Comparison of electrically evoked stapedial reflexes in patients with cochlear implants surgically implanted using Veria and posterior tympanotomy approaches

OBJECTIVE

The study aimed to compare ipsilateral and contralateral electrically evoked stapedial reflex thresholds in children with a unilateral cochlear implant surgically implanted either through Veria or posterior tympanotomy approaches.

METHODS

Forty-nine children using cochlear implants were studied, of whom 27 underwent the Veria approach and 22 underwent the posterior tympanotomy approach. The electrically evoked stapedius reflex thresholds were measured ipsilaterally and contralaterally by stimulating four equally spaced electrodes.

RESULTS

The ipsilateral electrically evoked stapedius reflex threshold was absent in all four electrodes in the children implanted using the Veria approach. However, the ipsilateral electrically evoked stapedius reflex threshold was present in 70 per cent of the children implanted using the posterior tympanotomy approach. The contralateral electrically evoked stapedius reflex threshold was present in most of the children for both surgical approaches.

CONCLUSION

The presence of the ipsilateral electrically evoked stapedius reflex threshold varies depending on the surgical technique used for cochlear implantation. However, contralateral reflexes are present in the majority of children using cochlear implants, irrespective of the surgical approach.

Balancing Act: A Comprehensive Review of Vestibular Evaluation in Cochlear Implants

Cochlear implantation, a transformative intervention for individuals with profound hearing loss, has evolved significantly over the years. However, its impact on the vestibular system, responsible for balance and spatial orientation, remains a subject of ongoing research and clinical consideration. This narrative review highlights key aspects of vestibular evaluation in patients undergoing cochlear implantation. Preoperative vestibular assessment is crucial to establish baseline vestibular function and identify any pre-existing balance issues. Various tests, including caloric, rotational chair, vestibular-evoked myogenic potential, and video head impulse tests, play a vital role in evaluating vestibular function. The goal is to assess the risk of vestibular disturbances arising from the surgery, guide surgical planning, and detect pre-existing alterations that could be totally or partially compensated. While some patients experience minimal vestibular disruptions, others may encounter transient or persistent balance issues following cochlear implant surgery. Postoperative vestibular testing allows for the early detection of such disturbances, enabling timely interventions like vestibular rehabilitation and evaluating changes produced due to surgical complications or changes in the patient's prior conditions. Challenges in vestibular evaluation include individual variability in patient responses, the proximity of the cochlea to the vestibular system, and the need to tailor testing protocols to individual needs. Further research is essential to refine testing protocols, minimize vestibular disturbances, and improve outcomes for cochlear implant candidates. A multidisciplinary approach involving otolaryngologists, audiologists, and physical therapists is integral to comprehensive patient care in this context. In conclusion, vestibular evaluation in patients undergoing cochlear implantation is critical for optimizing surgical planning, managing postoperative issues, and enhancing the overall quality of life for individuals embarking on the journey of restored hearing.

Assessment and management of vestibular migraine within ENT

OBJECTIVE

Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic.

METHOD

Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine.

RESULTS

A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging.

CONCLUSION

This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.

A Clinical Infrared Video-Oculoscopy Suppression Head Impulse (IR-cSHIMP) Test

BACKGROUND

We propose a Suppression Head IMPulse (SHIMP) test method that provides for equipment only through the use of InfraRed Video-OculoScopy (IR-VOS) and allows horizontal and vertical semicircular canal function evaluation in bedside mode. We therefore named the test InfraRed clinical SHIMP (IR-cSHIMP).

METHODS

To check IR-cSHIMP diagnostic efficiency, we studied 22 normal subjects, 18 patients with unilateral, and 6 with bilateral deficient vestibulopathy. Each subject first underwent a vestibular examination and, only later, an IRc-SHIMP test.

RESULTS

When the IR-cSHIMP test was performed in the horizontal plane, all normal subjects showed anti-compensatory saccades. When the vertical semicircular canal function was evaluated, the same result was obtained in all normal subjects except three, which were considered false positives. In patients with vestibular deficits, the test performed in the horizontal and vertical planes were always pathological, with 100% agreement between clinical and instrumental tests.

CONCLUSIONS

Our bedside method proved to be fast, simple, and effective in discriminating between healthy and pathological subjects. It required only the same skill as the better-known cHIT. For these reasons, we believe that the IR-cSHIMP should be part of daily clinical practice as a useful tool in the selection of patients to undergo more sophisticated investigations.

A proposed classification system for presigmoid approaches: a scoping review

OBJECTIVE

The "presigmoid corridor" covers a spectrum of approaches using the petrous temporal bone either as a target in treating intracanalicular lesions or as a route to access the internal auditory canal (IAC), jugular foramen, or brainstem. Complex presigmoid approaches have been continuously developed and refined over the years, leading to great heterogeneity in their definitions and descriptions. Owing to the common use of the presigmoid corridor in lateral skull base surgery, a simple anatomy-based and self-explanatory classification is needed to delineate the operative perspective of the different variants of the presigmoid route. Herein, the authors conducted a scoping review of the literature with the aim of proposing a classification system for presigmoid approaches.

METHODS

The PubMed, EMBASE, Scopus, and Web of Science databases were searched from inception to December 9, 2022, following the PRISMA Extension for Scoping Reviews guidelines to include clinical studies reporting the use of "stand-alone" presigmoid approaches. Findings were summarized based on the anatomical corridor, trajectory, and target lesions to classify the different variants of the presigmoid approach.

RESULTS

Ninety-nine clinical studies were included for analysis, and the most common target lesions were vestibular schwannomas (60/99, 60.6%) and petroclival meningiomas (12/99, 12.1%). All approaches had a common entry pathway (i.e., mastoidectomy) but were differentiated into two main categories based on their relationship to the labyrinth: translabyrinthine or anterior corridor (80/99, 80.8%) and retrolabyrinthine or posterior corridor (20/99, 20.2%). The anterior corridor comprised 5 variations based on the extent of bone resection: 1) partial translabyrinthine (5/99, 5.1%), 2) transcrusal (2/99, 2.0%), 3) translabyrinthine proper (61/99, 61.6%), 4) transotic (5/99, 5.1%), and 5) transcochlear (17/99, 17.2%). The posterior corridor consisted of 4 variations based on the target area and trajectory in relation to the IAC: 6) retrolabyrinthine inframeatal (6/99, 6.1%), 7) retrolabyrinthine transmeatal (19/99, 19.2%), 8) retrolabyrinthine suprameatal (1/99, 1.0%), and 9) retrolabyrinthine trans-Trautman's triangle (2/99, 2.0%).

CONCLUSIONS

Presigmoid approaches are becoming increasingly complex with the expansion of minimally invasive techniques. Descriptions of these approaches using the existing nomenclature can be imprecise or confusing. Therefore, the authors propose a comprehensive classification based on the operative anatomy that unequivocally describes presigmoid approaches simply, precisely, and efficiently.

Clinically relevant increases in serum neurofilament light chain and glial fibrillary acidic protein in patients with Susac syndrome

BACKGROUND AND PURPOSE

Serum levels of neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) are promising neuro-axonal damage and astrocytic activation biomarkers. Susac syndrome (SS) is an increasingly recognized neurological condition and biomarkers that can help assess and monitor disease evolution are highly needed for the adequate management of these patients. sNfL and sGFAP levels were evaluated in patients with SS and their clinical relevance in the relapse and remission phase of the disease was assessed.

METHODS

As part of a multicentre study that enrolled patients diagnosed with SS from six international centres, sNfL and sGFAP levels were assessed in 22 SS patients (nine during a relapse and 13 in remission) and 59 age- and sex-matched healthy controls using SimoaTM assay Neurology 2-Plex B Kit.

RESULTS

Serum NfL levels were higher than those of healthy controls (p < 0.001) in SS patients and in both subgroups of patients in relapse and in remission (p < 0.001 for both), with significantly higher levels in relapse than in remission (p = 0.008). sNfL levels showed a negative correlation with time from the last relapse (r = -0.663; p = 0.001). sGFAP levels were slightly higher in the whole group of patients than in healthy controls (p = 0.046) and were more pronounced in relapse than in remission (p = 0.013).

CONCLUSION

In SS patients, both sNFL and sGFAP levels increased compared with healthy controls. Both biomarkers had higher levels during clinical relapse and much lower levels in remission. sNFL was shown to be time sensitive to clinical changes and can be useful to monitor neuro-axonal damage in SS.

Customised acoustic therapy delivered through a web-based platform-An innovative approach to tinnitus treatment

OBJECTIVES

Customised acoustic therapy aims to moderate the neural pathways implicated in the pathophysiology of tinnitus. This study aimed to assess the efficacy of customised acoustic therapy administered via a web-based treatment platform.

DESIGN

Clinical trial with prospective recruitment. Fifty-eight participants underwent 6 weeks of customised acoustic therapy.

SETTING

Treatment was delivered for 2 h each day using a smartphone, tablet or computer. Treatment was integrated into usual daily activities.

PARTICIPANTS

Participants with subjective tinnitus were recruited through public and private otolaryngology clinics and electronic and print media.

MAIN OUTCOMES MEASURED

FiveQ, a novel 5 question tinnitus questionnaire, was measured at baseline and each week of treatment. Statistical analyses, including Wilcoxon, Mann-Whitney and mixed linear regression, were used to assess treatment efficacy and identify factors associated with treatment response.

RESULTS

39/58 participants (67.2%) had an improvement in symptom severity scores, 4 had no change (6.9%) and 15 had a decline from baseline (25.9%). Mean FiveQ scores improved by 22.9% from 40.8 (SD = 21.4) at baseline to 31.5 (SD = 21.3) following 6 weeks of treatment (p < 0.001). With the exception of the slight tinnitus group, all other groups (from mild to catastrophic) demonstrated a treatment response. Participants with low frequency tinnitus (<2000 Hz) had a significantly greater treatment response (p < 0.001).

CONCLUSION

Customised acoustic therapy administered via a web-based platform demonstrated encouraging efficacy. At least mild symptoms at baseline and low frequency tinnitus were associated with a greater treatment response. Customised acoustic therapy offers accessible and efficacious tinnitus treatment, however longer term clinical studies are required to confirm the observed initial benefit is maintained.

Cholesteatoma Masquerading as Recurrent Langerhans Cell Histiocytosis

Langerhans cell histiocytosis is a rare condition affecting the temporal bone in up to 60% of cases. Symptoms are non-specific and the differential diagnosis includes infection, benign lesions such as cholesteatoma, and malignant lesions of the skull base. Here, we report the case of a 14-yearold child referred with chronic ear discharge, and background of multifocal Langerhans cell histiocytosis 9 years prior. Recurrence of Langerhans cell histiocytosis was initially suspected and systemic treatment was considered. Further imaging workup and surgical exploration of the mastoid showed a secondary acquired cholesteatoma arising from a dehiscent posterior ear canal wall. Surgical removal of the cholesteatoma was performed with a canal wall down procedure. We review the presentation and management of temporal bone Langerhans cell histiocytosis. We recommend that cholesteatoma should be considered in case of recurrence of otological symptoms in patients with a background of Langerhans cell histiocytosis.

A Tried and Tested Waterproof Draping Method for Major Ear Surgery

Preparing and maintaining a clean operative field is the standard of care in all surgical fields globally. Major ear surgery has its own challenges such as the long surgical procedure time and the tricky local anatomical landscape. A waterproof method of draping for major ear surgery is described in this technical report. This method allows for the collection of irrigation fluid in a reservoir while maintaining continued isolation of the operative field during surgery. We discuss the advantages of using a 3M Steri-Drape^TM Aperture Pouch Drape to square the surgical site and create a pouch dedicated to irrigation fluid. Following that, running locking stitches are performed for further reinforcement of the adhesion to the skin, often done in longer procedures. We have identified a technique to ensure better draping. In over 150 cases draped in this method, we have not witnessed drape edge lift, water ingress, or skin avulsion/injury.

Let Us Not Forget About Bleeding: A Case Report and Brief Literature Review on Hemorrhagic Vestibular Schwannoma

Hemorrhagic vestibular schwannoma (HVS) consisting of acute intratumoral and subarachnoid hemorrhage is a rare phenomenon. We present the case of a 31-year-old woman who attended the Otorhinolaryngology department with right-sided intense tinnitus, dizziness, imbalance, and headache. Brain computed tomography revealed a spontaneous hyperdensity in the posterior fossa with marked deformation of the brainstem, middle cerebral peduncle, and cerebellum, with the near collapse of the fourth ventricle. Ophthalmology evaluation confirmed bilateral papilledema. Brain magnetic resonance imaging confirmed a voluminous 33 x 28 x 29 mm extra-axial lesion centered on the right pontine-cerebellar angle cistern, extending from the plane of the trigeminal nerve/tent of the cerebellum. The acoustic pore was enlarged. The patient underwent retrosigmoid craniotomy and microscopic tumor resection showing significant improvement in the follow-up. Pathological findings confirmed HVS. Delayed treatment of HVS can increase morbidity or even be fatal. The objective of this work is to describe and revise HVS, in order to bring awareness to this uncommon entity.

FiveQ: A new easy-to-use validated clinical instrument for tinnitus severity

OBJECTIVES

Tinnitus is a complex and debilitating phenomenon with potentially significant implications on quality of life. New presentations can be resource and time intensive for clinicians. Validated comprehensive tinnitus questionnaires may lack practical utility in the high-volume clinical setting. Concise, targeted questionnaires may offer an efficient alternative. This study aimed to assess the validity of the FiveQ, a novel five question construct designed to measure tinnitus severity. Convergent validity was assessed through correlating FiveQ against two comprehensive validated questionnaires, the Tinnitus Handicap Questionnaire (THQ) and Tinnitus Handicap Inventory (THI).

DESIGN

Cross-sectional study with prospective recruitment. The 117 voluntarily recruited participants completed the FiveQ, THI and THQ questionnaires. Results were comparatively analysed.

SETTING

Recruitment was via electronic and print media, audiology clinics and public and private otolaryngology outpatient clinics. Surveys were completed electronically.

PARTICIPANTS

Members of the public aged over 18 with subjective tinnitus were invited to participate.

MAIN OUTCOME MEASURED

Analyses for establishing the content validity, construct validity, internal consistency, explorary factor analysis, and responsiveness of FiveQ was performed.

RESULTS

FiveQ demonstrated a high positive correlation with both the THI (r = 0.773, p < .001) and THQ (r = 0.808, p < .001). Internal consistency for FiveQ reached an acceptable threshold (Cronbach's alpha 0.86). Exploratory factor analysis demonstrated that one latent factor underlies the five items of the FiveQ. FiveQ demonstrated better responsiveness than both the THI and THQ after a 6 week interval repeat measurement.

CONCLUSION

FiveQ demonstrated high-positive correlations with existing validated tinnitus questionnaires as well as acceptable internal consistency and factor analysis. The concise construct of FiveQ allows clinicians to efficiently estimate tinnitus severity, target treatment towards dominant symptoms and establish a reliable estimation of treatment response following interventions.

Vestibular-Evoked Cerebral Potentials

The human vestibular cortex has mostly been approached using functional magnetic resonance imaging and positron emission tomography combined with artificial stimulation of the vestibular receptors or nerve. Few studies have used electroencephalography and benefited from its high temporal resolution to describe the spatiotemporal dynamics of vestibular information processing from the first milliseconds following vestibular stimulation. Evoked potentials (EPs) are largely used to describe neural processing of other sensory signals, but they remain poorly developed and standardized in vestibular neuroscience and neuro-otology. Yet, vestibular EPs of brainstem, cerebellar, and cortical origin have been reported as early as the 1960s. This review article summarizes and compares results from studies that have used a large range of vestibular stimulation, including natural vestibular stimulation on rotating chairs and motion platforms, as well as artificial vestibular stimulation (e.g., sounds, impulsive acceleration stimulation, galvanic stimulation). These studies identified vestibular EPs with short latency (<20 ms), middle latency (from 20 to 50 ms), and late latency (>50 ms). Analysis of the generators (source analysis) of these responses offers new insights into the neuroimaging of the vestibular system. Generators were consistently found in the parieto-insular and temporo-parietal junction-the core of the vestibular cortex-as well as in the prefrontal and frontal areas, superior parietal, and temporal areas. We discuss the relevance of vestibular EPs for basic research and clinical neuroscience and highlight their limitations.

Primary presentation of sarcoidosis with profound bilateral sensorineural hearing loss

We present a case of a 7-year-old Afro-Caribbean girl presenting with rapidly progressive bilateral sensorineural hearing loss. She was found to have an elevated Angiotensin converting enzyme (ACE) and mediastinal lymphadenopathy containing non-caseating granulomas with multinucleate giant cells, in keeping with sarcoidosis. Cranial imaging demonstrated labyrinthitis. She underwent urgent bilateral cochlear implantation with rehabilitation of hearing sufficient to restart education within 1 month.

Benefit of cochlear implantation in a patient with Myhre syndrome

Myhre syndrome is a rare disorder characterised by short stature, skeletal anomalies, facial dysmorphism and hearing loss (HL), resulting from heterozygous mutations of the SMAD4 gene. We describe the benefits of cochlear implant (CI) in a patient with sensorineural HL carrying a mutation (NM_005359.6: c.1498A>G; p.lle500Val) within the SMAD4 gene, detected by whole-exome sequencing. The CI was inserted through the round window despite otospongiotic abnormalities. Pure-tone audiometry improved up to 20 dBHL. Speech perception in noise (Simplified Noise Reduction - SNR +10) increased from 0% pre implantation with hearing aids to 50% post implantation. The postoperative setting of the electrical stimulation limits yielded an asymmetric map, with lower levels for central electrodes and higher levels for lateral ones. Action potential could not be evoked via medial electrodes, suggesting a cochlear nerve dysfunction. Outcomes related to quality of life and cognitive impairment improved. CI was shown to be an effective auditory rehabilitation strategy.

Surgical corridors for congenital aural atresia with otogenic cerebellar abscess and lateral sinus thrombosis

The following is a case report of an adolescent with mental retardation who had congenital aural atresia with contralateral congenital facial palsy. She developed multiple intracranial complications (cerebellar abscess and lateral sinus thrombosis) due to cholesteatoma. We managed her in a multidisciplinary approach. This report discusses case management, emphasising the meticulous intraoperative steps taken in identifying the landmarks and precautions adopted to avoid postoperative facial palsy and other complications.

Association between obstructive sleep apnea and persistent-postural perceptual dizziness

BACKGROUND

Obstructive sleep apnea (OSA) has been linked to vestibular dysfunction, but no prior studies have investigated the relationship between Persistent Postural Perceptual Dizziness (PPPD), a common cause of chronic dizziness, and OSA.

OBJECTIVE AND METHODS

We determined the frequency of OSA in an uncontrolled group of PPPD patients from a tertiary dizziness clinic based on polysomnogram (PSG). We then assessed the sensitivity and specificity of common OSA questionnaires in this population.

RESULTS

Twenty-five patients with PPPD underwent PSG (mean age 47, 60% female, mean BMI 29.5). A majority, or 56%, of patients were diagnosed with OSA, and in most, the OSA was severe. OSA patients were older (56 years versus 40 years, p = 0.0006) and had higher BMI (32 versus 26, p = 0.0078), but there was no clear gender bias (56% versus 64% female, p = 1.00). The mean sensitivity and specificity of the STOP BANG questionnaire for detecting OSA was 86% and 55%, respectively. Sensitivity and specificity of the Berlin Questionnaire was 79% and 45%, respectively.

CONCLUSIONS

The prevalence of OSA was much higher in our small PPPD group than in the general population. Screening questionnaires appear to demonstrate good sensitivity to detect PPPD patients at risk of OSA in this small study. Future studies should confirm these findings and determine whether treatment of OSA improves symptoms in PPPD.

Mal de débarquement syndrome – “sickness of disembarkment”

Mal de débarquement syndrome is an uncommon vestibular disorder characterized by a constant sensation of swaying or motion after one disembarks from a vehicle such as a ship or plane, however, spontaneous onset also appears. These symptoms temporarily subside when the patient is subjected again to passive motion like driving a car. Chronic fatigue, anxiety, and depression are frequently associated with primary symptoms. The diagnosis is challenging, and often made by the patients themselves. The underlying pathophysiology and definitive therapy are unknown. Exposure to optokinetic stimulations and transcranial magnetic stimulations open therapeutic perspectives. We report a case series of 5 patients who presented with constant rocking, bobbing sensation that had been ongoing for several months. We found normal inner-ear function, non-related abnormalities and normal brain imaging. By presenting our patients' histories, we discuss the different diagnostic issues that help to diagnose this condition. We aimed to report the most recent findings on aetiology and treatment methods and to share our experiences with different therapeutic attempts. Mal de débarquement syndrome is a diagnosis of exclusion and often unrecognized. A thorough clinical history, negative or non-specific clinical findings with a high degree of suspicion are needed for recognizing this disorder. Increasing awareness can lead to early diagnosis and prevent multiple physician visits and unnecessary diagnostic testing. Frequent diagnostic failure has a negative impact on the quality of life, associated with anxiety and depression. Orv Hetil. 2020; 161(20): 846-851.

Integrating mental and physical health assessment in a neuro-otology clinic: feasibility, acceptability, associations and prevalence of common mental health disorders

People with persistent physical symptoms are at risk of psychological symptoms, although recognition in medical settings is low. This is a retrospective observational study of 954 patients in a hospital outpatient neuro-otology clinic in order to assess the feasibility and acceptability of an electronic informatics system for collection of patient-reported outcomes, with real-time feedback to guide clinical care and describe the prevalence of anxiety and depressive symptoms.The proportion of patients successfully completing the screen was high (70%). The decline rate was low (5%). The most common reason to decline was lack of confidence with technology. The prevalence of probable depression was 21% and for probable anxiety was 29%. Suicidal ideation was present in 5%. Anxiety and depression were highly correlated to dizziness specific outcome measures (p<0.01).Electronic screening is feasible and acceptable to patients and staff in this setting, helping to identify service needs, inform care and monitor outcomes.

Herpes zoster oticus with meningitis masquerading as malignant otitis externa

This is a case of an 85-year-old woman whom was admitted with otalgia and an abducens nerve palsy alongside a Pseudomonas otitis externa; she was presumed to have malignant otitis externa. However, despite optimum treatment and resolution of her otitis externa, she went on to develop an ipsilateral facial nerve palsy and sensorineural hearing loss. After further investigation, it was discovered that varicella-zoster meningitis was causing her polyneuropathy. She eventually responded to antivirals and steroids and, at follow-up, her sixth and seventh cranial nerve palsies had completely resolved, though a hearing deficit remained. This case highlights the importance of keeping a diagnosis under review, with the help of the multidisciplinary team, when the clinical course is not progressing as expected.

Examination of Current Treatments and Symptom Management Strategies Used by Patients With Mal De Debarquement Syndrome

Introduction: Mal de Debarquement Syndrome (MdDS) is a neurological disorder which affects the vestibular system pathways, manifesting as a constant sensation of movement in the form of rocking, bobbing, or swaying. The mechanism of MdDS is poorly understood and there is a lack of awareness amongst medical professionals about the condition. This study aimed to examine treatments and symptom management strategies used by MdDS patients and evaluate their self-reported effectiveness.

Method: Motion-Triggered and Spontaneous/Other onset MdDS patients responded to a set of comprehensive questions as a retrospective survey regarding epidemiological details, diagnostic procedures, onset, and symptom triggers, hormonal influences as well as treatments and symptom management strategies used to reduce symptoms. The Motion-Triggered questionnaire was made available through Survey Monkey and the Spontaneous/Other Onset questionnaire through Qualtrics. The link for each questionnaire was made available on online MdDS support groups and on various research websites. Descriptive statistics were used for epidemiological data and Pearson's Chi Square tests were used for comparisons between and within both subtype groups.

Results: A total of 370 patients participated in the surveys, with 287 valid responses collected for the section regarding treatment and symptom management strategies. The success of the treatments and symptom management strategies did not vary between subtypes Benzodiazepines/Antidepressants were reported as being most beneficial in reducing symptoms in both groups.

Conclusion: This was the first attempt to evaluate the reported success of treatments and symptom management strategies in MdDS patients by assessing the patients' perceived helpfulness. The treatments and symptom management strategies reported to be the most helpful in managing and/or reducing symptoms are proposed to be effective due to their stress-reducing capacities. We hope this study will broaden MdDS awareness and that this study will increase patient knowledge regarding treatments and symptom management strategies that other patients found helpful.

Focused Neuro-Otological Review of Superficial Siderosis of the Central Nervous System

Background

Infratentorial siderosis (iSS) is a progressive degenerative disorder targeting primarily the cerebellum and cranial nerve eighth; therefore, progressive ataxia and its neuro-otological findings are common. Toxicity from hemosiderin involves selectively vulnerable neurons and glia in these posterior fossa structures. Other neurologic findings may be present, though our focus relates to the cochlea-vestibular cerebellar involvement. Radiographic evidence of siderosis may be the result of recurrent, albeit covert bleeding in the subarachnoid space, or the consequence of an overt post-traumatic or aneurysmal subarachnoid hemorrhage (SAH). The radiographic iSS appearance is identical regardless of the SAH cause. A recent study provides compelling evidence to search and correct possible hemorrhage sources in the spinal canal. The removal of residual existing hemosiderin deposits that may potentially cause clinical symptoms remains as a major therapeutic challenge.

Methods

We reviewed large data sources and identified salient papers that describe the pathogenesis, clinical and neurotologic manifestations, and the radiographic features of iSS.

Results

The epidemiology of iSS is unknown. In a recent series, clinically evident iSS was associated with recurrent SAH; by contrast, in a follow-up period ranging from weeks up to 11 years after a monophasic episode of SAH, radiographic siderosis was clinically silent. However, the post-aneurysmal or post-trauma SAH sample size in this single study was small and their observation period relatively short; moreover, the burden of intraneuronal hemosiderin is likely greater with recurrent SAH. There are a few reports of late iSS, several decades after traumatic SAH. A recent report found subjective hearing loss in aneurysmal SAH individuals with radiographic siderosis. Only in recent years, it is safe to perform magnetic resonance imaging (MRI) in post-aneurysmal SAH, because of the introduction of titanium, MRI-compatible aneurysm clips.

Conclusion

iSS can be associated with significant neurotologic and cerebellar morbidity; the recurrent SAH variant is frequently clinically symptomatic, has a shorter latency and greater neurotologic disability. In these cases, a thorough search and management of a covert source of bleeding may stop clinical progression. The frequency and clinical course of radiographic iSS after traumatic and post-aneurysmal SAH is largely unknown. Detection of radiographic iSS after trauma or aneurysm bleeding suggests that the slower clinical course could benefit from an effective intervention if it became available. The use of cochlear implants is a valid alternative with advanced hearing impairment.

Noise-induced hearing loss - An examination of the methods of assessment in a cross-sectional study of 87 industrial workers

OBJECTIVES

The surveillance of noise-induced hearing loss (NIHL) according to the Health and Safety Executive (HSE) differs from the medico-legal criteria used to assess NIHL. Our study compares the two systems and proposes a novel method of simplifying the medico-legal criteria and applying it to ascertain noise-induced hearing loss.

DESIGN

The anonymised audiograms of a group of 87 industrial workers from a single site were analysed with both methods.

RESULTS

The comparison showed approximately one-third of the workers assessed in this study had their noise-induced hearing loss underestimated by the HSE criteria. The majority of these individuals were over 40 years of age.

CONCLUSIONS

The HSE criteria for noise-induced hearing loss need review and re-alignment with the medico-legal criteria to address the discrepancy between the two systems.

Head-Eye Vestibular Motion Therapy Affects the Mental and Physical Health of Severe Chronic Postconcussion Patients

Context

Approximately 1.8–3.6 million annual traumatic brain injuries occur in the United States. An evidence-based treatment for concussions that is reliable and effective has not been available.

Objective

The objective of this study is to test whether head–eye vestibular motion (HEVM) therapy is associated with decreased symptoms and increased function in postconcussive syndrome (PCS) patients that have been severely impaired for greater than 6 months after a mild traumatic brain injury.

Design

Retrospective clinical chart review.

Setting and participants

Tertiary Specialist Brain Rehabilitation Center.

Interventions

All subjects underwent comprehensive neurological examinations including measurement of eye and head movement. The seven modules of the C3 Logix Comprehensive Concussion Management System were used for pre- and postmeasurements of outcome of HEVM therapy.

Materials and methods

We utilized an objective validated measurement of physical and mental health characteristics of our patients before and after a 1-week HEVM rehabilitation program. We included only PCS patients that were disabled from work or school for a period of time exceeding 6 months after suffering a sports concussion. These subjects all were enrolled in a 5-day HEVM rehabilitation program at our Institutional Brain Center with pre- and post-C3 Logix testing outcomes.

Results

There were statistical and substantive significant decreases in PCS symptom severity after treatment and statistical and substantive significant increases in standardized assessment of concussion scores. The outcomes were associated with positive changes in mental and physical health issues. This is a retrospective review and no control group has been included in this study. These are major limitations with retrospective reviews and further investigations with prospective designs including a randomized controlled study are necessary to further our understanding.

Conclusion

Head–eye vestibular motion therapy of 5 days duration is associated with statistical and substantive significant decreases of symptom severity associated with chronic PCS.

Randomized Controlled Study of a Remote Flipped Classroom Neuro-otology Curriculum

CONTEXT

Medical Education can be delivered in the traditional classroom or via novel technology including an online classroom.

OBJECTIVE

To test the hypothesis that learning in an online classroom would result in similar outcomes as learning in the traditional classroom when using a flipped classroom pedagogy.

DESIGN

Randomized controlled trial. A total of 274 subjects enrolled in a Neuro-otology training program for non-Neuro-otologists of 25 h held over a 3-day period. Subjects were randomized into a "control" group attending a traditional classroom and a "trial" group of equal numbers participating in an online synchronous Internet streaming classroom using the Adobe Connect e-learning platform.

INTERVENTIONS

Subjects were randomized into a "control" group attending a traditional classroom and a "treatment" group of equal numbers participating in an online synchronous Internet streaming classroom.

MAIN OUTCOME MEASURES

Pre- and post-multiple choice examinations of VOR, Movement, Head Turns, Head Tremor, Neurodegeneration, Inferior Olivary Complex, Collateral Projections, Eye Movement Training, Visual Saccades, Head Saccades, Visual Impairment, Walking Speed, Neuroprotection, Autophagy, Hyperkinetic Movement, Eye and Head Stability, Oscilllatory Head Movements, Gaze Stability, Leaky Neural Integrator, Cervical Dystonia, INC and Head Tilts, Visual Pursuits, Optokinetic Stimulation, and Vestibular Rehabilitation.

METHODS

All candidates took a pretest examination of the subject material. The 2-9 h and 1-8 h sessions over three consecutive days were given live in the classroom and synchronously in the online classroom using the Adobe Connect e-learning platform. Subjects randomized to the online classroom attended the lectures in a location of their choice and viewed the sessions live on the Internet. A posttest examination was given to all candidates after completion of the course. Two sample unpaired t tests with equal variances were calculated for all pretests and posttests for all groups including gender differences.

RESULTS

All 274 subjects demonstrated statistically significant learning by comparison of their pre- and posttest scores. There were no statistically significant differences in the test scores between the two groups of 137 subjects each (0.8%, 95% CI 85.45917-86.67952; P = 0.9195). A total of 101 males in the traditional classroom arm had statistically significant lower scores than 72 females (0.8%, 95% CI 84.65716-86.53096; P = 0.0377) but not in the online arm (0.8%, 95% CI 85.46172-87.23135; P = 0.2176) with a moderate effect size (Cohen's d = -0.407).

CONCLUSION

The use of a synchronous online classroom in neuro-otology clinical training has demonstrated similar outcomes to the traditional classroom. The online classroom is a low cost and effective complement to medical specialty training in Neuro-Otology. The significant difference in outcomes between males and females who attended the traditional classroom suggests that women may do better than males in this learning environment, although the effect size is moderate.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, identifier NCT03079349.

An Attempt of Early Detection of Poor Outcome after Whiplash

The main concern with whiplash is that a large proportion of whiplash patients experience disabling symptoms or whiplash-associated disorders (WAD) for months if not years following the accident. Therefore, identifying early prognostic factors of WAD development is important as WAD have widespread clinical and economic consequences. In order to tackle that question, our study was specifically aimed at combining several methods of investigation in the same WAD patients at the acute stage and 6 months later. Our longitudinal, open, prospective, multi-center study included 38 whiplash patients, and 13 healthy volunteers matched for age, gender, and socio-economic status with the whiplash group. Whiplash patients were evaluated 15-21 days after road accident, and 6 months later. At each appointment, patients underwent a neuropsychological evaluation, a full clinical neurological examination, neurophysiological and postural tests, oto-neurological tests, cervical spine cord magnetic resonance imaging (MRI) with tractography (DTI). At 6 months, whiplash patients were categorized into two subgroups based on the results of the Diagnostic and Statistical Manual of Mental Disorders as having either favorable or unfavorable progression [an unfavorable classification corresponding to the presence of post-concussion symptom (PCS)] and we searched retrospectively for early prognostic factors of WAD predicting the passage to chronicity. We found that patients displaying high level of catastrophizing at the acute stage and/or post-traumatic stress disorder associated with either abnormalities in head or trunk kinematics, abnormal test of the otolithic function and at the Equitest or a combination of these syndromes, turned to chronicity. This study suggests that low-grade whiplash patients should be submitted as early as possible after the trauma to neuropsychological and motor control tests in a specialized consultation. In addition, they should be evaluated by a neuro-otologist for a detailed examination of vestibular functions, which should include cervical vestibular evoked myogenic potential. Then, if diagnosed at risk of WAD, these patients should be subjected to an intensive preventive rehabilitation program, including vestibular rehabilitation if required.

Referral and final diagnoses of patients assessed in an academic vertigo center

Objective: To identify under-diagnosed neuro-otological disorders and to evaluate whether under-diagnosing depends on the age of the patient. Materials and methods: Retrospective analysis of medical charts from 951 consecutive patients (685 under and 266 above the age of 65 years) who entered diagnostic procedures at the Interdisciplinary Center for Vertigo and Balance Disorders, University Hospital Zurich, Switzerland. Final diagnoses were compared to referral diagnoses. Results: Relative to referral diagnoses, the proportion of patients finally diagnosed with benign paroxysmal positional vertigo (BPPV) almost doubled both in younger (<65 year from 12.7 to 25.1%) and older patients (from 20.7 to 37.6%). Striking relative increases were found for the diagnoses multisensory dizziness in older patients (from 20.7 to 37.6%) and vestibular migraine in younger patients (1.8 to 20.2%). In both age groups, the proportion of patients with undetermined diagnoses was reduced by about 60% (younger: 69.8 to 9.8%; older: 69.2 to 12.4%) by the diagnostic procedures in the vertigo center. These changes were all significant (p < 0.05) in McNemar tests with continuity correction (2 × 2 tables: focused diagnosis vs. other diagnoses, referral vs. final). Conclusion: Significant changes of diagnoses can be expected by a specialized neuro-otological work-up. In particular, BPPV, multisensory dizziness, and vestibular migraine are under-diagnosed by referring physicians. This finding calls for better education of primary care takers in the field of neuro-otology.