A retrospective study on the outcomes of stapedotomy with vein graft interposition and vein graft surround techniques

OBJECTIVE

This study evaluated audiological outcomes of stapedotomy using two different techniques, vein graft interposition and vein graft surround, for sealing the stapes fenestra.

METHOD

A retrospective study of 130 patients who underwent stapedotomy for otosclerosis was performed. A total of 84 patients underwent the vein graft surround procedure and 46 underwent the vein graft interposition procedure. Post-operative hearing outcome was compared between them.

RESULTS

A total of 55 of 130 patients had a post-operative air-bone gap of less than 10 dB. A total of 57 patients had an air-bone gap within 20 dB. The average air-bone gap was 13.16 dB at 3 months with a mean improvement of 22.06 dB (11.98 dB for vein graft interposition and 13.80 dB for vein graft surround; p = 0.79).

CONCLUSION

There was no significant difference in hearing outcome between the two techniques. The vein graft interposition technique is preferred for large fenestra or stapedectomy cases and in cerebrospinal fluid gusher cases. The vein graft surround technique is easier to perform and preferred in small fenestra stapedotomy.

Recurrent Meningitis in a Non-user Cochlear Implantee

Meningitis is a known complication in patients with inner ear malformations. Here we present a case of recurrent meningitis following cochlear implantation, in a patient with cochleovestibular anomaly. Good knowledge in radiology to identify the inner ear malformations, presence of cochlea and cochlear nerve is essential before planning cochlear implantation and meningitis can occur several decades after cochlear implantation.

An Effective Home-Based Particle Repositioning Procedure for Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV)

Patients with benign paroxysmal positional vertigo (BPPV) find it difficult to visit the hospital many times for a standard Epley's maneuver performed only by a specialist. The aim of this study was to compare the efficacy of a home-based particle repositioning procedure (HBPRP) with the standard Epley's maneuver in treating patients with posterior canal BPPV. A prospective non-blinded randomized controlled study was conducted. Patients were randomized into two groups, where one group received the standard treatment and other received a new HBPRP. The vertigo scale, duration of nystagmus during Dix-Hallpike test and frequency of vertigo, were documented on first, second and third visits, with complications noted during the second and third visits. These parameters were compared between both the groups following the treatment, during all visits. The patients were randomized into 2 arms with 15 each. Those belonging to group 1 received Epley's maneuver and group 2 received HBPRP. There was no significant difference in the baseline characteristics of patients in both groups. Both groups of patients had significant improvement of symptoms at the end of the study. A comparison of both groups at 2nd and 3rd visits showed no differences in frequency of vertigo, reduction in vertigo scale and duration of nystagmus following Dix-Hallpike test between both groups. HBPRP is a safe and effective procedure and can be taught as a home-based treatment for patients diagnosed with posterior canal BPPV.

Comparing Intratympanic Gentamicin with Methylprednisolone in Meniere's Disease with Non-Serviceable Hearing

Abstract

To compare the effectiveness of high dose fixed alternate day intratympanic gentamicin with methylprednisolone in the treatment of patients with unilateral, intractable Meniere's disease with poor hearing. Randomized single blind prospective parallel group trial in a tertiary referral centre. Twenty-two patients with definite unilateral Meniere's disease with average pure tone thresholds worse than 50 dB in the affected ear were enrolled. Eleven patients were treated with intratympanic buffered gentamicin and the other eleven were administered intratympanic methylprednisolone (both 4 injections, 40 mg/ml, on alternate days). Patients were assessed pre-intervention, 3 months post intervention and subsequently followed up for 2-4 years. Both groups of patients had significant control of vertigo, DHI scores and THI scores after treatment while the functional scores in the methylprednisolone group was not better than the pre- treatment scores in the long-term follow-up. 9 of 11(82%) patients in gentamicin group and 3 of 11(27%) patients in the methylprednisolone group achieved Class A vertigo control. The gentamicin group had better post intervention DHI scores (p = 0.016, 3 months and p = 0.046, long term) and Functional score (p = 0.014, 3 months and p = 0.05, long term). The hearing in both groups and THI scores, post intervention was similar between both groups. In patients with unilateral intractable MD with non-serviceable hearing, high fixed doses of both intratympanic gentamicin and methylprednisolone are effective in alleviating disease symptoms in long term follow-up. However, intratympanic gentamicin resulted in better control of vertigo, total DHI score and functional level scores than intratympanic methylprednisolone with no significant difference in hearing levels.

Trail Registration Number

Clinical Trials Registry of India (CTRI- REF/2016/10/012363).

Cochlear Implant in Klippel-Feil Syndrome: Challenges and Concerns

Cochlear implantation (CI) can be safely performed in patients with syndromic hearing loss. Here we present a case of CI in a child with Klippel-Feil syndrome with various skeletal, extraskeletal, cochleovestibular and Arnold-Chiari malformations. Multidisciplinary approach and good preoperative imaging play a key role in planning for surgery.

Etiopathology and Prevalence of Pulsatile Tinnitus in a Tertiary Care Referral Hospital

The diverse etiopathogenesis of pulsatile tinnitus (PT) makes it a difficult condition to diagnose and treat. To describe the clinical features, investigations and diagnosis of patients presenting with pulsatile tinnitus (PT). Retrospective chart review in an otology unit of a tertiary care referral centre. All medical records of patients who had a complaint of pulsatile tinnitus during the period 1st January 2014-1st May 2020 were included in the study. Data regarding history, characteristics of tinnitus, examination findings, investigations and diagnosis were collected and analyzed. Sixty-four patients with complaints of PT presented to our clinic during this time period and were included in the study giving a prevalence of 0.09%. Definite diagnosis was made in 62 (96.8%) cases with a detailed history, clinical examination and tailored investigations. Pathologies diagnosed were paraganglioma (25%), superior semicircular canal dehiscence (20.3%), anterior inferior cerebellar artery loop (7.8%), sigmoid sinus wall dehiscence (10.9%), sigmoid sinus diverticulum (6.25%), jugular bulb anomalies (7.8%) and hyperpneumatised petrous apex (3.1%) among others. Rare causes encountered were IgG4 disease, far advanced otosclerosis, vestibular aqueduct dehiscence and idiopathic intracranial hypertension. Pulsatile tinnitus is a rare complaint in the Otology clinic. Almost all cases of PT can be diagnosed correctly and appropriate treatment initiated with a logical approach to investigations.

A Comparative Study of Outcomes and Quality of Life in Canal Wall up Mastoidectomies and Canal Wall down Mastoidectomies

Abstract

Chronic Otitis Media (COM) of the squamosal type was primarily managed by performing a canal wall down mastoidectomy; however, the latter era otolaryngologist envisioned benefits in preserving the posterior canal wall. Our primary objective was to assess the disease specific quality of life following canal wall up (CWU) mastoidectomy and canal wall down (CWD) mastoidectomy surgery after a 6 month post-operative period. A prospective observational study was done from September 2017 to August 2018 where the charts of 380 patients from Christian Medical College, Vellore were reviewed. Details of patients above 18 years who had undergone the above surgeries for COM active squamosal disease from the period of January 2014 to December 2016; and had their post-operative follow up (average of 16 months) during the period of study were looked at. The CWU group had a significantly better disease-specific quality of life in the symptoms subscale than the CWD group (p value < 0.01). The CWU group showed a significant air-bone gap closure to 23.3 dB as compared to 27.7 dB in CWD (p value = 0.005). The recurrence rates were 4.5% (9 cases) in the CWU group and 3.9% (7 cases) in the CWD group, which was not statistically significant. Both CWU and CWD methods of mastoidectomy for COM squamosal type give comparable outcomes in terms of recurrence with the CWU group having a better disease-specific quality of life after surgery.

Level of Evidence

2a.

Prevalence, clinical profile, and diagnosis of pediatric dizziness in a tertiary care hospital

INTRODUCTION

Pediatric dizziness is an uncommon complaint presenting to the Otolaryngology clinic. While the term dizziness may be used to describe any altered sensation of orientation to the environment which includes presyncope, light-headedness and ataxia, vertigo refers to a false sensation of motion of self or surroundings. Although a variety of etiologies are known to cause dizziness and vertigo, evaluation of this symptom becomes challenging in children who are unable to clearly explain what they experience, the provoking factors, associated symptoms and the duration of attacks. Vestibular tests are also difficult to conduct in the pediatric age group leading to apathy from the clinician.

OBJECTIVES

To ascertain the prevalence of pediatric vertigo in children under 18 years of age, presenting to the Otolaryngology Clinic of a tertiary care hospital, and to describe the clinical profile, investigations and diagnosis in these children.

METHODS

A prospective cross-sectional, descriptive clinical study was undertaken from January 1, 2018 to April 30, 2019. All children below the age of 18 years presenting to our department with primary complaints of dizziness were included in the study. After a thorough history and physical examination, screening methods and diagnostic tests were conducted to make a diagnosis. Referrals were sought from other specialties when necessary.

RESULTS

The number of children visiting the Department for various ENT ailments during the study period was 10,950. Among these 89 children presented with a primary complaint of dizziness. Their ages ranged from 3 to 18 years; mean age was 11.42 years (SD 3.45). A diagnosis was made in all except two children. The most common cause of dizziness in the age group less than 6 years was benign paroxysmal vertigo of childhood (BPVC) and in the older children was migraine associated vertigo, which was also the commonest overall diagnosis made (28.1%). This was followed by circulation related dizziness like orthostatic hypotension and vasovagal syncope (15.7%).

CONCLUSIONS

The prevalence of pediatric dizziness in children presenting to the Otolaryngology clinic was 0.8%. The diagnosis of pediatric vertigo may be challenging, but careful history and examination along with guided investigations and referrals results in correct diagnosis in almost all patients.

Sustained benefit of cognitive behaviour therapy for health anxiety in medical patients (CHAMP) over 8 years: a randomised-controlled trial

BACKGROUND

Health anxiety is an under-recognised but a frequent cause of distress. It is particularly common in general hospitals.

METHODS

We carried out an 8-year follow-up of medical out-patients with health anxiety (hypochondriasis) enrolled in a randomised-controlled trial in five general hospitals in London, Middlesex and Nottinghamshire. Randomisation was to a mean of six sessions of cognitive behaviour therapy adapted for health anxiety (CBT-HA) or to standard care in the clinics. The primary outcome was a change in score on the Short Health Anxiety Inventory, with generalised anxiety and depression as secondary outcomes. Of 444 patients aged 16-75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics, 306 (68.9%) were followed-up 8 years after randomisation, including 36 who had died. The study is registered with controlled-trials.com, ISRCTN14565822.

RESULTS

There was a significant difference in the HAI score in favour of CBT-HA over standard care after 8 years [1.83, 95% confidence interval (CI) 0.25-3.40, p = 0.023], between group differences in generalised anxiety were less (0.54, 95% CI -0.29 to 1.36), p = 0.20, ns), but those for depression were greater at 8 years (1.22, 95% CI 0.42-2.01, p < 0.003) in CBT-HA than in standard care, most in standard care satisfying the criteria for clinical depression. Those seen by nurse therapists and in cardiology and gastrointestinal clinics achieved the greatest gains with CBT-HA, with greater improvement in both symptoms and social function.

CONCLUSIONS

CBT-HA is a highly long-term effective treatment for pathological health anxiety with long-term benefits. Standard care for health anxiety in medical clinics promotes depression. Nurse therapists are effective practitioners.

Skull base osteomyelitis with secondary cavernous sinus thrombosis: a rare presentation of an animate foreign body in the ear

A 42-year-old woman presented with fever, left ear pain, restricted mouth opening, difficulty in swallowing and inability to open her left eyelid for a period of 10 days. She was treated with antibiotics for the same at a local medical facility; however, a sudden decrease in her left eye vision prompted her to visit our tertiary centre. Her history was insignificant except for having multiple left ear syringing for an insect removal 10 days before onset of her current symptoms. On examination, she had ptosis of the left eye with chemosis, dilated pupil with only perception of light and restricted ocular mobility. Oral examination revealed trismus and bulge in the left peritonsillar region. Left ear examination revealed a large central perforation with mucopurulent discharge. CT of the neck with contrast demonstrated a collection in the left peritonsillar space with left internal carotid artery thrombosis. MRI of the brain with gadolinium revealed left cavernous sinus thrombosis with acute infarcts in the left frontal lobe. An emergency incision and drainage of the left peritonsillar abscess was performed. Culture grew broad aseptate fungal hyphae. Despite starting on antifungal therapy, she succumbed to her illness.

Standard Programming of Retrograde Electrode Insertion via Middle-Turn Cochleostomy in Labyrinthitis Ossificans

Successful cochlear implantation in the setting of labyrinthitis ossificans is challenging. Various surgical techniques are described to circumvent the region of ossification and retrograde insertion of the electrode array is one such option. While reverse programming is often recommended in the case of retrograde electrode insertion, we present our experience of retrograde electrode insertion for labyrinthitis ossificans, where standard programming was adopted due to patient preference and provided satisfactory outcomes.

Transnasal Flexible Laryngoscopy Using Different Topical Preparations and Methods of Application-A Randomized Study

BACKGROUND

The field of laryngology has grown exponentially since the advent of the transnasal flexible laryngoscopy. Flexible laryngoscopy when performed skillfully using the proper technique, facilitates a good view of the hidden areas of the larynx.

OBJECTIVE

To compare the effectiveness of the topical agents in providing a more comfortable experience for the patient, allowing the practitioner to advance the endoscope with less friction, pain and discomfort for the patient using 10% lidocaine spray, 2% lidocaine gel, 4% lidocaine with xylometazoline (1:1) soaked pledgets, or aqueous gel.

MATERIALS AND METHODS

A prospective randomized single-blinded clinical trial was conducted in a tertiary care teaching hospital in South India where 376 patients were recruited and allocated into four groups based on the topical preparation used. Following endoscopy, each subject filled a questionnaire grading their experience on a visual analogue scale. The clinician also then answered a questionnaire on aspects of the endoscopy performed.

RESULTS

The pain score and the ease of performing the procedure among the different groups were comparable. Those in the 10% lidocaine arm experienced significant burning sensation (P = 0.0001). The other variables such as throat pain (P = 0.783), gag reflex (P = 0.318), unpleasant taste (P = 0.092), globus (P = 0.190), swallowing difficulty after the procedure (P = 0.273), difficulty in breathing (P = 0.744) and willingness to have a repeat procedure (P = 0.883) were also comparable.

CONCLUSION

Aqueous gel can be used topically during a flexible nasopharyngolaryngoscopy instead of an anesthetic agent alone or one combined with a nasal decongestant.

The effects of N95 mask and face shield on speech perception among healthcare workers in the coronavirus disease 2019 pandemic scenario

OBJECTIVE

The current circumstances of the coronavirus disease 2019 pandemic necessitate the use of personal protective equipment in hospitals. N95 masks and face shields are being used as personal protective equipment to protect from aerosol-related spread of infection. Personal protective equipment, however, hampers communication. This study aimed to assess the effect of using an N95 mask and face shield on speech perception among healthcare workers with normal hearing.

METHODS

Twenty healthcare workers were recruited for the study. Pure tone audiometry was conducted to ensure normal hearing. Speech reception threshold and speech discrimination score were obtained, first without using personal protective equipment and then repeated with the audiologist wearing an N95 mask and face shield.

RESULTS

A statistically significant increase in speech reception threshold (mean of 12.4 dB) and decrease in speech discrimination score (mean of 7 per cent) was found while using the personal protective equipment.

CONCLUSION

Use of personal protective equipment significantly impairs speech perception. Alternate communication strategies should be developed for effective communication.

Posterior semicircular canal dehiscence: a diagnostic and surgical conundrum

Third window defects have increasingly been identified as a cause of vertigo. These defects are bony dehiscences that occur in the bony labyrinth, resulting in abnormal pressure gradient in the inner ear fluids leading to sound (Tullio's phenomenon) or pressure (Hennebert's sign) induced vertigo. The superior semicircular canal dehiscence syndrome is a well-described entity in this regard, however defects of the posterior semicircular canal are rare and may have overlapping symptomatology. We describe the history, clinical profile and management of a patient who had importunate symptoms despite being on conservative management for a year and had resolution of vestibular symptoms following surgical management.

Adenomyosis:A Clinico-pathological Study

BACKGROUND

Adenomyosis is defined by the presence within the myometrium of benign endometrial glands and stroma. Several theories have evolved to explain the pathogenesis of adenomyosis. A third of adenomyosis cases are asymptomatic. Symptoms are however non-specific and are generally related to abnormal vaginal bleeding, pain, infertility, and feeling of pelvic mass. Adenomyosis do coexist with other pathological entities. Diagnosis is achieved through imaging and histology. Treatment could be medical, surgical or a combination of both. The objective of this study was to analyze diagnosed st stcases of adenomyosis, between 1 January 2007, and 31 December 2013 at the Jos University Teaching Hospital in relation to patient's age, common symptoms, and coexisting utero-cervical pathologies.

METHODOLOGY

The data from the Medical Records department, Radiology department, and Histopathology department at the Jos University Teaching Hospital, Jos, were mobilized. The information retrieved for each case included: age, symptoms, and coexisting utero-cervical lesions. Archival slides were reviewed to histologically confirm the diagnosis of adenomyosis. In cases with missing slides, archival tissue blocks were retrieved, sectioned into 5µm slides, stained with haematoxylin and eosin, and reviewed microscopically to confirm the diagnosis of adenomyosis.

RESULTS

One hundred and fifty seven (157) cases of adenomyosis were diagnosed at the Jos University Teaching Hospital. All cases were histologically diagnosed retrospectively after hysterectomy. The cases were divided into two broad groups: 107(68.2%) cases with adenomyosis only (A), and 50(31.8%) with coexistence of adenomyosis and leiomyoma (AL). The mean age for the general study population was 43.57+8.56, while those for A and AL groups were 44.37+9.12, and 41.86+6.99 respectively. The age group 41-50 years had the highest number of cases in both the A and AL groups: 53(49.5%) and 21(42.0%) cases respectively. The most frequent symptom was menorrhagia, occurring in 87(81.3%), 43(86.0%), and 130(82.8%) cases in the A, AL, and general population respectively.

CONCLUSION

Adenomyosis is commoner in the fourth decade of life. It commonly coexists with leiomyoma with menorrhagia being the most frequent symptom. Retrospective histology after a hysterectomy is the diagnostic tool for the disease in our center.

Sunbed use and campaign initiatives in the Danish population, 2007-2009: a cross-sectional study

BACKGROUND

Denmark has experienced an increase in melanoma incidence since the 1960s. In 2007, a skin cancer prevention campaign was launched, one of the targets being the widespread use of sunbeds in Denmark. The antisunbed campaign comprised public affairs initiatives and campaign activities, which included the social media, with young people as the main target.

OBJECTIVE

The aim of this study was to describe the development in sunbed use after the start of the campaign in the period 2007-2009.

METHODS

A population-based sample of 14,514 respondents aged 15-59 years completed four questionnaires in 2007-2009 on artificial exposure to ultraviolet radiation. We examined the relations between sunbed use, time and demographic factors using logistic regression analysis.

RESULTS

The odds ratio (OR) for being a sunbed user in 2009 when compared with 2007 was 0.61 (0.54-0.69); in the age group of 15-19 years, the OR was 0.42 (0.30-0.69). In 2009, however, 23% of Danes (33% of 15-19-year-olds) still reported sunbed use within the past 12 months, and more than 50% had experienced sunburn caused by a sunbed. In 2009, the majority of the population, including the age group of 15-19 years, was in favour of restricting admission to sunbed parlours for children under 18 years.

CONCLUSIONS

Sunbed use in Denmark decreased concurrently with the campaign activities, with the largest change in the youngest age group, which was a prioritized target of the campaign. Results suggest that a legislative solution should be found to avoid exposure of a large proportion of children to ultraviolet radiation and to reduce future melanoma incidence.

Skull Base Osteomyelitis Caused by an Elegant Fungus

Malignant otitIs externa (skull base osteomyelitis) is predominantly caused by bacteria while fungal etiology is rare. We report a middle aged diabetic gentleman who succumbed to invasive skull base infection due to Apophysomyces elegans a fungus belonging to Zygomycetes which causes only skin and soft tissue infections. Mortality and invasive infections due to this genus is rarely reported, especially in the ear.

Inception and movement of a 'subgrain boundary precursor' in ice under an applied stress, observed by X-ray synchrotron radiation Bragg imaging

Basal slip of dislocations, the easiest deformation mechanism of ice crystals, does not allow a response to any strain state. The first steps of another mechanism, with a moving subgrain boundary precursor region, which permits accommodating the effect of an applied load, is investigated on an ice single crystal, mainly using synchrotron radiation Bragg diffraction imaging. During this process, the evolution of the local integrated intensity shows that there is both a general multiplication of dislocations within the crystal and a movement of basal dislocations towards the surface. The 'subgrain boundary precursor' region evolves towards a classical grain boundary when further deformed.