Questioning the value of stalk drilling after external auditory canal osteoma excision: case series, literature review, and meta-analysis

OBJECTIVES

To question the value of drilling the site of the stalk ("insertion site" or "stalk" drilling) of a pedunculated external auditory canal osteoma (EACO) in reducing recurrence.

DATA SOURCES

A retrospective medical chart review of all patients treated for EACO in one tertiary medical center, a systematic literature review using Medline via "PubMed", "Embase", and "Google scholar" search, and a meta-analysis of the proportion for recurrence of EACO with and without drilling.

RESULTS

The local cohort included 19 patients and the EACO origin was the anterior EAC wall in 42% and the superior EAC wall in 26%. The most common presenting symptoms were aural fullness and impacted cerumen (53% each), followed by conductive hearing loss (42%). All patients underwent post-excision canaloplasty, and one sustained EACO recurrence. Six studies suitable for analysis were identified (63 EACOs). Hearing loss, aural fullness, otalgia, and cerumen impaction were the most common clinical presentations. The most common EACO insertion site was the anterior EAC wall (37.5%), followed by the superior EAC and posterior walls (25% each). The inferior EAC wall was least affected (12.5%). There was no significant difference in recurrence between EACOs whose stalk insertions were drilled (proportion 0.09, 95% confidence interval [CI] 0.01-0.22) to the ones whose insertion was not drilled (proportion 0.05, 95% CI 0.00-0.17). The overall recurrence proportion was 0.07 (95% confidence interval 0.02-0.15).

CONCLUSION

EACO insertion site drilling does not reduce recurrence and should be avoided in the absence of a definite pedicle projecting to the EAC lumen.

Fast-Tracking of Publication Times of Otolaryngology Papers During the COVID-19 Pandemic

Introduction  The outbreak of COVID-19 has produced an unprecedented number of trials and articles. Objective  To study the impact of the COVID-19 pandemic on otolaryngology-head and neck surgery (ORL-HNS) journal processing times. Methods  Original papers search of published in selected ORL-HNS journals in terms of times from submission-to-acceptance (S-A), acceptance-to-first online publication (A-P), and submission-to-online publication (S-P). Papers were divided into those published in the pre-COVID-19 era and those during the COVID-19 era. The latter were further divided into unrelated to COVID-19 and related to COVID-19. Results  A total of 487 articles from 5 selected ORL-HNS journals were included, of which 236 (48.5%) were published during the pre-COVID-19 era and 251 (51.5%) were published during the COVID-19 era. Among them, 180 (37%) papers were not related to COVID-19, and 71 (14.5%) were related to COVID-19. The S-A duration of COVID-19-related articles was significantly shorter compared with that of papers submitted in the pre-COVID-19 era and to papers submitted in the COVID-19 era but unrelated to COVID-19 (median 6 to 34 days compared to 65 to 125 and 46 to 127, respectively) in all 5 journals. The most prominent reductions in S-A and S-P times were documented in the laryngology and otology/neurotology disciplines, respectively. Conclusions  Processing times of the included papers were significantly shorter in most of the selected ORL-HNS journals during the COVID-19 era compared with the pre-COVID-19 era. COVID-19-related papers were processed more rapidly than non-COVID-19-related papers. These findings testify to the possibility of markedly expediting S-P times and hopefully set a precedent for postpandemic publishing schedules. Level Of Evidence: 5.

Video head impulse test for the assessment of vestibular function in patients with idiopathic sudden sensorineural hearing loss without vertigo

OBJECTIVE

Idiopathic sudden sensorineural hearing loss may be accompanied by dizziness without true vertigo. This study used the video head impulse test to evaluate vestibular function in idiopathic sudden sensorineural hearing loss patients who described experiencing dizziness and not true vertigo.

METHODS

A prospective study was conducted of 30 consecutive patients diagnosed with idiopathic sudden sensorineural hearing loss with dizziness without true vertigo. A comparison of the video head impulse test results of the patients who complained of dizziness (symptomatic group) with a group of patients with idiopathic sudden sensorineural hearing loss and no dizziness (asymptomatic) was performed.

RESULTS

Nine patients (30 per cent) were symptomatic. Two of those patients had abnormal video head impulse test findings. Seven patients in the asymptomatic group (7 out of 21, 33 per cent) presented with abnormal video head impulse test results. No significant difference in vestibular function between the two groups was detected by the video head impulse test.

CONCLUSION

The site of insult in patients with idiopathic sudden sensorineural hearing loss without true vertigo is usually limited to the cochlea or the cochlear nerve.

Meta-Analysis of Acceptance and Commitment Therapy for Tinnitus

Acceptance and commitment therapy (ACT) was found to be effective with a diverse range of clinical conditions. The aim of this study is to evaluate the efficacy of ACT-based treatment for individuals with tinnitus. Meta-analysis of the scientific literature of Medline via PubMed, EMBASE, Web of Science and Google Scholar. The meta-analysis included 3 studies. The pooled mean difference in the Tinnitus Handicap Inventory (THI) score was 17.67 points lower [95% CI (- 23.50) to (- 11.84)] for the intervention arm compared to the non-treated control arm. The significant clinical reduction in the THI score indicates that ACT is an effective treatment for tinnitus.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03878-z.

Vertebrobasilar System Laterality and Idiopathic Sudden Sensorineural Hearing Loss

INTRODUCTION

The etiology of idiopathic sudden sensorineural hearing loss (ISSNHL) remains elusive, with vascular compromise as a proposed cause. This study aimed to explore the correlation between the vertebrobasilar vascular system laterality (VBVSL) and ISSNHL laterality.

METHODS

We conducted a retrospective analysis of consecutive patients diagnosed with ISSNHL from 2015 to 2020. The VBVSL pattern was established via magnetic resonance imaging scans by a neuroradiologist. ISSNHL occurring contralaterally to the basilar artery (BA) curvature or ipsilaterally to the dominant vertebral artery (VA) was designated as a "positive match," with all other scenarios classified as a "negative match."

RESULTS

Our study included 191 ISSNHL patients (median age 57 years, 89 males, 93 right ears). The majority of patients did not exhibit a positive match between ISSNHL laterality and the sides of BA curvature or dominant VA (28.8% and 36.6% for BA and VA, respectively). Notably, VA-positive match patients were significantly older than VA-negative match patients (59 vs. 53 years, p = 0.043), with a similar trend observed in BA-positive match compared to BA-negative match (59 vs. 54.5 years, p = 0.057). However, there was no significant difference in any other clinical, audiometric, or outcome factors between the positive and negative match groups.

CONCLUSION

The findings suggest no association between VBVSL and ISSNHL laterality. Furthermore, patients in the positive match group did not exhibit distinct clinical or audiometric features compared to those without a match.

Preoperative Anxiety Levels and Postoperative Middle Ear Surgery Pain Levels

OBJECTIVE

This study aimed to characterize self-reported postoperative pain after tympanoplasty and tympanomastoidectomy and correlate pain severity with the patient's preoperative anxiety state.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral medical center.

PATIENTS

Adult patients undergoing any middle ear surgery between July 2018 and July 2019.

MAIN OUTCOME MEASURES

Patient responses to an otology questionnaire (OQ) for scoring pain intensity on a visual analog scale preoperatively and on postoperative days (PODs) 1-4, 21, and 63. The responses were correlated with anxiety state (assessed by State-Trait Personality Inventory [STPI] scores) and clinical and operative data, including surgical technique-related details.

RESULTS

Sixty patients were enrolled (mean age ± standard deviation, 40 ± 19.7 yr, 26 men). Their median preoperative (baseline) visual analog scale pain score was 6 on POD1, 5 on POD3, and 1 at 3 and 7 weeks. Their median preoperative OQ score was 32 of 70 (45.7%), 37 of 70 (52.8%) on POD1, 33 of 70 (47.1%) on POD3, 6 of 70 (8.5%) at 3 weeks, and 6 of 70 at 7 weeks. Their overall mean preoperative anxiety level (STPI score) was 2.63 ± 1.50. STPI scores were significantly higher among patients who reported OQ scores equal to or higher than the median during PODs 1 to 4 in comparison to patients who reported OQ scores lower than the median. The α Cronbach correlation between anxiety and postoperative pain scores on POD1 was 0.97.

CONCLUSION

Preoperative anxiety levels are closely associated with postoperative pain levels after any middle ear surgery. Measures to control preoperative anxiety are warranted to alleviate postoperative pain.

Could the Audiometric Criteria for Sudden Sensorineural Hearing Loss Miss Vestibular Schwannomas?

OBJECTIVE

To investigate the likelihood of missing a vestibular schwannoma (VS) diagnosis in patients who present with a sudden hearing loss (SHL) that does not meet the most accepted audiometric criteria for sudden sensorineural hearing loss (SSNHL) (a decrease of ≥30 dB at three consecutive frequencies).

METHODS

All adult patients (>18 years) diagnosed with SHL of any severity in a tertiary care referral medical center between 2015 and 2020 and who underwent an MRI scan to rule out VS were included. Statistical analyses were conducted to evaluate the difference between the rate of VS among patients with an initial audiogram, which met the abovementioned criteria, and those who did not. Other audiometric criteria for SNHL were also evaluated (≥10 dB at ≥2 frequencies and ≥ 15 dB at one frequency).

RESULTS

Of the 332 patients included in the study, 152 met the audiometric criteria for SSNHL, and 180 did not. Both groups had a similar VS rate (8.6% vs. 8.9%, p = 0.914). Similar results were found when other audiometric criteria for asymmetric SNHL were analyzed. In a subgroup analysis of patients with VS-associated SSNHL, neither the tumor size nor the Koos classification was associated with any of the audiometric criteria systems.

CONCLUSION

There should be a high index of suspicion for the presence of VS in patients with an SHL of any severity.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:670-675, 2023.

Is Sudden Sensorineural Hearing Loss an Otologic Emergency? Evidence-Based Cutoff for Optimal Treatment Initiation for Sudden Unilateral Sensorineural Hearing Loss: A Case Series and Meta-Analyses

OBJECTIVES

To study the need for defining unilateral idiopathic sudden sensorineural hearing loss (ISSNHL) as an otologic emergency and establish an evidence-based cutoff for treatment initiation for optimal outcome.

METHODS

A systematic literature search of "MEDLINE" via "PubMed," "Embase," and "Web of Science" and original case series comparing the outcome of steroidal treatment for ISSNHL as a function of delays of patient presentation, of diagnosis, and of treatment initiation. Total delay was defined as days from ISSNHL onset to first steroidal dose and divided into up to 3 days, up to 7 days, up to 14 days, and >14 days.

RESULTS

The literature search identified 1,469 ears and our original case series contributed 154 ears suitable for study inclusion, resulting in 1,623 ears for statistical analysis. An odds ratio (OR) of 0.42 (95% confidence interval [CI], 0.25-0.71) was calculated for recovery if treatment had been initiated within the third day since the sudden occurrence of a unilateral hearing loss compared with treatment initiation on or after the fourth day (I 2 = 40.1%). The calculated OR for recovery was 0.35 (95% CI, 0.26-0.47) when treatment was initiated during the first 7 days after the sudden hearing loss onset compared with a delay of 8 days or more (I 2 = 52.1%). The OR was 0.31 (95% CI, 0.21-0.46) when treatment was initiated during the first 14 days after the event compared with a longer delay (I 2 = 0.0%).

CONCLUSION

Unilateral ISSNHL should be considered a medical emergency. Initiating treatment before 3 days have elapsed since the event portends the best outcome.

LEVEL OF EVIDENCE

Level I.

Association of inflammatory markers with hearing loss in young adults

OBJECTIVES

To assess the correlation between inflammatory markers (IM) and hearing loss (HL) in a large cohort of apparently healthy individuals.

DESIGN

A cross sectional study.

SETTING

Tel-Aviv Medical Center (a tertiary referral center) Inflammatory Survey Participants Individuals who attended the Tel-Aviv Medical Center Inflammatory Survey (TAMCIS) for a routine annual health check.

RESULTS

Out of 2,500 individuals included in the final study cohort, 1,170 (47.3%) had some hearing impairment. Those with a hearing loss in 1 or both ears had significantly higher levels of neutrophils, lymphocytes, neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, and red blood cell counts. There was a difference between low- and high- frequencies losses associated with the inflammatory status.

CONCLUSIONS

IM levels were associated with the presence of a HL, supporting a link between inflammatory changes and hearing loss.

Bell's Palsy and Pregnancy: Incidence, Comorbidities and Complications. A Meta-analysis and Systematic Review of the Literature

OBJECTIVE

Data on the association between Bell's palsy (BP) and pregnancy is scarce and there is an ongoing debate regarding the association of BP and pregnancy. We aimed to investigate the prevalence of BP among pregnant patients and determine the frequency of pregnant women in BP cohorts and vice versa, assess which term of the pregnancy and peripartum bears a higher risk for BP occurrence, and determine the prevalence of maternal comorbidities associated with BP during pregnancy MATERIALS AND METHODS: Screening standard articles and extracting data from Ovid MEDLINE (1960-2021), Embase (1960-2021), and Web of Science (1960-2021). All study types were included except for case reports. PRISMA guidelines were followed. Data were pooled by means of both fixed and random-effects models.

RESULTS

The search strategy identified 147 records. Twenty-five of the studies that met our inclusion criteria described 809 pregnant patients with BP in a total of 11,813 BP patients and they were included in the meta-analysis. The incidence of BP among the pregnant patients was 0.05%; The incidence of pregnant patients among all BP patients was 6.62%. Most of the BP occurrences were during the third trimester (68.82%). The pooled incidence of gestational diabetes mellitus; hypertension; pre-eclampsia/eclampsia and fetal complications among the pregnant patients with BP was 6.3%, 13.97%, 9.54%, and 6.74%, respectively.

CONCLUSIONS

This meta-analysis revealed a low incidence of BP during pregnancy. A Higher proportion occurred during the third trimester. The association of BP and pregnancy warrants further exploration.

Neurovascular conflict and sudden unilateral sensorineural hearing loss: coincidence or coexistence?

OBJECTIVE

To study the association between neurovascular conflict (NVC) of the 8th cranial nerve (CN8) and unilateral sudden sensorineural hearing loss SSNHL (SSNHL).

METHODS

A systematic literature search of "MEDLINE" via "PubMed," "Embase," and "Google-Scholar" was conducted. Meta-analysis of pooled data was performed for NVC prevalence of SSNHL affected ears versus controls.

RESULTS

The literature search identified 941 publications, of which, 9 included in qualitative synthesis (1030 ears) and 5 in quantitative synthesis (484 ears). NVC was as prevalent as 0.8-69% for affected ears and as 19-57% for controlled ears. No association between MRI protocol and NVC prevalence was proved. An odds ratio of 1.05 (95% confidence interval = 0.79-1.39) was calculated for association of NVC in unilateral SSNHL ears versus controls.

CONCLUSION

The prevalence of NVC of CN8 in unilateral SSNHL affected ears is not significantly bigger than controls. Hence, NVC of CN8 is probably NOT associated with unilateral SSNHL.

LEVEL OF EVIDENCE: 1

Balance Performance of Post-Call Medical Residents

BACKGROUND

Fatigue is thought of as a leading cause of iatrogenic accidents. A significant deterioration in qualitative balance function has been shown in sleep deprived individuals.

AIM/OBJECTIVES

To quantify the degree to which balance is impaired by sleep deprivation (SD) in post-call medical residents.

METHODS

Medical residents voluntarily underwent computed dynamic posturography (CDP) before and after an on-call night, at an identical time of the day. Order of test performance was random to avoid behavioral learning. Each participant served as his or her own control.

RESULTS

Seventeen residents were enrolled (median age 32years). Average sleeping duration the night before and during the night shift was 6.5 and 1 hour, respectively. The average response times difference between alert and fatigued was 10.15 milliseconds (95% CI: 6.81-13.49 milliseconds), yielding a significantly prolonged response times from 120 milliseconds before to 130 milliseconds after the night shift (P < .001). Comparison of additional measurements of CDP performance did not differ between test conditions.

CONCLUSION

Medical residents are fatigued due to the effect of on-call nights. Sleep deprivation prolongs response times to vestibular stimuli. This finding probably has an effect on execution of manual skills and may reflect a more generalized slowing of responses and overall performance impairment.

SIGNIFICANCE

The vestibular system is susceptible to SD.

Spontaneous recovery rate of idiopathic sudden sensorineural hearing loss: A systematic review and meta-analysis

PURPOSE

Steroids comprise the mainstay of treatment for idiopathic sudden sensorineural hearing loss (ISSNHL). Since steroidal treatment was integrated to clinical practice guidelines, newly published no-treatment or placebo arms in clinical trials are scarce. To evaluate the effectiveness of steroidal treatment ± hyperbaric oxygen therapy, the data should be compared to spontaneous recovery. The aim of this paper is to find the most accurate spontaneous recovery rate, in the light of which, other treatment modalities should be judged.

MATERIALS AND METHODS

Eligible studies published until July 2021 were identified through systematic searches of 'PubMed', 'Web of Science' and 'Google Scholar'. Retrospective studies and randomised/non-randomised control trials involving only adult participants (≥18 years) with ISSNHL, and placebo/no treatment were included. Only articles that used the American Academy of Otolaryngology-Head and Neck Surgery's diagnostic criteria for ISSNHL were included.

RESULTS

942 records initially identified, 166 duplicates and 753 articles were excluded based on article subject, title, and abstract. The full texts of 13 articles were reviewed. Seven studies were included for qualitative synthesis, five papers included in quantitative synthesis. 180 ears were included in pooled statistics. The pooled spontaneous recovery was 60.28% (95% confidence interval [CI] = 38.88%-79.94%) with a heterogeneity of 86.0% (95% CI = 69.4%-93.6%).

CONCLUSIONS

Spontaneous recovery of ISSNHL should not be over-looked, as it may be close to 60%. This may have both clinical and research implications.

Telemedicine for Patients With Unilateral Sudden Hearing Loss in the COVID-19 Era

Importance

Developing a telemedicine tool to discriminate between patients who need urgent treatment for sudden sensorineural hearing loss (SSNHL) from those who do not takes on special importance during the COVID-19 pandemic.

Objective

To explore the feasibility of a telemedicine model to assist in the evaluation of new-onset unilateral sudden hearing loss (SHL) among patients who do not have access to medical resources, especially during the COVID-19 pandemic.

Design, Setting, and Participants

This prospective cohort investigation of a telemedicine model was conducted at a tertiary referral medical center between May 2020 and January 2021, with the interpreting physician blinded to the results of formal audiograms. The study included a consecutive sample of adult patients (aged ≥18 years) referred to the otolaryngology emergency department in our medical center with the chief complaint of new-onset unilateral SHL.

Interventions

The telemedicine model comprised 2 sequential steps: a Weber test using the Hum Test and a smartphone-based vibration, and uHear app-based audiometry.

Main Outcomes and Measures

Discrimination between patients with and without SSNHL by using the telemedicine model. All diagnoses subsequently confirmed by a formal audiogram.

Results

Fifty-one patients with new-onset unilateral SHL participated in the study study (median age, 45 [range, 18-76] years; 28 [54.9%] men). The sensitivity and specificity of the telemedicine model for fulfilling the audiometric criteria of SSNHL (loss of ≥30 dB in ≥3 consecutive frequencies) were 100% (95% CI, 84%-100%) and 73% (95% CI, 54%-88%), respectively. The PPV was 72% (95% CI, 53%-87%), the NPV was 100% (95% CI, 85%-100%), and the accuracy was 84.3% (95% CI, 71%-93%). Although 8 participants had false-positive results, all of them had SSNHL that did not meet the full audiometric criteria.

Conclusions and Relevance

The telemedicine model presented in this study for the diagnosis of SSNHL is valid and reliable. It may serve as a primary tool for the discrimination between patients in need of urgent care for SSNHL from those who are not, especially during the COVID-19 pandemic.

Evaluation of the Quality of Online Information on Sudden Sensorineural Hearing Loss

OBJECTIVE

To evaluate the quality of leading Internet resources of information on sudden sensorineural hearing loss (SSNHL).

STUDY DESIGN

Cross-sectional descriptive design.

SETTINGS

An online search by means of the Google search engine.

METHODS

An online search was conducted using terms related to SSNHL. We defined "quality" according to scaled readability measures (Flesch Reading Ease [FRE] and Flesch-Kincaid Grade-Level [FKGL]), as well as "understandability" and "actionability" (Patient Education Materials Assessment Tool), and Clinical Practice Guideline (CPG) adherence. Scoring was performed by two independent physicians.

RESULTS

The 10 most frequently encountered patient education websites were analyzed. The average FRE score was "fairly difficult" (mean 57.28, median 55.55, range 46.4-71.8) and the average FKGL score was "standard" (mean 9th grade, median 9th grade, range 5th-10th grade). Nine websites were understandable (mean 83%, median 84%, range 69-100%), and seven had good actionability scores (mean 73%, median 75%, range 50-100%). Most websites conformed with the CPG for patient education at a reasonable level (mean 5.6, median 5.5, range 3-7). Notably, all websites encouraged seeking medical help.

CONCLUSION

Internet resources for patient education on SSNHL vary in quality and are generally understandable to the average layman. There is still much room for better, more comprehensive and easier-to-read information to improve patients' medical knowledge about their condition.Level of Evidence: 1.

Brief cognitive-behavioral training for tinnitus relief using a mobile application: A pilot open trial

BACKGROUND

Tinnitus may be a disabling, distressing disorder whereby patients report of sounds, in the absence of external stimulus. Recent evidence supports the effectiveness of psychological interventions, particularly, cognitive behavioral therapy (CBT) based intervention for the reduction of tinnitus-related distress and disability. This study assessed the effectiveness of mobile delivered cognitive training exercises to reduce tinnitus-related distress.

MATERIALS AND METHODS

Out of 26 patients diagnosed with tinnitus, 14 participants completed all 48 levels of the app. Levels of pre-post intervention tinnitus intrusiveness and handicap were evaluated using the short Hebrew version of the Tinnitus Handicap Inventory (H-THI). Mood was assessed using a Visual Analogue Scale (VAS). Participants were instructed to complete 3-4 min of daily training for 14 days.

RESULTS

Repeated-measures ANOVA of completers showed a significant large-effect size reduction on H-THI scores. 50% of completers have shown reliable change (indicated by their Reliable Change Index [RCI] scores). No significant change was found in mood.

DISCUSSION

Several minutes a day of training using a CBT-based app targeting maladaptive believes may decreased patients' tinnitus intrusiveness and handicap.

CONCLUSIONS

Mobile apps can provide access to CBT-based interventions, using an efficient, inviting and simple platform, addressing the ramifications of tinnitus symptoms.

To patch or not to patch acute isolated traumatic tympanic membrane perforations: a case series and systematic literature review

OBJECTIVE

To date, there is no consensus about the benefits of paper patching over spontaneous healing in the management of isolated acute traumatic tympanic membrane perforations (IATTMP). In this systematic literature review and case series, we compared paper patching of IATTMP to spontaneous healing in terms of healing rate and time to heal.

DATABASES REVIEWED

A systematic literature search of English-language studies published from 1/1975 to 9/2020 was conducted using PubMed via MEDLINE, and 201 studies were identified. Another 346 studies were derived from the references of those articles. Twenty-four studies remained after omitting duplications and articles that did not meet the inclusion criteria.

METHODS

Demographics, medical history, physical examination, and audiometric results in the selected publications and in a new series of patients treated for IATTMP between 1/2018 and 1/2021 in a single tertiary referral center were retrieved and analyzed.

RESULTS

The literature review yielded 2796 ears of which 466 underwent paper patching (intervention arm). Complete perforation healing was documented in 67-97% of control arm and 92-93% of intervention arm. Our new series included 29 ears of which six underwent paper patching. Complete healing was observed in 83% and 78% in the interventional and control arms, respectively.

CONCLUSIONS

Although paper patching and watchful waiting had similar success rates in patients with IATTMP, healing after paper patching was slightly quicker among our patients. Patching is a readily applicable and technically simple office-based intervention that should be preferentially considered for IATTMP.

Non-melanoma skin cancer diagnosis: a comparison between dermoscopic and smartphone images by unified visual and sonification deep learning algorithms

Purpose

Non-melanoma skin cancer (NMSC) is the most frequent keratinocyte-origin skin tumor. It is confirmed that dermoscopy of NMSC confers a diagnostic advantage as compared to visual face-to-face assessment. COVID-19 restrictions diagnostics by telemedicine photos, which are analogous to visual inspection, displaced part of in-person visits. This study evaluated by a dual convolutional neural network (CNN) performance metrics in dermoscopic (DI) versus smartphone-captured images (SI) and tested if artificial intelligence narrows the proclaimed gap in diagnostic accuracy.

Methods

A CNN that receives a raw image and predicts malignancy, overlaid by a second independent CNN which processes a sonification (image-to-sound mapping) of the original image, were combined into a unified malignancy classifier. All images were histopathology-verified in a comparison between NMSC and benign skin lesions excised as suspected NMSCs. Study criteria outcomes were sensitivity and specificity for the unified output.

Results

Images acquired by DI (n = 132 NMSC, n = 33 benign) were compared to SI (n = 170 NMSC, n = 28 benign). DI and SI analysis metrics resulted in an area under the curve (AUC) of the receiver operator characteristic curve of 0.911 and 0.821, respectively. Accuracy was increased by DI (0.88; CI 81.9–92.4) as compared to SI (0.75; CI 68.1–80.6, p < 0.005). Sensitivity of DI was higher than SI (95.3%, CI 90.4–98.3 vs 75.3%, CI 68.1–81.6, p < 0.001), but not specificity (p = NS).

Conclusion

Telemedicine use of smartphone images might result in a substantial decrease in diagnostic performance as compared to dermoscopy, which needs to be considered by both healthcare providers and patients.

The Actual Incidence and Types of Hearing Losses in Bullous Myringitis: Case Series and Systematic Review

OBJECTIVE

To calculate the incidence of sensorineural hearing loss (SNHL; pure or as part of a mixed hearing loss, MHL) among bullous myringitis (BM) patients with a coexisting HL to assess whether steroidal treatment should be initiated even before the findings of a formal audiogram are available.

METHODS

Retrospective medical record review in a tertiary referral center and systematic review of the English literature.

RESULTS

The medical records of 81 patients with BM were retrieved among whom 50 patients (62%) had actually sustained a HL, although only 39/81 patients reported a HL when asked. Twenty-four patients had a MHL, 18 had a SNHL, and eight had a conductive HL (CHL). The systematic review included 106 ears: 17 had no HL, 53 had a MHL, 20 had a SNHL, and 16 had a CHL. The combined published and current results yielded a SNHL and MHL rates of 38/139 (27%) and 77/139 (55%), respectively of all BM patients with confirmed HL.

CONCLUSION

BM is intuitively associated with a CHL resulting from the impeded function of the affected middle ear. Medical history and physical examination are not sufficient to exclude a SNHL in BM patients, and formal audiometry is mandatory for exclusion/confirmation in this setting. Nevertheless, steroidal treatment should not be delayed until the performance of formal audiometry because the actual rate of pure CHL in this setting is very low.Level of Evidence: 2.

Meta-analysis of time to extrusion of tympanostomy tubes by tympanic membrane quadrant

OBJECTIVES

To investigate the published time to extrusion of tympanostomy tubes inserted in the various quadrants of the tympanic membrane.

METHODS

Publications were selected by a search with 'PubMed', 'Embase' and 'Web of Science'. A meta-analysis of time to extrusion as a function of tympanic membrane quadrant intubation was performed.

DESIGN, SETTING, PARTICIPANT-NOT RELEVANT MAIN OUTCOME MEASURED

Extrusion rate of tympanostomy tubes inserted in the various quadrants of the tympanic membrane.

RESULTS

Eleven studies describing 2232 tympanostomy tubes were enrolled into the quantitative meta-analysis. The extrusion rate was evaluated at 3-month intervals up to 24 months post-intubation, and it did not differ significantly at any of the time points tested for the superior and inferior anterior quadrants. The cumulative extrusion rates were as follows: 11 and 9%, 32 and 23%, 59 and 36%, 80 and 67%, 87 and 70%, 88 and 82%, and 96 and 89% in the superior and anterior quadrants, respectively, at 3, 6, 9, 15, 18, 21 and 24 months post-intubation, respectively.

CONCLUSION

Time to extrusion of tympanostomy tubes are similar for all 3 tympanic membrane quadrants. The anterior superior quadrant intubation has no superiority in terms of intubation time.

Case Series and Systematic Review of Treatment Outcomes for Auricular Pseudocysts

OBJECTIVE

Auricular pseudocyst (AP: intracartilaginous cyst, endochondral AP, cystic chondromalacia, and benign idiopathic cystic chondromalacia) is a benign condition of unknown etiology. This report systematically reviews the published demographics, treatment protocols, and outcomes of AP between the various medical disciplines, and compares the findings to a theretofore-unreported 12-patient cohort. Primary outcome measure was AP complete resolution without recurrence.

DATA SOURCE

A systematic literature search of "MEDLINE" via "PubMed" and "Google Scholar" was performed in June, 2020. The 12 new patients were enrolled between January 2016 and December 2020.

STUDY SELECTION

Seventy-four papers met the study inclusion criteria and provided data on sex distribution, surgical approach and outcome, performance of approaches according to medical specialty, and recurrence rates of the reported AP populations.

DATA EXTRACTION

The appropriateness and study design quality were independently assessed by two reviewers.

DATA SYNTHESIS

The primary outcome was therapeutic success. A comparative analysis was also performed on the same extracted information that was retrieved from the medical files of the 12 new patients (10 men, 2 women, average age 24 yrs, range, 17-38).

CONCLUSIONS

AP is not uncommon. In line with the published literature, incision and curettage with excision of the anterior pseudocystic wall (deroofing) resulted in a recurrence rate of less than 17% with good cosmetic outcome among all 12 patients. Aspiration alone was associated with increased recurrence rates. Deroofing emerged as the preferred modality, with good cosmetic outcome and reduced recurrence rate. It was usually performed by otolaryngologists, while dermatologists used more conservative approach more frequently. Incision and drainage combined with compression reduces risk of recurrence.

Residual Perforation Risk Assessment of Intratympanic Steroids via Tympanostomy Tube Versus Transtympanic Injections

OBJECTIVES/HYPOTHESIS

To investigate the risk of residual tympanic membrane (TM) perforation after intratympanic (IT) steroidal treatment administered via transtympanic injection compared with trans-tympanostomy tube (TyT).

STUDY DESIGN

Case series, systematic review and meta analysis.

METHODS

Data were retrieved from the medical files of an original cohort of all consecutive patients with sudden sensorineural hearing loss necessitating IT steroidal treatment in a tertiary medical center between January 1, 2016 and November 20, 2020. A systematic literature search of "MEDLINE" via "PubMed," "Embase," and "Web of Science" on comparable published cases was performed and meta-analysis was established.

RESULTS

Eighteen studies describing 818 ears were included in the quantitative meta-analysis in addition to a local cohort of 140 ears. The proportion of residual TM perforation was 1.11% and 1.14% (95% confidence interval: 0.01%-3.27% and 0.028%-2.38%) in the TyT and trans-tympanic groups, respectively, suggesting no significant difference in residual TM perforation risk between these techniques.

CONCLUSION

IT steroid therapy via trans-TyT is not associated with more residual perforations than IT steroid therapy via transtympanic injections.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E2583-E2591, 2021.

Weber test accuracy in sudden sensorineural hearing loss: which frequency is best?

BACKGROUND

Recent guidelines encourage the use of Webet test (WT) as a part of the physical examination of a newly suspected sudden sensorineural hearing loss (SSNHL) patient. However, the most sensitive tuning-fork frequency has never been identified.

OBJECTIVE

To identify the most sensitive frequency for initial WT of patients with suspected SSNHL.

METHODS

Medical records of patients with confirmed SSNHL, who underwent formal audiometry in which the WT was carried out with different frequencies were analyzed.

RESULTS

319 medical records were identified. The most sensitive WT frequency was 500 Hz, with a sensitivity of 94.49% (223/236. confidence interval 90.76-97.03). There was a non-significant difference between 1000 Hz EBO and 500 Hz EBO (p = .1655), a tendency towards a significant difference between 1000 Hz EBO and 2000 Hz EBO (p = .0578), and a significantly better sensitivity than the 4000 Hz EBO (p = .0163).

CONCLUSION

The most sensitive WT frequency for SSNHL diagnosis is 500 Hz. However, the sensitivity of this frequency is 94.49%.

SIGNIFICANCE

512 or 1024 Hz should be used to better identified SSNHL. Even WT lateralization to the affected ear, does not preclude the diagnosis of SSNHL. Formal audiometry should be used in any case of medical history suspected for sudden hearing loss with normal otoscopy.

Paper Patching Versus Watchful Waiting of Traumatic Tympanic Membrane Perforations: A Meta-Analysis

OBJECTIVES/HYPOTHESIS

The aim of the study was to investigate the healing rates, the restoration of hearing, and the time for complete healing of paper patching versus watchful waiting for traumatic tympanic membrane perforations (TTMPs).

STUDY DESIGN

Systematic review with meta analysis.

METHODS

Publications were selected by a search on "PubMed," "Embase," and "Web of Science." A meta-analysis of risk ratios for paper patching (intervention arm) and watchful waiting (control arm) was performed.

RESULTS

Five studies describing 393 TTMPs were included in the quantitative meta-analysis. TTMP healing rates ranged between 84.2% and 95.2% in the intervention arm and between 76.7% and 84.8% in the control arm. The pooled risk ratio of healed TTMPs was significantly higher in the intervention arm than in the control arm (risk ratio: 1.12, 95% confidence interval: 1.04-1.21).

CONCLUSIONS

TTMPs have high healing potential with and without intervention. The healing rate of paper patching was superior to that of watchful waiting alone.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:2091-2097, 2021.

Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials

BACKGROUND

Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse and the cervical vestibular-evoked myogenic potentials (cVEMPs).

OBJECTIVE

To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS.

METHODS

Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cVEMPs and the vHIT.

RESULTS

Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades.

CONCLUSIONS

This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.

Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials

BACKGROUND

Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse.

OBJECTIVE

To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS.

METHODS

Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cervical vestibular-evoked myogenic potentials (cVEMPs), and the v-HIT.

RESULTS

Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades.

CONCLUSIONS

This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.

Two brief group interventions for individuals with tinnitus in Israel

Background/Aims

Subjective tinnitus is a common impairment throughout the world and typically cannot be cured. Coping strategies are cognitive, affective, and behavioural approaches for managing stressors like tinnitus. The aim of this study was to investigate the effects of two brief interventions on coping and tinnitus-related distress.

Methods

A total of 45 individuals with tinnitus in Israel were allocated into one of three groups: acceptance and commitment therapy, coping effectiveness training, or a waitlist control group. Outcomes were assessed at three time points by the Brief Coping Orientation to Problems Experienced scale and the Tinnitus Handicap Inventory, a measure of tinnitus-related distress.

Results

There was a significant difference among the groups on post-intervention Tinnitus Handicap Inventory assessment, but not on coping, when controlling for baseline scores. Pairwise comparisons indicated that the coping effectiveness training group scored significantly lower on the Tinnitus Handicap Inventory than the waitlist control group.

Conclusions

While the results are promising, a larger study is needed to further explore the efficacy of the brief coping effectiveness training intervention.

Increased incidence of Susac syndrome: a case series study

BACKGROUND

Susac syndrome (SuS) is a rare condition characterized by a clinical triad of sensorineural hearing loss, branch artery occlusion and encephalopathy. This study reports an increased incidence of SuS in Israel. We describe the clinical characteristics of these patients, diagnostic procedures and the use and subsequent outcomes of newly published treatment guidelines.

METHODS

This is a single center retrospective study. Patients who were diagnosed with SuS between July 2017 and August 2018 were enrolled in this study.

RESULTS

Seven patients were diagnosed with SuS according to the diagnostic criteria in a time period of 13 months. The annual incidence was recently evaluated in Austria to be 0.024/100000, therefore, our case series represent at least a 5.4- fold increase in the annual incidence of SuS expected in Israel and a 7-fold increase in the annual incidence expected in our medical center. Mean time from the onset of the symptoms to diagnosis was three weeks and follow-up time was twenty four months. Recent exposure to cytomegalovirus was serologically evident in three patients and one patient had high titer of anti-streptolysin antibody. All patients underwent brain MRI, fluorescein angiography and audiometry. All patients were treated according to the newly recommended guidelines. All patients achieved clinical and radiological stability.

CONCLUSIONS

We report of an increased incidence of SuS in Israel. Infectious serological findings may imply a post infectious mechanism. The use of the recommended diagnostic procedures reduced the time to diagnosis. Newly published treatment guidelines led to favorable clinical outcomes.

Should air travel be avoided shortly after an idiopathic sudden sensorineural hearing loss?

Introduction: The effect of air travel on the recovery rate after idiopathic sudden sensorineural hearing loss (ISSNHL) has not been established. The advice to avoid flights is essentially based upon conjecture.Objectives: To analyze the recovery rate of patients who traveled by air shortly after they were treated for ISSNHL.Materials and methods: The hospital records of 115 newly diagnosed adult patients with unilateral ISSNHL were retrospectively collected. Included were patients who traveled by air within 90 days since the ISSNHL occurrence. The treatment protocol included oral prednisone and intratympanic dexamethasone injection when indicated. Audiograms performed upon presentation and 90 days later were compared.Results: Twelve patients were included (median age 45.5 years). The median treatment delay was 3 days. The average time from the ISSNHL to air-travel was 37 days, and the average air-travel distance was 13,362 km. The degree of HL was moderate, moderately severe, and severe (4 patients each). Seven patients (58%) underwent full recovery. No patients experienced further deterioration of their audiometric results after air-travel.Conclusions: This study does not support the avoidance of air-travel after ISSNHL.Significance: This study is the first to investigate the effect of air-travel on ISSNHL recovery rates, a clinical question that rises commonly.

Outcome of surgery for chronic suppurative otitis media with resistant Pseudomonas aeruginosa

OBJECTIVE

To assess the effectiveness of surgical treatment of active chronic suppurative otitis media (CSOM) with ciprofloxacin-resistant Pseudomonas aeruginosa (P. aeruginosa) that failed comprehensive local and systemic treatment.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Eleven patients with ciprofloxacin-resistant P. aeruginosa CSOM that remained active despite comprehensive local and systemic treatment. All patients were operated by a single surgeon between February 2016 and July 2019 INTERVENTION(S): Tympanoplasty alone was performed in seven cases and accompanied by mastoidectomy in the other four cases.

MAIN OUTCOME MEASURE(S)

Resolution of infection and tympanic graft take on otoscopy. The secondary outcome measure is hearing.

RESULTS

Tympanic graft take was successful and the infectious process was resolved in 8 out of the 11 cases, yielding a success rate of 73%. The average follow-up was 20 months. No surgical complications occurred.

CONCLUSIONS

Tympanoplasty, with or without mastoidectomy, is safe and yields acceptable anatomical and functional success rates when intensive local and systemic treatment fails to stop the purulent discharge.

Hearing Improvement after Sudden Sensorineural Hearing Loss as a Predictor of Vestibular Schwannoma

INTRODUCTION

Sudden sensorineural hearing loss (SSNHL) can be the presenting symptom of vestibular schwannoma (VS). Usually, steroidal treatment is given before magnetic resonance imaging (MRI) is performed.

OBJECTIVES

The aim of this study was to investigate whether there is a different pattern of steroidal treatment response after SSNHL in patients with and without a VS, in order to determine whether rapid hearing improvement can serve as a predictor of the presence of VS.

METHODS

Charts of patients with SSNHLs were reviewed. Analysis of the presenting symptoms of patients with an SSNHL with and without a coexisting VS and comparison of the response to steroids of the two groups of patients was performed.

RESULTS

A total of 420 patients were treated for SSNHLs during the study period. Treatment consisted of intraoral prednisone 1 mg/kg/day. The male-to-female ratio was 1.00:1.17, and the median age at diagnosis was 38 years (range 18-82); neither parameter correlated with the presence of VS. MRI scans demonstrated a VS in 20 patients (4.76%). Audiometric testing 7 days after steroidal treatment initiation revealed that the pure-tone average of 240 patients (60%) without VS improved, and that of the 16 (80%) patients with VS improved by the same audiometric criteria (p = 0.0007).

CONCLUSIONS

Improvement of hearing within 1 week after steroidal treatment initiation in patients with SSNHLs may suggest the presence of a VS.

Optimal Head Position Following Intratympanic Injections of Steroids, As Determined by Virtual Reality

OBJECTIVES

To study optimal head position after intratympanic steroid injections to enhance drug bioavailability.

STUDY DESIGN

Application of virtual and in vitro models of the intratympanic anatomy.

SETTING

The surgical 3-dimensional printing laboratory of a tertiary academic medical center.

SUBJECTS AND METHODS

A high-resolution computerized tomographic scan of healthy temporal bone and surrounding soft tissue was segmented and reconstructed to a 3-dimensional model. The tympanic membrane was perforated in the posterior-inferior quadrant. Methylene blue-stained 10-mg/mL dexamethasone was administered to the middle ear cleft, after which a 3-dimensional rotation in space was performed to hypothesize the optimal position in relation to gravity. The same stereolithography file used for the actual model was used for a digital virtual liquid flow simulation. The optimal head position was defined as the one with the maximum vertical distance between the round window membrane and the plane of the aditus ad antrum and eustachian tube orifice.

RESULTS

The virtual model yielded the following position of the head as optimal: 53º rotation away from the injected ear in the vertical axis (yaw), 27º rotation toward the noninjected ear in the longitudinal axis (roll), and 10º neck extension in the transverse axis (pitch).

CONCLUSIONS

Virtual imaging determined that 53º and 27º yaw and roll, respectively, away and 10º pitch were the optimal position for drug delivery after intratympanic injection to the middle ear and that an erect head position provided optimal passage of steroids from the middle ear to the inner ear.

Tinnitus Perspectives among Israeli Ear, Nose and Throat Physicians: A Nationwide Survey

OBJECTIVES

To study the compliance of ear, nose, and throat (ENT) physicians to the American Association Otolaryngology-Head - Neck Surgery (AAO-HNS) clinical practice guidelines (CPG) for tinnitus and to identify the disparity of both diagnosis and management options in the absence of a local protocol for the management of adult tinnitus.

MATERIALS AND METHODS

A voluntary and anonymous questionnaire was emailed in a Google spread-out sheet format to all practicing ENT physicians across the country (n=370). Overall, 126 ENT physicians responded to the questionnaire (34% of the physicians to whom the questionnaire was sent).

RESULTS

Medical history focuses on tinnitus characteristics and otological signs, and symptoms are often queried (80%-98%). Physicians routinely perform an otoscopic examination, whereas other relevant possible physical findings, such as temporomandibular joint disorders or neck trauma, are less frequently examined. Treating physicians have the most frequent recourse to sound therapy and cognitive behavioral therapy in accordance with AAO-HNS CPG.

CONCLUSION

The publication of the AAO-HNS CPG for tinnitus is important, permitting a common approach for the diagnosis and management of primary tinnitus (PT). A diagnosis and management scheme that takes into consideration both the AAO-HNS CPG for tinnitus as well as physician diagnosis and management paradigms is suggested.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio among Patients with Vestibular Neuritis

OBJECTIVE

To compare the level of the inflammatory markers (IM) neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) among healthy subjects and those presenting with vestibular neuritis (VN).

METHODS

A cross-sectional retrospective study was conducted in a tertiary hospital setting. The medical records of patients (20-60 years old) who were hospitalized between the years 2005 and 2014 with the diagnosis of VN were retrieved. Inclusion criteria were: (1) acute vertigo lasting for at least 24 h, (2) absence of auditory complaints, (3) presence of horizontal unidirectional nystagmus during physical examination, (4) absence of neurological symptoms or signs. The levels of the IM were compared with levels reported among two large cohorts of healthy subjects, within the same age range.

RESULTS

A statistically significant difference was found between the levels of NLR in VN subjects compared with controls, with higher levels of NLR in VN subjects (p < 0.001), while no significant difference was found between both groups concerning the levels of PLR.

CONCLUSION

Higher levels of IM were found among VN patients, with significantly higher levels of NLR, but not PLR. This may suggest a possible inflammatory etiology of VN.

A Smartphone-Based Weber Test May Discriminate between a Conductive and a Sensorineural Hearing Loss

Objective: The aim of this paper was to compare the accuracy of a smartphone-based Weber test (SPWT) with the traditional tuning fork Weber test (TFWT) in identifying and differentiating between sensorineural hearing loss (SNHL) and conductive hearing loss (CHL). Study Design: We conducted a prospective, noncontrolled clinical study. Methods: Sixty patients referred to the emergency department due to unilateral hearing loss (HL) were enrolled. They were asked to press a single uncovered smartphone on their forehead and conduct a Weber test by means of the smartphone’s vibration application. The results were compared to the TFWT. Results: Twenty-six (43%) patients were diagnosed with a SNHL, and 34 (57%) with a CHL. The SPWT was in agreement with the TFWT (at a frequency of 512 Hz) in 55 (92%) patients. The sensitivity and specificity of the TFWT were 84.6 and 94.1%, respectively. The sensitivity and specificity of the SPWT were 76.9 and 97.1%, respectively. Conclusion: SPWT can serve as an auxiliary diagnostic tool in the absence of a 512-Hz tuning fork to assist in the identification of the type of HL and to potentially hasten the diagnosis and provision of treatment when indicated.

Blast-Induced Cholesteatomas After Spontaneous Tympanic Membrane Healing

OBJECTIVES

To characterize blast-induced cholesteatomas (BIC) in terms of symptoms, presentation, and location within the middle ear cleft (MEC).

DESIGN

A search for all English language articles in "MEDLINE" via "PubMed" and "Google Scholar" was conducted.

RESULTS

A total of 67 ears with BIC were included. Fifty-eight ears in which the traumatic perforation failed to spontaneously close were excluded, leaving seven case reports (eight patients, nine ears) for statistical analysis. Time between blast exposure to spontaneous tympanic membrane (TM) closure was 16 days to 10 months. Time between blast exposure and cholesteatoma diagnosis was 5 months to 4 years. The cholesteatomas were diagnosed due to symptoms in two ears, as asymptomatic finding on physical examination in one ear and as asymptomatic finding in axial imaging in three ears.

CONCLUSIONS

BICs can develop behind intact tympanic membrane or along with TM perforation. Based on the current review, when a TM perforation and spontaneous healing were documented, after blast exposure, MRI scan is an integral component of the follow-up. The optimal timing for MRI performance after blast exposure, is yet to be identified.

Diagnostic Criteria for Somatosensory Tinnitus: A Delphi Process and Face-to-Face Meeting to Establish Consensus

Since somatic or somatosensory tinnitus (ST) was first described as a subtype of subjective tinnitus, where altered somatosensory afference from the cervical spine or temporomandibular area causes or changes a patient’s tinnitus perception, several studies in humans and animals have provided a neurophysiological explanation for this type of tinnitus. Due to a lack of unambiguous clinical tests, many authors and clinicians use their own criteria for diagnosing ST. This resulted in large differences in prevalence figures in different studies and limits the comparison of clinical trials on ST treatment. This study aimed to reach an international consensus on diagnostic criteria for ST among experts, scientists and clinicians using a Delphi survey and face-to-face consensus meeting strategy. Following recommended procedures to gain expert consensus, a two-round Delphi survey was delivered online, followed by an in-person consensus meeting. Experts agreed upon a set of criteria that strongly suggest ST. These criteria comprise items on somatosensory modulation, specific tinnitus characteristics, and symptoms that can accompany the tinnitus. None of these criteria have to be present in every single patient with ST, but in case they are present, they strongly suggest the presence of ST. Because of the international nature of the survey, we expect these criteria to gain wide acceptance in the research field and to serve as a guideline for clinicians across all disciplines. Criteria developed in this consensus paper should now allow further investigation of the extent of somatosensory influence in individual tinnitus patients and tinnitus populations.

Superior semicircular canal dehiscence with concomitant otosclerosis-A literature review and case discussion

Computed tomography scan should be performed as a routine before every stapes surgery, in order to exclude concomitant superior semicircular canal dehiscence, since no other clinical, audiological, or electro-physiological criteria are available to exclude concomitant superior semicircular canal dehiscence in the otosclerotic temporal bone.

Age-dependent variations of scalp thickness in the area designated for a cochlear implant receiver stimulator

Objective

The integrity of the scalp overlying a cochlear implant receiver stimulator (RS) is critical for the long‐term survival of the implant. Exposure or extrusion of the device will likely result in the need for its removal. There is a global trend of acceleration of population aging, thus raising the prevalence of cochlear implantation (CI) in the elderly. The aim of this study was to define age‐dependent changes in scalp thickness and discuss the implication of that anatomical characteristic for CI in the geriatric population.

Methods

Scalp thickness over the location of the RS in the temporo‐parietal area was measured directly with a needle in patients of various ages.

Results

Two‐hundred thirty‐six temporo‐parietal scalps were measured in patients aged 18 to 85 years. A strong inverse correlation was found between age and scalp thickness (rs = ‐0.723, P < .001). Scalp thickness decreased with age from a mean of 8 mm in the third decade of life to 5 mm in the ninth decade of life.

Conclusion

The human scalp thins with age and most likely undergoes a reduction in its strength. As a consequence, implantable hearing devices that are shielded by the scalp can be at increased risk of exposure and extrusion in the aging recipient. This needs to be taken into account when considering an implantation procedure, the surgical approach and patient instructions on need for and venues for continuing care over time.

Level of Evidence

2B

The association between auditory nerve neurovascular conflict and sudden unilateral sensorineural hearing loss

HYPOTHESIS

There may be an association between a neurovascular conflict (NVC) of the auditory nerve and unilateral sudden sensorineural hearing loss (SSNHL).

BACKGROUND

Compression of cranial nerves by vascular structures can lead to significant symptomatology that may require surgical decompression. Notable examples are trigeminal neuralgia and hemifacial spasm. Magnetic resonance imaging (MRI) is part of the workup for SSNHL, and it may depict an NVC of the auditory nerve. Here we look into the association between this NVC and unilateral SSNHL.

METHODS

A retrospective analysis was performed on all consecutive patients with unilateral SSNHL who underwent an MRI scan in our medical center. The data collected included age, gender, side and severity of hearing loss, and accompanying complaints. Each MRI scan was reviewed by a neuroradiologist who was unaware of hearing loss laterality. The presence, side, extent, and location of a potential NVC involving the auditory nerve were determined, and a correlation between radiological findings and auditory parameters was sought.

RESULTS

Fifty-four patients (male-to-female ratio 26:28, age range 25-80 years) were enrolled into the study. Fourteen of them (25.9%) had normal MRI findings. Twenty-six patients had a unilateral NVC, and the pathology was ipsilateral to the side of hearing loss in only 12 of them (46.2%). Fourteen (25.9%) patients had MRI findings of bilateral NVCs. There was no significant correlation between the side of the SSNHL and any radiological findings (P = .314).

CONCLUSION

The data presented herein support the conclusion that there is no association between CN8 NVC and unilateral SSNHL.

LEVEL OF EVIDENCE

2b.

Smelling Pseudomonas aeruginosa infections using a whole-cell biosensor - An alternative for the gold-standard culturing assay

Improved easy-to-use diagnostic tools for infections are in strong demand worldwide. Yet, despite dramatic advances in diagnostic technologies, the gold-standard remains culturing. Here we offer an alternative tool demonstrating that a bacterial biosensor can efficiently detect Pseudomonas aeruginosa infections in patients suffering from otitis externa. Detection was based on specific binding between the biosensor and 2-aminoacetophenone (2-AA), a volatile produced by P. aeruginosa in high amounts. We collected pus samples from ears of 26 subjects exhibiting symptoms of otitis externa. Detection of P. aeruginosa using the biosensor was compared to detection using gold-standard culturing assay and to gas-chromatograph-mass-spectrometry (GC-MS) analyses of 2-AA. The biosensor strain test matched the culture assay in 24 samples (92%) and the GC-MS analyses in 25 samples (96%). With this result in hand, we designed a device containing a whole-cell luminescent biosensor combined with a photo-multiplier tube. This device allowed detection of 2-AA at levels as low as 2 nmol, on par with detection level of GC-MS. The results of the described study demonstrate that the volatile 2-AA serves as an effective biomarker for P. aeruginosa in ear infections, and that activation of the biosensor strain by 2-AA provides a unique opportunity to design an easy-to-use device that can specifically detect P. aeruginosa infections.

A Subjective Rating Scale for Initial Assessment of Sudden Unilateral Sensorineural Hearing Loss

OBJECTIVE

To examine the value of a subjective numerical rating scale (NRS) in the initial evaluation of patients suspected of suffering from unilateral sudden sensorineural hearing loss (SSNHL) until a formal audiogram is available.

STUDY DESIGN

Prospective noncontrolled clinical study.

METHODS

Thirty-one consecutive patients referred to the emergency department due to suspected unilateral SSNHL and with no other aural pathology by history or physical examination were enrolled. Patients were asked to characterize the severity of their hearing loss using an NRS of 1 (normal hearing) to 6 (complete deafness). SSNHL was defined as an SNHL of at least 30 dB over 3 consecutive frequencies that occurred in 3 days or less. A formal audiogram was obtained subsequently as soon as available.

RESULTS

Twenty-four patients were treated with steroids and met the audiometric criteria of SSNHL. All scored their NRS as 3 or more. None of the 7 patients whose NRS grades were ≤2.5 met the criteria for SSNHL. Two patients were treated with steroids although their hearing did not meet the audiometric criteria for SSNHL as the hearing loss was limited to 2 consecutive frequencies. The NRS score for both was <3.

CONCLUSION

In addition to the patient's history and physical examination, a NRS can be a useful tool in the preliminary assessment of patients suspected of having SSNHL until audiometry becomes available. In the scale of 1-6, an NRS score of 3 or more reliably predicts the need to treat the patient with steroids according to the accepted criteria.

Acute otitis media guidelines in selected developed and developing countries: uniformity and diversity

BACKGROUND

Acute otitis media (AOM) is a common childhood disease, with an enormous economic and healthcare-related burden. Guidelines and consensus papers for AOM diagnosis and management were published in many countries. Our objective was to study the differences and similarities between these protocols in developing and developed countries.

METHODS

The keywords: 'acute otitis media' AND 'children' AND ['treatment' or 'management'] AND ['guideline' or 'consensus'] were used in various electronic databases between 1 January 1989 through 31 December 2015. Overall, 99 sources from 62 countries were retrieved: 53 from 22 developed countries, and 46 from 40 developing countries. Representative guidelines from America (the USA, Argentina), Europe (Italy, Moldova), Africa (South Africa, Tanzania, Ethiopia), Asia (Japan, Afghanistan, Sri Lanka),and Oceania (South Australia, Fiji) were compared.

RESULTS

Paediatric societies publish guidelines in most developed countries; in developing countries, the Ministry of Health usually initiates guideline formulation. Most guidelines use the same diagnostic criteria and offer watchful waiting in mild-moderate scenarios. Amoxicillin is the suggested first-line antibiotic, whereas options for second-line and third-line therapies vary. Duration of therapy varies and is usually age dependent: 5-7 days for children <2 years and 10 days for children >2 years in developed countries, while duration and age groups vary greatly in developing countries. Reduction of AOM risk factors is encouraged in developed countries, but rarely in developing countries.

CONCLUSIONS

Guidelines for AOM from developing and developed countries are similar in many aspects, with variation in specific recommendations, due to local epidemiology and healthcare accessibility. Formulation of regional guidelines may help reduce AOM burden.

Integrin-based therapy of pancreatic adenocarcinoma: current status and future perspectives

Pancreatic ductal adenocarcinoma (PDAC), although tenth in cancer incidence, holds the dubious distinction of being the fifth cause of cancer deaths in the Western countries and possibly the deadliest malignancy. Inoperable PDAC is characterized by late diagnosis, extensive metastases, extremely poor response to chemotherapy and, consequently, poor patients' prognosis-6.7% 5-year survival. PDAC reflects the failure of the medical profession to significantly prolong patients' lives and modest expectations for future cure. PDAC is characterized by extensive desmoplastic reaction, resulting in approximately 50% of tumor's volume consisting of non-tumor cells and extracellular matrix (ECM) stroma. These properties imply an important role for cell-ECM interaction, making cell-matrix adhesion molecules, such as integrins, of special interest as possible candidate targets for future anti-PDAC therapies. This review will attempt to overview the status of studies dealing with the involvement of integrins in the unique aggressive character of PDAC, the current status of experimental cancer therapies targeted at integrins, and the possible application of these preliminary clinical experiments to future PDAC therapy. I will also try to delineate the reasons for the failures of PDAC therapies and make some modest suggestions that might improve the health scientific community approaches to this extremely difficult problem.