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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.
Jiang XJ, Guo XY, Yuan W, Li Q, Zhong C, Jiang Z, Xiang ZL, Li TJ, Wei Y, Zhang X.
ACTA OTO-LARYNGOLOGICA
2012;132(8):798-802.
Long-term improvements in quality of life after functional endoscopic sinus surgery for adolescents with chronic rhinosinusitis.
Jiang XJ, Guo XY, Yuan W, Li Q, Zhong C, Jiang Z, Xiang ZL, Li TJ, Wei Y, Zhang X.
ACTA OTO-LARYNGOLOGICA
2012;132(8):798-802.

AUDIOLOGICAL MEDICINE

Auditory cortical responses in noise
Reviewed by: Diego Zanetti
Nov/Dec 12 (Vol 21 No 5)
 

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 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, 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 of 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.
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

Auditory cortical responses in noise
Reviewed by: Vinaya KC Manchaiah
Nov/Dec 12 (Vol 21 No 5)
 

Hearing impairment is one of the most frequent chronic conditions in adults. Some population studies have found some links between hearing impairment and diabetes. Whilst there is suggested association between diabetes mellitus and sensorineural hearing loss, the pathophysiological relationships between these two conditions are not well understood. Diabetes mellitus is a complex and systemic metabolic disease that can have consequences on a wide range of body tissues and physiological functions, for example, complications of vascular and neurological malfunction. Researchers have speculated and propose microvascular involvement of the inner ear as one of the pathophysiological explanations. Authors in this paper have conducted a systematic literature review to examine the relationship between diabetes mellitus and sensorineural hearing loss. They conclude that the association between diabetes and hearing loss still remains controversial, as there is very little evidence to link it to microangiopathy. They recommend that large cohort studies are necessary in order to evaluate if diabetes mellitus causes specific changes in the inner ear, due to microvascular disease.

Reference

Hearing loss and diabetes mellitus: evidences of cochlear microangiopathy?
Ciorba A, Aimoni C, Bovo R.
AUDIOLOGICAL MEDICINE
2012;10(3):105-8.
Hearing loss and diabetes mellitus: evidences of cochlear microangiopathy?
Ciorba A, Aimoni C, Bovo R.
AUDIOLOGICAL MEDICINE
2012;10(3):105-8.

AURIS NASUS LARYNX

The surgical outcome of radiofrequency tissue volumetric reduction of inferior nasal turbinates
Reviewed by: Laith Tapponi
Nov/Dec 12 (Vol 21 No 5)
 

Ideally, turbinate surgery should result in an improvement in nasal breathing without damaging the mucosal lining. Mucosal preservation maintains normal functioning of the turbinate, promotes quicker recovery, lesser bleeding and pain and reduces the likelihood of atrophic rhinitis developing. Radiofrequency tissue volumetric reduction is a safe, less morbid and effective method of reducing turbinate volume. The heat emanates from the tissue and not the electrode, because the alternating current generated induces ionic agitation at the cellular level with consequent tissue heating. The healing process induces fibrosis with wound contraction, leading to tissue volume reduction. This prospective study is a small clinical study of 35 patients with a short-term assessment, up to eight weeks after surgery. They used not only subjective symptom scores but also an objective test with multidetector CT scanning, compared pre- and postoperatively. The turbinate volume decrease was significantly better among patients with a larger turbinate compared to those with smaller turbinates. A skin allergy test was also performed and patients with allergic rhinitis or previous turbinate surgery were excluded, which will limit the beneficial outcome of radiofrequency tissue volumetric reduction surgery in this study.

Reference

Quantitative measurement of radiofrequency volumetric tissue reduction by multidetector CT in patients with inferior turbinate hypertrophy.
Bahadir O, Kosucu P.
AURIS NASUS LARYNX
2012;39(6):588-92.
Quantitative measurement of radiofrequency volumetric tissue reduction by multidetector CT in patients with inferior turbinate hypertrophy.
Bahadir O, Kosucu P.
AURIS NASUS LARYNX
2012;39(6):588-92.

BMC EAR, NOSE AND THROAT DISORDERS

Is stress a predisposing factor for tinnitus?
Reviewed by: Gauri Mankekar
Nov/Dec 12 (Vol 21 No 5)
 

Tinnitus is a debilitating disorder and is known to cause stress. The authors studied if long-term stress is a predisposing factor for tinnitus. They subjected 21 tinnitus participants and 21 controls, comparable in all ways, to basal saliva cortisol assessment on three non-consecutive days. They were given 0.5mg dexamethasone orally at 23.00 hours on the first day. Their saliva cortisol levels were measured hourly the next morning. Detection and discomfort hearing threshold were measured before and after dexamethasone suppression test. The authors found that patients with tinnitus had heightened glucocorticoid sensitivity in terms of an abnormally strong glucocorticoid receptor mediated HPA axis feedback and a lower tolerance for sound loudness with suppressed cortisol levels. They conclude that long-term stress exposure and its adverse effects are an important predisposing factor for, or a significant pathological consequence of tinnitus.

Reference

Cortisol suppression and hearing thresholds in tinnitus after low dose dexamethasone challenge.
Simoens VL, Hebert S.
BMC EAR, NOSE AND THROAT DISORDERS
2012;12:4.
Cortisol suppression and hearing thresholds in tinnitus after low dose dexamethasone challenge.
Simoens VL, Hebert S.
BMC EAR, NOSE AND THROAT DISORDERS
2012;12:4.

BMC EAR, NOSE AND THROAT DISORDERS

Role of genetic polymorphism in developing sudden sensorineural hearing loss (SSNHL)
Reviewed by: Gauri Mankekar
Nov/Dec 12 (Vol 21 No 5)
 

PAI-1 is a key molecule for thrombus formation and inflammation. It has been reported that levels of PAI-1 are significantly higher in patients with SSNHL than in controls, thereby suggesting that it is a possible risk factor and a potential therapeutic target for SSNHL. The PAI-1 gene has variation in the promoter region either 4G or 5G. Polymorphism of the 4G/5G of PAI -1 is known to be associated with cardiovascular and thromboembolic phenomena. In this study the authors investigated the 4g/5g polymorphism of PAI-1 gene in Italian patients with SSNHL and the role of this polymorphism as a risk factor in developing SSNHL.  They enrolled 103 patients with SSNHL and 113 matched controls in Italy. Hearing loss outcome was measured three months after hearing loss. DNA was isolated from peripheral blood and the 4G/5G polymorphism in the -675 promoter region was genotyped with an allele specific PCR. They found that 5G/5G genotype had a two time lower frequency in SSNHL patients compared to healthy controls and was associated with reduced odds compared to 4G/5G genotype. Also patients with 5G/5G genotype showed more than two time higher ratio of hearing recovery after systemic corticosteroid treatment compared to 4G/5G genotype, suggesting a better clinical outcome. This study is clinically significant for diagnosis, treatment and prognosis of SSNHL and may provide a new therapeutic modality for SSNHL.

Reference

Association of the 4g/5g polymorphism of plasminogen activator inhibitor-1 gene with sudden sensorineural hearing loss. A case control study
Cho SH, Chen H, Kim IS, Yokose C, Kang J, Cho D, Cai C, Palma S, Busi M, Martini A, Yoo TJ.
BMC EAR, NOSE AND THROAT DISORDERS
2012;12:5.
Association of the 4g/5g polymorphism of plasminogen activator inhibitor-1 gene with sudden sensorineural hearing loss. A case control study
Cho SH, Chen H, Kim IS, Yokose C, Kang J, Cho D, Cai C, Palma S, Busi M, Martini A, Yoo TJ.
BMC EAR, NOSE AND THROAT DISORDERS
2012;12:5.

COCHLEAR IMPLANTS INTERNATIONAL

A comparison of the psychological well-being of cochlear implant users with the general population
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

The authors attempted to compare the psychological well-being experienced by cochlear implant users with that of the general population in Norway. They conducted a questionnaire-based cross-sectional multicentre study, in which 53 of 73 (73%) unilateral cochlear implant users and 177 of 318 (56%) matched reference subjects from the general population participated. Psychological well-being was measured by the Psychological General Well-being Index (PGWB). The indexes of the cochlear implant users and the general population sample were compared using ordinary linear regression, adjusting for the matching variables. The results revealed no difference in mean PGWB index between the cochlear implant users and the general population sample with indexes of 85.5 and 83.4, respectively. The 95% confidence interval for the adjusted difference was −3.0 to 6.9. Moreover, the cochlear implant users had slightly better scores in the dimensions, general health and vitality. The authors concluded that the cochlear implant users experience a psychological well-being similar to that of the general population. Although the results are very encouraging, we should take into account that methods of well-being measurement and recruitment of the controls may significantly affect the outcomes

Reference

Psychological well-being among cochlear implant users: a comparison with the general population.
Rembar SH, Lind O, Romundstad P, Helvik AS.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):41-9.
Psychological well-being among cochlear implant users: a comparison with the general population.
Rembar SH, Lind O, Romundstad P, Helvik AS.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):41-9.

COCHLEAR IMPLANTS INTERNATIONAL

A rare complication of cochlear implantation: necrotising meningoencephalitis mimicking cerebellopontine angle tumour
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

The authors described a case of localised necrotising meningoencephalitis with loss of implant function, facial nerve palsy, and vertigo after cochlear implant surgery. Magnetic resonance imaging (MRI) and computed tomography scans before CI surgery and after three years showed no abnormalities, especially no evidence of a tumour in the cerebellopontine angle (CPA). Due to recurrent facial nerve palsy, the implant was explanted in order to be able to visualise the CPA without artifacts caused by the device in MRI scan. The MRI scan then showed a tumour in the CPA. Following removal of the mass, histopathological and immunohistochemical examination revealed no tumour but a necrotising meningoencephalitis. Another interesting point in this case was the migration of the electrode array from scala tympani to scala vestibuli attributed to labyrinthitis. This is a very rare complication indeed!!

Reference

Necrotizing meningoencephalitis mimicking cerebellopontine angle tumor as late complication following cochlear implantation.
Arndt S, Schild C, Doostkam S, Birkenhäger R, Laszig R, Prinz M, Aschendorff A.
COCHLEAR IMPLANTS INTERNATIONAL
2012; 13 (1): 60-64.
Necrotizing meningoencephalitis mimicking cerebellopontine angle tumor as late complication following cochlear implantation.
Arndt S, Schild C, Doostkam S, Birkenhäger R, Laszig R, Prinz M, Aschendorff A.
COCHLEAR IMPLANTS INTERNATIONAL
2012; 13 (1): 60-64.

COCHLEAR IMPLANTS INTERNATIONAL

Acoustic neuroma and cochlear implantation
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

In this paper the authors presented two patients who underwent cochlear implant despite the presence of a vestibular schwannoma (VS) on the same side. The first case was a 59-year-old male, diagnosed with VS after nine months of good hearing with a cochlear implant. Obviously the tumour had been missed in the preoperative assessment with CT-scan alone. The second case was 26-year-old female, known case of NFII, who had received a cochlear implant after radiosurgery. The authors concluded that both cases suggest that cochlear implantation can work well in the presence of VS, even in the presence of previous radiosurgery. They added that this adds significantly to the management options available to NFII patients as the results seem to be better than those expected for auditory brainstem implant (ABI), and with a much simpler and safer intervention (although the possibility of intracochlear schwannomas making difficult array insertion and other concomitant or later tumours needing MRI follow-up should be taken into account). However, the first case had to be explanted due to the tumour growth and the second case had a very short follow-up. Nevertheless, both implants were working, at least for a short period of time, even in the presence of a VS in the same side.

Reference

Cochlear implant rehabilitation for patients with vestibular schwannoma: report of two cases.
Amoodi HA, Makki FM, Cavanagh J, Maessen Heather, 
Bance M.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):124-7.
Cochlear implant rehabilitation for patients with vestibular schwannoma: report of two cases.
Amoodi HA, Makki FM, Cavanagh J, Maessen Heather, 
Bance M.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):124-7.

COCHLEAR IMPLANTS INTERNATIONAL

Bilateral cochlear implantation in an elderly patient with long-term deafness in the one ear and short-term deafness in the other ear
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

It is well known that implantation in an ear with long-term deafness may have inferior outcomes in comparison to ears with short duration of deafness. The authors present a case of a 70-year-old man with single-sided deafness (SSD) in the right ear since childhood, who developed a sudden severe hearing loss in the left ear at the age of 63. Eventually, after he received cochlear implants in both ears, he started to present behavioural auditory processing skills associated with binaural hearing, such as improved ability to understand speech in the presence of background noise, and sound localisation. Outcomes were measured using cortical auditory evoked potentials, speech perception in noise, sound localisation tests, and a self-rating questionnaire. The authors concluded that even after more than 50 years of unilateral deafness it was possible, for this particular patient, to develop binaural interaction and sound localisation as a result of electric auditory stimulation. Although some crucial comparisons in the various settings are unclear or lacking in this study, the overall impression of the rather unexpected benefit in this patient is very encouraging. However, we should be very careful in such cases as neuroplasticity varies considerably from patient to patient.

Reference

Bilateral cochlear implants in long-term and short-term deafness.
McNeill C, Noble W, Purdy S, O'Brien A, Sharma M.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13 (1):50-3.
Bilateral cochlear implants in long-term and short-term deafness.
McNeill C, Noble W, Purdy S, O'Brien A, Sharma M.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13 (1):50-3.

COCHLEAR IMPLANTS INTERNATIONAL

Bilateral implantation. How do we assess candidacy?
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

Bilateral cochlear implantation is gradually being approved by many cochlear implant centres as a standard method of management of deafness, at least in selected cases. However, there is no consensus regarding the criteria for bilateral cochlear implantation. The authors conducted a postal survey to all practices performing cochlear implantation in the United States and Canada. The survey queried centres regarding candidacy criteria for bilateral implantation, testing parameters, definition of best aided condition, use of testing in noise, localisation, and quality-of-life questionnaires. The survey was resent to non-responding centres four weeks after the initial mailing. The authors found that best aided condition (70%) and hearing in noise (52%) were used to establish bilateral candidacy, while 45% of centres offered bilateral implants to all candidates. The majority of respondents defined as best aided as hearing aids only (57% non-exclusive) or cochlear implant and hearing aid together (57%). Only 25% considered a cochlear implant alone as best aided. Reimbursement affected candidacy decision for 45%. Although there is a significant weakness in this study (overall response rate only 40%), it is obvious that there is a wide variability in the criteria used for bilateral cochlear implantation. Therefore, consensus is urgently needed.

Reference

Assessing candidacy for bilateral cochlear implants: A survey of practices in the United States and Canada.
Schwartz SR, Watson S, Backous DD.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):86-92.
Assessing candidacy for bilateral cochlear implants: A survey of practices in the United States and Canada.
Schwartz SR, Watson S, Backous DD.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):86-92.

COCHLEAR IMPLANTS INTERNATIONAL

Cochlear implantation and computer modelling of the cochlea: what we know today
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

This article reviews the current knowledge on computer modelling of the cochlea and how it affects the developments in cochlear implantation. It summarises, and categorises features of models used in different studies and makes recommendations for future development. It is now possible to analyse the micromechanics of the cochlea and the transient response of tissue to external stimulation. The paper is classified into four sections detailing features of the cochlear models, electrodes, electrical stimulation, and software used in different studies. It shows that, although the significant progress, issues like fluid-flow properties, modelling of electrode-tissue interface, and inclusion of capacitive properties in the cochlear models are still unresolved. However, basic science and modern technology derived from the computer science may contribute to the analysis and better understanding of these issues.

Reference

Computer modelling of the cochlea and the cochlear implant: a review.
Agrawal V, Newbold C.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):113-23.
Computer modelling of the cochlea and the cochlear implant: a review.
Agrawal V, Newbold C.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):113-23.

COCHLEAR IMPLANTS INTERNATIONAL

Do children with bilateral implants wear both implants all the time?
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

This very interesting question the authors attempted to answer. Forty-six of the first 48 children sequentially or simultaneously implanted at ≤3.5 years at the Melbourne Clinic participated. Classification into categories was based on daily use of both implants at two months post-switch-on, with follow-up information obtained at 12 months. Category 1 included children wearing both implants full time (at least 90% of the walking hours), category 2 part time, category 3 limited amount of time, and category 4 never. The 37 Category 1 children wore both implants full time at two months, and 35 still did so at 12 months. The two Category 2 children used both implants four hours daily at two months, but achieved full-time use within 12 months. The five Category 3 children used both implants for ≤1 hour, with only three achieving full-time use within 12 months. The two Category 4 children did not use two implants at two months, and one still did not wear both implants at 12 months. There were weak / modest but significant relationships between category and of the time between implants and age at bilateral implantation. This is in favour of younger age at implantation and short time interval between implants. However, the weak / modest correlations found in this study suggest that these factors alone do not preclude older children with longer intervals between implants. Counselling and expectations should be modified accordingly

Reference

Adapting to bilateral cochlear implants: early post-operative device use by children receiving sequential or simultaneous implants at or before 3.5 years.
Galvin KL, Hughes KC.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):105-112.
Adapting to bilateral cochlear implants: early post-operative device use by children receiving sequential or simultaneous implants at or before 3.5 years.
Galvin KL, Hughes KC.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):105-112.

COCHLEAR IMPLANTS INTERNATIONAL

Graeme Clark: the pioneer who led the way
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

It is extremely interesting to hear history from the ones who created it. In this paper, Graeme Clark himself outlines the discoveries at the University of Melbourne leading to the multi-channel cochlear implant. His early experimental electrophysiological research had demonstrated temporal coding that occurred for only low frequencies, that is, below 200-500 pulses/second. Then, confirmed these findings perceptually in behaviourally conditioned animals. In addition, these studies showed that temporal discrimination occurred across spatial coding channels. These experimental results correlated with the later conscious experience for electrical stimulation in his implant patients. Gradually, the inaugural strategy, discovered in 1978, extracted the second formant for place of stimulation, voicing for rate of stimulation, and sound pressure for current level. This was the first coding strategy to provide open-set speech understanding, as shown by standard audiological tests, and it became the first clinically successful interface between the world and human consciousness. In 1989, he operated on the first patient to receive a bilateral implant, and in 1990, the first with a bimodal processor. In 1985, he implanted his first children with the multi-channel device and found that speech understanding and spoken language were greatly improved the younger the child at surgery, and especially when younger than 12 months. Speech understanding was strongly related to the development of place coding. In 1990, the US Food and Drug Administration approved the implant for deaf children, the first by any world health regulatory body making it the first major advance in helping deaf children to communicate. An exciting story!!!

Reference

The multi-channel cochlear implant and the relief of severe-to-profound deafness.
Clark G.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):69-85.
The multi-channel cochlear implant and the relief of severe-to-profound deafness.
Clark G.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):69-85.

COCHLEAR IMPLANTS INTERNATIONAL

How useful are objective electrophysiological measures in post-implantation device tuning?
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

The authors aimed to determine the prevalence of cochlear implant electrode failure and the relationship with overall device failure. They analysed the electrode status in 322 functioning and in-use devices from 366 adult cochlear implant patients. An additional 21 devices that had been explanted were also analysed. Electrode failure was defined as unacceptably high impedance alone or in combination with aberrant percepts. It was very interesting to note that at least one electrode had been turned off in 173 devices (54%). Most deactivated electrodes were the basal-most and had been turned off to improve sound quality. Of 437 deactivated electrodes, 33 were considered to have failed and were represented in 22 devices. These 22 devices were still in use at the time of the study without further electrode failures or device failure. There were no statistically significant differences in electrode failure rates among device manufacturers. There were 21 devices explanted of which 10 were due to device failure. One of five hard failures and two of three soft failures had deactivated electrodes prior to explantation. The authors concluded that electrode failure does not necessarily predict impending device failure. This is rather reassuring although further long-term prospective longitudinal studies are needed to confirm this finding.

Reference

Electrode failure and device failure in adult cochlear implantation.
Schow B, Friedland D, Jensen J, Burg L, Runge CL.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):35-40.
Electrode failure and device failure in adult cochlear implantation.
Schow B, Friedland D, Jensen J, Burg L, Runge CL.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):35-40.

COCHLEAR IMPLANTS INTERNATIONAL

Hypoplastic or no cochlear nerve in the MRI-scan. Is P1 CAEP a good prognostic biomarker?
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

Although cochlear implantation in children is a fairly routine procedure, cases exist for which implant candidacy is questionable. Among these cases are children with cochlear nerve deficiency (CND). In these children, cochlear implantation may be contraindicated as the cochlear nerve fibres may be very few or non-existent. The authors attempted to investigate whether P1 cortical auditory evoked potential (CAEP) is an objective tool to assist in the evaluation of cochlear implant candidacy in children with a radiological diagnosis of CND. Four children suffering from CND were assessed with CAEP. Three demonstrated robust P1 CAEP responses, indicating activation of the central auditory pathways by auditory stimulation, despite the diagnosis of CND. The authors concluded that these children are good candidates for cochlear implantation and suggest the addition of the P1 CAEP measurement to the usual electrophysiological, audiometric, and radiological test battery may prove to be useful in determining cochlear implant options for children with CND. However, these conclusions are weakened by the fact that these children had some residual hearing with measurable hearing thresholds indicating that the system is in place and working. The real question is what we do in cases with CND and no response in ABR and ASSR testing.

Reference

Assessment of cochlear implant candidacy in patients with cochlear nerve deficiency using the P1 CAEP biomarker.
Roland P, Henion K, Booth T, Campbell JD, Sharma A.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):16-25.
Assessment of cochlear implant candidacy in patients with cochlear nerve deficiency using the P1 CAEP biomarker.
Roland P, Henion K, Booth T, Campbell JD, Sharma A.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):16-25.

COCHLEAR IMPLANTS INTERNATIONAL

Implantation in patients with keratitis-ichthyosis-deafness syndrome: still challenging
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

Implantation in keratitis-ichthyosis-deafness (KID) syndrome, often caused by GJB2 mutations, is considered to be very challenging due to skin and flap problems related to the syndrome. The authors conducted correlative clinical and molecular genetic analysis on two implanted patients with KID syndrome, and tabulated their clinical outcomes. Both patients carried a de novo 148G>A GJB2 mutation and had initially successful surgery. In one case, due to skin-related problems, despite extensive salvage surgery cochlear explantation was required. This patient now communicates with sign language and lip-reading. This contrasts with the outcome of the other patient who, at the 10-year postoperative interval, is able to easily use the telephone. The authors concluded that patients with KID syndrome appear to be good candidates for cochlear implantation but may face significant skin-related problems which could disrupt successful postoperative rehabilitation. New methods of treatment may limit the associated risk in implanted patients with KID syndrome.

Reference

Cochlear implantation in keratitis-ichthyosis-deafness syndrome ‐ 10-year follow-up of two patients.
Smyth CM, Sinnathuray AR, Hughes AE, Toner J.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):54-9.
Cochlear implantation in keratitis-ichthyosis-deafness syndrome ‐ 10-year follow-up of two patients.
Smyth CM, Sinnathuray AR, Hughes AE, Toner J.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(1):54-9.

COCHLEAR IMPLANTS INTERNATIONAL

The psychological status of implanted teenagers
Reviewed by: Thomas Nikolopoulos
Nov/Dec 12 (Vol 21 No 5)
 

Teenagers have traditionally been one of the most controversial groups of cochlear implant candidacy. This study attempted to investigate the relationship between psychological well-being and self-perception in teenagers with cochlear implants, in relation to their perceptions of hearing, deaf signing, and orally communicating deaf peers. The authors assessed the self-perceptions in 22 cochlear implant users aged 12-18 years, using the repertory grid technique that allows the respondent to generate personally relevant ‘identity’ constructs. Psychological well-being was assessed using the Beck Youth Inventory, a series of five self-report questionnaires assessing anxiety, depression, disruptive behaviour, anger, and self-esteem. The results suggested that perceiving oneself as close to any peer, irrespective of which peer, was associated with better psychological well-being. There was also a significant positive association between perceived degree of similarity specifically to hearing peers, and psychological well-being. The closer the implanted adolescents perceived themselves to be to their hearing peers, the better their overall psychological well-being. In contrast, perceiving oneself as more similar to deaf signing peers or deaf oral peers was not significantly associated with psychological well-being. Although some elements of the study are rather unclear (selection of patients and rate of respondents), the results are very interesting as they explore important areas of the psychological status of implanted teenagers.

Reference

Deafness-related self-perceptions and psychological well-being in deaf adolescents with cochlear implants.
Mance J, Edwards L.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):93-104.
Deafness-related self-perceptions and psychological well-being in deaf adolescents with cochlear implants.
Mance J, Edwards L.
COCHLEAR IMPLANTS INTERNATIONAL
2012;13(2):93-104.

DEAFNESS AND EDUCATION INTERNATIONAL

Deaf children's reading comprehension
Reviewed by: Vinaya KC Manchaiah
Nov/Dec 12 (Vol 21 No 5)
 

Deaf people are presented with various challenges during early days in terms of learning speech and language. Becoming successful readers is one such challenge throughout their school and beyond into employment. This study was aimed at examining different perspectives of deaf education practitioners on deafness and reading comprehension by involving a full deaf education support team. This comprised of teachers of the deaf, communication support workers, and deaf instructors from a UK citywide service covering early years, primary and secondary settings. In focus groups, these practitioners were asked to consider what reading comprehension involves for deaf learners and also to identify factors that influence success. The analysis involved identifying themes in the data and showed some commonalities and differences across different practitioners. It is suggested that these aspects shape different understandings of the reading comprehension issues. Moreover, themes which were identified as problematic, such as the processes of decoding and the role of sign language are drawn out as focus areas for further discussion.

Reference

Practitioner talk on deaf children's reading comprehension: analysing multiple voices.
Swanwick RA, Kitchen R, Clarke PJ.
DEAFNESS AND EDUCATION INTERNATIONAL
2012;14(2);100-20.
Practitioner talk on deaf children's reading comprehension: analysing multiple voices.
Swanwick RA, Kitchen R, Clarke PJ.
DEAFNESS AND EDUCATION INTERNATIONAL
2012;14(2);100-20.

EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK

CPAP affects nasal mucosa in patients with OSA
Reviewed by: Ian Coulter
Nov/Dec 12 (Vol 21 No 5)
 

The authors have aimed to determine the effects of nasal CPAP treatment on the morphology and function of nasal mucosa in patients with obstructive sleep apnoea (OSA). Twenty-five patients with an apnoea-hypopnoea index ≥15 following polysomnography were included in the study. The authors utilised the saccharine test and nasal biopsies (from middle and inferior turbinates and septal mucosa) to assess mucociliary transport time and histopathological changes respectively, before and three months following the initiation of CPAP treatment. Nasal CPAP treatment was introduced with a mean pressure of 9.54 cmH2O. Differences in mucociliary transport time pre and post treatment were not statistically significant (10.50 versus 11.50 min), but the degree of inflammation and fibrosis was found to be significantly increased after CPAP treatment. The authors recommend close follow-up of patients receiving CPAP treatment and the consideration of medical precautions to protect nasal mucosa.

Reference

The effects of CPAP treatment on nasal mucosa in patients with obstructive sleep apnea
Saka C, Vuralkan E, Firat IH, Alicura S, Hücümenoğlu S, Akin I, Ardiç, Gökler A.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269(9):2065-7.
The effects of CPAP treatment on nasal mucosa in patients with obstructive sleep apnea
Saka C, Vuralkan E, Firat IH, Alicura S, Hücümenoğlu S, Akin I, Ardiç, Gökler A.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269(9):2065-7.

EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK

Pneumococcus vaccine ineffective at preventing OME
Reviewed by: Ian Coulter
Nov/Dec 12 (Vol 21 No 5)
 

El-Mahzangy and colleagues have conducted a systematic review of the literature to determine whether vaccination against pneumococcus effectively prevents otitis media with effusion (OME). They reviewed randomised controlled trials (RCTs) from the last 10 years, conducted on children (0-18 years) and published in English (Level Ia evidence). Of the three RCTs analysed, one examined the effect of antipneumococcal vaccination on recurrence of OME following tympanostomy tube extrusion, while the other two were secondary analyses of data from previously published RCTs. A meta-analysis of the three trials found no significant difference between vaccination with polyvalent pneumococcal vaccine and control with regard to OME and tympanostomy tube insertion. The authors go on to state that the results of this meta-analysis do not support routine immunisation against pneumococci for the prevention of OME. Due to the paucity of studies examining the disease in question, surely more research is required to resolve this issue.

Reference

Can vaccination against pneumococci prevent otitis media with effusion?
El-Makhzangy AMN, Ismail NM, Galal SB, Sobhy TS, Hegazy AA.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269(9):2021-6
Can vaccination against pneumococci prevent otitis media with effusion?
El-Makhzangy AMN, Ismail NM, Galal SB, Sobhy TS, Hegazy AA.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269(9):2021-6

EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK

The effect of grommet guidelines
Reviewed by: Ian Coulter
Nov/Dec 12 (Vol 21 No 5)
 

This audit has analysed the effect of two national guidelines concerning grommet surgery. The two guidelines examined were the Department of Health’s (DoH) 2002 Day Surgery guidelines stipulating that at least 75% of grommet insertions should be undertaken as day-cases and the National Institute for Health and Clinical Excellence (NICE) guidelines from 2008 aimed at reducing inappropriate grommet insertions. Retrospective data from the patient episode databases of England (Health Episode Statistics) and Wales (Patient Episode Database of Wales) from 2000 until 2010 were utilised. In all, 341,526 and 16,400 grommets insertions were performed in England and Wales, respectively. Linear regression analysis found that implementation of the Day Surgery guidelines significantly improved day-case rates (P<0.0001) and reduced mean waiting times. In contrast, regression analysis demonstrated that implementation of the NICE guidelines had no effect on the number of grommet insertions in England and Wales. The authors point out that implementation of guidelines can have different results and are not necessarily a guarantee of improvement or success

Reference

Have two UK national guidelines had any effect on grommets day-case utilisation and rate over the last 10 years?
Al-Hussaini A, Owens D, Tomkinson A.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269(9):2053-6.
Have two UK national guidelines had any effect on grommets day-case utilisation and rate over the last 10 years?
Al-Hussaini A, Owens D, Tomkinson A.
EUROPEAN ARCHIVES OF OTORHINOLARYNGOLOGY AND HEAD AND NECK
2012;269(9):2053-6.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Rehabilitative therapy for dysphagia in Parkinson’s disease
Reviewed by: Gauri Mankekar
Nov/Dec 12 (Vol 21 No 5)
 

Dysphagia is a common problem in patients with Parkinson’s disease. Clinicians use either compensatory or rehabilitative treatment options to manage the problem. This review article explores the evidence behind the available treatment options and attempts to draw some conclusion about which treatment options are likely to provide the best outcomes. The authors demonstrate that there is very little evidence to support the use of either compensatory or rehabilitative approaches. They argue that the rehabilitative methods could possibly have a greater potential to increase swallowing safety and improve quality of life in the long term than compensatory methods alone and research evidence is necessary to establish this.

Reference

Rehabilitation or compensation: time for a fresh perspective on speech language therapy for dysphagia and Parkinson’s disease?
Smith SK, Roddam H, Sheldrick H.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2012;351-64.
Rehabilitation or compensation: time for a fresh perspective on speech language therapy for dysphagia and Parkinson’s disease?
Smith SK, Roddam H, Sheldrick H.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2012;351-64.

INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS

Stuttering increases burden of listeners
Reviewed by: Gauri Mankekar
Nov/Dec 12 (Vol 21 No 5)
 

Listeners tend to avert their gaze when they encounter stuttering. This could have strong social and communicative implications for both listeners and speakers. This paper examined listener’s eye gaze responses to stuttering speech, relative to fluent speech, in three cultural groups (African American, European-American and Chinese adults). The study indicates that the listener’s gaze aversion in response to stuttering is likely to be the result of a reduction in gaze fixation duration rather than gaze fixation amount. In addition, attention shift and compensation strategies for speech perception may also contribute to eye gaze change. This implies that observing stuttering is a burden for listeners both emotionally and cognitively. Also cultural differences in eye gaze responses to stuttering were observed mainly between Chinese and Caucasian American listeners.

Reference

Culture and listener’s gaze responses to stuttering.
Zhang J, Kalinowski J.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2012;388-97.
Culture and listener’s gaze responses to stuttering.
Zhang J, Kalinowski J.
INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS
2012;388-97.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Does genetic mutational spectrum predict progression of hearing loss?
Reviewed by: Madhup K Chaurasia
Nov/Dec 12 (Vol 21 No 5)
 

One of the most important questions one faces in genetic hearing loss is whether it will progress or not. Genetic studies can confirm whether the hearing loss is autosomal recessive or dominant, mutational or of mitochondrial nature. Sometimes it can be X-linked. This study compares the molecular basis of the genetic pattern of 72 subjects of ages ranging from one to 65 years, and focuses on mutations in the gap junction protein beta-2 gene known as GJB2 encoding the connexin 26 protein and GJB6 encoding connexin 30 protein. Sixteen patients had pathological genotypes of which GJB mutations was involved in 15. A new mutation in the GJB6 protein (p.Met203Val) was discovered and found to be responsible for mild hearing loss. However, there was no statistically significant difference observed between progressive and non-progressive hearing loss. Therefore it is not possible to foretell progression of hearing loss on the basis of genotypes. An interesting hypothesis presented here states that intracellular transport of important metabolites such as glucose is defective in the central cochlear cell and this is related to connexin mutation. Any environmental factors, such as pollution with noise or neurotoxic chemicals or smoking can further aggravate the situation, facilitating progression of hearing loss. The article provides an interesting insight into this aspect of hearing loss in times when genetic repair of such conditions is underway. It is however a bit intriguing how pure tone audiometry was possible in very young children!

Reference

Novel connexin 30 and connexin 26 mutational spectrum in patients with progressive sensorineural hearing loss.
Battelino S, Repič Lampert B, Zargi M, Podkrašek KT.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(8):763-9.
Novel connexin 30 and connexin 26 mutational spectrum in patients with progressive sensorineural hearing loss.
Battelino S, Repič Lampert B, Zargi M, Podkrašek KT.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(8):763-9.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Inferior turbinate hypertrophy – bone or soft tissue enlargement?
Reviewed by: Madhup K Chaurasia
Nov/Dec 12 (Vol 21 No 5)
 

Septal deviation usually results in enlargement of the inferior turbinate on the more patent site. The deviation may be congenital or post-traumatic and the treatment can depend on whether the increased bulk is contributed mainly by conchal bone or hypertrophied mucosa. In this study the authors compare enlargement of the inferior turbinate between two groups of patients with septal deviation, in one this being congenital and in the other due to trauma. The assessment was done with nasal endoscopy and CT scans. Six measurements were made to evaluate whether it was the conchal bone or the mucosa that mainly contributed to the enlargement. The measurements were subjected to statistical analysis. It was noted that in cases of congenital septal deviation, the main contribution to turbinate enlargement was by thickened conchal bone whereas in the post-traumatic group, it was the mucosa that was hypertrophied. These findings have a bearing on the treatment plan and indicate the need to remove the thickened conchal bone in cases with congenital septal deviation which may not be necessary in cases with traumatic septal deviation. The strength of this study is exclusion of cases with allergic and eosinophilic rhinitis but is limited by small number of cases in each group.

Reference

Evaluation of inferior turbinate hypertrophy in patients with congenital and traumatic nasal septal deviation.
Korkut AY, Islim F, Gulseven Ciftci S, Dogan R, Gedikli O, Kahya V.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(8):784-8.
Evaluation of inferior turbinate hypertrophy in patients with congenital and traumatic nasal septal deviation.
Korkut AY, Islim F, Gulseven Ciftci S, Dogan R, Gedikli O, Kahya V.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(8):784-8.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Is nasal packing necessary in FESS?
Reviewed by: Madhup K Chaurasia
Nov/Dec 12 (Vol 21 No 5)
 

Bleeding following functional endoscopic sinus surgery is one of the commonest complications. This may range from mild ooze to active flow of blood requiring packing in the postoperative period. However packing causes a lot of discomfort and pain on removal. It can also lead to sleep apnoea. In this study the authors compared two groups in a randomised controlled, partly blinded study – one receiving Merocel packs and others not having any sort of nasal packing. The incidence of bleeding in patients without packs was slightly higher but it did not require any intervention. There was no statistically significant difference in terms of nasal obstruction, facial pain and headache following surgery. The same was the case with crusting, formation of synechiae, closure of antrostomy, and lateralisation of the middle turbinate. The authors therefore feel that nasal packing is not necessary after FESS surgery. Packing or no packing does not affect results but avoiding packs can save pain and discomfort and of course, cost. The use of bipolar cautery is not mentioned but presumably it was not used. This can avoid the need for nasal packing. Absorbable material helps same day discharge but is costly. The strength of the study is that all patients had nasal polyps which are known to cause more bleeding. More studies are required to standardise the immediate postoperative management following FESS.

Reference

Effect of polyvinyl acetyl sponge nasal packing on post-operative care of nasal polyposis patients: a randomised, controlled, partly blinded study.
Saedi B, Sadeghi M and Farschi S.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(4):380-4.
Effect of polyvinyl acetyl sponge nasal packing on post-operative care of nasal polyposis patients: a randomised, controlled, partly blinded study.
Saedi B, Sadeghi M and Farschi S.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(4):380-4.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Meniett device treatment for Meniere’s disease
Reviewed by: Madhup K Chaurasia
Nov/Dec 12 (Vol 21 No 5)
 

Literature abounds in studies on treatment of Meniere’s disease but those providing level 1 sources of evidence are indeed very few. This is a randomised, placebo controlled, double blinded clinical trial on treatment of Meniere’s disease by low pressure therapy through Meniett device in patients who did not respond to betahistine. Subjects were included according to the criteria defined by the American Academy of Otolaryngology – Head and Neck Surgery. Cases with bilateral disease or those who had previous surgery or Gentamicin injection were excluded. There were 37 patients in the treatment group and 31 in the placebo group. The Meniett low pressure therapy was delivered with the help of a tympanostomy tube three times a day for 16 weeks. Patients in the placebo group received a much reduced pressure therapy which was done to mask the difference between the active and the placebo device. Treatment with betahistine was continued during this therapy. Analysis was based on Likert scale for vertigo and level of activity. There was a statistically significant improvement in the vertigo score and in terms of fewer sick days. However the scores for vertigo days, activity score, hearing levels and horizontal semi circular canal function did not change significantly. The general outcome was that the subjective symptoms improved significantly in the treatment group compared with the placebo group. Results have been compared with three previous studies which did not have audiometric and nystagmographic measurements. Longer periods of trial are recommended considering that Meniere’s disease has a tendency for spontaneous remission. The duration of the disease before this therapy and exact matching of the dose of betahistine in the two groups would have been a useful addition to the data.

Reference

Effect of transtympanic low-pressure therapy in patients with unilateral Meniere’s disease unresponsive to betahistine: a randomised, placebo-controlled double blinded clinical trial.
Gürkov R, Filipe Mingas LB, Rader T, Louza J, Olzowy B, Krause E.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(4):356-62.
Effect of transtympanic low-pressure therapy in patients with unilateral Meniere’s disease unresponsive to betahistine: a randomised, placebo-controlled double blinded clinical trial.
Gürkov R, Filipe Mingas LB, Rader T, Louza J, Olzowy B, Krause E.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(4):356-62.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

What causes recurrent / bilateral facial nerve paralysis?
Reviewed by: Madhup K Chaurasia
Nov/Dec 12 (Vol 21 No 5)
 

Bell’s palsy is not a rare condition, affecting 13-34 cases per 100,000 but the exact cause still remains doubtful. There is some evidence to support the role of herpes simplex virus causing the dysfunction which recovers in 85 percent of patients. The authors present two cases of recurrent facial paralysis. Extensive investigations and MRI were done in both without any reliable clues. One case seemed to have a familial susceptibility and returned with facial weakness of the other side with one branch spared. Human leucocyte antigens were hypothesised but studies presented ambiguous results. The other case had two episodes of presumably Bell’s paralysis and then developed right LMN paralysis as well. The ESR was raised along with gamma-globulins and the CSF showed raised proteins and glucose. However, no cause could be deduced from extensive investigations, including viral polymerase chain reaction testing and tests for T. pallidum and B. burgdorferi. Several causes have been mentioned and discussed to provide an interesting reading of this rather difficult condition which also suggests CSF examination to exclude leptomeningeal metastasis. For the sake of completion, it would help also to do a topographical search, such as with acoustic reflex and MRI of the parotid, especially when a division is spared or involved, considering the possibility of early branching of the nerve.

Reference

Differential diagnosis or recurrent or bilateral peripheral facial palsy.
Oosterveer DM, Benit CP, De Schryver EL.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(8):833-6.
Differential diagnosis or recurrent or bilateral peripheral facial palsy.
Oosterveer DM, Benit CP, De Schryver EL.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(8):833-6.

JOURNAL OF LARYNGOLOGY AND OTOLOGY

Which is more effective and less expensive for cleaning flexible nasendoscopes – chlorine dioxide wipes or automated washer?
Reviewed by: Madhup K Chaurasia
Nov/Dec 12 (Vol 21 No 5)
 

Flexible nasal endoscopes are an essential requirement for an ENT clinic. In terms of patient safety, effective decontamination of these between patients is also an absolute requirement. In has been a matter of debate which of the two methods of decontamination, chlorine dioxide wipes or automated washer is more effective and less expensive. In this in vitro study the authors compared the efficacy and costs of the two methods. Precontamination swabs were taken off the tip of nasal endoscopes which were then contaminated with Staphylococcus epidermidis culture. After decontamination, swabs were taken again to assess the efficacy. There were S. epidermidis and non S. epidermidis bacteria in both chlorine dioxide and automated washer cleaning groups, before and after decontamination. However, in the chlorine dioxide method, only one out of fifty grew S. epidermidis compared to 14 out of 50 in the automated washer group post-decontamination swabs. Costs involved in the two methods were also calculated and it was found that in the long term, the automated washer was cheaper by about £16,000 a year, for a department requiring about 8,400 washes per year. The authors contend that the chlorine dioxide method, though more effective, is prone to human errors and automated washers are more suited to larger volumes of flexible nasendoscope use. The study is interesting but has been conducted in a purely experimental setting and does not meet the practicalities of real situations where transport of nasendoscopes and human errors possibly arising out of work pressures may impose further variables to this study.

Reference

Sequential cohort study comparing chlorine dioxide wipes with automated washing for decontamination of flexible nasendoscopes.
Phua CO, Mahalingappa Y, Karagama Y.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(8):809-14.
Sequential cohort study comparing chlorine dioxide wipes with automated washing for decontamination of flexible nasendoscopes.
Phua CO, Mahalingappa Y, Karagama Y.
JOURNAL OF LARYNGOLOGY AND OTOLOGY
2012;126(8):809-14.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Management of lip haemangiomas; minimising peri-oral scars
Reviewed by: Mr Stuart Clark
Nov/Dec 12 (Vol 21 No 5)
 

This paper from the United States retrospectively reviewed 11 patients with haemangioma of the lower lip aged 14 months to 17 years. A two stage procedure was advocated for haemangiomas that crossed the vermilion border in order to minimise scarring. A three stage procedure was undertaken for a bulky central lip haemangioma. There seems some common sense in serial surgery to minimise scarring particularly for the larger lesions. The benefit for smaller lesions may be of some debate.

Reference

Management of Lip Haemangiomas Minimizing Peri-Oral Scars.
Chang CS, Wong A, RhodeCH, Ascherman JA, Wu JK.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65(2):163-8.
Management of Lip Haemangiomas Minimizing Peri-Oral Scars.
Chang CS, Wong A, RhodeCH, Ascherman JA, Wu JK.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65(2):163-8.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Medpore and rhinoplasty
Reviewed by: Mr Stuart Clark
Nov/Dec 12 (Vol 21 No 5)
 

Medpore has a less than ideal reputation in the use of rhinoplasty. This paper from Greece suggests that it is safe for elective patients with a low complication rate. Eight patients had dorsal defects and fifty patients nasal tip depression. A double dorsum tip implant was used in one patient. In the follow-up, a period ranging from 12-54 months, three patients experienced foreign body reactions and implant rejection all in dorsal implants. With a rejection rate of 5.1% it is claimed that it compares very favourably with previous report of alloplastic materials. They claim their success rate is due to meticulous patient selection including negative prognostic factors and factors that would affect local tissue blood supply, pocket and recipient site section, and type closure.

Reference

The use of medpore alloplastic material in rhinoplasty: experience and outcomes. 
Skouras A, Skouras G, Karypidis D, Asimakopoulou F.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65()35-42.
The use of medpore alloplastic material in rhinoplasty: experience and outcomes. 
Skouras A, Skouras G, Karypidis D, Asimakopoulou F.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65()35-42.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Non-surgical treatment of bat ears
Reviewed by: Mr Stuart Clark
Nov/Dec 12 (Vol 21 No 5)
 

This paper from the Netherlands promotes splinting to correct ear deformities in the newborn. It prospectively looks at 132 babies and 209 ears were treated. A bendable rounded splint was placed in the scaphal hollow to define the anti-helical fold and to serve as a supporting pillar. The splinted ear is then fixed to the head using tape. After four continuous weeks of splinting should there have been any failure to achieve correction of shape therapy was stopped. Results were evaluated after removal of the splints and again at one year. It concluded that protruding ears have a reasonable chance of successful correction in children of up to six weeks of age if the deformity is mainly due to a flat antihelix; splinting time of 10 weeks could be expected.

Reference

A Prospective Study on Non-Surgical Correction of Protruding Ears: The Importance of Early Treatment.
Van Wijk MP, Beugen CC, Kon M.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65(1):54-60.
A Prospective Study on Non-Surgical Correction of Protruding Ears: The Importance of Early Treatment.
Van Wijk MP, Beugen CC, Kon M.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65(1):54-60.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Nose replantation artery only microanastomosis
Reviewed by: Mr Stuart Clark
Nov/Dec 12 (Vol 21 No 5)
 

This is a report of two cases from Belgium where one patient had a complete nasal amputation from a dog bite, in the other a small fibrofatty bridge of tissue remained. The lateral nasal artery was used in both cases and leeches applied immediately postoperatively. Both procedures were undertaken as a one stage immediate procedure to good effect.

Reference

Artery only microanastomosis in nose replantation: report of two cases.
Stillaert FB, Roche N, Zeltzer A, Monstrey S.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2012;65(4):513-6.
Artery only microanastomosis in nose replantation: report of two cases.
Stillaert FB, Roche N, Zeltzer A, Monstrey S.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2012;65(4):513-6.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Plate removal following facial fracture
Reviewed by: Mr Stuart Clark
Nov/Dec 12 (Vol 21 No 5)
 

This is a paper from Japan which analyses 138 patients who had had open reduction and internal fixation for a facial or frontal bone fracture. They found that plates at the fronto zygomatic suture could cause high rates of complication. These complications included thermal hypersensitivity, palpability, and visibility. It was the unit’s policy that non-absorbable plates and screws be removed electively. They note the significant relationship between plate thickness and the ‘complication’ at the fronto zygomatic suture. The paper generally fails to make the case that these are complications and that plates require removal. In addition the concern of timing of placement of plates in relation to injury, particularity to the fractured mandible, would be the most pertinent question to answer.

Reference

Association between plate location and plate removal following fracture repair.
Kutoba Y, Kuroki T, Akita S, Koizumi T, Hasegawa M, Rikihisa N, Mitsukaw N, Satoh K.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2012;65(3):372-8.
Association between plate location and plate removal following fracture repair.
Kutoba Y, Kuroki T, Akita S, Koizumi T, Hasegawa M, Rikihisa N, Mitsukaw N, Satoh K.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2012;65(3):372-8.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Psychopathology in cosmetic patients
Reviewed by: Mr Stuart Clark
Nov/Dec 12 (Vol 21 No 5)
 

This retrospective paper analyses 135 patients who returned questionnaires following cosmetic surgery treatment at a clinic in the Netherlands. Their aim was to investigate the psychological condition in cosmetic surgery patients. This was on a background that cosmetic surgery is becoming increasingly popular and the prevalence of patients with body dysmorphic disorder in the cosmetics setting is thought to vary from 5-15% in the USA. They also noted that cosmetic treatments rarely improved those patients with body dysmorphic disorder symptoms. Eighty-six percent of the patients surveyed were happy with their surgery, and 22-59% of the study sample obtained relatively high scores when questioned about body image dissatisfaction. This group also had a higher percentage of rejections for cosmetic surgery at some time in the past. Approximately one fifth of the respondents had high symptoms of body dysmorphic disorder. There was no difference with age or BMI although they had lower self-esteem, were more often dissatisfied with the results and more psychopathology in general. The authors recognise the benefits of a prospective rather than retrospective study and advocate short questionnaires for screening to recognise potential problem patients.

Reference

Psychopathology symptoms in a sample of female cosmetic surgery patients.
Mulkens S, Bos AE, Uleman R, Muris P, Mayer B, Velthuis P.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2012;65(3):321-7.
Psychopathology symptoms in a sample of female cosmetic surgery patients.
Mulkens S, Bos AE, Uleman R, Muris P, Mayer B, Velthuis P.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2012;65(3):321-7.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Reverse superficial temporal artery flap
Reviewed by: Mr Stuart Clark
Nov/Dec 12 (Vol 21 No 5)
 

This article from Japan looks at five pedicled and one free superficial temporal artery flap. It was used in the reconstruction of temporal intraoral extra oral defects. This appears nice and is a further way of introducing live tissue to lateral head and neck defects. It may be worth considering in some rare circumstances, but overall maybe does not have that much to offer.

Reference

The reverse superficial temporal artery flap from the preauricular region, for small facial defects.
Yamauchi M, Yotsuyanagi T, Yamashita K, Ikeda K, Urushidate S, Mikami M.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65(2):149-55.
The reverse superficial temporal artery flap from the preauricular region, for small facial defects.
Yamauchi M, Yotsuyanagi T, Yamashita K, Ikeda K, Urushidate S, Mikami M.
JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY
2012;65(2):149-55.

JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY

Zygomatic malunion and cheek ptosis treated by malarplasty
Reviewed by: Mr Stuart Clark
Nov/Dec 12 (Vol 21 No 5)
 

This paper from Korea discusses a malarplasty as treatment for the wide mid face and prominent malar. Malunion and cheek ptosis are recognised as major complications of this procedure and this paper attempts to analyse 24 patients who had this treatment via a coronal approach. They recognise that, in the west, augmentation is a more common procedure. Cheek ptosis was a disadvantage of the intra oral approach and that inappropriate fixation may contribute to this. They advocate appropriate fixation and suggest that surgery via the intra oral approach can be minimised by decreasing the amount of malar reduction.

Reference

Three-dimensional assessment of zygomatic malunion using computed tomography in patients with cheek ptosis caused by reduction malarplasty.
Baek RM, Kim J, Kim BK.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2012;65(4):448-55.
Three-dimensional assessment of zygomatic malunion using computed tomography in patients with cheek ptosis caused by reduction malarplasty.
Baek RM, Kim J, Kim BK.
JOURNAL OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY
2012;65(4):448-55.

JOURNAL OF VESTIBULAR RESEARCH

Effects of a unilateral vestibular implant non-human primates
Reviewed by: Victor Y Osei-Lah
Nov/Dec 12 (Vol 21 No 5)
 

Bilateral vestibular hypofunction (BVH) is a disabling condition. An efficient vestibular prosthesis should be able to restore the vestibulo-ocular reflex (VOR) for gaze stabilisation, restore perception of head orientation in space and contribute to postural control. The authors have been working on such prosthesis in squirrel and rhesus monkeys. The prosthesis used is one-dimensional, because it provides electrical stimulation of the ampullae of only one canal: the lateral canal in the squirrel monkey and the posterior canal in the rhesus monkey. To achieve a state of BVH, canal plugging and aminoglycosides were used in the squirrel and rhesus monkeys respectively. Eye movements and VOR during sinusoidal and velocity step rotation were determined (in both monkeys) and perception and posture in the rhesus monkey. Results in three sensory states were analysed: normal, BVH non-stimulated and BVH stimulated. In the squirrel monkey, a unilateral stimulation generated a VOR but the gain was enhanced by chronic stimulation. As expected, bilateral stimulation generated a larger VOR gain than unilateral stimulation. In the rhesus monkey, the authors rated the effect of one-dimensional stimulation on posture as modest. These results are encouraging and I agree with the authors that ‘the effects of a three-dimensional prosthesis on the VOR, perception, and postural control will produce greater shifts towards normal than the one-dimensional prosthesis’ – a hypothesis underpinning an on-going study.

Reference

Responses evoked by a vestibular implant providing chronic stimulation.
Thompson LA, Haburcakova C, Gong W, Lee DJ, Wall III C, Merfeld DM, Lewis RF.
JOURNAL OF VESTIBULAR RESEARCH
2012;22(1):11-15.
Responses evoked by a vestibular implant providing chronic stimulation.
Thompson LA, Haburcakova C, Gong W, Lee DJ, Wall III C, Merfeld DM, Lewis RF.
JOURNAL OF VESTIBULAR RESEARCH
2012;22(1):11-15.

JOURNAL OF VESTIBULAR RESEARCH

Human vestibular implants – overcoming key barriers
Reviewed by: Victor Y Osei-Lah
Nov/Dec 12 (Vol 21 No 5)
 

The use of implantable devices in neurotology is well established for hearing disorders but, by comparison the development of vestibular implants, is in its infancy. The authors of this paper focus on three main prerequisites, in their opinion, that must be fulfilled in order to develop a vestibular implant for humans – ethical, anatomical and physiological. The ethical hurdle was overcome by a psychiatric assessment of the volunteer for electrical stimulation of the vestibular system and for members of the ethical committee being present during the procedure. The volunteer did not experience ‘too much’ discomfort. The complexity of the vestibular anatomy posed a different challenge in terms of electrode placement. The authors found that the best approach was to place the electrodes close to the lateral (for horizontal eye movements) and posterior ampullary (for vertical eye movements) nerves, rather than on the ampullae of the semicircular canals, so as to minimise complications. To test the effectiveness of electrode placement and to refine stimulation, the procedure was done under local anaesthesia, in order to observe nystagmus. A detailed surgical approach was described. The third prerequisite; physiological – the implant should be able to generate smooth pursuit, restore a resting vestibular tone, maintain gaze stability and to prevent the sensation of vertigo. This was achieved by a series of ‘on-off’ stimulations until the vestibular system reached a steady ‘adapted’ state without the subject experiencing uncomfortable symptoms. However this adapted state was lost after about 18 hours. The authors concluded that their experiments have shown that human vestibular implantation is feasible after fulfilling the three main prerequisites. One limitation of the study was to what extent stimulating the canals affected the otolith organs. This is certainly an interesting development but more research is needed.

Reference

Ethical, anatomical and physiological issues in developing vestibular implants for human use.
Guyot J-P, Gay A, Kos MI, Pelizzone M.
JOURNAL OF VESTIBULAR RESEARCH
2012;22(1):3-9.
Ethical, anatomical and physiological issues in developing vestibular implants for human use.
Guyot J-P, Gay A, Kos MI, Pelizzone M.
JOURNAL OF VESTIBULAR RESEARCH
2012;22(1):3-9.

JOURNAL OF VESTIBULAR RESEARCH

Mapping of vestibular evoked myogenic potentials
Reviewed by: Victor Y Osei-Lah
Nov/Dec 12 (Vol 21 No 5)
 

Vestibular evoked myogenic potentials (VEMPs) have become an acceptable tool in neurotological practice. The location of the electrodes – active and reference – is crucial to obtaining reliable results. For optimum response the active electrode should be placed at the mid-point of the sternocleidomastoid muscle (SCM) or near the motor point. In this study, the author, a world authority on the subject, analysed the VEMP responses (p13-n23 wave complex and amplitude) when the active and reference electrodes were placed at different locations. Five healthy subjects were recruited. The motor point was identified at a distance of 9-12.5cm above the sternoclavicular joint along the belly of the SCM (or on average, 63% of the distance between the joint and the mastoid process). In addition to the motor point, seven other recording sites were used – eight channels in total. One electrode was placed on the motor point and one 3cm above it in the line of the SCM. Two others below, were each separated by 3cm. Four other recording sites were placed 3cm transverse to the muscle belly, two at the level of the motor point and two 3cm either side of the electrode below. The reference electrode was placed at the sternoclavicular joint in the first run and the C7 process in the second run. Unsurprisingly, the motor point elicited the most robust response. Whereas the p13 latency increased the further away the active electrode was from the motor point, the n23 latency remained fairly the same, leading the author to conclude that the former acts as a travelling wave and the latter, a standing wave. The study further confirmed that the sternoclavicular joint is preferred to C7 for the reference electrode.

Reference

Mapping the vestibular evoked myogenic potential (VEMP).
Colebatch JB.
JOURNAL OF VESTIBULAR RESEARCH
2012;22(1):27-32.
Mapping the vestibular evoked myogenic potential (VEMP).
Colebatch JB.
JOURNAL OF VESTIBULAR RESEARCH
2012;22(1):27-32.

NEUROSURGERY

Immunoediting – emerging technology for oncology
Reviewed by: Gauri Mankekar
Nov/Dec 12 (Vol 21 No 5)
 

This review article provides an exhaustive overview of factors influencing the interplay between a developing tumour and the host immune system focusing on the concept of immunoediting in malignant gliomas. Immunoediting hypothesis is thought to comprise of three phases: elimination – wherein immunity subserves an extrinsic tumour suppressor function and destroys nascent tumour cells; equilibrium – wherein tumour cells are constrained in a period of latency under immune control; escape – wherein tumour cells outpace immunity and progress clinically. The authors discuss the relevance of immunoediting by exploring the de novo immune response to gliomas, how the tumours persist in vivo, the mechanism by which the cells may escape or attenuate immunity and ultimately how this concept may influence immunotherapeutic approaches. Immunoediting is another promising modality emerging in oncology management.

Reference

Cancer immunoediting in malignant glioma.
Dunn GP, Fecci PE, Curry WT.
NEUROSURGERY
2012;71(2):201-23.
Cancer immunoediting in malignant glioma.
Dunn GP, Fecci PE, Curry WT.
NEUROSURGERY
2012;71(2):201-23.

NEUROSURGERY

Non-diagnostic IPSS should be followed by transphenoidal exploration for a pituitary source
Reviewed by: Gauri Mankekar
Nov/Dec 12 (Vol 21 No 5)
 

Inferior Petrosal Sinus Sampling (IPSS) is an invasive and diagnostic procedure for confirming a pituitary source of excess adrenocorticotropic hormone (ACTH) in Cushing disease. The authors reviewed 288 IPSS procedures performed over 24 years to determine the appropriate course of action after non-diagnostic IPSS. The procedure was considered non-diagnostic if the procedure was performed successfully and the results predicted an ectopic source, but none could be found even after extensive imaging, or if the IPS could not be bilaterally cannulated due to technical difficulties or anatomic variants. The patients with non-diagnostic IPSS underwent exploratory transsphenoidal surgery and in 95% of these patients a pituitary source was surgically proven with a remission rate of 83%. Therefore the authors suggest transsphenoidal surgery in cases of ACTH dependent Cushing disease and non-centralised or technically unsuccessful IPSS without evidence of ectopic tumour.

Reference

Transsphenoidal surgery for Cushing disease after non-diagnostic inferior petrosal sinus sampling.
Sheth SA, Mian MK, Neal J, Tritos NA, Nachtigall L, Klibanski A, Biller BMK, Swearingen B.
NEUROSURGERY
2012;71(1):14-22.
Transsphenoidal surgery for Cushing disease after non-diagnostic inferior petrosal sinus sampling.
Sheth SA, Mian MK, Neal J, Tritos NA, Nachtigall L, Klibanski A, Biller BMK, Swearingen B.
NEUROSURGERY
2012;71(1):14-22.

NEUROSURGERY CLINICS OF NORTH AMERICA

Cancer nanotechnology
Reviewed by: Gauri Mankekar
Nov/Dec 12 (Vol 21 No 5)
 

Glioblastoma is the most common primary malignancy of the brain and also a difficult cancer to treat. Conventional treatments have had modest success in reducing initial tumour burden. However infiltrating cancer cells beyond the main tumour mass lead to recurrence and patient death. This article discusses the exciting role of cancer nanotechnology for imaging and providing targeted therapy for glioblastoma. The authors describe how magnetic nanoparticles can be used as MRI contrast agents as well as therapeutic agents by the use of thermotherapy. Nanoparticle formulation chemotherapeutics can be more effective than conventional chemotherapy due to their ability to target cells and release the drug. Gene delivery through the use of nanoparticles could be a safe option to deliver therapeutic genes to tumour cells. Radioactive nanoparticles can deliver targeted long-term brachytherapy to lesions. Gold nanoparticles can be used to treat tumours through phototherapy. In future when applied to head – neck oncology this amazing emerging nanotechnology may revolutionise diagnosis and management

Reference

Nanotechnology applications for Glioblastoma
Nduom EK, Bouras A, Kaluzova M, Hadjipanayis CG
NEUROSURGERY CLINICS OF NORTH AMERICA
2012;23(3):439-49.
Nanotechnology applications for Glioblastoma
Nduom EK, Bouras A, Kaluzova M, Hadjipanayis CG
NEUROSURGERY CLINICS OF NORTH AMERICA
2012;23(3):439-49.

OTOLOGY & NEUROTOLOGY

Direct intracochlear drug administration
Reviewed by: Rebecca Heywood
Nov/Dec 12 (Vol 21 No 5)
 

While it is accepted that intratympanic extracochlear drug delivery probably achieves higher intracochlear drug levels than systemic administration, little is really known about the distribution of drug levels in the inner ear. Direct intracochlear administration may offer higher intracochlear levels and less fluctuation in concentration if it were feasible. In this study dexamethasone-phosphate was injected in to the scala tympani of guinea pigs over 20 minutes either directly through the round window or through a basal turn cochleostomy. Perilymph was sampled from the apex at 40, 100 and 220 minutes in different animals and the concentration gradients calculated. The authors experienced problems with drug leakage from the injection sites and therefore applied sodium hyaluronate gel over the round window and cyanoacrylate to the cochlear fenestration site. The mean peak concentration was higher at 40 than at 100 and 220 minutes, though this was not statistically significant. Drug levels were still detectable at 220 minutes. The peak concentration achieved was approximately 10 times higher than that following two to three hours of extracochlear application to the round window niche. There was a lower basal-apical concentration gradient than during similar experiments using extracochlear administration. Direct intracochlear drug delivery is shown to offer significant benefits over intratympanic delivery. It could potentially be put to other uses such as administration of stem cells and proteins for regeneration if a way can be found to perform it safely in humans in the future.

Reference

Dexamethasone levels and base-to-apex concentration gradients in the scala tympani perilymph after intracochlear delivery in the guinea pig.
Hahn H, Salt AN, Biegner T, Kammerer B, Delabar U, Hartsock JJ, Plontke SK.
OTOLOGY & NEUROTOLOGY
2012;33(4):660-5.
Dexamethasone levels and base-to-apex concentration gradients in the scala tympani perilymph after intracochlear delivery in the guinea pig.
Hahn H, Salt AN, Biegner T, Kammerer B, Delabar U, Hartsock JJ, Plontke SK.
OTOLOGY & NEUROTOLOGY
2012;33(4):660-5.

OTOLOGY & NEUROTOLOGY

No benefit from oral steroids in sudden sensorineural hearing loss?
Reviewed by: Rebecca Heywood
Nov/Dec 12 (Vol 21 No 5)
 

This paper challenges the most widely accepted treatment for idiopathic sudden sensorineural hearing loss – oral steroids. A well-conducted prospective, randomised, triple blinded, placebo-controlled study involving 14 centres across Sweden was carried out. Treatment was started within seven days of onset of symptoms with prednisolone or placebo. A dose of 60mg of prednisolone was given daily for three days followed by a dose reduction of 10mg per day up to eight days treatment. A dose of 10mg per day was continued in incomplete responders up to 30 days. No significant difference in hearing recovery was observed between prednisolone and placebo group at day eight or at day 90 in the 93 patients eventually included in the modified intention to treat study. Vertigo, abnormal laboratory findings and baseline change in hearing thresholds were found to be poor prognostic variables at day 90. The main drawback of the study is numbers: the authors were able to recruit only half as many patients as they intended. Many patients were ineligible due to presentation more than seven days after onset of symptoms and others chose steroid treatment either following their personal research or on the advice of doctors at recruiting centres. The apparent lack of effect of steroid treatment may therefore be due to type II error. The authors have addressed this in their discussion and cite their previous findings from the Swedish national database, which also found no benefit following steroid treatment, as support for their conclusions. The data certainly adds to the literature on treatment for SSNHL but the authors do not currently recommend a change in treatment policy away from standard treatment with steroids prior to meta-analysis with other data.

Reference

Corticosteroid treatment of idiopathic Sudden Sensorineural Hearing Loss: Randomized Triple-Blind Placebo-Controlled Trial.
Nosrati-Zarenoe R, Hultcrantz E.
OTOLOGY & NEUROTOLOGY
2012;33(4):523-31.
Corticosteroid treatment of idiopathic Sudden Sensorineural Hearing Loss: Randomized Triple-Blind Placebo-Controlled Trial.
Nosrati-Zarenoe R, Hultcrantz E.
OTOLOGY & NEUROTOLOGY
2012;33(4):523-31.

PEDIATRIC ALLERGY AND IMMUNOLOGY

Is CRS one disease?
Reviewed by: Evangelia Tsakiropoulou
Nov/Dec 12 (Vol 21 No 5)
 

This is a very sophisticated review which summarises the accumulating evidence for a differentiation of CRS phenotypes described in current literature. Nasal polyps are characterised by a specific remodelling pattern, with oedema as a common finding due to the lack of TGF-ί, a profibrotic factor, and the action of metallo-proteinases (MMPs) over their antagonists. In contrast, CRS without polyps is a rather fibrotic disease, with high concentration of collagen. In CRS without polyps a mild Th1 inflammatory reaction is present. However, CRS with nasal polyps usually is a more severe inflammation, for example in cystic fibrosis; nasal polyps follow a neutrophilic inflammatory pattern with high concentrations of IL-17 and IL-8. Moreover, Staphylococcal superantigens are responsible for the activation of T and B cells along with a significant increase in total IgE concentrations both in tissue and in the serum. However, this finding is characteristic only of nasal polyposis, and is not observed in CRS without polyps or polyps in cystic fibrosis patients. Additionally, increased IgE is often found in serum of patients with asthma. The authors suggest that the term CRS should be revised and conclude that further studies on biological markers and histological subtypes are needed.

Reference

Chronic rhinosinusitis: From one disease to different phenotypes.
Bachert C, Zhang N, van Zele T, Gevaert P.
PEDIATRIC ALLERGY AND IMMUNOLOGY
2012;23(Suppl 22):2-4.
Chronic rhinosinusitis: From one disease to different phenotypes.
Bachert C, Zhang N, van Zele T, Gevaert P.
PEDIATRIC ALLERGY AND IMMUNOLOGY
2012;23(Suppl 22):2-4.

RHINOLOGY

Anatomical variation of the septum affecting intranasal spray delivery
Reviewed by: Lakhbinder Bal
Nov/Dec 12 (Vol 21 No 5)
 

Intranasal medications, such as topical steroid sprays, are commonly used to treat a range of sinonasal diseases. In these patients, if a septal deviation is present (prevalence in healthy adults between 19.5-26%) or other anatomical deformity, it can inhibit the delivery of the medication to the areas of the nasal cavity where it will have most effect. This study investigates how a deviated nasal septum affects the quantity and distribution of spray particles and the effects of inspiratory airflow and head position. Deposition of spray particles was analysed using a 3D computational fluid dynamics (CFD) model created from the CT scan of a human nose with left-sided septal deviation and a right inferior turbinate hypertrophy. Five simulations were conducted with particle sizes ranging from 20-110mm, a spray speed of 3m/s, plume angle of 68 degrees and with steady state inspiratory airflow either present or absent at varying head positions. The results revealed that, with inspiratory airflow present, posterior deposition on the obstructed side was approximately four times less than the contralateral side, regardless of head position and was statistically significant. When airflow was absent, predicted deposition beyond the nasal valve on the left and right side was between 16% and 69% lower and positively influenced by a dependant head position. Advancing techniques such as CFD provide useful information on how we can best instruct our patients in the optimal use of their nasal sprays, in the presence of anatomical deformities. However, it must be noted that this study is based on a single subject only and therefore does not take into account patients with less / more severe deviations and the impact on particle deposition. In addition, the airflow simulations were based on laminar steady state conditions and did not take into account turbulence and the cyclic nature of airflow.

Reference

Deviated nasal septum hinders intranasal sprays: a computer simulation study.
Frank DO, Kimbell JS, Cannon D, Pawar SS, Rhee JS.
RHINOLOGY
2012;50(3):311-8.
Deviated nasal septum hinders intranasal sprays: a computer simulation study.
Frank DO, Kimbell JS, Cannon D, Pawar SS, Rhee JS.
RHINOLOGY
2012;50(3):311-8.

SEMINARS IN SPEECH AND LANGUAGE

Electrical stimulation and aphasia
Reviewed by: Laith Tapponi
Nov/Dec 12 (Vol 21 No 5)
 

The goal of this review article is to define the current state of research into transcranial brain stimulation to treat or enhance the treatment of aphasia, and identify the mechanism by which repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) affect behaviour. Several studies have revealed that inhibitory stimulation of right hemisphere regions homologous to Broca’s area actually enhances speech production in patients with nonfluent aphasia. Although the potential for both rTMS and tDCS is clear, the specific mechanism by which these methods work is far less certain. Studies to date have used similar paradigms that appear to be effective, yet no definitive research shows this to be best practice. It is vital that continued investigations into efficacy, dosage, type, and site of stimulation be completed in order for brain stimulation to be optimized as a therapeutic tool. There is still much research to be completed before these methods can be incorporated into general clinical practice.

Reference

 

Transcranial brain stimulation to treat aphasia: a clinical perspective.
Fridriksson J, Hubbard H, Hudspeth S.
SEMINARS IN SPEECH AND LANGUAGE
2012;33(3):188-202.
Transcranial brain stimulation to treat aphasia: a clinical perspective.
Fridriksson J, Hubbard H, Hudspeth S.
SEMINARS IN SPEECH AND LANGUAGE
2012;33(3):188-202.

SEMINARS IN SPEECH AND LANGUAGE

The outcomes of long-term electrical stimulation on dysphagia
Reviewed by: Laith Tapponi
Nov/Dec 12 (Vol 21 No 5)
 

This review is to summarise the physiological effects of surface electrical stimulation during swallowing and at rest, yet many unanswered questions about its efficacy remain. The investigation of percutaneous electrical stimulation on swallowing function is limited to a small number of studies. Together, the future of swallowing research and clinical practice has numerous potential for developing effective management strategies for dysphagia. This can be achieved with progressive partnerships among highly skilled clinicians and experienced researchers to ascertain the full potential and limitations of electrical stimulation as well as other swallowing management options that are both known and not yet discovered.

Reference

Electrical Stimulation and Swallowing: How Much Do We Know?
Humbert IA, Michou E, MacRae P, Crujido L.
SEMINARS IN SPEECH AND LANGUAGE
2012;33(3):208-16.
Electrical Stimulation and Swallowing: How Much Do We Know?
Humbert IA, Michou E, MacRae P, Crujido L.
SEMINARS IN SPEECH AND LANGUAGE
2012;33(3):208-16.

WORLD JOURNAL OF SURGICAL ONCOLOGY

Htr A 1 – potential target for the treatment of oesophageal cancers
Reviewed by: Gauri Mankekar
Nov/Dec 12 (Vol 21 No 5)
 

High temperature requirement serine peptidase 1 (HtrA 1) is considered to be a tumour suppressor gene which reduces the transforming ability of fibroblasts and suppresses the growth of highly invasive tumours like ovarian cancer and invasive melanoma. The authors of this study investigated the expression and role of HtrA 1 in human oesophageal cancer tissues and its expression and relevance in the occurrence and development of oesophageal cancers. They used semi –quantitative reverse transcription PCR and Western Blot to measure HtrA 1 mRNA and protein expression in human oesophageal cancer tissues and their adjacent normal oesophageal tissues. They also used RNA interference or transfected an HtrA 1 recombinant plasmid to downregulate or overexpress the HtrA 1 protein in the Eca 109 human oesophageal cancer cell line. Resulting changes in the invasiveness of Eca-109 cells were observed and the relationship between HtrA 1 protein expression and the occurrence, development and metastasis of human oesophageal cancer was explored. The study showed that the expression of HtrA 1 mRNA and protein in oesophageal cancer was significantly lower than the levels expressed in their adjacent normal oesophageal tissue. Patients with early pathological stage (I–II) tumours had significantly higher HtrA 1 mRNA and protein expression levels than patients with mid to late stage (III–IV) tumours. The study shows a significant correlation between the expression of Htr A 1 protein and oesophageal cancers. The authors conclude that in future HtrA 1 may be a potential target for the treatment of oesophageal cancer.

Reference

HtrA 1 expression associated with the occurrence and development of oesophageal cancer.
Yu Y, Shao W, Hu Y, Zhang J, Song H, Zhu Z-h, 
WORLD JOURNAL OF SURGICAL ONCOLOGY
2012;10:179.
HtrA 1 expression associated with the occurrence and development of oesophageal cancer.
Yu Y, Shao W, Hu Y, Zhang J, Song H, Zhu Z-h, 
WORLD JOURNAL OF SURGICAL ONCOLOGY
2012;10:179.

ACTA OTOLARYNGOLOGICA

Fifty-four thousand patients in Sweden show that tonsil surgery provides effective symptom relief
Reviewed by: Victoria Possamai
Sep/Oct 12 (Vol 21 No 4)
 

The Swedish National Tonsil Surgery Register has been in place since 1997. This study reviews the 11 years up to 2008 during which time patient data has been collected for approximately half of all patients undergoing this surgery. It was interesting to note that the frequency of tonsillectomies per population performed per year in Sweden (10,000 in a population of nine million) is somewhat higher than the UK (50,000 in a population of 62 million). The most common physician reported indication was obstruction (49%) followed by recurrent tonsillitis (35%) suggesting that they perform many more tonsillectomies for obstruction than in the UK. There is no comment as to the proportion of children and adults that makes up the total. The main outcome measure is the patient / parent reported symptom relief six months postoperatively. The bottom line is that, for all indications, the symptom improvement was high (92%). This is defined as the patient reporting ‘my symptoms are gone’ or ‘my symptoms are almost gone’. The other interesting finding was that 13.9% patients made an unplanned outpatient visit after their operation with pain, bleeding, infection and difficulty eating and drinking. This group reported a lower degree of symptom relief at six months, felt likely to be due to this negative experience affecting the perceived positive impact on the preoperative symptoms.

Reference

Tonsil surgery efficiently relieves symptoms: analysis of 54696 patients in the National Tonsil Surgery Register in Sweden.
Stalfors J, Ericsson E, Hemlin C, Hultcrantz E, Månsson I, Roos K, Hessén Söderman AC.
ACTA OTO-LARYNGOLOGICA
2012;132(5):533-9.
Tonsil surgery efficiently relieves symptoms: analysis of 54696 patients in the National Tonsil Surgery Register in Sweden.
Stalfors J, Ericsson E, Hemlin C, Hultcrantz E, Månsson I, Roos K, Hessén Söderman AC.
ACTA OTO-LARYNGOLOGICA
2012;132(5):533-9.

ACTA OTOLARYNGOLOGICA

Stratifying risk depending on degree of laryngeal dysplasia
Reviewed by: Victoria Possamai
Sep/Oct 12 (Vol 21 No 4)
 

When explaining a diagnosis of laryngeal dysplasia to a patient I have often wondered the true relevance of the classification ‘mild’, ‘moderate’ or ‘severe’ in truly predicting the likelihood of progression. This study from China tackles this question. Eighty-six patients with preinvasive laryngeal lesions were followed up for a minimum of two years. The rates of progression to invasive carcinoma were 0/22 with mild dysplasia, 5/25 (20%) with moderate dysplasia, 2 of 14 (15%) with severe dysplasia and 10/25 (40%) with carcinoma in situ. The authors suggest that moderate and severe dysplasia behave in a similar fashion, whilst CIS is more aggressive and should be considered as a separate entity. I would contend that their numbers and follow-up make it a little difficult to come to firm conclusions particularly when they comment that over 50% of cases progressed three years after the initial biopsy.

Reference

Is severe dysplasia the same lesion as carcinoma in situ? 10 year follow-up of laryngeal precancerous lesions.
Zhang HK, Liu HG.
ACTA OTO-LARYNGOLOGICA
2012;132(3):325-8.
Is severe dysplasia the same lesion as carcinoma in situ? 10 year follow-up of laryngeal precancerous lesions.
Zhang HK, Liu HG.
ACTA OTO-LARYNGOLOGICA
2012;132(3):325-8.

ALLERGY

Is Chinese herbal medicine effective against allergic rhinitis?
Reviewed by: Evangelia Tsakiropoulou
Sep/Oct 12 (Vol 21 No 4)
 

Persistent allergic rhinitis has an increased prevalence in the Western world. It is a disease that affects quality of life and often cannot be fully controlled by means of existing medical treatment. Therefore, many patients seek for help in alternative medicine. This review aims to evaluate randomised controlled trials from 1999 to 2011 on the efficacy and safety of Chinese herbal medicine used for treating persistent allergic rhinitis. According to this interesting meta-analysis, nasal symptoms were successfully controlled after treatment with Chinese herbs. Moreover, the total serum IgE level was reported as reduced, although not significantly. Disadvantage of the analysis was the small number of studies included (seven) and the relatively low study population for a meta-analysis; total number of patients (533). The authors conclude that Chinese herbs seem to be effective in patients with persistent allergic rhinitis. Additionally, they underline the need for qualitative-designed studies in order to draw firm conclusions and to recognise Chinese herbal formulae as a well established therapeutic strategy. However, I am obliged to present significant limitations of the study. The quality of the individual-controlled trials was not particularly high. Secondly, for most of the studies, treatment duration was not long enough to correctly evaluate the efficacy of the adopted treatment. The approach used presents a mixture of different treatments, giving heterogeneous results. There was not enough data regarding long-term treatment results. Thus, in my opinion, the evidence remains weak owing to methodological flaws, making it difficult to draw any firm conclusion.

Reference

Meta-analysis of clinical trials on traditional Chinese herbal medicine for treatment of persistent allergic rhinitis.
Wang S, Tang Q, Qian W, Fan Y. 
ALLERGY
2012;67(5):583-92.
Meta-analysis of clinical trials on traditional Chinese herbal medicine for treatment of persistent allergic rhinitis.
Wang S, Tang Q, Qian W, Fan Y. 
ALLERGY
2012;67(5):583-92.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Benign nasal lesions: a useful review
Reviewed by: Edward W Fisher
Sep/Oct 12 (Vol 21 No 4)
 

This review covers some lesions which, with the exception of inverted papilloma, tend to be written about and read about only rarely. Pyogenic granuloma and its variety of synonyms are described well and in particular the authors’ own views of management of hereditary haemorrhagic telangiectasia (HHT) is well described. The use of a micro-debrider to treat individual lesions of HHT has produced good results in the hands of the authors, avoiding the tissue destruction associated with cautery.

Reference

Inverted papillomas and benign nonneoplastic lesions of the nasal cavity.
Wood JW, Casiano RR.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26(2):157-63.
Inverted papillomas and benign nonneoplastic lesions of the nasal cavity.
Wood JW, Casiano RR.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26(2):157-63.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

Complications of endoscopic sinus surgery (ESS): who is most at risk?
Reviewed by: Edward W Fisher
Sep/Oct 12 (Vol 21 No 4)
 

This study, from Japan, examined 706 patients prospectively for risk factors in relation to complications. There was a low overall complication rate of 5.8%, and the great majority was minor. The only main technical difference compared to the UK was the very intensive postoperative (daily) nasal toilet / debridement carried out, but there is no reason to suppose that this technical difference would skew results significantly. The main finding that surprised me was that experience of the surgeon played no obvious part statistically, but that the presence or absence of asthma and the polyp grade (severity) were the two stand-out factors that predisposed to complications. The authors, sensibly, concluded that perhaps more effort should be put into minimising the effects of these two factors by intensive preoperative medical management (such as with oral corticosteroids).

Reference

Risk factors for complications of endoscopic sinus surgery for chronic rhinosinusitis.
Asaka D, Nkayama T, Hama T, Okushi T, Matsuwaki Y, Yoshikawa M, Yanagi K, Moriyama H, Otori N.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26(1):61-4.
Risk factors for complications of endoscopic sinus surgery for chronic rhinosinusitis.
Asaka D, Nkayama T, Hama T, Okushi T, Matsuwaki Y, Yoshikawa M, Yanagi K, Moriyama H, Otori N.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012;26(1):61-4.

AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY

The current position on Samter’s Triad
Reviewed by: Edward W Fisher
Sep/Oct 12 (Vol 21 No 4)
 

There are few rhinologists that do not sigh when faced with an ASA-sensitive patient with aggressive nasal polyps, seeking their umpteenth operation. The availability of aspirin desensitisation in the United Kingdom is variable and certainly not a routine part of the management of this difficult group of patients in the UK. This review article gives a US perspective on the condition and offers some useful references. The ENT section is brief and predictable, telling us nothing new, but the section on aspirin desensitisation helps explain why this is currently confined to major centres in the UK. The term ‘aspirin-exacerbated airway disease’ (AEAD) is used to describe the combination of lower and upper airway disease that occur in this group. The use of desensitisation is clearly resource-intensive, and how popular this becomes in the UK remains to be seen.

Reference

Aspirin-sensitive asthma and upper airway diseases.
Chang JE, Chin W, Simon R.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012 26(1):27-30.
Aspirin-sensitive asthma and upper airway diseases.
Chang JE, Chin W, Simon R.
AMERICAN JOURNAL OF RHINOLOGY AND ALLERGY
2012 26(1):27-30.

ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY

Best surgical approach for acoustic neuroma surgery
Reviewed by: Maher El Alami
Sep/Oct 12 (Vol 21 No 4)
 

Removing vestibular schwannoma can be performed with good results in view of hearing preservation and damage to the facial nerve. This is a retrospective analysis of 2,400 cases operated on between 1983 and 2010 in particular focusing on the surgical approach used and the evidence of recurrent (residual-MEA) disease. Approaches used were the translabyrinthine, retrosigmoid or middle fossa approach. Minimum follow-up was 12 months (range: 12-267 months) by MRI scanning. Total tumour removal was achieved in 2,252 cases (93.8%). Of these, most had undergone a translabyrinthine approach (2,011 patients). In this group four recurrences were found. Facial nerve integrity was achieved in 91.4% of cases with a function HB I and II in 61%. 9.8% had reduced VII function of HB V and VI. Translabyrinthine approach had a recurrence rate of 0.05%, retrosigmoid 0.7%, and middle fossa had a 1.8% recurrence rate. Recurrences developed up to 13 years post-surgery and the authors advise follow-ups to 15 years. They suggest the size, but in particular the locationof the tumour is significant for the risk of recurrence. The fundus of the IAC was a particularly significant area for potential recurrence and the translabyrinthine approach provides the best approach to this. The authors include a literature review of previously published case series in their discussion. This article condenses a lot of information and although there are the drawbacks of a retrospective analysis of a heterogeneous case mix, this review provides a good analysis of the prognosis of surgically treated vestibular schwannoma.

Reference

Rate of recurrent vestibular schwannoma after total removal via different surgical approaches.
Ahmed RA, Sivalingam S, Tpsakal V, Russo A, Taibah A, Sanna M.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(3):156-61.
Rate of recurrent vestibular schwannoma after total removal via different surgical approaches.
Ahmed RA, Sivalingam S, Tpsakal V, Russo A, Taibah A, Sanna M.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(3):156-61.

ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY

Building your own trachea
Reviewed by: Maher El Alami
Sep/Oct 12 (Vol 21 No 4)
 

Reconstructing the trachea after resection has always been a challenging problem. More recently the introduction of a collagen sponge structure with a polypropylene ring and a Marlex mesh has been an important innovation in this field. The authors have used this principle in patients in their centre. The problem remains the mucosal regeneration of the surface. In this experimental study the authors have used a collagen gel, with and without additional growth factor (b-FGF), on previously tracheotomised rats. The technique and the histological results are clearly described in this report. The rats were later put down and the regeneration was examined histologically. The results were promising, showing a prolonged healing acceleration of over 14 days due to the addition of growth factors. The authors hope this technique allows better reconstruction after surgery for tracheal stenosis. The results of this study may directly influence clinical application in the near future.

Reference

Regeneration of tracheal epithelium using a collagen vitrigel-sponge scaffold containing basic fibroblast growth factor.
Tani A, Tada Y, Takezawa T, Imaizuma M, Nomoto Y, Nakamura T, Omori K.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(4):261-8.
Regeneration of tracheal epithelium using a collagen vitrigel-sponge scaffold containing basic fibroblast growth factor.
Tani A, Tada Y, Takezawa T, Imaizuma M, Nomoto Y, Nakamura T, Omori K.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(4):261-8.

ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY

Does low-molecular heparin prevent noise-induced hearing loss?
Reviewed by: Maher El Alami
Sep/Oct 12 (Vol 21 No 4)
 

This study looks at the proposition of treating adults with noise-induced hearing loss post exposure. A total of 60 adults between 35-45 years of age diagnosed with bilateral NIHL were included. All subjects had been exposed to noise >85dB but were compliant with advised hearing protection. Only patients with hearing loss of 2-8kHz and residual hearing in the other frequencies in line with or above normal hearing were included, trying to exclude other causes of hearing loss. Attempts were made to exclude other confounding factors for hearing loss. All subjects were exposed to professional noise. The patients’ audiological parameters (pure tone audiometry, otoacoustic emissions and ABR) were recorded pre-treatment, post-treatment and at two months. Subjects were randomly divided into groups receiving 10 days of s.c. Enoxaparin (LMWH). All patients in the study group showed improvement of their PTA and their OAEs while ABR testing remained unchanged post-treatment. These improvements decreased at two months after treatment. Parameters in the control group remained unchanged. The authors speculate about the role of LMWH in the regulation of apoptosis and the anti-inflammatory properties of heparin on neural tissue. This study highlights the potential of neuro-protective agents in the treatment and protection against noise induced hearing loss.

Reference

Audiometric characteristics in patients with noise-induced hearing loss after sodium enoxaparin treatment.
Mora R, Salzano FA, Guastini L.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(2):85-90.
Audiometric characteristics in patients with noise-induced hearing loss after sodium enoxaparin treatment.
Mora R, Salzano FA, Guastini L.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(2):85-90.

ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY

Flying after tympanoplasty
Reviewed by: Maher El Alami
Sep/Oct 12 (Vol 21 No 4)
 

Traditional teaching still advocates against flying after tympanoplasty. In this study results in 169 patients after tympanoplasty were reviewed. One hundred patients travelled home by land; however 69 patients flew to their homes in Sicily and Sardinia on Day 1 after the operation on commercial aircraft. The operations performed were analysed looking at techniques employed, type of grafts used and looking at their success rates with either success or failure at one month postoperatively. Five per cent of patients had failures in the flight group, whereas 14% of the non-flight group failed. Graft material, under- or on-lay technique did not seem to make a difference. These results mirror results from other groups. Unfortunately criteria for failure or success were not clearly stated and there is no information on medium-term results, as a month postoperatively seems to be rather short. This study suggests the risk of air travel after ear surgery may be overstated (including on-lay grafts).

Reference

Effects of early commercial air travel on graft healing rates after tympanoplasty.
Konishi M, Sivalingam S, Shin SH, Vitullo F, Falcioni M.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(2):110-2.
Effects of early commercial air travel on graft healing rates after tympanoplasty.
Konishi M, Sivalingam S, Shin SH, Vitullo F, Falcioni M.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(2):110-2.

ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY

Injecting the vocal folds
Reviewed by: Maher El Alami
Sep/Oct 12 (Vol 21 No 4)
 

Subepithelial injection of the vocal folds at laryngoscopy has been used for a while and this study presents the experience using this technique in 178 consecutive patients listed for (Micro)laryngoscopy. The technique is described clearly and the potential benefits are presented. The injected saline solution helps to lift superficial lesions off the vocal ligament, thus enabling diagnosis and dissection of these lesions. The authors are pleased with their results and spend seven pages recommending this technique. Even though presented as a prospective study, very little is mentioned about the alternatives and potential problems with this technique. The potential uses for oncological surgery are stated but never quantified. Even though coming from a well-established institution this is a disappointing paper adding very little to what we already know (a missed opportunity).

Reference

Subepithelial vocal fold Infusion: a useful diagnosis and 
therapeutic technique.
Burns JA, Friedman AD, Luth MJ, Zeitels SM.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(4):224-30.
Subepithelial vocal fold Infusion: a useful diagnosis and 
therapeutic technique.
Burns JA, Friedman AD, Luth MJ, Zeitels SM.
ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY
2012;121(4):224-30.

ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY

Parotidectomy in the periphery
Reviewed by: Maher El Alami
Sep/Oct 12 (Vol 21 No 4)
 

Counselling patients about the risks of parotidectomy is important. In this retrospective analysis the authors have analysed their experience in a non-teaching hospital setting and have compared their results with results from major centres for head and neck surgery. Between 1990 and 2007, 341 parotid operations were performed. Eighty-two per cent were performed to remove tumours while the remaining ones were performed as diagnostic procedures and for the treatment of sialadenitis. Of the tumour operations 33% were for malignant disease while the 67% were performed for benign disease. Of the malignant disease SCC was the most common, while 13% were performed for lymphoma. The rate of facial nerve weakness postoperatively was 17%. Thirty-six of 57 cases of nerve damage had surgery for malignancies. In 7.6% the facial nerve was sacrificed. Abscess occurred in 3%, and Frey syndrome was diagnosed in 8%. The case mix in this series is different to many others published and there is a higher number of metastatic SCC. This could be a result of longer survival of cancer patients and possibly due to shifts in the epidemiology of parotid tumours. The authors also published their result of facial nerve damage which is higher than often declared by others. Different figures may be a result of different referral patterns and possibly epidemiological data. This article is a reminder to look at changing pat