Patient-directed follow-up for the clinical scaphoid fracture.

Aims: Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods: We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient's guide to 'opt-in' and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient 'fast'-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results: From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion: A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture.

Analysis of Patients Diagnosed with Benign Paroxysmal Positional Vertigo and the Corresponding Incidence and Patterns of Electric Toothbrush Use.

Objective To investigate whether mechanical vibrational energy from using an electric toothbrush may cause an increase in the incidence of benign paroxysmal positional vertigo (BPPV) and prevent successful treatment of BPPV with canalith repositioning procedure. Methods This was a retrospective study conducted at an otolaryngology private practice. A survey of 111 patients who were diagnosed with BPPV in an otolaryngology practice between May 2012 and January 2017 was conducted using a questionnaire that included questions regarding demographics, inner ear pathology, treatment method, and use of an electric toothbrush. The results were recorded and compared using a chi-square test of analysis or Fisher's exact test. Results Overall, 47 (42.3%) of the 111 BPPV patients used an electric toothbrush, whereas 64 of the 111 (57.6%) patients did not. Six (12.7%) of the 47 patients experienced dizziness with electric toothbrush use. Of the 47 patients using an electric toothbrush, 33 (70.2%) had a resolution of symptoms after Epley treatment, whereas 14 (23.4%) of 47 patients did not. Of the 64 patients who did not use an electric toothbrush, 15 (23.4%) did not have resolution after Epley treatment. Of the 47 patients using an electric toothbrush, 6 (12.8%) had a recurrence of BPPV diagnosed in the office, whereas 41 (82.2%) did not. Seven (10.9%) of those who did not use an electric toothbrush had a recurrence of BPPV, whereas 57 (89.1%) of the 64 patients did not. These results were not statistically significant (p = 0.77). Conclusions This study suggests that the mechanical vibrations from electric toothbrush use do not have an association with recurrent BPPV. The results align with some publications demonstrating that vibrations in the head and neck area from the use of an electric toothbrush can initiate dizziness; however, it does not appear that this modality of vibration is significant for inducing recurrent BPPV.

Incidental mastoid effusion diagnosed on imaging: Are we doing right by our patients?

OBJECTIVES/HYPOTHESIS: To investigate whether radiologist-produced imaging reports containing the terms mastoiditis or mastoid opacification clinically correlate with physical examination findings of mastoiditis. Additionally, to investigate whether and how often otolaryngology was unnecessarily consulted and inappropriate antibiotic therapy was initiated. STUDY DESIGN: Retrospective chart review within a large community hospital setting. METHODS: A retrospective review of 160 patients who had imaging tests performed for nonotolaryngology indications from January 2011 to March 2017 at our facility. Indications, patient demographics, otolaryngology consultations, and new antibiotics started were recorded. Physical examinations were documented. RESULTS: Physical examination revealed that only 14 of 160 patients (8.8%) had clinical evidence of otologic disease. However, of the 160 patients meeting the inclusion criteria, 18 (11.3%) received an otolaryngology consultation, and 18 (11.3%) had antibiotics started. Eleven of the 18 patients in each group (61.1%) had a normal physical examination, two (11.1%) had serous otitis media, one (5.6%) had chronic otitis media, and four (22.2%) had acute otitis media. No patients were found to have clinical mastoiditis. χ2 analysis revealed no significance in the radiologic diagnosis of mastoiditis versus mastoid opacification in relation to physicians requesting otolaryngology consultations (P = .241) or starting patients on antibiotics (P = .951). CONCLUSIONS: This study highlights the prevalence of incidental but clinically insignificant opacification of the mastoid cavity. We believe that nonotolaryngology physicians are, overall, competent to correlate such radiologic findings clinically and to prevent unnecessary consultations and inappropriate treatment, which add significant costs to our overstretched healthcare system. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:852-857, 2019.

The impact of commercialisation on public perceptions of stem cell research: exploring differences across the use of induced pluripotent cells, human and animal embryos.

The development of pluripotent cells that enable stem cell research (SCR) without destroying human embryos is now a leading priority for science. Public and political controversies associated with human embryonic SCR experienced in the recent past should be alleviated if scientists no longer need to harvest cells from human embryos. This research suggests however additional issues needing attention in order to gain the public's trust and support: the use of mouse embryos and the commercialisation of research. Using a representative sample of 2,800 Australians, and an experimental telephone survey design, this research compared levels and predictors of public support for stem cell research across three cell source conditions: human embryo (HE), mouse embryo (ME) and induced pluripotent cells (iPSCs). The results revealed that the public were significantly more likely to support research using iPSCs than HE and ME cells and public compared to private research (regardless of the cell source). There was no significant difference in support for HE compared to ME research, but the former was viewed as more likely to lead to accessible health care benefits and to be associated with more trustworthy scientists. The results of a multimediation structural equation model showed that the primary reason support for SCR significantly dropped in a private compared to public context (i.e., the commercialisation effect) was because public scientists were trusted more than private scientists. This effect was consistent across all three SCR materials, suggesting that the use of mouse embryos or even iPSCs will not reduce the publics' concern with commercialised science. The implications these results have for public acceptance of stem cell and animal research are discussed in relation to possible solutions such as increasing public awareness of the regulation of animal research and benefit sharing.

Successes and complications of the Baha system.

OBJECTIVE: To determine the incidence and type of complications, as well as patient satisfaction, associated with the Baha system. STUDY DESIGN: Retrospective case review. SETTING: The Silverstein Institute, Sarasota, Florida, and the Columbia University Medical Center, New York, New York. PATIENTS: Patients with conductive/mixed hearing loss and single-sided deafness implanted with the Baha system between June 1998 and December 2007. INTERVENTION: Implantation with the Baha system. MAIN OUTCOME MEASURE: Incidence and type of complications associated with Baha implantation and patient satisfaction as measured by a questionnaire administered on site or by telephone. RESULTS: : In our series of 218 patients (223 ears), there were no major complications. Of these patients, 4.5% required revision surgery for soft tissue complications and 1.3% needed revision for failure of osseointegration. Eight percent (8%) required local care and resolved within 2 to 3 weeks of treatment. Five percent (5%) required in office procedures. One hundred six (106) patients satisfactorily completed the survey questionnaire. Ninety-two percent (92%) reported using the device regularly and 77% were happy with the device. On average, patients reported using the device 10.1 h/d, 5.6 d/wk. CONCLUSION: The Baha system is safe and effective in the rehabilitation of patients with conductive or mixed hearing losses and with single-sided deafness. The high success rate, patient satisfaction rate, and predictable auditory outcome place the Baha among the leading choices for auditory rehabilitation.

Osseointegration timing for Baha system loading.

OBJECTIVES: The process of osseointegration for creating a biological bond between titanium oxide and bone is time dependent. However, different surgeons have used very varied time frames before loading the implant. The waiting time in dental implant loading ranged from immediate to 6 months. The Baha system (Cochlear Limited, Englewood, CO) traditional waiting period consisted of 3 months for adults and 4 to 6 months for children. The purpose of the study was to evaluate the safety of reducing the waiting time to 6 weeks in adults. STUDY DESIGN: Retrospective study of patients who underwent Baha implantation and exteriorization between March, 2004 and July 2005. METHODS: Twenty-six adult patients underwent Baha titanium implantation and exteriorization in a single stage. They were loaded with the external processor after an average of 6.5 weeks. The etiology of their hearing loss (HL) included conductive HL, mixed HL, and unilateral sensorineural HL. Follow-up period ranged between 6 and 20 months. RESULTS: All patients were successfully implanted with the titanium implants, loaded at the 6 week interval, and have safely retained their prosthesis. The only reported complication was dermatitis, which occurred in three patients. Patients were pleased to receive the external processor earlier. CONCLUSION: The reduction of the waiting period from 3 months to 6 weeks did not result in any failure of osseointegration of the titanium implants. The earlier activation resulted in enhanced patient satisfaction. A larger series would be needed to definitively recommend shortening of the interval between Baha implantation and device loading.

Osteonecrosis of the mandible or maxilla associated with the use of new generation bisphosphonates.

OBJECTIVE: The use of bisphosphonates is well established for the treatment of patients with metastatic bone disease, osteoporosis, and Paget's disease. Osteonecrosis of the mandible or maxilla associated with the use of bisphosphonates is a newly described entity never before discussed in the otolaryngology literature. In this paper, we review a series of patients diagnosed with osteonecrosis, all treated with new generation bisphosphonates. Our objective is to inform and educate others, particularly otolaryngologists/head and neck surgeons, about this drug induced entity, a condition that should be recognized early to avoid potential devastating consequences. STUDY DESIGN: Retrospective chart review of a series of patients from a tertiary referral center. METHODS: Pathology reports of specimens submitted from either the mandible or maxilla were reviewed from the previous 12 months. Any patient diagnosed with osteonecrosis without evidence of metastatic disease at that site was included; those with a previous history of radiation therapy were excluded. Each patient's medical history and profile were reviewed. RESULTS: Twenty-three patients were identified with osteonecrosis of the mandible or maxilla. All of these were associated with the use of new generation bisphosphonates: zolendronate (Zometa, Novartis), pamidronate (Aredia, Novartis), and alendronate (Fosamax, Merck). Eighteen patients with known bone metastases had been treated with the intravenous form, whereas five patients with either osteoporosis or Paget's disease were using oral therapy. Patients typically presented with a nonhealing lesion, often times the result of previous dental intervention. Although the majority of these patients were treated with conservative surgical debridement, we present a case requiring a near total maxillectomy. CONCLUSIONS: Drug induced osteonecrosis of the mandible or maxilla has been recently recognized as a sequelae of treatment with the new generation of bisphosphonates. Most patients can be treated with conservative surgical debridement and cessation of bisphosphonate therapy, whereas a few may require radical surgical intervention. Other recommendations include regimented prophylactic care with an assessment of dental status before the administration of bisphosphonates, avoidance of dental procedures, and close monitoring of oral hygiene.