Surgical Coaching: Patient Perspectives Regarding Surgeon Coaches in the Operating Room

BACKGROUND

Surgical coaching programs have been introduced as platforms for ongoing professional development amongst independently practicing surgeons. While there is a plethora of evidence regarding the effectiveness of surgical coaching for practicing staff surgeons, patients' opinions regarding surgical coaching are largely unknown.

OBJECTIVES

To determine patients' baseline attitudes and opinions about the hypothetical situation of their treating surgeon having a surgical coach present during their upcoming operation, and to determine patients' baseline knowledge and prior exposure to surgical coaching.

DESIGN AND SETTING

This study was conducted at a tertiary hospital in Vancouver, Canada. Patients on the surgical waitlist of 2 independently practicing Otolaryngologists within the subspeciality of Neurotology were invited to participate in the study. Participants engaged in a semi-structured interview to discuss their opinions and knowledge of physician coaches and to learn about surgical coaching. The interview was conducted based on a pre-set script.

RESULTS

Of the 100 patients approached, 70 consented to participate. Forty-three (61%) participants identified as female, and the mean age was 56±15 years. Initially, 84% of participants (n = 59) consented to the hypothetical presence of a surgical coach. Post-discussion, this number increased to 95.7% (n = 67, p = 0.04). Prior participant exposure to coaching related to employment, education, athletics, or music was high (90%, n = 63). Younger participants between 25 and 45 years of age were more amenable to the presence of a surgical coach compared to participants >66 years of age (p = 0.01). After the interview, 55 (79%) participants were interested in learning more about surgical coaching.

CONCLUSION

Many patients were unaware of the rationale and importance of surgical coaching programs for practicing staff surgeons. Most patients, especially younger patients, were amenable to the presence of a surgical coach during their surgery, and this number increased in all age categories with patient education about surgical coaching.

The relationship between minority stress factors and suicidal ideation and behaviours amongst transgender and gender non-conforming adults: A systematic review

BACKGROUND

The impact of Minority Stress (MS) upon suicidal ideation and behaviours amongst Transgender and Gender Non-Conforming (TGNC) adults is not sufficiently understood, hence our intervention efforts on an individual and societal level are limited. This review aims to evaluate recent literature that reports on the association between MS and suicidal ideation and behaviours amongst TGNC adults.

METHODS

PsycINFO, Web of Science, MEDLINE, CINAHL and EMBASE were systematically searched for relevant articles. Peer reviewed and grey literature were considered. Included papers reported quantitative analyses on associations between MS factors and suicidal ideation and behaviours amongst TGNC adults. The quality of papers was assessed.

RESULTS

28 papers were identified as eligible. Findings suggested positive associations between external and internal minority stressors and suicidal ideation and behaviour. Dysfunctional individual coping was associated with a greater likelihood of suicide attempts. Community resilience was negatively associated with suicidal outcomes, but did not consistently buffer the effects of minority stress.

LIMITATIONS

Overall quality of included papers was 'poor'. Almost all papers were cross-sectional by design, therefore causality cannot be inferred. Many papers measured variables using non-standardised measures undermining the reliability and validity of reported results.

CONCLUSIONS

Findings offer support to the application of MS theory to the understanding of suicidal ideation and behaviour amongst TGNC. Future research should use standardised measures and longitudinal designs to better support the investigation of directionality and causality. More research is needed to understand the complex interactions between minority stress factors and the role of resilience in this population.

Risk of Stroke and Myocardial Infarction After Sudden Sensorineural Hearing Loss: A Meta-Analysis

OBJECTIVES/HYPOTHESIS

The pathophysiology of idiopathic sudden sensorineural hearing loss (ISSNHL) is still unknown, but labyrinthine artery infarction has been proposed. The objective of this study was to perform a systematic review and conduct a meta-analysis assessing the risk of developing stroke and myocardial infarction after presentation with ISSNHL.

METHODS

A systematic literature review was conducted using Pubmed, Embase, Web of Science, and Cochrane Libraries. All studies investigating an association between ISSNHL and stroke and/or myocardial infarction (MI) were included. Adhering to the MOOSE guideline, two independent reviewers extracted data, assessed risk of bias, and evaluated the relevance and quality of evidence.

RESULTS

Three observational studies evaluating the risk of stroke in ISSNHL were included (n = 6,521 patients). All individual study results indicated an increased relative risk of stroke after ISSNHL (unadjusted relative risk range 1.21-1.63). Pooled adjusted hazard ratios revealed a 1.42-fold increased risk of stroke after ISSNHL (hazard ratio [HR] 1.42; 95% confidence interval [CI] 1.15-1.75, I² = 55%). Subgroup analysis of one study demonstrated that the increased risk is only present in adults aged above 50 years (HR 1.23; 95% CI 1.07-1.42). Five observational studies evaluating the risk of MI in patients with ISSNHL were included (n = 61,499 patients). Pooled analyses demonstrated that ISSNHL was not associated with MI (HR 1.08, 95% CI 0.87-1.34).

CONCLUSION

ISSNHL may be an independent risk factor for the subsequent development of stroke especially in a subgroup of elderly patients. More studies are needed to confirm this association and to assess whether such patients would benefit from cardiovascular risk assessment and management to prevent future strokes. Laryngoscope, 131:1369-1377, 2021.

Guidance for otolaryngology health care workers performing aerosol generating medical procedures during the COVID-19 pandemic

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for Coronavirus disease 2019 (COVID-19) has a predilection for infecting the mucosa of the upper and lower airways. Otolaryngologists and supporting health care workers (HCWs) are particularly at high risk of becoming infected while treating patients as many in-office procedures and surgeries are Aerosol Generating Medical Procedures (AGMP). Based on a review of the literature and various guidelines, recommendations are made to mitigate the risk to health care workers of becoming infected with SARS-CoV-2 while providing clinical care.

Recommendations

During the COVID-19 pandemic all elective and non-time sensitive Otolaryngology procedures should be deferred to mitigate the risk of transmission of infection to HCWs. For non-AGMPs in all patients, even COVID-19 positive patients Level 1 PPE (surgical mask, gown, gloves and face shield or goggles) is sufficient. If local prevalence is favourable and patients are asymptomatic and test negative for SARS-CoV-2, Level 1 PPE can be used during short duration AGMPs, with limited risk of infected aerosol spread. For AGMPs in patients who test positive for SARS-CoV-2 a minimum of Level 2 PPE, with adequate protection of mucosal surfaces, is recommended (N95/FFP2 respirator, gown, double gloves, goggles or face shield and head cover). For long duration AGMPs that are deemed high-risk in COVID-19 positive patients, Level 3 PPE can provide a higher level of protection and be more comfortable during long duration surgeries if surgical hoods or PAPRs are used. It is recommended that these procedures are performed in negative pressure rooms, if available. It is essential to follow strict donning and doffing protocols to minimize the risk of contamination.

Conclusions

By following strict infection prevention recommendations, the risk of HCWs becoming infected with SARS-CoV-2 while treating patients can be minimized. As the COVID-19 pandemic evolves rapidly, these recommendations should serve as guidance and need to be interpreted based on local factors and availability of healthcare resources.

Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology - head and neck surgery during the COVID-19 pandemic

BACKGROUND

Aerosol generating medical procedures (AGMPs) present risks to health care workers (HCW) due to airborne transmission of pathogens. During the COVID-19 pandemic, it is essential for HCWs to recognize which procedures are potentially aerosolizing so that appropriate infection prevention precautions can be taken. The aim of this literature review was to identify potential AGMPs in Otolaryngology - Head and Neck Surgery and provide evidence-based recommendations.

METHODS

A literature search was performed on Medline, Embase and Cochrane Review databases up to April 3, 2020. All titles and abstracts of retrieved studies were evaluated and all studies mentioning potential AGMPs were included for formal review. Full text of included studies were assessed by two reviewers and the quality of the studies was evaluated. Ten categories of potential AGMPs were developed and recommendations were provided for each category.

RESULTS

Direct evidence indicates that CO2 laser ablation, the use of high-speed rotating devices, electrocautery and endotracheal suctioning are AGMPs. Indirect evidence indicates that tracheostomy should be considered as potential AGMPs. Nasal endoscopy and nasal packing/epistaxis management can result in droplet transmission, but it is unknown if these procedures also carry the risk of airborne transmission.

CONCLUSIONS

During the COVID-19 pandemic, special care should be taken when CO2 lasers, electrocautery and high-speed rotating devices are used in potentially infected tissue. Tracheal procedures like tracheostomy and endotracheal suctioning can also result in airborne transmission via small virus containing aerosols.

Cost-effectiveness of School Hearing Screening Programs: A Scoping Review

Objective

School hearing screening is a public health intervention that can improve care for children who experience hearing loss that is not detected on or develops after newborn screening. However, implementation of school hearing screening is sporadic and supported by mixed evidence to its economic benefit. This scoping review provides a summary of all published cost-effectiveness studies regarding school hearing screening programs globally. At the time of this review, there were no previously published reviews of a similar nature.

Data Sources

A structured search was applied to 4 databases: PubMed (Medline), Embase, CINAHL, and Cochrane Library.

Review Methods

The database search was carried out by 2 independent researchers, and results were reported in accordance with the PRISMA-ScR checklist and the JBI methodology for scoping reviews. Studies that included a cost analysis of screening programs for school-aged children in the school environment were eligible for inclusion. Studies that involved evaluations of only neonatal or preschool programs were excluded.

Results

Four of the 5 studies that conducted a cost-effectiveness analysis reported that school hearing screening was cost-effective through the calculation of incremental cost-effectiveness ratios (ICERs) via either quality- or disability-adjusted life years. One study reported that a new school hearing screening program dominated the existing program; 2 studies reported ICERs ranging from 1079 to 4304 international dollars; and 1 study reported an ICER of £2445. One study reported that school-entry hearing screening was not cost-effective versus no screening.

Conclusion

The majority of studies concluded that school hearing screening was cost-effective. However, significant differences in methodology and region-specific estimates of model inputs limit the generalizability of these findings.

Otology/Neurotology recommendations - Choosing Wisely campaign

The Choosing Wisely Canada Campaign aims to raise awareness amongst physicians and patients regarding unnecessary tests and treatment. The otology/neurotology subspecialty group within the Canadian Society of Otolaryngology – Head & Neck Society developed a list of five common otologic presentations to help physicians deliver high quality effective care: (1) Don’t order specialized audiometric and vestibular testing to screen for peripheral vestibular disease, (2) Don’t perform computed tomography or blood work in the evaluation of sudden sensorineural hearing loss, (3) Don’t perform auditory brain responses (ABR) in patients with asymmetrical hearing loss, (4) Don’t prescribe oral antibiotics as first line treatment for patients with painless otorrhea associated with tympanic membrane perforation or tympanostomy tube, and (5) Don’t perform particle repositioning maneuvers without a clinical diagnosis of posterior canal benign paroxysmal positional vertigo.

The prognostic value and pathophysiologic significance of three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) magnetic resonance imaging in idiopathic sudden sensorineural hearing loss: A systematic review and meta-analysis

BACKGROUND

The underlying pathophysiology of idiopathic sudden sensorineural hearing loss (ISSNHL) is still unknown. However, an increasing number of observational studies report intralabyrinthine signal alterations in patients with ISSNHL using three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) magnetic resonance imaging (MRI). These findings warrant a meta-analysis.

OBJECTIVE OF REVIEW

To conduct a meta-analysis assessing the value of 3D-FLAIR MRI in identifying possible underlying labyrinthine pathophysiologic mechanisms and prognostication in patients with ISSNHL.

SEARCH STRATEGY

Two reviewers independently searched the Pubmed, Embase and Cochrane Library from inception until October 10, 2018 and evaluated eligibility based on titles and abstracts of all retrieved studies. All studies reporting on 3D-FLAIR imaging in ISSNHL were included. Subsequently, the full text of eligible studies were evaluated.

EVALUATION METHOD

Adhering to the MOOSE guideline, two independent reviewers extracted data, assessed risk of bias and evaluated the relevance and quality of evidence. Data on the number of patients and events were extracted and hearing levels were converted to standardised mean differences (SMD) for conducting meta-analyses. Random effects models for meta-analyses were applied.

RESULTS

Eight observational studies met our inclusion criteria (n = 638 patients). In 29%, high signal intensity was found on 3D-FLAIR imaging, suggesting labyrinthine pathology (labyrinthitis [79%], intralabyrinthine haemorrhage [21%]). High signal intensity on 3D-FLAIR was associated with poorer hearing (SMD: 14 dB, 95% CI 5.67-22.94) and vertigo (RR: 1.92, 95% CI 1.16-3.17) at baseline. Multivariate analyses demonstrated that patients with high 3D-FLAIR signal intensity had 21 dB lower final hearing pure-tone averages (SMD: 21 dB, 95% CI 9.08-33.24).

CONCLUSIONS

Three-dimensional fluid-attenuated inversion recovery MR imaging can identify an underlying labyrinthine condition in up to 29% of patients with sudden hearing loss in whom previously no cause could be identified. Their final pure-tone averages are more than 20 dB worse than 3D-FLAIR-negative patients, suggesting more severe labyrinthine damage. Findings such as these may contribute to our understanding of pathophysiologic mechanisms of ISSNHL.

Subjective and objective vestibular changes that occur following paediatric cochlear implantation: systematic review and meta-analysis

Objective

Cochlear implantation can result in post-operative vestibular dysfunction of unknown clinical significance. The objective of this study was to characterize the presence, magnitude, and clinical significance of vestibular dysfunction that occurs after pediatric cochlear implantation.

Data sources

The databases Embase, Medline (OvidSP), and PubMed were used. Only articles published in English were included. Grey literature and unpublished sources were also reviewed.

Study selection

Articles published from 1980 until the present which documented pre-operative and post-operative vestibular testing on children under the age of 18 were used.

Data extraction

Parameters that were assessed included number of patients, pre- and post-operative vestibular-evoked myogenic potentials (VEMPs), head impulse testing (HIT), calorics, and posturography, timing of pre- and post-operative testing, symptomatology, and other demographic data such as etiology of the hearing loss.

Data synthesis

Ten articles were included. Relative risk values evaluating the effect of cochlear implantation on vestibular function were calculated for VEMPs and caloric testing due to the availability of published data. I² values were calculated and 95% confidence intervals were reported. Separate analyses were conducted for each individual study and a pooled analysis was conducted to yield an overall relative risk. Assessment on risk of bias in individual studies and overall was performed.

Conclusion

Pediatric cochlear implantation is associated with a statistically significant decrease in VEMP responses post-operatively (RR 1.8, p < 0.001, I² 91.86, 95%CI 1.57–2.02). Similar results are not seen in caloric testing. Insufficient data is available for analysis of HIT and posturography. Further studies are necessary to determine the effect of cochlear implantation on objective vestibular measures post-operatively and whether any changes seen are clinically relevant in this population.

Post-Traumatic Dizziness: Clinical and Medicolegal Aspects

Subjective complaints of dizziness after mild-to-moderate traumatic brain injury are common. Alterations in the mode of injury have changed the presentation symptoms. Evolutions in neuroimaging challenge conventional concepts regarding lack of evidence of injury following mild head trauma and provide hope for elucidating the site of lesion in patients with post-traumatic balance symptoms. Yet the vestibular clinician must maintain a healthy level of suspicion regarding potential exaggeration of symptoms and disability in patients with a financial incentive. Unique conditions warrant particular attention by the vestibular clinician, including chronic traumatic encephalopathy, catastrophization, and persistent postural and perceptual dizziness. The clinical significance of abnormalities, particularly on vestibular-evoked myogenic potential testing, needs to be better defined prior to their widespread application in the medical legal arena. The role of the medical expert is to provide opinion on matters requiring special knowledge to assist the court in reaching its findings. As such, this chapter provides an update on recent advances to consider in patients with dizziness after trauma.

Vestibular Neuritis: Recent Advances in Etiology, Diagnostic Evaluation, and Treatment

Purpose of Chapter: This chapter highlights the recent advances in etiology, diagnostic evaluation, and management of vestibular neuritis (VN). Recent Findings: The viral hypothesis has been strengthened with new evidence as the main etiology of VN. Recent evidence indicates that bedside oculomotor findings play a critical role in differentiating VN from stroke. The implementation of cervical and ocular vestibular evoked myogenic potential, and video head impulse test in vestibular function testing has made it possible to diagnose selective damage of the vestibular nerves. The management of the acute phase of VN is primarily medical, while long-term treatment is designed to improve vestibular compensation. Summary: VN is clearly defined as an important viral inner ear disorder.

Shared decision making and decisional conflict in the Management of Vestibular Schwannoma: a prospective cohort study

Background

Patients with vestibular schwannomas (VS) are faced with complex management decisions. Watchful waiting, surgical resection, and radiation are all viable options with associated risks and benefits. We sought to determine if patients with VS experience decisional conflict when deciding between surgery or non-surgical management, and factors influencing the degree of decisional conflict.

Methods

A prospective cohort study in two tertiary ambulatory skull-base clinics was performed. Patients with newly diagnosed or newly growing vestibular schwannomas were recruited. Patients were given a demographic form and the decisional conflict scale (DCS), a validated measure to assess the degree of uncertainty when making medical decisions. The degree of shared decision making (SDM) experienced by the patient and physician were assessed via the SDM-Q-10 and SDM-Q-Doc questionnaires, respectively. Non-parametric statistics were used. Questionnaires and demographic information were correlated with DCS using Spearman correlation coefficient and Mann-Whitney U. Logistic regression was performed to determine factors independently associated with DCS scores.

Results

Seventy-seven patients participated (55% female, aged 37–81 years); VS ranged in size from 2 mm–50 mm. Significant decisional conflict (DCS score 25 or greater) was experienced by 17 (22%) patients. Patients reported an average SDM-Q-10 score of 86, indicating highly perceived level of SDM. Physician and patient SDM scores were weakly correlated (p = 0.045, Spearman correlation coefficient 0.234). DCS scores were significantly negatively correlated with a decision to pursue surgery, presence of a trainee, and higher SDM-Q-10 score. DCS was higher with female gender. Using logistic regression, the SDM-Q-10 score was the only variable associated with significantly reduced DCS.

Conclusions

About one fifth of patients deciding how to manage their vestibular schwannoma experienced a significant degree of decisional conflict. Involving the patients in the process through shared decision-making significantly reduced the degree of uncertainty patients experienced.

Onset of clinical improvement of depressive illness following electroconvulsive therapy

Aims and method

To examine the onset and course of clinically observable improvement in patients receiving electroconvulsive therapy (ECT). A prospective design was used In which 19 consecutive patients receiving ECT were followed up from commencement to termination of ECT. The Clinical Global Improvement Scale was administered at every ECT session to monitor their Improvement.

Results

Eleven of the 19 subjects Improved minimally and another subject Improved substantially after the first two ECT treatments.

Clinical implications

ECT produces clinically observable improvement in depression within a few days of starting treatment perhaps earlier than is generally acknowledged.

A closer look at subjective caloric sensations: Is there more to vertigo than spinning?

BACKGROUND

There is a prevailing opinion that spinning sensations signify a peripheral vestibular pathology while non-spinning sensations are not of vestibular origin.

OBJECTIVES

1) Characterize the subjective sensations reported by patients during caloric testing. 2) Assess if the sensation was correlated with the peak slow phase velocity (SPV).

METHODS

Retrospective chart review at a Canadian adult tertiary-quaternary care balance centre for patients undergoing diagnostic caloric testing between December 2014 and September 2015.

RESULTS

Of 163 patients included, 122 had normal calorics and 41 demonstrated unilateral weakness. Spinning/rotatory movements were the most commonly reported sensations (55-70%). No sensation was reported among 10-20% of patients. Other non-rotatory sensations were reported 20-25% of the time. Both lack of sensation and other sensations were more likely to be correlated with SPVs that were significantly lower than those associated with spinning/rotating sensations. However, 18% of patients with normal calorics and robust SPVs with warm irrigation still reported non-spinning sensations.

CONCLUSIONS

During caloric irrigation, subjective sensations other than spinning and rotating are reported 20-25% of the time and these tend to be associated with lower peak SPV. Non-spinning vertigo is not uncommon as a subjective description of vestibular sensation even in normal patients with strong SPVs.

Threat effects on human oculo-motor function

Neuro-anatomical evidence supports the potential for threat-related factors, such as fear, anxiety and vigilance, to influence brainstem motor nuclei controlling eye movements, as well as the vestibular nuclei. However, little is known about how threat influences human ocular responses, such as eye saccades (ES), smooth pursuit eye tracking (SP), and optokinetic nystagmus (OKN), and whether these responses can be facilitated above normal baseline levels with a natural source of threat. This study was designed to examine the effects of height-induced postural threat on the gain of ES, SP and OKN responses in humans. Twenty participants stood at two different surface heights while performing ES (ranging from 8° to 45° from center), SP (15, 20, 30°/s) and OKN (15, 30, 60°/s) responses in the horizontal plane. Height did not significantly increase the slope of the relationship between ES peak velocity and initial amplitude, or the gain of ES amplitude. In contrast height significantly increased SP and OKN gain. Significant correlations were found between changes in physiological arousal and OKN gain. Observations of changes with height in OKN and SP support neuro-anatomical evidence of threat-related mechanisms influencing both oculo-motor nuclei and vestibular reflex pathways. Although further study is warranted, the findings suggest that potential influences of fear, anxiety and arousal/alertness should be accounted for, or controlled, during clinical vestibular and oculo-motor testing.

Current insights in noise-induced hearing loss: a literature review of the underlying mechanism, pathophysiology, asymmetry, and management options

BACKGROUND

Noise-induced hearing loss is one of the most common forms of sensorineural hearing loss, is a major health problem, is largely preventable and is probably more widespread than revealed by conventional pure tone threshold testing. Noise-induced damage to the cochlea is traditionally considered to be associated with symmetrical mild to moderate hearing loss with associated tinnitus; however, there is a significant number of patients with asymmetrical thresholds and, depending on the exposure, severe to profound hearing loss as well.

MAIN BODY

Recent epidemiology and animal studies have provided further insight into the pathophysiology, clinical findings, social and economic impacts of noise-induced hearing loss. Furthermore, it is recently shown that acoustic trauma is associated with vestibular dysfunction, with associated dizziness that is not always measurable with current techniques. Deliberation of the prevalence, treatment and prevention of noise-induced hearing loss is important and timely. Currently, prevention and protection are the first lines of defence, although promising protective effects are emerging from multiple different pharmaceutical agents, such as steroids, antioxidants and neurotrophins.

CONCLUSION

This review provides a comprehensive update on the pathophysiology, investigations, prevalence of asymmetry, associated symptoms, and current strategies on the prevention and treatment of noise-induced hearing loss.

Mental practice in postgraduate training: a randomized controlled trial in mastoidectomy skills

Background

Mental practice, the cognitive rehearsal of a task in the absence of overt physical movement, has been successfully used in teaching complex psychomotor tasks including sports and music, and recently, surgical skills.

The objectives of this study were, 1) To develop and evaluate a mental practice protocol for mastoidectomy 2) To assess the immediate impact of mental practice on a mastoidectomy surgical task among senior Otolaryngology─Head & Neck Surgery (OHNS) residents.

Method

Three expert surgeons were interviewed using verbal protocol analysis to develop a mastoidectomy mental practice script. Twelve senior Residents from Canadian training programs were randomized into two groups. All Residents were video-recorded performing a baseline mastoidectomy in a temporal bone lab. The intervention group received mental practice training, while the control group undertook self-directed textbook study. All subjects were then video-recorded performing a second mastoidectomy. Changes in pre- and post-test scores using validated expert ratings, the Task Specific Evaluation of Mastoidectomy and the Global Evaluation of Mastoidectomy, were statistically analyzed.

Results

A mental practice script was successfully developed based on interviews of three expert surgeon-educators. Task Specific Evaluation and Global Evaluation scores increased in both the mental practice and textbook study groups; there was no significant difference between the two groups in the change in scores post-intervention. There was a high and statistically signficant correlation between evaluators on the outcome measures.

Conclusions

We were not able to demonstrate a significant difference for the benefits of mental practice in mastoidectomy, possibly due to the sample size. However, mental practice is a surgical education tool which is portable, accessible, inexpensive and safe.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-016-0162-2) contains supplementary material, which is available to authorized users.

Endoscopic ear surgery in Canada: a cross-sectional study

Background

Endoscopic ear surgery is an emerging technique with recent literature highlighting advantages over the traditional microscopic approach. This study aims to characterize the current status of endoscopic ear surgery in Canada and better understand the beliefs and concerns of the otolaryngology – head & neck surgery community regarding this technique.

Methods

A cross-sectional survey study of Canadian otolaryngologists was performed. Members of the Canadian Society of Otolaryngology were contacted though an online survey carried out in 2015.

Results

The majority of participants in this study (70 %) used an endoscope in their practice, with a large proportion utilizing the endoscope for cholesteatoma or tympanoplasty surgery. To date, 38 Canadian otolaryngologists (70 % of respondents) have used an endoscope for at least 1 surgical case, but only 6 (11 %) have performed more than 50 endoscopic cases. Of the otolaryngologists who use endoscopes regularly, the majority still use the microscope as their primary instrument and use the endoscope only as an adjunct during surgery. However, the general attitude surrounding endoscopes is positive; 81 % believe that endoscopes have a role to play in the future of ear surgery and 53 % indicated they were likely to use endoscopes in their future practice. Participants who were earlier in their practice or who had more exposure to endoscopic techniques in their career were more likely to have a positive stance towards endoscopic ear surgery (p < 0.05, p < 0.01, respectively). The main concern regarding endoscopic ear surgery was the technical challenge of one-handed surgery, while the primary perceived advantage was the reduced rates of residual or recurrent disease.

Conclusions

Endoscopic ear surgery is a new technique that is gaining momentum in Canada and there is enthusiasm for its incorporation into future practice. Further investment in training courses and guidance for those looking to start or advance the use of endoscopes in their practice will be vital in the years to come.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-016-0117-7) contains supplementary material, which is available to authorized users.

Vestibulo-spinal and vestibulo-ocular reflexes are modulated when standing with increased postural threat

We investigated how vestibulo-spinal reflexes (VSRs) and vestibulo-ocular reflexes (VORs) measured through vestibular evoked myogenic potentials (VEMPs) and video head impulse test (vHIT) outcomes, respectively, are modulated during standing under conditions of increased postural threat. Twenty-five healthy young adults stood quietly at low (0.8 m from the ground) and high (3.2 m) surface height conditions in two experiments. For the first experiment (n = 25) VEMPs were recorded with surface EMG from inferior oblique (IO), sternocleidomastoid (SCM), trapezius (TRP), and soleus (SOL) muscles in response to 256 air-conducted short tone bursts (125 dB SPL, 500 Hz, 4 ms) delivered via headphones. A subset of subjects (n = 19) also received horizontal and vertical head thrusts (∼150°/s) at each height in a separate session, comparing eye and head velocities by using a vHIT system for calculating the functional VOR gains. VEMP amplitudes (IO, TRP, SOL) and horizontal and vertical vHIT gains all increased with high surface height conditions (P < 0.05). Changes in IO and SCM VEMP amplitudes as well as horizontal vHIT gains were correlated with changes in electrodermal activity (ρ = 0.44-0.59, P < 0.05). VEMP amplitude for the IO also positively correlated with fear (ρ = 0.43, P = 0.03). Threat-induced anxiety, fear, and arousal have significant effects on VSR and VOR gains that can be observed in both physiological and functional outcome measures. These findings provide support for a potential central modulation of the vestibular nucleus complex through excitatory inputs from neural centers involved in processing fear, anxiety, arousal, and vigilance.

The effects of creatine supplementation on thermoregulation and isokinetic muscular performance following acute (3-day) supplementation

AIM

The purpose of this investigation was to determine the effects of 3 d of creatine supplementation on thermoregulation and isokinetic muscular performance.

METHODS

Fourteen males performed two exercise bouts following 3 d of creatine supplementation and placebo. Subjects exercised for 60 min at 60-65% of VO2max in the heat followed by isokinetic muscular performance at 60, 180, and 300°·s(-1). Dependent variables for pre- and postexercise included nude body weight, urine specific gravity, and serum creatinine levels. Total body water, extracellular water and intracellular water were measured pre-exercise. Core temperature was assessed every 5 min during exercise. Peak torque and Fatigue Index were used to assess isokinetic muscular performance.

RESULTS

Core temperature increased during the run for both conditions. Total body water and extracellular water were significantly greater (P<0.05) following creatine supplementation. No significant difference (P>0.05) was found between conditions for intracellular water, nude body weight, urine specific gravity, and serum creatinine. Pre-exercise scores for urine specific gravity and serum creatinine were significantly less (P<0.05) versus post-exercise. No significant differences (P>0.05) were found in peak torque values or Fatigue Index between conditions for each velocity. A significant (P<0.05) overall velocity effect was found for both flexion and extension. As velocity increased, mean peak torque values decreased.

CONCLUSION

Three d of creatine supplementation does not affect thermoregulation during submaximal exercise in the heat and is not enough to elicit an ergogenic effect for isokinetic muscle performance following endurance activity.

Symptom Resolution Rates of Posttraumatic versus Nontraumatic Benign Paroxysmal Positional Vertigo

Objective

To determine the rate of symptom resolution in patients with posttraumatic benign paroxysmal positional vertigo (BPPV) and to determine if it differs from resolution rates in patients with BPPV and without a history of head trauma.

Data Sources

Systematic review of the literature was performed using Medline, EMBASE, and Cochrane databases. English and French articles meeting inclusion criteria and published between 1946 and October 2014 were included.

Review Methods

Data were independently extracted from the articles by 2 reviewers using data collection forms developed a priori. Inclusion and exclusion criteria were decided a priori. Studies were included if they reported on at least 1 case of posttraumatic BPPV (t-BPPV), reported on outcomes of all patients with t-BPPV, had a clearly defined inception point, and provided a clear diagnosis of BPPV (defined a priori by reviewers).

Results

A total of 3017 titles, 362 abstracts, and 67 articles were reviewed, from which 16 articles met inclusion criteria and underwent data extraction. There were a total of 207 patients with posttraumatic BPPV identified. Among the 207 patients, 151 (73%) had resolution of symptoms. The T-BPPV patients may have more multi-canal involvement and may require more repositioning maneuvers for resolution compared to patients with nontraumatic BPPV.

Conclusions

Available evidence does not support the notion that symptom resolution rates in patients with posttraumatic BPPV are worse than those with nontraumatic BPPV. However, well-designed studies with adequate cohorts are lacking. Additional well-executed studies are needed to confirm this lack of difference in resolution rates.

Radiological prevalence of superior and posterior semicircular canal dehiscence in children

OBJECTIVE

Establishing the prevalence of semicircular canal dehiscence in a pediatric population using temporal bone CT imaging.

STUDY DESIGN

Retrospective analysis of all temporal bone CT scans during a 5-year period (2007-2012).

METHODS

CT scan images were reformatted in the plane of the canals and assessed by two independent reviewers with a third to resolve disagreement. Detailed chart review was performed for those found to have dehiscence. Superior and posterior canals were classified as "dehiscent", "possibly dehiscent", "thin" or "normal" for each case.

RESULTS

649 temporal bones were assessed from 334 children (under 18 years of age). The prevalence rate of superior canal dehiscence (SCD) was 1.7% (3.3% of individuals). Posterior canal dehiscence (PCD) was present in 1.2% (2.1% of individuals). There were no cases of bilateral SCD, and one case of bilateral PCD. Age under 3 years was associated with a higher prevalence of thinning but not dehiscence. Congenital inner ear malformation was not related to a higher probability of dehiscence. The superior petrosal sinus was associated with the SCD in three cases (27.3%). Retrospective chart review highlighted possible vestibular symptoms in 3/11 patients with SCD (27.3%).

CONCLUSIONS

This forms the largest pediatric study of canal dehiscence to date. This study's prevalence rate is significantly lower than previous reports. The identified association with overlying venous structures may reflect the etiological process involved. The occurrence in children supports the hypothesis of a congenital predisposition for development of canal dehiscence syndrome.

Lack of Association between Human Herpesvirus and Vestibular Schwannoma

Objective

To assess for the presence of human herpesvirus (HHV) using immunohistochemical and polymerase chain reaction (PCR) assay in surgically excised vestibular schwannoma (VS) samples.

Study Design

Cross-sectional study.

Setting

A retrospective laboratory-based study of tumors from patients with vestibular schwannoma.

Subjects and Methods

Tissue microarrays (TMAs) representing sporadic and NF2-associated VS from 121 patients, as well as appropriate positive and negative controls, were studied. TMA sections were immunostained using antibodies directed against HHV-1, HHV-2, HHV-3, HHV-4, HHV-5, and HHV-8. PCR was used for the detection of all 8 known human herpesviruses.

Results

There was no detectable HHV (HHV-1, HHV-2, HHV-3, HHV-4, HHV-5, HHV-8) by immunohistochemistry in any of the 121 cases of sporadic and NF2 cases analyzed. These data were further validated by DNA sequence analyses using PCR in a subset of the VS samples, all of which were found to be negative for all HHV.

Conclusions

The data offer no support for an association between HHV and the development of sporadic or NF2-associated VS in humans.

In vitro efficacy of N-acetylcysteine on bacteria associated with chronic suppurative otitis media

Background

The safety and efficacy of Ciprodex® has been demonstrated for treatment of chronic suppurative otitis media (CSOM). However, symptoms fail to resolve in 9-15% of patients. The objective of this study is to evaluate the efficacy of N-acetylcysteine (NAC) on S. aureus, and planktonic and sessile (biofilm forming) P. aeruginosa in vitro using clinical isolates from patients with CSOM.

Methods

1) Stability was assessed using liquid chromatography-mass spectrometry for each component in a prepared mixture of Ciprodex® and NAC over 15 days. Sterility was assessed by measuring bacterial growth on a blood agar plate. Efficacy was assessed using a disc diffusion method by inoculating plates with S. aureus ATCC 29513 and P. aeruginosa ATCC 27853, and measuring the clearance zone.

2) Fifteen P. aeruginosa strains were isolated from patients with CSOM and tested in vitro using the bioFILM PA™ antimicrobial susceptibility assay. Treatment solutions included Ciprodex® & ciprofloxacin +/- NAC, and NAC alone (0.25%, 0.5% & 1.25%).

Results

1) NAC combined with Ciprodex® demonstrated stability, sterility, and efficacy over a two-week period

2) P. aeruginosa strains in the sessile (33%-40%) and planktonic (13%) state demonstrated resistance to Ciprodex® and ciprofloxacin. When NAC ≥0.5% was used in isolation or as an adjunct to either of these medications, no resistance was found in the sessile or planktonic state among all 15 strains.

Conclusion

1) Ciprodex® combined with NAC has a shelf life of at least two weeks given the documented preservation of stability, sterility, and clinical efficacy of the mixed compounds.

2) P. aeruginosa strains demonstrated resistance to both Ciprodex® and ciprofloxacin. NAC ≥0.5% overcomes issues with resistance and shows promise in the treatment of CSOM.

An unusual instance of stridor: airway obstruction from a nasogastric tube knot in a 1-month old infant

We report a 1 month old infant with a spontaneously knotted nasogastric tube. Attempted removal of the nasogastric tube was unsuccessful, prompting further investigation. Plain radiographs revealed a large, multi-looped knot impacted in the nasopharynx and oropharynx. The tube was subsequently removed through the mouth under general anesthesia without complication, revealing a large, impressive knot of the distal end of the nasogastric tube.

Stabilization media increases recovery in paucicellular cerebrospinal fluid specimens submitted for flow cytometry testing

BACKGROUND

Flow cytometric immunophenotpying (FCI) of cerebrospinal fluid (CSF) and other paucicellular fluids has been demonstrated to have increased sensitivity in detection of lymphoma and leukemia when compared to cytomorphology [(1) de Graaf et al., Cytometry Part B 2011, 80B:271-281; (2) Szamosi et al., CLSI Document H56-A-Body Fluid Analysis for Cellular Composition; Approved Guideline, Wayne, PA: Clinical and Laboratory Standards Institute, 2006; (3) Kraan et al., Flow Cytometric Immunophenotyping of Cerebrospinal Fluid. Current Protocols in Cytometry, Hoboken, NJ: Wiley, 2008]. However, low cellularity has been an historical problem with these samples. Several studies indicate that immediate addition of a stabilization media (e.g., RPMI with fetal calf serum (FCS)) to CSF improves the cell yield for FCI [(1) de Graaf et al.]. Such stabilization medias can, however, significantly increase cost.

METHODS

We compared FCI results in CSF stabilized with RPMI 1640 (without additional additives) to results obtained using non-stabilized CSF. Samples were processed according to published CLSI guidelines [(2) Szamosi et al.].

RESULTS

About 98/105 (93%) CSF specimens stabilized with RPMI had adequate numbers of viable cells (>100) for performing FCI. About 65/217 (30%) CSF specimens without stabilization had adequate numbers of viable cells for analysis (70% either quantity not sufficient (QNS) or specimen viability below analytical limits).

CONCLUSIONS

Utilizing RMPI without FCS as a stabilization media results in increased cell yield and improved FCI results. We have found FCS is not required to achieve high quality results in FCI of paucicellular CSF specimens.