Tone burst electrocochleography disproves a diagnosis of Meniere's disease treated aggressively

Reliable confirmation of the presence or absence of endolymphatic hydrops is essential to avoid confusing vestibular migraine with Meniere's disease. MRI inner ear imaging is a promising new method to confirm hydrops, avoiding both unnecessary invasive or destructive inner ear treatments, but it is not universally available. Tone burst electrocochleography is an older simple, quick, safe, and sensitive test that is potentially available, with existing (or minorly upgraded) equipment at most tertiary medical centers. In Meniere's disease hydrops remains after intratympanic treatments. A case is presented of a 45 year-old man with a long history of recurrent vertigo attacks who, due to an erroneous diagnosis of Meniere's disease, was given five intratympanic treatments with no effect. He was subsequently found by tone burst electrocochleography to have no hydrops and was differentially diagnosed with probable vestibular migraine. Response to treatment confirms this diagnosis. This patient's electrocochleographic findings are compared with two other patients with definite Meniere's disease, one of whom had demonstrable hydrops despite intratympanic gentamycin treatments.

On the classification of hydropic ear disease (Menière's disease)

More than 150 years after its initial description by Prosper Menière, the disease named after him is still at the center of scientific debates. Two recent developments have specifically created a breeding ground for controversy: (1) Since its first description 10 years ago, magnetic resonance imaging diagnosis of endolymphatic hydrops in living patients has seen an increasing and worldwide application. (2) The Bárány Society Classification Committee published diagnostic criteria for Menière's disease in 2015 and proposed a concept of the disease that has elicited widespread criticism. In order to promote the understanding of the underlying controversies and arguments, this article gives an overview of and discusses relevant classification proposals for Menière's disease, including the new classification system of hydropic ear disease.

Barriers around access to abortion experienced by rural women in New South Wales, Australia

INTRODUCTION

Little is known about Australian rural women's overall experiences of accessing an abortion service and the barriers they encounter. Approximately one in three Australian women access an abortion at some time in their lives. Most abortions are undertaken during the first trimester of pregnancy in private clinics. Although both medical and surgical abortions are uncomplicated medical procedures, abortion remains a contentious area of women's health. Whilst it is clear that rural women experience disparities in relation to access to health care, there is a gap in the evidence on rural women's experiences of accessing an abortion. The aim of the present study was to identify factors that women in rural New South Wales (NSW) experience in accessing abortion services and suggestions about how rural women could be better supported when seeking access to an abortion service.

METHODS

In-depth qualitative interviews were undertaken with rural women living in NSW who had had an abortion in the previous 15 years. Participants self-selected for a phone or face-to-face interview, in response to promotion of the study through women's services, community flyers and press releases.

RESULTS

Rural women in this study experienced many barriers to accessing an abortion. Women travelled 1-9 hours one way to access an abortion in clinics. Several women borrowed money for the abortion fee. Five themes were identified: finding information about the provider; stigma, shame and secrecy; logistics involved in accessing the clinic related to travel, money and support; medical and surgical abortion; and ways rural women could be better supported in this process. Suggestions to improve rural women's access to abortion services included more affordable services that were 'closer to home' as a way to reduce travel and cost, and to normalise abortion as a women's health rights issue.

CONCLUSIONS

Despite welcome legal and pharmaceutical reform in Australia, results from this small study indicate that there is a long way to go remove barriers on issues rural women experience in their process of accessing reproductive care, including the pervasiveness of abortion stigma. Services closer to home may help reduce inequities in access to health care experienced by rural women. Strategies such as broader use of tele-health and willingness of general practitioners to become authorised prescribers for medical abortions could help to reduce long distances to travel to services and the financial burden experienced by rural women.

When not to syringe an ear

This article reviews the potential hazards of ear syringing and the Accident Compensation Corporation Medical Misadventure Unit's experience of alleged iatrogenic injury over a 17-month period. Syringing claims account for about 25% of the total claims received by the ACC ENT Medical Misadventure Committee. Forty-seven claims were accepted as either mishap or error, and 63 claims were declined. Perforation of the drum was by far the commonest injury resulting in significant disability. Severe iatrogenic otitis externa accounted for most of the remainder. Practice nurses had syringed the ears of approximately two-thirds of the claimants with significant disability. The contraindications to ear syringing are listed and discussed. The correct technique, with a few "do and don't" pointers, is briefly reviewed. Management of the unintentional injury is discussed.

Prospective, randomized, controlled study comparing two dosing regimens of gentamicin/oral ciprofloxacin switch therapy for acute pyelonephritis

Aminoglycosides are drugs of choice for severe gram-negative urinary tract sepsis. Recent evidence suggests that they are just as efficacious, but less nephrotoxic and ototoxic, if given as a single daily dose rather than in divided doses. We considered that a single, large dose of an aminoglycoside followed by oral therapy with a different antibiotic might be equally effective and possibly less toxic. This randomized, controlled study compared a single large i.v. dose (10 mg/kg) of gentamicin (S) with a standard multiple dose regimen (M) of gentamicin (2.5 mg/kg i.v. stat and then computer generated divided doses aiming for peak and trough concentrations of 8 and 1.5 mg/l respectively) for the treatment of patients with suspected acute pyelonephritis requiring hospitalization for parenteral antibiotic treatment. All patients were switched to oral ciprofloxacin either four hours after the S dose or when clinically appropriate in the M regimen. For all patients the total duration of treatment was five days. Fifty-three patients (48 women; mean age 32 yr) were enrolled. Clinical and bacteriological efficacy could be assessed in 41 patients. Thirteen of 16 in the S arm and 24 of 25 in the M arm were clinically cured and the other four clinically improved. Fifteen of 16 in the S arm and 23 of 25 in the M arm were cured bacteriologically (sterile urine 7-10 days after treatment). In 41 patients high tone audiometry was carried out before or very soon after the start of treatment, and again at the end of treatment. Ototoxicity (> or = 10 dB loss in > or = 2 frequencies in both ears) was observed in 3 of 18 in the S group (17%) and 7 of 23 in the M group (30%) (NS). Other side-effects and toxicity were mild and not different between groups. Substantial cost savings occurred in the S group. In summary, a large single dose of gentamicin was comparable in efficacy and toxicity to a standard regimen, but cheaper and more convenient to use.

The management of preauricular sinus

Preauricular sinus is a common congenital condition which does not always cause symptoms. It is often misdiagnosed, can be difficult to treat surgically, and recurrences are common. The results of treatment in twelve Christchurch patients are discussed and a surgical technique is described.

Abnormally patent eustachian tube syndrome

Seven new cases of abnormally patent eustachian tube syndrome are presented. It is an uncommon disorder in which the voice and breathing are heard loudly in the affected ear. In mild cases blocked ear sensation may be the only symptom. The common predisposing causes are rapid weight loss and pregnancy. It usually resolves without surgical intervention. An occasional patient is extremely distressed by the symptoms.

Chondrosarcoma arising in the nasal septum

A case is presented of a chondrosarcoma arising in the nasal septum and extending into the maxillary sinuses. This tumour is unusual in the head and neck and rarely arises in the nasal septum. Diagnostic difficulties are discussed. The treatment was radical surgery with removal of a major portion of the upper jaw, necessitating reconstruction with a maxillo-facial prothesis.

The presenting symptoms of head and neck cancer

The late presentation of head and neck malignancies is often attributable to failure by the patient and the doctors to appreciate the significance of early symptoms. The presenting features of 522 cases are summarised. They emphasize that the following clinical features are significant, especially in a patient who smokes or drinks: local pain, pain referred to the ear, hoarseness, dysphagia, dyspnoea and stridor, persistent sore throat, nasal obstruction, bleeding, problems fitting dentures and a neck lump. An adequate history and ability to examine the head and neck region are prerequisites to early diagnosis. A knowledge of the presenting features of head and neck malignancies could be stressed more adequately by public health authorities.

Fatal epistaxis from an aneurysm of the intracranial internal carotid artery

An instance of fatal epistaxis is reported in a patient with an unsuspected aneurysm of the infraclinoid portion of the internal carotid artery. There was no known history of trauma. The aneurysm was subsequently detected on an old X-ray film. Epistaxis from an aneurysm at this site is nearly always preceded by significant head trauma and is associated with cranial nerve palsies, a syndrome with a high mortality. Epistaxis from rupture of a non-traumatic aneurysm is very rare.

Carcinoma of the ureter

A case of primary carcinoma of the ureter is presented. The features of 12 previous cases are summarised and discussed with reference to the literature. The tumour occurs most commonly in the sixth and seventh decades and is often diagnosed late. Subsequent bladder tumours are common, so vigilant follow-up is necessary.

Histocompatibility antigens and immune responsiveness; their relevance to rheumatic diseases

Associations between histocompatibility antigens and human diseases have been found. Some of the highest correlations are with the so-called "rheumatoid variant" disorders. Data gained from ummunogenetic studies in laboratory animals has been invoked in speculation on the significance of the high antigen associations in disease pathogenesis. While much of this data better supports theories on the aetiology of other conditions with less significant antigen associations, it is discussed here with reference to the rheumatic diseases.