly used to manage midline anterior skull base tumours. This approach offers a direct route to the tuberculum sellae and medial aspect of both the optic canals and does not require manipulation of neurovascular structures. In this excellent collaborative paper from otolaryngologists, neurosurgeons and neurologists the advantages of this approach especially for removal of tuberculum sellae and planum sphenoidale menigiomas extending into the optic canal are highlighted. The authors present a decision-tree algorithm to manage these patients. They suggest that although the optic canal can be decompressed early during surgery, it is not required and the tumour can be safely debulked without manipulating the optic nerves.

Reference

The importance and timing of optic canal exploration and decompression during endoscopic endonasal resection of tuberculum sella and planum sphenoidale meningioma.
NEUROSURGERY
Attia M, Kandasamy J, Jakimovski D, Bedrosian J, Alimi M, Lee DLY, Anand VK, Schwartz TH.
2012;71(3):ONS 58-67.
The importance and timing of optic canal exploration and decompression during endoscopic endonasal resection of tuberculum sella and planum sphenoidale meningioma.
NEUROSURGERY
Attia M, Kandasamy J, Jakimovski D, Bedrosian J, Alimi M, Lee DLY, Anand VK, Schwartz TH.
2012;71(3):ONS 58-67.

ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA

Management of the fractures of the Frontal sinus
Reviewed by: Sunil Kumar Bhatia
Jan/Feb 13 (Vol 21 No 6)
 

This paper is written as part of the edition on paranasal sinus surgery. The treatment of frontal sinus fractures is an internationally controversial topic with no unanimous protocols agreed. The authors review current thoughts and suggest some guidelines for the management of this injury. Surgical anatomy is addressed initially, followed by mechanism of injury, a method of classification and diagnosis. Traditional approaches using a bicorporal flap and its advantages / disadvantages are then discussed. I enjoyed reading about endoscopic approaches and other minimal invasive approaches and their limitations. The outcome and assessment is interesting, overall complication rates vary from 4%-18%. The question posed is whether these are truly as a result of the treatment or non-treatment of the fracture. The desired outcome is a cosmetically acceptable repair that recreates a safe functioning nasofrontal apparatus that is separated from the brain and remains disease free. There is an algorithm for the management of these frontal sinus fractures for FESS and ORIF. This is an excellent paper that does what the authors set out to do, namely review current thoughts and start of the development of guidelines.

Reference

Management of frontal sinus fractures.
Doonquak L, Brown P, Mullings W.
ORAL AND MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA
2012;24(2):265-74.

OTOLOGY & NEUROTOLOGY

Cochlear implantation following head injury
Reviewed by: Rebecca Heywood
Jan/Feb 13 (Vol 21 No 6)
 

The outcomes of cochlear implantation in patients profoundly deaf as a result of head injury depends not just on the state of the cochlea, but also on the effects of the injury on central auditory pathways. Speech perception scores were compared before and after implantation in 20 patients (23 implants). Mechanism of injury, for example, road traffic accident varied widely, as did type of head injury, for example, brain contusion or temporal bone fracture. Mean age at implantation was 51 years and mean duration of deafness was 12 years (range 1-30 years). Bamford Kowal Bench (BKB) sentence score in quiet was 0% in all patients pre-operatively. Post-operatively the mean score was 64% in quiet (range 0-100%) and 61% in noise (range 0-97%). Mean post-operative City University of New York (CUNY) sentences with lip reading score was 83% (0-100%) and median Arthur Boothroyd (AB) words score was 60% (range 7-90%). Eight patients (10 implants) achieved very poor speech discrimination scores. Two of these were non-users. The most common features present in those with poor scores were partial obliteration of the basal turn, injury to the central auditory pathways and long duration between deafness and implantation. Otic capsule injury per se was not found to be associated with poor speech discrimination unless the cochlear duct was obliterated. However, nonauditory stimulation was present in 15% of patients, all of whom had fracture of the otic capsule. None of the patients with BKB scores higher than 80% had any radiological evidence of significant central auditory damage. Cochlear implantation can be used successfully for hearing rehabilitation in patients with profound deafness following head injury but they need to be selected with these factors in mind and counselled appropriately.

Reference

Cochlear implantation in patients profoundly deafened after head injury.
Khwaja S, Mawman D, Nichani J, Bruce I, Green K, Lloyd S.
OTOLOGY & NEUROTOLOGY 
2012;33:1328-1332.
Cochlear implantation in patients profoundly deafened after head injury.
Khwaja S, Mawman D, Nichani J, Bruce I, Green K, Lloyd S.
OTOLOGY & NEUROTOLOGY 
2012;33:1328-1332.

OTOLOGY & NEUROTOLOGY

Open set speech recognition after cochlear implantation for unilateral deafness
Reviewed by: Rebecca Heywood
Jan/Feb 13 (Vol 21 No 6)
 

This pilot study looks at speech in quiet and noise, sound localisation, discrimination of temporal and spectral cues and subjective reports of recipients of cochlear implants (CI) for unilateral deafness. Only three subjects were studied. All had severe to profound unilateral sensorineural deafness of reasonably short duration (up to five years) and normal or near-normal hearing (NH) in the contralateral ear. They were evaluated in three listening conditions: NH ear alone, CI alone and bilaterally. CI sound field thresholds were similar to or better than pure tone thresholds in the NH ear in all three patients. Localisation was significantly better for all patients bilaterally than with the NH ear alone. Patients achieved open set speech recognition using the CI alone, achieving consonant-nucleus-consonant (CNC) word scores of 75%, 30%, and 37% for patients 1 to 3 respectively. Sentence recognition in noise did not differ significantly between the NH alone and bilaterally and was not therefore impaired by the presence of the CI; word recognition in noise improved in 2 patients. Subjective reports were variable. This study is notable in that it differs from some previous reports which suggest that CI for unilateral deafness is of little benefit. This may be a result of patient selection. The primary reason of two of the patients in this study for seeking implantation was for relief from severe tinnitus and all three patients noted considerable improvement in their tinnitus when wearing the CI. Tinnitus relief would be a great motivating factor for them to persevere with the CI, possibly resulting in increased open set speech benefit. A larger group of patients needs to be studied over a longer period to ascertain the real benefits of CI for unilateral deafness.

Reference

Auditory abilities after cochlear implantation in adults with unilateral deafness: a pilot study.
Firszt JB, Holden LK, Reeder RM, Waltzman SB, Arndt S.
OTOLOGY & NEUROTOLOGY
2012;33:1339-1346.
Auditory abilities after cochlear implantation in adults with unilateral deafness: a pilot study.
Firszt JB, Holden LK, Reeder RM, Waltzman SB, Arndt S.
OTOLOGY & NEUROTOLOGY
2012;33:1339-1346.

RHINOLOGY

Clinical efficacy of a dry extract of five herbal drugs in acute viral rhinosinusitis
Reviewed by: Lakhbinder Bal
Jan/Feb 13 (Vol 21 No 6)
 

Acute rhinosinusitis (ARS) is characterised by sudden onset of two or more symptoms of nasal blockage / congestion, nasal discharge, facial pain or pressure and reduction / loss of smell. It can impact upon the quality of life of affected individuals and current recommended treatment includes intranasal steroids and antibiotics. However, there is increasing evidence that phytotherapeutic agents may be useful in the treatment of ARS. This study aims to investigate the efficacy and safety of a dose of BNO 1016 160 mg three times a day for 15 days a placebo on the symptoms of acute viral rhinosinusitis. BNO 1016 is a novel extract of a fixed combination of five herbal drugs (comprising gentian root, primula flower, sorrel herb, elderflower and verbena herb) in the ratio 1:3:3:3:3. It is a prospective randomised, double-blind, placebo-controlled study conducted in 37 centres across Germany. Criteria for patient selection was symptom duration of less than 3 days, mild-moderate facial pain, a Major Symptom Score (MSS) of  > 8 and < 12.  The primary efficacy endpoint was mean MSS at end of treatment. Secondary outcome measures included treatment response and changes in paranasal sinuses assessed by ultrasound. Treatment resulted in clinically relevant, significant differences in mean MSS for BNO 1016 placebo. BNO1016 provided symptom relief 2 days earlier than placebo. The number needed to treat for healing was 8. BNO1016 was superior regarding responder rates at day 10 and day 14 and percentage of patients without signs of ARS assessed by ultrasound at the end of treatment. Strengths of this study are that it is a well controlled study that is double-blind, randomised and placebo-controlled with clear inclusion / exclusion criteria. In addition, the symptoms assessment for ARS used in this study and the system of grading symptom severity are in line with the European Position paper on rhinosinusitis and nasal polyps (EPOS 2012).

Reference

Clinical efficacy of a dry extract of five herbal drugs in acute viral rhinosinusitis.
Jund R, Mondigler M, Steindl H, Stammer H, Stierna P, Bachert C; on behalf of the ARhiSi II Study Group.
RHINOLOGY
2012;50(4):417-26.
Clinical efficacy of a dry extract of five herbal drugs in acute viral rhinosinusitis.
Jund R, Mondigler M, Steindl H, Stammer H, Stierna P, Bachert C; on behalf of the ARhiSi II Study Group.
RHINOLOGY
2012;50(4):417-26.

RHINOLOGY

Unilateral peak nasal inspiratory flow, normal values in adult population
Reviewed by: Lakhbinder Bal
Jan/Feb 13 (Vol 21 No 6)
 

Rhinomanometry (RM) is currently the gold standard for the assessment of nasal resistance and nasal patency. However, peak nasal inspiratory flow (PNIF) has been shown to be as good an indicator of objective nasal patency as formal rhinometry in some studies. Previous studies of PNIF have involved obtaining data by testing both nostrils at the same time. The aim of this study was to establish baseline normal values of unilateral PNIF in adult patients. Seventy-nine patients were entered into the study. All had a score of < 1 on SNOT-22, were non-smokers, non-asthmatics with no previous sinonasal surgery, or taking medications that could affect nasal patency. Patients underwent measures via a portable youlten peak flow meter attached to a tight fitting mask. Maximal inspiration measurements were taken with both nostrils patent (PNIF). Then, adhesive tape was applied to one nostril at a time and PNIF for each nostril was measured – right nostril (rPNIF) and left nostril (lPNIF). The data was statistically analysed to obtain a model relating the variable lPNIF and rPNIF to the following exploratory variables – age, sex and height. The data shows that the effect of age on PNIF is significant whilst sex and height is marginally significant. However, on single nostril PNIF, age is not significant. This means that whilst PNIF decreases with age, both lPNIF and rPNIF do not statistically change with age. The only variable significantly related to both lPNIF and rPNIF was height. This confirms that nasal airflow in particular, when tested unilaterally, is related to pulmonary volumes and thereafter to patients’ height. This pilot study is an important step towards determining the usefulness and accuracy of PNIF and in particular unilateral PNIF as a method to aid diagnosis of nasal disease. This method could also be useful in the assessment of functional effects of unilateral nasal septal deviation and patient selection, e.g. for septoplasty. In addition, PNIF is a cheap, simple and easy to perform procedure suitable for the outpatient setting. The limits of this study are that it has a small sample size and therefore these results need to be confirmed in a larger study and then to be performed in obstructed patients as well as healthy subjects.

Reference

Unilateral peak nasal inspiratory flow, normal values in adult population.
Ottaviano G, Scadding GK, Scarpa B, Accordi D, Staffieri A, Lund VJ.
RHINOLOGY
2012;50-4:386-92.
Unilateral peak nasal inspiratory flow, normal values in adult population.
Ottaviano G, Scadding GK, Scarpa B, Accordi D, Staffieri A, Lund VJ.
RHINOLOGY
2012;50-4:386-92.

THE BRITISH JOURNAL OF RADIOLOGY

IMRT for nasopharyngeal carcinoma: helical tomography vs segmental multileaf collimator
Reviewed by: Marcos Martinez Del Piero
Jan/Feb 13 (Vol 21 No 6)
 

This article compares the outcomes of helical tomography with radiotherapy provided by a fixed number of beam angles. The presumed advantage of helical tomography is a reduced dose of radiation to surrounding structures. This article stratified 30 patients into two similar groups in terms of demography, tumour characteristics and the use of chemotherapy. There is also a detailed description of the planning for both treatment modalities. Both treatment modalities performed equally in terms of their primary outcomes: survival and tumour control. However, using helical tomography the authors were able to reduce the amount of radiation to the surrounding structures (e.g. contralateral parotid gland). Helical tomography also appeared to reduce further the rate mucositis and patient reported xerostomia. Overall, the paper is well designed and the results are encouraging, but their primary outcomes were too ambitious with the sample size the authors had and with the short length of follow-up.

Reference

Intensity-modulated radiotherapy for nasopharyngeal carcinoma: improvement of the therapeutic ratio with helical tomotherapy versus segmental multileaf collimator-based techniques.
Chen AM, Yang CC, Marsano J, Liu T, Purdy JA.
THE BRITISH JOURNAL OF RADIOLOGY
2012;85:e537-e543.

ACTA OTO-LARYNGOLOGICA

The surgical outcome of Functional Endoscopic Sinus Surgery for adolescents
Reviewed by: Laith Tapponi
Nov/Dec 12 (Vol 21 No 5)
 

Chronic rhinosinusitis requires long-term comprehensive treatment. Surgery is considered in cases that are refractory to medical treatment. Two hundred and seventy adolescent patients were randomised into the study group, and 273 healthy adolescents were randomly selected during the same period and included in the control group. Exclusion criteria for the study group: (1) cystic fibrosis or immunodeficiency disorder; (2) age below 12 and above 18 years; (3) partially completed questionnaires that influenced the statistical analysis; and (4) inverted papilloma, granuloma, and vasculitis identified by postoperative pathologic study. Inclusion criteria for the control group: (1) no ear, nose nor throat disease; and (2) healthy adolescents aged 12-18 years. The quality of life was assessed before and within 3-8 years after the surgery using the SNOT scale. After the investigation was completed, a person blinded to the experiment was assigned for the statistical analysis. There was significant improvement for the following symptoms: need to blow nose, nasal blockage / congestion, sneezing, runny nose, cough, postnasal flow, thick nasal discharge, ear fullness, fatigue, poor sleep quality, waking up during sleep, ear pain, reduced work efficiency, inability to concentrate, depression, agitation, irritability and sadness. The following symptoms showed no significant differences: dizziness, facial pressure, and embarrassment. This study showed a long-term improvement in postoperative quality of life, in a large adolescent survey. The selection of appropriate patients may further improve the surgical outcomes and quality of life after FESS, by inquiring about the patient's symptoms and history of medical treatment carefully.

Reference

Long-term improvements in quality of life after functional endoscopic sinus surgery for adolescents with chronic rhinosinusitis.