Adverse events associated with Vibrant Soundbridge: A MAUDE study

OBJECTIVE

To summarize adverse events and their root causes reported to the United States Food and Drug Administration (FDA) on Vibrant Soundbridge (VSB) hearing device (Med-El, Innsbruck, Austria), an active middle ear implant for patients with moderate to severe hearing loss.

MATERIALS AND METHODS

The FDA's Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports of VSB adverse events from January 1, 2012, to July 27, 2022.

RESULTS

Six hundred sixty-three total medical device reports were identified, from which 913 adverse events were extracted. Of these, 498 (54.5 %) were adverse events to patients (AEPs), while 415 (45.5 %) were device malfunctions (DMs). The most common AEPs were hearing performance issues 428 (85.9 %). The most common DMs were compromised conductive link 125 (30.1 %). Root causes identified for DMs were iatrogenic 85 (58.6 %), patient-related 28 (19.3 %), and trauma and external causes 32 (22.1 %). The most common iatrogenic root cause 12 (14.1 %) involved damage to the conductive link during revision surgery. The most common patient-related causes of DMs were excessive middle ear tissue growth 16 (57 %), and abrupt body movements 5 (28.6 %). The most common external cause of DM was cleaning of the ear canal or mastoid cavity 20 (62.5 %).

CONCLUSIONS

Despite its well-known limitations, the MAUDE database provides valuable information on possible complications of VSB as it relates to device malfunction or adverse events for patients. Implementation of standardized reports with relevant and well-defined categories could certainly allow for a more meaningful analysis.

Impact of Cochlear Dose on Hearing Preservation Following Stereotactic Radiosurgery in Treatment of Vestibular Schwannomas: A Multi-Center Study

OBJECTIVE

Stereotactic radiosurgery (SRS) is a well-established treatment for vestibular schwannomas (VS). Hearing loss remains a main morbidity of VS and its treatments, including SRS. The effects of radiation parameters of SRS on hearing remain unknown. The goal of this study is to determine the effect of tumor volume, patient demographics, pretreatment hearing status, cochlear radiation dose, total tumor radiation dose, fractionation, and other radiotherapy parameters on hearing deterioration.

METHODS

Multicenter retrospective analysis of 611 patients who underwent SRS for VS from 1990-2020 and had pre- and post-treatment audiograms.

RESULTS

Pure tone averages (PTAs) increased and word recognition scores (WRSs) decreased in treated ears at 12-60 months while remaining stable in untreated ears. Higher baseline PTA, higher tumor radiation dose, higher maximum cochlear dose, and usage of single fraction resulted in higher post radiation PTA; WRS was only predicted by baseline WRS and age. Higher baseline PTA, single fraction treatment, higher tumor radiation dose, and higher maximum cochlear dose resulted in a faster deterioration in PTA. Below a maximum cochlear dose of 3 Gy, there were no statistically significant changes in PTA or WRS.

CONCLUSIONS

Decline of hearing at one year in VS patients after SRS is directly related to maximum cochlear dose, single versus 3-fraction treatment, total tumor radiation dose, and baseline hearing level. The maximum safe cochlear dose for hearingtbrowd preservation at one year is 3 Gy, and the use of 3 fractions instead of one fraction was better at preserving hearing.

Idiopathic Intracranial Hypertension: A Comprehensive Overview

Idiopathic intracranial hypertension (IIH), also called pseudotumor cerebri syndrome, is a disorder defined as elevated intracranial pressure (ICP) of unknown cause. It is a diagnosis of exclusion in most cases, and all other forms of elevated ICP must be ruled out. With its increasing prevalence, it is much more likely for physicians, otolaryngologists included, to encounter this condition. It is important to have a clear understanding of the typical and atypical presentation of this disease, along with its evaluative workup and management options. This article reviews IIH with a focus on those factors that are specifically relevant to otolaryngologic care.

Impact of COVID-19 on Otolaryngology Literature

Objectives/Hypothesis

To understand the effect of the COVID‐19 pandemic on the volume, quality, and impact of otolaryngology publications.

Study Design

Retrospective analysis.

Methods

Fifteen of the top peer‐reviewed otolaryngology journals were queried on PubMed for COVID and non‐COVID‐related articles from April 1, 2020 to March 31, 2021 (pandemic period) and pre‐COVID articles from the year prior. Information on total number of submissions and rate of acceptance were collected from seven top‐ranked journals.

Results

Our PubMed query returned 759 COVID articles, 4,885 non‐COVID articles, and 4,200 pre‐COVID articles, corresponding to a 34% increase in otolaryngology publications during the pandemic period. Meta‐analysis/reviews and miscellaneous publication types made up a larger portion of COVID publications than that of non‐COVID and pre‐COVID publications. Compared to pre‐COVID articles, citations per article 120 days after publication and Altmetric Attention Score were higher in both COVID articles (citations/article: 2.75 ± 0.45, P < .001; Altmetric Attention Score: 2.05 ± 0.60, P = .001) and non‐COVID articles (citations/article: 0.03 ± 0.01, P = .002; Altmetric Attention Score: 0.67 ± 0.28, P = .016). COVID manuscripts were associated with a 1.65 times higher acceptance rate compared to non‐COVID articles (P < .001).

Conclusions

COVID‐19 was associated with an increase in volume, citations, and attention for both COVID and non‐COVID articles compared to pre‐COVID articles. However, COVID articles were associated with lower evidence levels than non‐COVID and pre‐COVID articles.

Level of Evidence

3 Laryngoscope, 132:1364–1373, 2022

Sensorineural Hearing Loss and Tinnitus Characteristics in Patients With Idiopathic Intracranial Hypertension

OBJECTIVES

To characterize patterns of sensorineural hearing loss (SNHL) and tinnitus in patients with idiopathic intracranial hypertension (IIH).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adult patients diagnosed with IIH via lumbar puncture (LP) between 2010 and 2020 who had available audiograms. The study included a total of 40 patients; 33 women, and 7 men with a median age of 43.

INTERVENTIONS

Diagnostic LP and audiogram.

MAIN OUTCOME MEASURES

Otologic symptoms, ophthalmologic signs, hearing thresholds, cerebrospinal fluid opening pressures.

RESULTS

The most commonly reported symptoms were tinnitus in 28 (70%, 23 pulsatile and 5 tonal), aural fullness in 11 (28%), and vertigo in 10 (25%). Twenty-nine patients had ophthalmologic examinations and 18 had evidence of papilledema. Twenty-five (63%) patients had hearing loss in at least one ear at one frequency range. Patients presented with both unilateral and bilateral hearing loss across low, middle, and high frequency ranges. No significant association was observed between hearing loss threshold and LP opening pressure except for 250 Hz in the left ear. After stratification by tinnitus group (pulsatile, tonal, and no tinnitus), no significant difference was found between mean hearing loss threshold at different frequencies. In addition, no significant mean age difference was identified in patients within each tinnitus group.

CONCLUSIONS

There was no classic pattern or presentation for hearing loss in our IIH patients. They developed sudden, unilateral, or bilateral SNHL in low, middle, or high frequency range. The degree of hearing loss did not correlate with CSF opening pressure.

Vestibular Migraine and Its Comorbidities

Vestibular migraine (VM) is one of the most common neurologic causes of vertigo. Symptoms and International Classification of Headache Disorders criteria are used to diagnose VM because no objective tests, imaging or audiologic, have been shown to reliably diagnose this condition. Central auditory, peripheral, and central vestibular pathway involvement has been associated with VM. Although the interaction between migraine and other vestibular disorders can be a challenging scenario for diagnosis and treatment, there are data to show that vestibular rehabilitation and a variety of pharmacologic agents improve reported symptoms and vertigo frequency.

Head and neck osteosarcomas: An analysis of treatment trends and survival outcomes in the United States (2004-2016)

BACKGROUND

Head and neck osteosarcoma (HNOS) is a rare primary bone tumor with limited data to guide treatment approaches.

METHODS

The NCDB was used to identify patients diagnosed with HNOS. Kaplan-Meier and Cox multivariate regression were used to examine the impact of each treatment on overall survival (OS).

RESULTS

We identified 821 patients diagnosed with HNOS. Utilization of neoadjuvant chemotherapy + surgery increased from zero cases in 2004 to 24% of cases in 2016. Among surgically treated patients, 5-year OS was 55.8% (CI: 51.7-60.1%). No difference was seen in OS between each treatment cohort on multivariate analysis. However, neoadjuvant chemotherapy + surgery + adjuvant chemotherapy had improved 18-month survival compared to surgery alone (95.8% vs. 78.5%, p = 0.031).

CONCLUSIONS

Our study demonstrated no survival benefit in perioperative chemotherapy or radiation therapy; however, short-term survival improvement in patients receiving both neoadjuvant and adjuvant chemotherapy displays promise and requires further investigation.

High-Fidelity Surgical Middle Ear Simulator: A Pilot Study

OBJECTIVES

To assess a middle ear simulator as a surgical training tool among a cohort of novice trainees.

STUDY DESIGN

Prospective pilot study.

SETTING

The George Washington University Hospital (tertiary care academic hospital).

PARTICIPANTS

Twenty one medical students and physician assistant students completed the protocol. Each student produced four recordings over 10 attempts. The two raters were attending surgeons from the George Washington University Hospital.

INTERVENTIONS

Stapedotomies performed on a high-fidelity middle ear simulator. Participants were assessed at baseline with a Purdue pegboard test and trained with video and a low fidelity middle ear simulator.

MAIN OUTCOME MEASURES

Two experts rated recordings on scales based upon a validated objective skills assessment test (OSAT) format.

RESULTS

Inter-rater reliability was strong across all stapedotomy skills scores and global rating scores. Participants demonstrated statistically significant improvement up to the third recording (seventh attempt), but the scores on the fourth recording (tenth attempt) were not significantly different from the third. One participant failed to improve in score over 10 attempts. Pegboard test performance was not correlated with score improvement. Low-fidelity trial time was significantly correlated to stapedotomy and global rating scores.

CONCLUSIONS

This pilot study serves as the first investigation of this middle ear simulator amongst a cohort of trainees. A high-fidelity middle ear simulator may serve as a measurement tool to select future surgical trainees, customize training pathways, and assess surgical capacity before graduation.

Characterization of Sensorineural Hearing Loss in Adult Patients With Sickle Cell Disease: A Systematic Review and Meta-analysis

OBJECTIVES AND MAIN OUTCOME MEASURES

To determine the prevalence of sensorineural hearing loss (SNHL) attributable to sickle cell disease (SCD) in the global adult population and to identify factors contributing to its severity.

STUDY DESIGN

Systematic Review and Meta-analysis.

METHODS

We performed a comprehensive literature search for scientific articles in PubMed, Scopus, CINAHL, Web of Science, and the Cochrane Library that reported the incidence of hearing loss in populations over 18 years of age with SCD.

RESULTS

We identified 138 studies from the initial search, 12 of which met inclusion criteria and were utilized for data analysis. A total of 636 SCD patients and 360 controls were included in the Cochrane Review Manager 5.3 meta-analysis. There was a statistically significant increase in the prevalence of SNHL in adults with SCD compared with the general population with a cumulative risk ratio (RR) of 6.03.

CONCLUSIONS

This is the first systematic investigation of the relationship between SCD and SNHL in adult patients across the globe. SNHL is more prevalent in patients with SCD, specifically those of the HbSS genotype, than the general population likely due to the pathophysiology of the disease and its effects on labyrinthine microvasculature. The increased prevalence of SNHL in the adult SCD population warrants future research into the predictors of SNHL severity and merits routine audiometric monitoring of adult SCD patients.

Pediatric head and neck rhabdomyosarcoma: An analysis of treatment and survival in the United States (1975-2016)

INTRODUCTION

Rhabdomyosarcoma (RMS) is the most common soft tissue head and neck sarcoma in children. Stringent analysis of survival data is imperative to optimize treatment.

METHODS

The National Cancer Database (NCDB, 2004-2016) and the Surveillance, Epidemiology, and End Results Program (SEER, 1975-2016) were queried for patients ages 0-19 with RMS of the head and neck. Survival trends were analyzed using univariable logistic regression and Chi-square pairwise comparisons. Survival by treatment was analyzed using log-rank tests, Kaplan Meier, and multivariable Cox-proportional hazards regression.

RESULTS

1147 (63.3% age <10 years, 54.3% male) and 459 (71.4% age <10 years, 53.6% male) patients were identified in NCDB and SEER, respectively. In NCDB, embryonal (n = 625, 54.5%) and alveolar (n = 300, 26.2%) were the most common histology and nonparameningeal/non-orbital (n = 634, 55.3%), followed by parameningeal (n = 303, 26.4%) and orbital (n = 210, 18.3%) the most common location. Five-year overall survival (OS) was 70.3% with lower mortality risk for embryonal histology (adjusted HR [aHR] = 0.69, p = 0.0038). Orbital tumors had greatest survival (5-year OS = 92.4%) of all sites, and their mortality risk was higher with chemotherapy and radiation compared to surgery and radiation (aHR = 6.27, p = 0.0302). SEER analysis showed average increased survival by 4% per year (p < 0.0001), but no significant 5-year OS difference when comparing 1976-1980 and 2006-2010 (p = 0.0843).

CONCLUSIONS

Major prognostic factors for survival in childhood RMS of the head and neck were embryonal histology, orbital site, extent of disease, and use of SRT for orbital tumors. Larger population studies are required to demonstrate survival differences between treatment modalities for other sites.

Prevalence of Sensorineural Hearing Loss in Pediatric Patients with Sickle Cell Disease: A Meta-analysis

OBJECTIVES

To determine the prevalence of Sensorineural Hearing Loss (SNHL) attributable to Sickle Cell Disease (SCD) in the global pediatric population and to identify factors contributing to its severity.

STUDY DESIGN

Meta-analysis.

METHODS

We performed a comprehensive literature search for scientific articles in PubMed, Scopus, CINAHL, Web of Science, and the Cochrane Library that reported the incidence of hearing loss in populations under 18 years of age with excluding studies analyzing patients on iron chelation therapy, adults, or those without objective audiological analysis.

RESULTS

We identified 138 initial studies with 17 selected for analysis after applying the exclusion criteria. A total of 1,282 SCD patients and 553 controls were included in the meta-analysis. There was a statistically significant increase in the prevalence of SNHL in children with SCD compared to the general population with a cumulative risk ratio of 3.33.

CONCLUSION

This is the first systematic investigation of the relationship between SCD and SNHL in pediatric patients across the globe. The increased prevalence of SNHL in the pediatric SCD population warrants future research into the predictors of SNHL severity and merits routine audiometric monitoring of SCD patients to reduce the social and developmental morbidity of hearing loss at a young age. PROSPERO Registration #: CRD42019132601. Laryngoscope, 131:1147-1156, 2021.

Clinical Practice Guideline: Ménière's Disease Executive Summary

OBJECTIVE

Ménière's disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to midfrequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It also presents with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear. The underlying etiology of MD is not completely clear, yet it has been associated with inner ear fluid volume increases, culminating in episodic ear symptoms (vertigo, fluctuating hearing loss, tinnitus, and aural fullness). Physical examination findings are often unremarkable, and audiometric testing may or may not show low- to midfrequency sensorineural hearing loss. Imaging, if performed, is also typically normal. The goals of MD treatment are to prevent or reduce vertigo severity and frequency; relieve or prevent hearing loss, tinnitus, and aural fullness; and improve quality of life. Treatment approaches to MD are many, and approaches typically include modifications of lifestyle factors (eg, diet) and medical, surgical, or a combination of therapies.

PURPOSE

The primary purpose of this clinical practice guideline is to improve the quality of the diagnostic workup and treatment outcomes of MD. To achieve this purpose, the goals of this guideline are to use the best available published scientific and/or clinical evidence to enhance diagnostic accuracy and appropriate therapeutic interventions (medical and surgical) while reducing unindicated diagnostic testing and/or imaging.

Clinical Practice Guideline: Ménière's Disease

OBJECTIVE

Ménière's disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to midfrequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It also presents with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear. The underlying etiology of MD is not completely clear, yet it has been associated with inner ear fluid (endolymph) volume increases, culminating in episodic ear symptoms (vertigo, fluctuating hearing loss, tinnitus, and aural fullness). Physical examination findings are often unremarkable, and audiometric testing may or may not show low- to midfrequency sensorineural hearing loss. Conventional imaging, if performed, is also typically normal. The goals of MD treatment are to prevent or reduce vertigo severity and frequency; relieve or prevent hearing loss, tinnitus, and aural fullness; and improve quality of life. Treatment approaches to MD are many and typically include modifications of lifestyle factors (eg, diet) and medical, surgical, or a combination of therapies.

PURPOSE

The primary purpose of this clinical practice guideline is to improve the quality of the diagnostic workup and treatment outcomes of MD. To achieve this purpose, the goals of this guideline are to use the best available published scientific and/or clinical evidence to enhance diagnostic accuracy and appropriate therapeutic interventions (medical and surgical) while reducing unindicated diagnostic testing and/or imaging.

Detection and differentiation of opportunistic viral infections potentially contributing to renal graft rejection by tetraplex-nested PCR

The need for an intensive care protocol, sometimes weekly or biweekly, has led to a significant increase in laboratory costs for kidney recipients. In the present study, an inhouse tetraplex nested PCR assay was developed and validated for the specific detection of BKV, JCV, HCMV and EBV in clinical samples. We determined the Limit of Detection (LOD) and analytical specificity. To demonstrate the diagnostic performance of the assay, a total of 102 archival plasma samples were tested and compared with a commercial uniplex real-time PCR kits. The analytical sensitivity of the in-house tetraplex nested PCR assay was 173 copies/ml, when all four viruses were present in the specimens. These values were 79.2, 58.7, 87.6 and 96.1 copies/ml when only, BKV, JCV, HCMV and EBV respectively, were present. The cross-reactivity assays were shown no detectable signal in the tetraplex PCR results. The estimated diagnostic sensitivities were 92.6% for BKV, 92.3% for JCV and 100% for both HCMV and EBV as compared with commercial kits. Regarding the sensitivity and specificity, it seems that the developed Multiplex Nested PCR assay could be used as a reliable virusassociated renal rejection (VRR) panel in post renal transplant surveillance.

Patterns of Migraine Disease in Otolaryngology: A CHEER Network Study

Objective

To evaluate the prevalence of migraine disease in an otolaryngologic cohort and migraine-related otologic and sinonasal symptoms in this population.

Study Design

Cross-sectional study utilizing the CHEER (Creating Healthcare Excellence through Education and Research) network for recruitment.

Setting

Patients were recruited in a cross-sectional and pragmatic manner in 14 CHEER sites between June 2015 and March 2017 (9 academic, 5 community based).

Subjects and Methods

Patients were included if they were aged ≥18 years and seen for any concern that was not head and neck cancer. Patients with any history of brain abnormality or headaches that began within 2 weeks of a medical illness, trauma, or head injury were excluded. Patients were screened for migraine with a validated instrument. If they screened positive on the Migraine Assessment Tool (MAT+), the subjects also filled out validated and custom questionnaires for sinonasal, otologic, and migraine-specific symptoms.

Results

Of 1458 patients screened, 235 (16.1%) screened positive for migraine (MAT+), which is higher than general population (13%, P < .001). The MAT+ group was significantly younger (47.2 vs 55.6 years of age, P < .001) and predominantly women (80.0% vs 55.9%, P < .001). The MAT+ cohort commonly reported ear- and sinus-related symptoms, such as tinnitus (70.5%), ear pressure (61.9%), balance problems (82%), facial pressure (85%), and rhinorrhea (49.9%). There were significantly higher levels of sinus burden with higher levels of dizziness handicap, Jonckheere-Terpstra test = 11,573.00, z = 7.471, P < .001.

Conclusion

Migraine disease has a higher prevalence in an otolaryngologic cohort than in the general population, presenting with a high rate of sinonasal and otologic symptoms that may be due to or exacerbated by migraines.

Facial Nerve Outcome and Tumor Control Rate as a Function of Degree of Resection in Treatment of Large Acoustic Neuromas: Preliminary Report of the Acoustic Neuroma Subtotal Resection Study (ANSRS)

BACKGROUND

Patients with large vestibular schwannomas are at high risk of poor facial nerve (cranial nerve VII [CNVII]) function after surgery. Subtotal resection potentially offers better outcome, but may lead to higher tumor regrowth.

OBJECTIVE

To assess long-term CNVII function and tumor regrowth in patients with large vestibular schwannomas.

METHODS

Prospective multicenter nonrandomized cohort study of patients with vestibular schwannoma ≥2.5 cm who received gross total resection, near total resection, or subtotal resection. Patients received radiation if tumor remnant showed signs of regrowth.

RESULTS

Seventy-three patients had adequate follow-up with mean tumor diameter of 3.33 cm. Twelve received gross total resection, 22 near total resection, and 39 subtotal resection. Fourteen (21%) remnant tumors continued to grow, of which 11 received radiation, 1 had repeat surgery, and 2 no treatment. Four of the postradiation remnants (36%) required surgical salvage. Tumor regrowth was related to non-cystic nature, larger residual tumor, and subtotal resection. Regrowth was 3 times as likely with subtotal resection compared to gross total resection and near total resection. Good CNVII function was achieved in 67% immediately and 81% at 1-year. Better immediate nerve function was associated with smaller preoperative tumor size and percentage of tumor left behind on magnetic resonance image. Degree of resection defined by surgeon and preoperative tumor size showed weak trend toward better late CNVII function.

CONCLUSION

Likelihood of tumor regrowth was 3 times higher in subtotal resection compared to gross total resection and near total resection groups. Rate of radiation control of growing remnants was suboptimal. Better immediate but not late CNVII outcome was associated with smaller tumors and larger tumor remnants.

ABBREVIATIONS

CNVII, cranial nerve VIIGTR, gross total resectionHB, House-BrackmannMRI, magnetic resonance imageNTR, near total resectionSTR, subtotal resection.

First results of a novel adjustable-length ossicular reconstruction prosthesis in temporal bones

OBJECTIVES/HYPOTHESIS

The performance of an ossicular replacement prosthesis (ORP) is influenced by its alignment and appropriate tension between the tympanic membrane and the stapes footplate. A novel ORP with a flexible element that potentially allows for length adjustment in situ is presented and tested for acoustic performance.

STUDY DESIGN

Laser Doppler vibrometry in fresh human cadaveric temporal bones was used to test the acoustic performance of the adjustable ORP relative to standard prostheses used for ossiculoplasty.

METHODS

The three-dimensional (3D) velocity of the stapes posterior crus was measured in the 0.2- to 20-kHz range using a Polytec CLV-3D laser Doppler vibrometer. The middle ear cavity was accessed through a facial recess approach. After measuring the normal response, the incus was removed and stapes velocity was measured in the disarticulated case, then after insertion of the new prosthesis, a conventional prosthesis (Kurz BELL Dusseldorf type), and a sculpted autologous incus prosthesis in each temporal bone. The 3D stapes velocity transfer function (SVTF) was calculated for each case and compared.

RESULTS

The novel ORP design restored stapes velocity to within 6 dB (on average) of the intact response. No significant differences in 3D-SVTF were found between the new, conventional, or autologous ORPs.

CONCLUSIONS

The inclusion of an in situ adjustable element into the ORP design did not adversely affect its acoustic performance. The adjustable element may increase the ease of achieving optimal ORP placement, especially through a facial recess approach.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:2559-2564, 2016.

Clinical Practice Guideline

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tinnitus. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 13 recommendations developed address the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the impact of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Clinical Practice Guideline

Objective

Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient’s quality of life. The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome.

Purpose

The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Action Statements

The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.

Temporal Bone Radiology: Beyond the Basics

Program Description:

Through this interactive presentation, the audience is exposed to challenging temporal bone radiology cases and offered strategies to improve their interpretation. We will cover key findings for chronic ear disease and conductive hearing loss, lateral skull base lesions, and the petrous apex. The emphasis is placed on subtle but pertinent findings on computed tomography and magnetic resonance imaging examinations and their importance in creating and narrowing a differential diagnoses. We will present guidelines to aid in the efficient acquisition and interpretation of imaging for patients with common otologic symptoms such as vertigo, sudden hearing loss, and pulsatile tinnitus.

Educational Objectives:

(1) Interpret key radiographic findings for common pathologic conditions of the temporal bone. (2) Order appropriate radiographic tests to evaluate common conditions and understand the strengths and limitations of various imaging modalities.

Managing the Unexpected in Otologic Surgery

Program Description:

Sponsored by the American Neurotology Society, this interactive presentation aims to provide general practitioners tips and techniques employed by experts in management of intraoperative complications encountered during common otology cases such as tympanoplasty, tympanomastoidectomy, and stapedotomy. The panelists will present illustrative cases and discuss best practice approaches to intraoperative cerebrospinal fluid (CSF) leak and encephaloceles, facial nerve injury, vascular complications, stapedotomy challenges, ossicular chain and external auditory canal damage, and inner ear violation.

Educational Objectives:

(1) Recognize unexpected circumstances and anatomic variations that could lead to complications in otologic surgery. (2) Manage intraoperative complications such as facial nerve palsy, vascular injury, encephaloceles, CSF leaks, postoperative sensorineural hearing loss, and vertigo.

Temporal Bone Radiology: Beyond the Basics

Program Description:

Through this interactive presentation, the audience is exposed to challenging temporal bone radiology cases and offered strategies to improve his or her interpretation. We will cover key findings for chronic ear disease and conductive hearing loss, lateral skull base lesions, and the petrous apex. The emphasis is placed on subtle but pertinent findings on computed tomography (CT) and MRI examinations and their importance in creating and narrowing a differential diagnosis. We will present guidelines to aid in the efficient acquisition and interpretation of imaging for patients with common otologic symptoms such as vertigo, sudden hearing loss, and pulsatile tinnitus.

Educational Objectives:

1) Interpret key radiographic findings for common pathologic conditions of the temporal bone. 2) Order appropriate radiographic tests to evaluate common conditions and understand the strengths and limitations of various imaging modalities.

Spontaneous Cerebrospinal Fluid Leak through the Posterior Aspect of the Petrous Bone

Spontaneous cerebrospinal fluid (CSF) leak through the posterior fossa (PF) aspect of the petrous bone is exceedingly rare. A case series allows analysis of etiologies and how they may differ from the more common middle fossa (MF) route of leakage. The design was a retrospective case series. The setting was a tertiary care institution. A series of three patients with PF spontaneous CSF leaks was identified. High-resolution imaging (CT and MRI) and intraoperative observations were evaluated. Both in this series and in previously reported cases, patients share the demographics typically found in the MF leak population. In our series, two patterns of PF CSF leak were identified: (1) large unilateral with cerebellar encephalocele and (2) small punctate defects just lateral to the endolymphatic sac. Two presented with simultaneous MF and PF leaks suggesting a shared etiology, at least in some cases, with a role for increased intracranial pressure. In spontaneous CSF leaks, it is important to evaluate the posterior petrous bone along with the tegmen. The concomitant appearance of MF with PF leaks points out the risk that repair via MF craniotomy could fail to identify a leakage site in the vicinity of the endolymphatic sac.

Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

OBJECT

The object of this study was to evaluate facial nerve outcomes in the surgical treatment of large vestibular schwannomas (VSs; ≥ 2.5 cm maximal or extrameatal cerebellopontine angle diameter) based on both the operative approach and extent of tumor resection.

METHODS

A PubMed search was conducted of English language studies on the treatment of large VSs published from 1985 to 2011. Studies were then evaluated and included if they contained data regarding the size of the tumor, surgical approach, extent of resection, and postoperative facial nerve function.

RESULTS

Of the 536 studies initially screened, 59 full-text articles were assessed for eligibility, and 30 studies were included for analysis. A total of 1688 tumor resections were reported. Surgical approach was reported in 1390 patients and was significantly associated with facial nerve outcome (ϕ= 0.29, p < 0.0001). Good facial nerve outcomes (House-Brackmann Grade I or II) were produced in 62.5% of the 555 translabyrinthine approaches, 65.2% of the 601 retrosigmoid approaches, and 27.4% of the 234 extended translabyrinthine approaches. Facial nerve outcomes from translabyrinthine and retrosigmoid approaches were not significantly different from each other, but both showed significantly more good facial nerve outcomes, compared with the extended translabyrinthine approach (OR for translabyrinthine vs extended translabyrinthine = 4.43, 95% CI 3.17-6.19, p < 0.0001; OR for retrosigmoid vs extended translabyrinthine = 4.98, 95% CI 3.57-6.95, p < 0.0001). There were 471 patients for whom extent of resection was reported. There was a strong and significant association between degree of resection and outcome (ϕ= 0.38, p < 0.0001). Of the 80 patients receiving subtotal resections, 92.5% had good facial nerve outcomes, compared with 74.6% (n = 55) and 47.3% (n = 336) of those who received near-total resections and gross-total resections, respectively. In the 2-way comparison of good versus suboptimal/poor outcomes (House-Brackmann Grade III-VI), subtotal resection was significantly better than near-total resection (OR = 4.21, 95% CI 1.50-11.79; p = 0.004), and near-total resection was significantly better than gross-total resection (OR = 3.26, 95% CI 1.71-6.20; p = 0.0002) in producing better facial nerve outcomes.

CONCLUSIONS

In a pooled patient population from studies evaluating the treatment of large VSs, subtotal and near-total resections were shown to produce better facial nerve outcomes when compared with gross-total resections. The translabyrinthine and retrosigmoid surgical approaches are likely to result in similar rates of good facial nerve outcomes. Both of these approaches show better facial nerve outcomes when compared with the extended translabyrinthine approach, which is typically reserved for especially large tumors. The reported literature on treatment of large VSs is extremely heterogeneous and minimal consistency in reporting outcomes was observed.

Clinical Consensus Statement

Objective

To develop a consensus statement on the appropriate use of computed tomography (CT) for paranasal sinus disease.

Subjects and Methods

A modified Delphi method was used to refine expert opinion and reach consensus by the panel.

Results

After 3 full Delphi rounds, 33 items reached consensus and 16 statements were dropped because of not reaching consensus or redundancy. The statements that reached consensus were grouped into 4 categories: pediatric sinusitis, medical management, surgical planning, and complication of sinusitis or sinonasal tumor. The panel unanimously agreed with 13 of the 33 statements. In addition, at least 75% of the panel strongly agreed with 14 of 33 statements across all of the categories.

Conclusions

For children, careful consideration should be taken when performing CT imaging but is needed in the setting of treatment failures and complications, either of the pathological process itself or as a result of iatrogenic (surgical) complications. For adults, imaging is necessary in surgical planning, for treatment of medical and surgical complications, and in all aspects of the complete management of patients with sinonasal and skull base pathology.

Spontaneous Cerebrospinal Fluid Leak through the Posterior Aspect of the Petrous Bone

Objective: Spontaneous cerebrospinal fluid (CSF) leak through the posterior fossa aspect of the petrous bone (PF) is very rare. A case series allows analysis of possible etiologies and how they may differ from the more common middle fossa (MF) route of leakage.

Method: A series of 3 patients with PF spontaneous temporal bone CSF leaks is described. High-resolution imaging (CT & MRI) and intraoperative observation characterize the anatomical characteristics of the pathway.

Results: This series of patients did share the demographics typically found in the MF leak population. Two patterns of PF CSF leak were identified: large unilateral with cerebellar encephalocele and bilateral small defects just lateral to the endolymphatic sac. Two out of our 3 patients presented with simultaneous MF and PF leaks suggesting the possibility of a shared etiology, at least in some cases, with a role for increased intracranial pressure.

Conclusion: In spontaneous CSF leaks it is important to evaluate the posterior petrous bone along with the tegmen. The concomitant appearance of MF with PF leaks points out the risk that repair via MF craniotomy could fail to identify a leakage site in the vicinity of the endolymphatic sac.

Functional hair cell mechanotransducer channels are required for aminoglycoside ototoxicity

Aminoglycosides (AG) are commonly prescribed antibiotics with potent bactericidal activities. One main side effect is permanent sensorineural hearing loss, induced by selective inner ear sensory hair cell death. Much work has focused on AG's initiating cell death processes, however, fewer studies exist defining mechanisms of AG uptake by hair cells. The current study investigated two proposed mechanisms of AG transport in mammalian hair cells: mechanotransducer (MET) channels and endocytosis. To study these two mechanisms, rat cochlear explants were cultured as whole organs in gentamicin-containing media. Two-photon imaging of Texas Red conjugated gentamicin (GTTR) uptake into live hair cells was rapid and selective. Hypocalcemia, which increases the open probability of MET channels, increased AG entry into hair cells. Three blockers of MET channels (curare, quinine, and amiloride) significantly reduced GTTR uptake, whereas the endocytosis inhibitor concanavalin A did not. Dynosore quenched the fluorescence of GTTR and could not be tested. Pharmacologic blockade of MET channels with curare or quinine, but not concanavalin A or dynosore, prevented hair cell loss when challenged with gentamicin for up to 96 hours. Taken together, data indicate that the patency of MET channels mediated AG entry into hair cells and its toxicity. Results suggest that limiting permeation of AGs through MET channel or preventing their entry into endolymph are potential therapeutic targets for preventing hair cell death and hearing loss.

Distal parotid duct pseudocyst as a result of blunt facial trauma

The sequelae of sharp trauma to the parotid duct, such as sialocele and salivary fistula, are well known. In contrast, complications of blunt trauma to the parotid duct are not as common. A search of the English-language literature revealed 2 cases of parotid pseudocysts caused by blunt trauma. Although no well-known management protocol exists for complications of blunt trauma to the parotid duct, the treatment modalities for sharp trauma complications potentially could be applied. We describe a case of a blunt-trauma-induced distal parotid duct pseudocyst that remained refractory to conservative management, including repeated aspiration and cannulation of the duct. After characterizing and localizing the pseudocyst with sialography and cross-sectional imaging, we performed a surgical repair. This repair involved marsupialization of the parotid duct to the level of the pseudocyst. The edges of the opening of the proximal duct and the pseudocyst were sutured to the oral mucosa, and a small intraoral drain was left in the pseudocyst to prevent collapse and abscess formation. The drain was removed after 5 days, and the patient experienced no further problems during 14 months of follow-up.

Bivalve cartilage inlay myringoplasty: an office-based procedure for closing small to medium-sized tympanic membrane perforations

OBJECTIVE

To determine whether bivalve inlay cartilage-perichondrium myringoplasty (BCM) is successful in closing tympanic membrane perforations in an office setting.

STUDY DESIGN

Retrospective case review.

SUBJECTS AND METHODS

Adult patients with chronic perforations underwent BCM under local and topical anesthesia. Success was defined as complete closure of perforation at follow-up of at least 1 month. Predictors of success were identified by comparing the success and failure groups on pre- and postoperative pure tone average (PTA), patient demographics (age, gender), and characteristics of the perforations (size, location, duration, etiology).

RESULTS

A total of 145 procedures were performed and the patients were followed for 1 to 78 months. The success rate for perforations smaller than 4 mm was 75 percent. Size of the perforation, and pre- and postoperative PTAs were significantly different between the two groups. The only significant predictors of success were preoperative PTA and size of perforation.

CONCLUSIONS

BCM is a viable option for closure of small and medium-sized perforations in an office setting.

In vivo imaging of mammalian cochlear blood flow using fluorescence microendoscopy

AIMS

We sought to develop techniques for visualizing cochlear blood flow in live mammalian subjects using fluorescence microendoscopy.

BACKGROUND

Inner ear microcirculation appears to be intimately involved in cochlear function. Blood velocity measurements suggest that intense sounds can alter cochlear blood flow. Disruption of cochlear blood flow may be a significant cause of hearing impairment, including sudden sensorineural hearing loss. However, inability to image cochlear blood flow in a nondestructive manner has limited investigation of the role of inner ear microcirculation in hearing function. Present techniques for imaging cochlear microcirculation using intravital light microscopy involve extensive perturbations to cochlear structure, precluding application in human patients. The few previous endoscopy studies of the cochlea have suffered from optical resolution insufficient for visualizing cochlear microvasculature. Fluorescence microendoscopy is an emerging minimally invasive imaging modality that provides micron-scale resolution in tissues inaccessible to light microscopy. In this article, we describe the use of fluorescence microendoscopy in live guinea pigs to image capillary blood flow and movements of individual red blood cells within the basal turn of the cochlea.

METHODS

We anesthetized eight adult guinea pigs and accessed the inner ear through the mastoid bulla. After intravenous injection of fluorescein dye, we made a limited cochleostomy and introduced a compound doublet gradient refractive index endoscope probe 1 mm in diameter into the inner ear. We then imaged cochlear blood flow within individual vessels in an epifluorescence configuration using one-photon fluorescence microendoscopy.

RESULTS

We observed single red blood cells passing through individual capillaries in several cochlear structures, including the round window membrane, spiral ligament, osseous spiral lamina, and basilar membrane. Blood flow velocities within inner ear capillaries varied widely, with observed speeds reaching up to approximately 500 microm/s.

CONCLUSION

Fluorescence microendoscopy permits visualization of cochlear microcirculation with micron-scale optical resolution and determination of blood flow velocities through analysis of video sequences.

Death following tonsillectomy in a child with Williams syndrome

Williams syndrome (WS) is an uncommon genetic syndrome due to a deletion of several genes on chromosome 7. The syndrome is associated with dysmorphic facies, neurological manifestations, idiopathic hypercalcemia, and cardiac abnormalities, particularly supravalvular aortic stenosis (SVAS). Children with Williams syndrome may have chronic serous otitis media and/or obstructive sleep apnea. Hyperacusis is also commonly seen in these children. We report a case of sudden death at the time of tonsillectomy/adenoidectomy and bilateral tympanostomy tube placement in a child with Williams syndrome. All children with Williams syndrome should have a thorough cardiac evaluation before undergoing general anesthesia for any otolaryngologic procedure.

Endoscopic selective neck dissection in a porcine model

OBJECTIVE

To investigate the feasibility of accomplishing a selective neck dissection (SND) endoscopically.

STUDY DESIGN

Prospective, nonrandomized experimental investigation in a porcine model.

METHODS

Unilateral endoscopic SNDs were performed in Yorkshire pigs. A spacious operative pocket was developed using a combination of hernia balloon expansion followed by low-pressure (4 mm Hg) carbon dioxide insufflation. The sternomastoid muscle, thymus, submandibular gland, lymph nodes, and fibrofatty tissue were removed in a procedure approximating a human SND. Data (operative time, blood loss, arterial blood gas values, weight of the specimen, and complications) were prospectively recorded. The specimens were analyzed by a pathologist, and the number and size of lymph nodes were recorded.

RESULTS

Fourteen endoscopic SNDs were successfully performed. No conversions to open surgery were necessary. The median operative time was 131 minutes (range, 95-235 minutes). The median estimated blood loss was 4 mL (range, 0-150 mL). The mean +/- SD specimen weight was 42.9 +/- 8.3 g; the mean number +/- SD of nodes retrieved from the neck specimen was 4.8 +/- 2.2, and the mean +/- SD maximal nodal dimension was 2.4 +/- 0.5 cm. The arterial PCO2 increased by an average of only 3.9 mm Hg from the beginning to the end of the surgery; correspondingly, the pH fell by only 0.02. There were no major complications, and no animals had to be euthanized prior to the completion of the procedure.

CONCLUSIONS

Endoscopic neck dissection in a porcine model can be accomplished with a combination of strategies to overcome the dilemma of creating and maintaining an operative pocket. The merger of SND with endoscopic technology offers the promise of truly minimally invasive surgery for the node-negative neck.