The Dawn and Advancement of the Knowledge of the Genetics of Migraine

Background: Migraine is a prevalent episodic brain disorder known for recurrent attacks of unilateral headaches, accompanied by complaints of photophobia, phonophobia, nausea, and vomiting. Two main categories of migraine are migraine with aura (MA) and migraine without aura (MO). Main body: Early twin and population studies have shown a genetic basis for these disorders, and efforts have been invested since to discern the genes involved. Many techniques, including candidate-gene association studies, loci linkage studies, genome-wide association, and transcription studies, have been used for this goal. As a result, several genes were pinned with concurrent and conflicting data among studies. It is important to understand the evolution of techniques and their findings. Conclusions: This review provides a chronological understanding of the different techniques used from the dawn of migraine genetic investigations and the genes linked with the migraine subtypes.

Google Trends Analysis of Otologic Symptom Searches Following COVID-19

Introduction

COVID-19 infection was accompanied by otologic symptoms, a pattern that was captured early by Google Trends. The objective of this study is to investigate searches for otologic symptoms and identify correlations with the pandemic onset.

Materials and Methods

Search interest for otologic symptoms was gathered using Google Trends from two years before and two years following the pandemic start date. A two-tailed Mann-Whitney U test was used to identify significant changes and effect size.

Results

In total, search interest for 14 terms was collected, with significant changes identified in 11. Six terms showed increased search interest, with the most significant rises observed for headache (r=0.589, p<0.001), dizziness (r=0.554, p<0.001), and tinnitus (r=0.410, p<0.001). Search interest decreased for five terms, with the most notable declines found in searches for migraine headache (r=0.35, p<0.001) and phonophobia (r=0.22, p=0.002). No significant changes were seen in ear pressure (p=0.142), neck pain (p=0.935), and sudden hearing loss (p=0.863) searches.

Conclusion

COVID-19 infection is often accompanied otologic symptoms and holds a diagnostic role. Fluctuating search interest may be attributed to a true increase in cases, media trends, or people's desires to stay informed. Google Trends robustly captured trends in search interest and presented itself as a valuable epidemiological tool.

Online ratings and narrative comments of American Head and Neck Society surgeons

BACKGROUND

We analyzed online rating scores and comments of head and neck surgeons to understand factors that contribute to higher ratings.

METHODS

Numerical ratings and comments for American Head and Neck Society physicians were extracted from Healthgrades, Vitals, RateMDs, and Yelp, with narrative comments categorized based on content. Physician practice location, education, and residency training were also compiled.

RESULTS

Patient ratings were significantly higher with supportive staff and affable physician demeanor but showed significant drops with longer wait times and difficulties scheduling appointments or follow-ups. Physician education and postgraduate training did not significantly affect ratings.

CONCLUSION

Online ratings and comments correlated to modifiable factors in clinical practice and may be informative in understanding patient needs.

Assessment of laryngologists' ratings on physician review websites

Objective

To assess and characterize online ratings and comments on laryngologists and determine factors that correlate with higher ratings.

Methods

All the American Laryngological Association (ALA) members were queried across several online platforms. Ratings were normalized for comparison on a five-point Likert scale. Ratings were categorized based on context and for positive/negative aspects.

Results

Of the 331 ALA members, 256 (77%) were rated on at least one online platform. Across all platforms, the average overall rating was 4.39 ± 0.61 (range: 1.00-5.00). Specific positive ratings including "bedside manners," "diagnostic accuracy," "adequate time spent with patient," "appropriate follow-up," and "physician timeliness" had significant positive correlations to overall ratings, by Pearson's correlation (P < 0.001). Long wait times had significant negative correlations to overall ratings (P < 0.001).

Conclusion

Online ratings and comments for laryngologists are significantly influenced by patient perceptions of bedside manner, physician competence, and time spent with the patient.

A Novel Technique of Reduction Meatoplasty for Correction of Very Large Meatus from a Previous Canal Wall-Down Mastoidectomy

OBJECTIVE

To evaluate the efficacy of reduction meatoplasty, a novel technique aiming to improve the usage of molded hearing aids and ear plugs in patients undergoing mastoid obliteration of a previous canal wall-down (CWD) mastoidectomy, complicated with a very large meatus.

PATIENTS

Twenty-six patients from a tertiary care neurotology clinic with a very large meatus from a previous CWD mastoidectomy, who were unable to use molded hearing aids or ear plugs for water protection.

INTERVENTION

Reduction meatoplasty after mastoid obliteration (cartilage strips and bone pate) of the CWD mastoidectomy. The procedure involves removing a wedge of skin and underlying soft tissue superiorly in the meatus.

MAIN OUTCOME MEASURES

Reduction in meatus size, enabling usage of hearing aids and ear plugs.

RESULTS

Twenty-six patients underwent mastoid obliteration and reduction meatoplasty to reduce meatus size. Patients were followed up for an average of 22 months postoperation. After operation, the meatus size was significantly reduced in all patients, enabling usage of over-the-counter ear plugs. In addition, all six patients with hearing aids could use standard occlusive hearing aid domes without requiring molded hearing aids. No patients showed symptoms of chronic infection in the mastoid cavity during the follow-up period.

CONCLUSIONS

Results of reduction meatoplasty showed significant improvements in functionality of the external auditory meatus, indicating that this technique is effective in reducing meatus size and improving the normal meatal anatomy after mastoid obliteration.

Reply to Theodorou et al. Comment on "Umemoto et al. Management of Migraine-Associated Vestibulocochlear Disorders. Audiol. Res. 2023, 13, 528-545"

We thank the authors for their insightful and thoughtful commentary on our recent publication [...].

Triamcinolone Injection for Cochlear Implant Magnet Adherence Issues

OBJECTIVES

To evaluate the effectiveness of triamcinolone injections in treating external magnet displacement in cochlear implant (CI) patients with adhesions problems of their processor.

PATIENTS

We present seven CI patients with magnet adhesion issues who presented to our tertiary care neurotology clinic. None of the patients had a history of head trauma, postimplant MRI, or surgery in the head and neck other than the cochlear implantation.

INTERVENTION

Triamcinolone 40 mg/mL injected subcutaneously at the CI magnet site.

MAIN OUTCOME MEASURE

Reduction of scalp thickness and successful magnet retention.

RESULTS

Our cohort consisted of seven patients (eight implant sites) of which five were overweight or obese. The temporoparietal scalp thickness measured on preoperative CT scans varied between 8.4 and 15.9 mm. Initial conservative measures such as hair shaving at the magnet site, using a headband, and increasing magnet strength failed in all patients. After receiving triamcinolone injections at the CI receiver site, six out of seven patients (seven out of eight CI sites) were able to use their processor again without the need for a headband for an average of 9.55 hours/day. The average number of injections required for each patient was 2.57 (SD = 2.18), median (range) = 1 (1-7). One patient required a flap thinning surgery but showed no improvement even after flap thinning. None of the patients showed skin irritation, breakdown, ulceration, necrosis, or magnet exposure during follow-up period.

CONCLUSIONS

The significant improvement in CI retention shows that triamcinolone injections are effective in making the subcutaneous tissue thinner and allowing magnet retention.

Migraine management for the otolaryngologist

Objective

To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine.

Methods

Narrative review of available literature.

Results

Migraine disorder can be described as a spectrum of otologic manifestations, with vestibular migraine now recognized with fully-fledged diagnostic criteria. Otologic manifestations are theorized to be due, in part, to trigeminal innervation of the inner ear structures and calcitonin gene-related peptide (CGRP) expression within the labyrinth. Patients can experience vertigo, aural fullness, enhanced tinnitus, and hearing loss without the characteristic migraine headache, leading to under recognition of these symptoms as migraine-related. Meniere's disease, mal de débarquement syndrome, persistent postural perceptual dizziness, and recurrent benign paroxysmal positional vertigo have close associations to migraine and may exist on the migraine spectrum. Migraine treatment consists of two goals: halting acute attacks (abortive therapy) and preventing attacks (prophylactic therapy). Abortive medications include triptans, corticosteroids, anti-histamines, and anti-emetics. Pharmacologic prophylaxis in conjunction with lifestyle modifications can decrease frequency and severity of symptoms and include tricyclic antidepressants, calcium channel blockers, anti-epileptic medications, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, beta-blockers, gepants, and monoclonal antibodies to CGRP. Promising evidence is emerging regarding the ability of migraine medications to positively treat the various otologic symptoms of migraine.

Conclusion

Migraine disorder manifesting with primarily cochleovestibular symptoms can be challenging to diagnose and manage for practicing clinicians. Patients with various vestibulopathies that are closely related to migraine may benefit from migraine treatment. Lifestyle choices and prophylactic medications are key to satisfactorily preventing acute migrainous attacks and improve function.

Management of Migraine-Associated Vestibulocochlear Disorders

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

Correlation Between Laterality of Hearing Loss and Migraine Features in Menière's Disease

OBJECTIVES

The objective of this study is to understand whether the hearing loss laterality in Menière's disease (MD) correlates with migraine symptoms laterality such as headache, neck stiffness, and otalgia.

METHODS

We performed a retrospective review of prospectively obtained data on patients presenting between September 2015 and October 2021 with definite or probable MD. A custom-designed, comprehensive questionnaire was used to identify patients' migraine-related symptoms. The clinical and audiometric data were used to diagnose patients with definite or probable MD using criteria set by the American Academy of Otolaryngology-Head and Neck Surgery.

RESULTS

In total, 113 patients with definite or probable MD were included in the study. The mean age of the patients was 60 ± 15 years with no gender predominance (49.6% male and 50.4% female). A total of 57 (50%) patients were presented with headaches. Among the migraine headache cohort, headache and otalgia were on the same side as the MD ear affected by hearing loss. In addition, in patients who present with otalgia as the primary feature of headache, otalgia was more likely to be on the same side as the ear affected by the hearing loss.

CONCLUSIONS

The high prevalence of migraine symptoms on the same side of the ear affected by MD among this cohort could suggest a shared pathophysiology in both MD and migraine, possibly involving migraine-related changes in both the cochlea and vestibule.

Artificial neural network prediction of post-thyroidectomy outcome

OBJECTIVES

The goal of this study was to develop a deep neural network (DNN) for predicting surgical/medical complications and unplanned reoperations following thyroidectomy.

DESIGN, SETTING, AND PARTICIPANTS

The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to extract patients who underwent thyroidectomy. A DNN consisting of 10 layers was developed with an 80:20 breakdown for training and testing.

MAIN OUTCOME MEASURES

Three primary outcomes of interest, including occurrence of surgical complications, medical complications, and unplanned reoperation were predicted.

RESULTS

Of the 21 550 patients who underwent thyroidectomy, medical complications, surgical complications and reoperation occurred in 1723 (8.0%), 943 (4.38%) and 2448 (11.36%) patients, respectively. The DNN performed with an area under the curve of receiver operating characteristics of .783 (medical complications), .709 (surgical complications) and .703 (reoperations). Accuracy, specificity and negative predictive values of the model for all outcome variables ranged 78.2%-97.2%, while sensitivity and positive predictive values ranged 11.6%-62.5%. Variables with high permutation importance included sex, inpatient versus outpatient and American Society of Anesthesiologists class.

CONCLUSIONS

We predicted surgical/medical complications and unplanned reoperation following thyroidectomy via development of a well-performing ML algorithm. We have also developed a web-based application available on mobile devices to demonstrate the predictive capacity of our models in real time.

Treatment of Stapedial Myoclonus as a Migraine-Related Phenomenon

OBJECTIVE

To describe a case series of patients with stapedial myoclonus (SM) whose conditions improved after prophylactic migraine treatment.

PATIENTS

We present seven cases of SM reported from a tertiary care neurotology clinic. All seven patients reported SM triggers similar to those of migraine headaches and suffered from concomitant headaches and/or vertigo, and were thus treated with a standard migraine protocol used at this neurotology clinic.

INTERVENTION

Prophylactic migraine treatment.

MAIN OUTCOME MEASURES

Reduction or resolution of SM.

RESULTS

In this series, seven patients with SM were included. Six of seven subjects were male (86%), with a mean age at presentation of 44 years. Four patients noted significant improvement in their symptoms, with a reduced frequency, duration, and intensity of their symptoms with the migraine regimen. Three patients experienced complete resolution of SM with their migraine treatment.

CONCLUSION

We report that treatment with prophylactic migraine treatment can provide long-term relief for patients with SM, which may suggest an etiological association between migraine and SM as well as a possible treatment for SM.

Tympanostomy tube placement for pressure-sensitive vertigo

Objective

To evaluate tympanostomy tube placement in patients with pressure-sensitive vertigo.

Methods

Retrospective case series.

Results

Six patients with pressure-sensitive vertigo reported resolution of their vertigo and other vestibular symptoms after placement of the tympanostomy tubes. All recurrences of symptoms were due to either extrusion or plugging of the tubes. All patients fulfilled the criteria for vestibular migraine. None of the patients had superior canal dehiscence on imaging or precedent event that triggered the problem, and all had a negative fistula test.

Conclusion

Tympanostomy tube placement should be considered in selected patients with vertigo exacerbated by seemingly small changes in atmospheric pressure (e.g., just prior to thunderstorms, air travel, or travel to the mountains). By eliminating the capability of the tympanic membrane to sense changes in pressure with a tube, patients with pressure-induced vertigo (in the absence of perilymph fistula or superior canal dehiscence) may have relief of their symptoms.

Level of Evidence IV

Migrainous Vertigo, Tinnitus, and Ear Symptoms and Alternatives

Migraine headaches frequently coexist with vestibular symptoms such as vertigo, motion sickness, and gait instability. Migraine-related vasospasm can also damage the inner ear, which results in symptoms such as sudden sensorineural hearing loss and resultant tinnitus. The pathophysiology of these symptoms is not yet fully understood, and despite their prevalence, there is no universally approved management. This review summarizes the data on complementary and integrative medicine in treating patients with migrainous ear disorders.

Cholesteatoma With Cochlear Fistula and Carotid Dehiscence

Cholesteatomas are non-neoplastic, invasive lesions created by the accumulation of keratinized squamous epithelium in the temporal bone. If left untreated, its expansion may cause local destruction of the surrounding structures, eventually leading to inner ear fistula, dehiscence of tegmen and possible intracranial pathology, and facial nerve paralysis. Surgical resection is the mainstay of curative treatment. We hereby present a case of a giant cholesteatoma in a 62-year-old patient who presented with a right-sided hemifacial spasm with later paralysis who was treated with botulinum toxin injection by a neurologist. CT scan imaging showed a very large cholesteatoma with involvement of the carotid canal, cochlea, and geniculate ganglion. The patient underwent transmastoid and subarcuate approach for resection which led to marked improvement of her symptoms.