Access to Sudden Hearing Loss Care at Urgent Care Centers.

OBJECTIVES: To compare patient access to urgent care centers (UCCs) with a diagnosis of sudden hearing loss based on insurance. METHODS: One hundred twenty-five random UCCs in states with Medicaid expansion and 125 random UCCs in states without Medicaid expansion were contacted by a research assistant posing as a family member seeking care on behalf of a patient with a one-week history of sudden, unilateral hearing loss. Each clinic was called once as a Medicaid patient and once as a private insurance (PI) patient for 500 total calls. Each phone encounter was evaluated for insurance acceptance and self-pay price. Secondary outcomes included other measures of timely/accessible care. Chi-square/McNemar's tests and independent/paired sample t-tests were performed to determine whether there were statistically significant differences between expansion status and insurance type. Calls ended before answering questions were not included in the analysis. RESULTS: Medicaid acceptance rate was significantly lower than PI (68.1% vs. 98.4%, p < 0.001). UCCs in Medicaid expansion states were significantly more likely to accept Medicaid (76.8% vs. 59.2%, p = 0.003). The mean wage-adjusted self-pay price was significantly greater in states with Medicaid expansion at $169.84 than in states without at $145.34 when called as a Medicaid patient (mean difference: $24.50, 95% Confidence Interval: $0.45-$48.54, p = 0.046). The rates of referral to an emergency department and self-pay price nondisclosure rates were greater for Medicaid calls than for private insurance calls (8.2% vs. 0.4% and 17.4% vs. 5.8%; p < 0.001 for both). CONCLUSION: Medicaid patients with otologic emergencies face reduced access to care at UCCs. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Tele-otology for Aboriginal and Torres Strait Islander People Living in Rural and Remote Areas.

OBJECTIVE: To evaluate a referral-based, tele-otology service in rural and remote areas of the Northern Territory, Australia. METHODS: A retrospective observational cohort study was performed of a tele-otology service in 93 Aboriginal and Torres Strait Islander communities (2011 to 2019). Assessments included face-to-face examinations performed by Clinical Nurse Consultants and audiologists, and asynchronous reviews performed by otolaryngologists. Multivariable logistic regression was performed to determine the likelihood of ear disease, adjusted for age and gender. Intra- and inter-rater agreement was assessed between otolaryngologists. RESULTS: A total of 3,950 patients were reviewed (6,838 encounters, 13,726 ear assessments). The median age of patients was 9.8 years (interquartile range: 7.2 years). Overall, 62.2% of patients were identified with ear disease and 62.5% identified with hearing loss. Substantial intra- and inter-rater agreement in diagnosis was found between otolaryngologists (κ = 0.71 and κ = 0.78, respectively). The most common ear conditions identified were chronic otitis media (COM, 28.1%) and otitis media with effusion (OME, 16.5%). Topical or oral antibiotics were initiated in 14.1% of all encounters, most often for acute otitis media or COM. Surgery was recommended in 27.7% of all encounters, most often myringoplasty, adenoidectomy, and myringotomy with insertion of tympanostomy tubes. CONCLUSION: Tele-otology is a critical component of an integrated approach to evaluating ear disease in Indigenous people living in rural and remote areas. The high prevalence of OME, COM, and surgical recommendations highlights the need for community engagement, regular follow-up, and early interventions to prevent long-term hearing loss. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Outcomes following cochlear implantation with eluting electrodes: A systematic review.

Objectives: To establish audiological and other outcomes following cochlear implantation in humans and animals with eluting electrodes. Methods: Systematic review and narrative synthesis. Databases searched (April 2023): MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov, and Web of Science. Studies reporting outcomes in either humans or animals following cochlear implantation with a drug-eluting electrode were included. No limits were placed on language or year of publication. Risk of bias assessment was performed on all included studies using either the Brazzelli or Systematic Review Centre for Laboratory animal Experimentation (SYRCLE) assessment tools. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Results: Searches identified 146 abstracts and 108 full texts. Of these, 18 studies met the inclusion criteria, reporting outcomes in 523 animals (17 studies) and 24 humans (1 study). Eluting electrodes included dexamethasone (16 studies), aracytine (1 study), nicotinamide adenine dinucleotide (1 study), the growth factors insulin-like growth factor 1 (IGF1) and hepatocyte growth factor (HGF) (1 study), and neurotrophin-3 (1 study). All included studies compare outcomes following implantation with an eluting electrode with a control non-eluting electrode. In the majority of studies, audiological outcomes (e.g., auditory brainstem response threshold) were superior following implantation with an eluting electrode compared with a standard electrode. Most studies which investigated post-implantation impedance reported lower impedance following implantation with an eluting electrode. The influence of eluting electrodes on other reported outcomes (including post-implantation cochlear fibrosis and the survival of hair cells and spiral ganglion neurons) was more varied across the included studies. Conclusions: Eluting electrodes have shown promise in animal studies in preserving residual hearing following cochlear implantation and in reducing impedance, though data from human studies remain lacking. Further in-human studies will be required to determine the clinical usefulness of drug-eluting cochlear implants as a future treatment for sensorineural hearing loss.

Incidence of Cochlear Implantation Complications in Saudi Arabia: A Comprehensive Systematic Review of the Literature.

This review aimed to determine the incidence of complications associated with cochlear implants (CI) in Saudi Arabia. We systematically searched PubMed, AIRE, OaIster, MEDLINE, Directory of Open Access Journals, Scopus, and Ovid from inception to January 2024. The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42023486687). Studies that reported CI complications in Saudi Arabia were included. This systematic review was conducted in accordance with PRISMA guidelines. A total of 17 articles with 2216 patients were included. The most common intraoperative complication was cerebrospinal fluid leakage (23 patients, 0.99%), followed by surgical difficulties (six patients, 0.26%), and dural accidental exposure and bleeding (three patients, 0.13%); the most common postoperative complications were vestibular symptoms (20 patients, 0.86%), followed by infection (17 patients, 0.73%), and device malfunction or migration (12 patients, 0.52%). The total complication rate ranged from 4-13%. Most of the included studies had a low risk. CI in Saudi Arabia has a complication rate similar to that reported in international studies. This review emphasizes the need for continued surveillance of CI outcomes to optimize procedural techniques and improve the safety and efficacy of CI in Saudi Arabia.

Four-Hour-Delayed Gadolinium 3D REAL IR and SPACE FLAIR MRI Correlated to Meniere Disease Histology.

Objectives: This study aims to showcase the complementary nature of utilizing both histopathology and magnetic resonance imaging (MRI) in understanding the otologic pathophysiology of Meniere disease. In addition, it seeks to raise awareness of the value of preserving and curating historical temporal bone collections which continue to inform our understanding of otologic diseases. Methods: The essential anatomical feature of Meniere disease-the distended membranous labyrinth-is explored through a comparison of early temporal bone studies with contemporary MRI techniques. The histopathologic photomicrographs are of inner ear specimens from deceased patients with symptoms consistent with Meniere disease. The MRI sequences from living patients exhibiting classic Meniere disease symptoms during life are captured 4 hours post-administration of gadolinium. Results: Both histopathologic examination and MRI imaging reveal consistent distention of the saccule, utricle, and scala media in patients with Meniere disease. The study shows the histologic photomicrographs of actual Meniere patients compared to the MRIs and successfully demonstrates the correlation between postmortem histological findings and MRI evidence of distension in living patients. Conclusions: A corresponding distension of the membranous labyrinth is seen in both the histologic specimens and the Meniere MRIs. This correlation suggests the potential utility of utilizing MRI to aid in diagnosing atypical Meniere disease and distinguishing it from other disease processes, such as migraine equivalent vertigo. The integration of historical temporal bone studies with modern MRI techniques offers valuable insights into the pathophysiology of otologic diseases. In addition, it emphasizes the importance of preserving and curating historical temporal bone collections for continued research and medical education purposes. Previous studies of delayed MRIs did not use Meniere disease temporal bone histopathology images.

A New Community-to-Hospital Specialist Otology Pathway Using Telemedicine: A Pilot Study of 50 Patients.

INTRODUCTION: Pathway innovation using smartphone otoscopy and tablet-based audiometry technologies to deliver ear and hearing services via trained audiologists may improve efficiency of the service. An ENT-integrated-community-ear service (ENTICES-combining community audiology management, remote ENT review and novel technologies) was piloted. We aimed to assess the efficiency and safety of ENTICES. METHOD: ENTICES was a community-based and audiologist-led pathway. Patients with otological symptoms were self-referred to this service. Smartphone otoscopy and tablet-based audiograms were performed. Two otologists reviewed all decisions made in the community by audiologists based on video-otoscopy, hearing tests and chart reviews. Data on the first 50 consecutive new patients attending either consultant-led hospital otology clinics (HOC), audiologist-led hospital advanced audiology diagnostics (AAD) or ENTICES clinics were collected between 1 August 2021 and 31 December 2021. Data were collected through chart reviews and questionnaires to compare the three pathways with respect to efficiency, patient satisfaction, technology utility and safety. RESULTS: No audiology-led ENTICES decisions were amended by hospital otologists following remote review. Remote review of video-otoscopy with history was sufficient for a diagnosis in 80% of cases. Adding hearing tests and standardised history increased the diagnostic yield to 98%. Patient satisfaction scores showed 100% service recommendation. The cost per patient, per visit, was £83.36, £99.07 and £69.72 for AAD, HOC or ENTICES, respectively. CONCLUSION: ENTICES provides a safe ear and hearing service that patients rated highly. Thirty-two per cent of hospital otology patients were eligible for this service. For those patients, ENTICES is 20% more cost-effective and can reduce the number of clinic visits by up to 60% compared with HOC.

Machine learning application in otology.

This review presents a comprehensive history of Artificial Intelligence (AI) in the context of the revolutionary application of machine learning (ML) to medical research and clinical utilization, particularly for the benefit of researchers interested in the application of ML in otology. To this end, we discuss the key components of ML-input, output, and algorithms. In particular, some representation algorithms commonly used in medical research are discussed. Subsequently, we review ML applications in otology research, including diagnosis, influential identification, and surgical outcome prediction. In the context of surgical outcome prediction, specific surgical treatments, including cochlear implantation, active middle ear implantation, tympanoplasty, and vestibular schwannoma resection, are considered. Finally, we highlight the obstacles and challenges that need to be overcome in future research.

An Ear Mystery: Conductive Hearing Loss with Normal Acoustic Reflexes and VEMPs.

The cause of sudden conductive loss in the absences of other vestibulo-audiologic abnormalities can be isolated to specific subsites of the ossicular chain using audiometric testing. In the absence of such abnormalities, a rare etiology may be the cause after an inciting trauma. Laryngoscope, 2024.

Management of Idiopathic Sudden Sensorineural Hearing Loss (ISSNHL) Intratympanic Platelet-Rich Plasma (PRP) Versus Intratympanic Steroid Injections: A Cross-Sectional Study.

<b><br>Introduction:</b> Idiopathic sensorineural hearing loss of 30 decibels (dB) or more over at least three contiguous audiometric frequencies with an onset of less than 3 days is referred to as sudden sensorineural hearing loss (ISSNHL) and is known as an ENT (ear, nose, and throat) emergency. When a patient's hearing suddenly deteriorates, they become confused, anxious, and worried. One of the primary therapies for sudden sensorineural hearing loss is intratympanic steroids. Intratympanic injections of platelet-rich plasma (PRP) improve inner ear hair cells, which enhances hearing.</br> <b><br>Aim:</b> To show the safety and efficacy of intratympanic PRP injection in the management of ISSNHL in comparison with intratympanic steroid injection.</br> <b><br>Methods:</b> The study group was comprised of 100 patients who had experienced ISSNHL within 30 days with no retrocochlear pathology, as demonstrated by a negative MRI scan. 50 patients received 6 intratympanic steroid injections, while the remaining 50 patients received 2 intratympanic injections of PRP at a 1-week interval.</br> <b><br>Results:</b> A total of 39 patients with PRP injection noted an improvement in their hearing of 25 db after 2 weeks and of 30 db after 2 months, with improved speech discrimination of 26% after 2 weeks and of 28% after 2 months. 31 patients with intratympanic steroid injection noted an improvement in their hearing of 18 db after 2 weeks and of 22 db after 2 months, with improved speech discrimination of 21% after 2 weeks and of 24% after 2 months.</br> <b><br>Conclusions:</b> PRP appears safe and efficient for the treatment of ISSNHL, with a low cost and no systemic side effects, as with oral steroids. Therefore, such research should be continued.</br>.

Introduction to the assessment and management of persistent postural-perceptual dizziness.

OBJECTIVE: Persistent postural-perceptual dizziness classifies patients with chronic dizziness, often triggered by an acute episode of vestibular dysfunction or threat to balance. Unsteadiness and spatial disorientation vary in intensity but persist for over three months, exacerbated by complex visual environments. METHOD: Literature suggests diagnosis relies on a clinical history of persistent subjective dizziness and normal vestibular and neurological examination findings. Behavioural diagnostic biomarkers have been proposed, to facilitate diagnosis. RESULTS: Research has focused on understanding the neural mechanisms that underpin this perceptual disorder, with imaging data supporting altered connectivity between neural brain networks that process vision, motion and emotion. Behavioural research identified the perceptual and motor responses to a heightened perception of imbalance. CONCLUSION: Management utilises head and body motion detection, and downregulation of visual motion excitability, reducing postural hypervigilance and anxiety. Combinations of physical and cognitive therapies, with antidepressant medications, help if the condition is associated with mood disorder.

Developing a production workflow for 3D-printed temporal bone surgical simulators.

INTRODUCTION: 3D-printed temporal bone models enable the training and rehearsal of complex otological procedures. To date, there has been no consolidation of the literature regarding the developmental process of 3D-printed temporal bone models. A brief review of the current literature shows that many of the key surgical landmarks of the temporal bone are poorly represented in models. This study aims to propose a novel design and production workflow to produce high-fidelity 3D-printed temporal bone models for surgical simulation. METHODS: Developmental phases for data extraction, 3D segmentation and Computer Aided Design (CAD), and fabrication are outlined. The design and fabrication considerations for key anatomical regions, such as the mastoid air cells and course of the facial nerve, are expounded on with the associated strategy and design methods employed. To validate the model, radiological measurements were compared and a senior otolaryngologist performed various surgical procedures on the model. RESULTS: Measurements between the original scans and scans of the model demonstrate sub-millimetre accuracy of the model. Assessment by the senior otologist found that the model was satisfactory in simulating multiple surgical procedures. CONCLUSION: This study offers a systematic method for creating accurate 3D-printed temporal bone models for surgical training. Results show high accuracy and effectiveness in simulating surgical procedures, promising improved training and patient outcomes.

Primary contact physiotherapy for patients with suggested vestibulopathy for an Australian ENT clinic: a retrospective cohort study.

OBJECTIVE: To examine the newly established role of a primary contact physiotherapist in an ENT clinic, in an Australian cohort and context, over two phases of development. METHODS: A retrospective cohort study was conducted with data collected from a medical record audit. Over the study duration, the primary contact physiotherapist completed initial appointments with patients; follow-up appointments were subsequently conducted by medical staff. RESULTS: There was a 46 per cent reduction in patients with suggested vestibulopathy requiring an ENT medical review. This reduction could hypothetically increase to 71 per cent with follow-up primary contact physiotherapist appointments. Improvements in the service delivery model and a primary contact physiotherapist arranging diagnostic assessments could improve waitlist times and facilitate better utilisation of medical staff time. CONCLUSION: The primary contact physiotherapist can help in the management of patients with suspected vestibulopathy on an ENT waitlist. This is achieved through: a reduction of patients requiring ENT review, improvements to waitlist time and improved utilisation of medical specialists' time.

Medical record prompts improve the frequency and documentation of dizziness and driving conversations in the ENT balance clinic.

BACKGROUND: Driving capacity is affected by vestibular disorders and the medications used to treat them. Driving is not considered during medical consultations, with 92 per cent of patients attending a centre for dizziness not discussing it with the doctor. OBJECTIVE: To investigate if medical record prompts facilitate dizziness and driving conversations in ENT balance clinics. METHODS: A questionnaire was designed to reflect the current standards of practice and advice given regarding driving and dizziness during balance clinic consultations. RESULTS: Medical record prompts facilitated the improved frequency and recording of shared decision-making conversations about driving and dizziness in 98 per cent of consultations. CONCLUSION: This study highlights the benefits of medical record prompts for documented and accurate shared decision-making conversations surrounding dizziness, vertigo, vestibular conditions and driving. This potentially improves safety for all road users, and protects the patient and clinician in the event of road traffic accidents and medico-legal investigations.

Pilot study to evaluate a training programme for primary care physiotherapists in the assessment and management of benign paroxysmal positional vertigo.

OBJECTIVE: This pilot study aimed to evaluate a training programme for primary care physiotherapists focused on the assessment and management of benign paroxysmal positional vertigo. METHODS: A six-month training programme and toolkit utilising the revised Standards for Quality Improvement Reporting Excellence ('SQUIRE 2.0') guidelines was developed to facilitate the learning of new knowledge and skills in the assessment and management of benign paroxysmal positional vertigo following Gagne's model of instructional design. A pre- and post-training knowledge and confidence questionnaire evaluated the impact of the training programme. RESULTS: Eleven participants started the training programme and five completed it. On average, knowledge increased by 54 per cent (range, 41-95 per cent) and confidence increased by 45 per cent (range, 31-76 per cent). A 73 per cent improvement in practical skills acquisition was demonstrated after the initial training session. CONCLUSION: A structured approach to learning demonstrates improvements in knowledge, skills and confidence of physiotherapists in the evidence-based management of benign paroxysmal positional vertigo.

Paediatric percutaneous bone anchored hearing aid implant failures: Comparing the experience of a tertiary centre with a systematic review of the literature and meta-analysis.

BACKGROUND: Despite the proven audiological benefits of Percutaneous Bone Anchored Hearing Aids (BAHAs) in paediatric patients with conductive or mixed hearing loss, their adoption has been limited due to concerns over implant failure and associated complications. This paper conducts a systematic review and meta-analysis to assess the prevalence of implant failure in paediatric populations, combined with a case series from our tertiary referral centre. METHODS: A comprehensive literature search identified 562 articles, from which 34 were included in the review, covering 1599 implants in 1285 patients. Our retrospective case series included consecutive patients from our tertiary referral centre who underwent percutaneous BAHA implantation from 2003-2019. RESULTS: Meta-analysis revealed an overall implant failure rate of 11%, predominantly attributed to traumatic extrusion. Our retrospective case series comprised 104 implantations in 76 patients, with a 4.8% failure rate. DISCUSSION: Factors contributing to the lower-than-expected failure rates in the case series likely included consistent use of 4 mm fixtures from a single manufacturer and older age at implantation. The study underscores the need for standardised reporting formats in bone conduction implants research, given the systematic review's limitations in study design heterogeneity, especially with the expected rise in the adoption of novel active devices.

Sudden Deafness and Vestibulopathy in a Patient with Antibody Treatment for Metastatic Lung Cancer.

We describe the case of a patient who presented with sudden onset vertigo and bilateral deafness while under immune checkpoint therapy for metastatic bronchial carcinoma. Extensive audiologic assessment and vestibular function testing, as well as cranial magnetic resonance imaging (cMRI) and lumbar puncture was performed. The diagnostic workup confirmed bilateral sensorineural deafness and bilateral loss of vestibular function, while imaging revealed enhancement of the vestibulocochlear nerve. Initially, immunotherapy with PD-L1 antibody atezolizumab was the assumed cause of the described symptoms. However, further findings strengthened the suspicion of meningeosis neoplastica. The differential diagnoses of hearing loss and vestibulopathy in the context of platin-based chemotherapy, checkpoint inhibitor therapy and metastatic disease should be kept in mind for appropriate workup and therapy. Laryngoscope, 2024.

Removal of Cyanoacrylate Glue From the External Auditory Canal With Hydrogen Peroxide and Acetic Acid: A Case Report.

Ear canal foreign bodies are commonly encountered in the field of otolaryngology. This is especially common in the pediatric otolaryngology discipline. As a foreign body, cyanoacrylate glue (also called "super glue") can be difficult to remove and cause significant patient distress. Multiple solvents can be described as aiding in removing such foreign bodies. Here, a case is described in which hydrogen peroxide and acetic acid were used sequentially to remove cyanoacrylate glue from the external auditory canal. We describe a technique allowing en bloc removal of the cyanoacrylate glue. Thankfully, the patient's hearing returned to baseline post-operatively with minimal complications. Overall, cyanoacrylate glue can be a very difficult foreign body to remove from the ear canal. In this case, the sequential use of hydrogen peroxide and acetic acid to soak the glue was a safe and successful method to facilitate glue removal from the ear canal.

Otitis in patients with Community-Acquired Bacterial Meningitis: A Nationwide Prospective Cohort Study.

BACKGROUND: Otitis is commonly associated with community-acquired bacterial meningitis but role of ear surgery as treatment is debated. In this study, we investigated the impact of otitis and ear surgery on outcome of adults with community-acquired bacterial meningitis. METHODS: We analyzed episodes of adults with community-acquired bacterial meningitis from a nationwide prospective cohort study in the Netherlands, between March 2006 to July 2021. RESULTS: A total of 2,548 episodes of community-acquired bacterial meningitis were evaluated. Otitis was present in 696 episodes (27%). In these patients the primary causative pathogen was Streptococcus pneumoniae (615 of 696 [88%]), followed by Streptococcus pyogenes (5%) and Haemophilus influenzae (4%). In 519 of 632 otitis episodes (82%) an ear-nose-throat specialist was consulted, and surgery was performed in 287 of 519 (55%). The types of surgery performed were myringotomy with ventilation tube insertion in 110 of 287 episodes (38%), mastoidectomy in 103 of 287 (36%) and myringotomy alone in 74 of 287 (26%). Unfavorable outcome occurred in 210 of 696 episodes (30%) and in 65 of 696 episodes was fatal (9%). Otitis was associated with a favorable outcome in a multivariable analysis (odds ratio 0.74; 95% CI 0.59-0.92; p =0.008). There was no association between outcome and ear surgery. CONCLUSIONS: Otitis is a common focus of infection in community-acquired bacterial meningitis in adults, with S. pneumoniae being the most common causative pathogen. Presence of otitis is associated with a favorable outcome. Ear surgery's impact on the outcome of otogenic meningitis patients remains uncertain.

Hampshire Sheep as a Large-Animal Model for Cochlear Implantation.

BACKGROUND: Sheep have been proposed as a large-animal model for studying cochlear implantation. However, prior sheep studies report that the facial nerve (FN) obscures the round window membrane (RWM), requiring FN sacrifice or a retrofacial opening to access the middle-ear cavity posterior to the FN for cochlear implantation. We investigated surgical access to the RWM in Hampshire sheep compared to Suffolk-Dorset sheep and the feasibility of Hampshire sheep for cochlear implantation via a facial recess approach. METHODS: Sixteen temporal bones from cadaveric sheep heads (ten Hampshire and six Suffolk-Dorset) were dissected to gain surgical access to the RWM via an extended facial recess approach. RWM visibility was graded using St. Thomas' Hospital (STH) classification. Cochlear implant (CI) electrode array insertion was performed in two Hampshire specimens. Micro-CT scans were obtained for each temporal bone, with confirmation of appropriate electrode array placement and segmentation of the inner ear structures. RESULTS: Visibility of the RWM on average was 83% in Hampshire specimens and 59% in Suffolk-Dorset specimens (p = 0.0262). Hampshire RWM visibility was Type I (100% visibility) for three specimens and Type IIa (> 50% visibility) for seven specimens. Suffolk-Dorset RWM visibility was Type IIa for four specimens and Type IIb (< 50% visibility) for two specimens. FN appeared to course more anterolaterally in Suffolk-Dorset specimens. Micro-CT confirmed appropriate CI electrode array placement in the scala tympani without apparent basilar membrane rupture. CONCLUSIONS: Hampshire sheep appear to be a suitable large-animal model for CI electrode insertion via an extended facial recess approach without sacrificing the FN. In this small sample, Hampshire specimens had improved RWM visibility compared to Suffolk-Dorset. Thus, Hampshire sheep may be superior to other breeds for ease of cochlear implantation, with FN and facial recess anatomy more similar to humans.