Evaluation and Management of Tinnitus: Are There Opportunities for Improvement?

OBJECTIVE: To review current information about diagnosis and management of tinnitus aiming to identify opportunities for achieving a cost-effective, efficient, evidence-based approach that meets the needs of tinnitus sufferers. DATA SOURCES: PubMed/MEDLINE. REVIEW METHODS: In total, 249 relevant published reports were reviewed. Pertinent keywords and MeSH terms identified reports via PubMed and EMBASE. Acknowledged experts were consulted on ways to improve tinnitus management. CONCLUSIONS: There may be opportunities to improve evaluation and management of patients with tinnitus using modern modes of communication and a multidisciplinary therapeutic approach. IMPLICATIONS FOR PRACTICE: Tinnitus can adversely affect quality of life while being time-consuming and costly to evaluate and manage. Based on both personal experience and the reports of others, patients with tinnitus who choose to see a physician primarily want to know two things: (1) that the tinnitus that is so distressing will not remain at the same level of severity forever and (2) that something can be done to help cope with the tinnitus that is so annoying. Recent advancements in internet communications, social media, information technology, artificial intelligence, machine learning, holistic medical care, mind-body integrative health care, and multidisciplinary approaches in medical therapeutics may be possibly making new ways of meeting the needs of patients with tinnitus.

Bilateral congenital cholesteatoma: A case report and review of the literature.

OBJECTIVES: Congenital cholesteatoma (CC) occurs less commonly than acquired cholesteatoma (AC), and bilateral CC (BCC) is even more rare with only 38 such cases having been reported in the past 42 years. Because of the rarity of this condition, providers confronted with cases of BCC may find it difficult to treat while balancing complete removal of disease, optimal hearing outcomes, and minimized surgical burden in the pediatric patient. This review alerts physicians that BCC occurs, highlights past presentations and management strategies, describes the considerations in treatment and offers an algorithm helpful in the management of BCC. METHODS: Review of a single case with extensive review of published reports from 1975 to 2017 pertaining to management of BCC. RESULTS: A five-year-old boy presented with bilateral congenital cholesteatoma. Tympanomastoidectomy was performed to remove cholesteatoma in the left ear then in the right ear months later. Ossicular chain reconstruction was deferred in both cases. Second look procedures revealed persistent cholesteatoma in both ears. In the descriptions of the 38 published BCC cases, the extent and location of the CC varied widely as did the approach to management. In the 18 cases that had descriptions of surgical management, four had second look procedures. In the 16 reports that described extent of cholesteatoma, 12 had the first of two or more operations on the ear with more extensive cholesteatoma. CONCLUSIONS: Risks are increased for recidivism/recurrence and hearing impairment in children with BCC compared to children with unilateral CC. We present a novel algorithm for management of BCC that recommends surgery for cholesteatoma removal first in the more severely affected ear and delayed OCR for both ears. Simultaneous surgery may be considered in certain cases.

Are validated patient-reported outcomes used on children in pediatric otolaryngology? A systematic review.

OBJECTIVES: Review the pediatric otolaryngology literature to 1) identify studies in which children completed patient-reported outcome (PRO) measures and 2) appraise the psychometric quality and validity of these PROs as they apply to pediatrics. METHODS: In October 2016, a systematic review was performed by two reviewers on PubMed/MEDLINE and EMBASE for all otolaryngology-related studies that utilized PROs in children. Inclusion criteria included articles that required children (age<18) to complete PROs. Exclusion criteria included validation studies, reviews, and abstracts. Interreviewer agreement was determined using Cohen's kappa. Quality and rigor of validation testing for included PROs was determined using the COnsensus-based Standards for selection of health status Measurement Instruments. RESULTS: Interrater agreement was very good (κ = 0.91; 95% CI, 0.85-0.98). Out of 316 articles retrieved, 11 met inclusion criteria. Eight PROs were identified. Six PROs were tested for validity and three of these PROs were tested for validity specifically within children. The most frequently utilized PRO was the Pediatric Rhinoconjunctivitis Quality of Life Questionnaire. Two studies (18.2%) utilized PROs within the scope of their validation. Seven studies (63.6%) used PROs outside the scope of their validation. Two studies (18.2%) used non-validated PROs. CONCLUSIONS: Patient-reported outcomes have become an integral part of research and quality improvement. There is a relative paucity of PROs directed towards children in pediatric otolaryngology and some studies utilized PROs that were not validated or not validated for use in this age group. Future efforts to design and validate more instruments may be warranted.

The Interactive Candidate Assessment Tool: A New Way to Interview Residents.

The purpose of the residency interview is to determine the extent to which a well-qualified applicant is a good fit with a residency program. However, questions asked during residency interviews tend to be standard and repetitive, and they may not elicit information that best differentiates one applicant from another. The iCAT (interactive Candidate Assessment Tool) is a novel interview instrument that allows both interviewers and interviewees to learn about each other in a meaningful way. The iCAT uses a tablet computer to enable the candidate to select questions from an array of video and nonvideo vignettes. Vignettes include recorded videos regarding some aspect of the program, while other icons include questions within recognizable categories. Postinterview surveys demonstrated advantages over traditional interview methods, with 93% agreeing that it was an innovative and effective tool for conducting residency program interviews. The iCAT for residency interviews is a technological advancement that facilitates in-depth candidate assessment.

Assessing work-related musculoskeletal symptoms among otolaryngology residents.

PURPOSE: Previous studies have suggested that musculoskeletal symptoms are common among practicing otolaryngologists. Early training can be the ideal time to foster knowledge of ergonomics and develop safe work habits, however, little data exists regarding musculoskeletal symptoms in residents. The purpose of this study was to identify and characterize musculoskeletal symptoms in a preliminary sample of otolaryngology residents. MATERIALS AND METHODS: A cross-sectional survey incorporating the Nordic Musculoskeletal Questionnaire was sent to 30 Otolaryngology-Head and Neck Surgery residencies to examine musculoskeletal symptoms among residents. A two-sample test of proportions was performed to compare symptoms between male and female residents. RESULTS: In total, 141 respondents (response rate=34.7%) completed the survey. Fifty-five percent of survey respondents were male and 45% were female. Musculoskeletal symptoms were most frequently reported in the neck (82.3%), followed by the lower back (56%), upper back (40.4%), and shoulders (40.4%). The most common symptoms were stiffness in the neck (71.6%), pain in the neck (61.7%), and pain in the lower back (48.2%). In total, 6.4% of residents missed work and 16.3% of residents stopped during an operation at some point due to their symptoms. Most residents (88.3%) believed their musculoskeletal symptoms were attributed to their surgical training. Female residents were significantly more likely to experience neck (p<0.0001) and wrist/hand (p=0.019) discomfort compared to male residents. CONCLUSIONS: Musculoskeletal symptoms were common among residents, approaching rates similar to those previously identified in practicing otolaryngologists. Increased emphasis on surgical ergonomics is warranted to improve workplace safety and prevent future injury.

Increasing Competitiveness for an Otolaryngology Residency: Where We Are and Concerns about the Future.

For graduating medical students, securing a residency in otolaryngology-head and neck surgery has become exceedingly difficult. This commentary explores the ways that applicants and residency programs are reacting to the increasing competitiveness in applying to, interviewing for, and matching to an otolaryngology residency. The commonly held perceptions of applicants are compared to perspectives held by residency program directors and resident selection committees. Unintended consequences of the growing trend for medical students to add a research year to their curriculum are presented. Some cautions and suggestions about how to improve the application and selection process are offered.

Otologic outcomes after blast injury: the Boston Marathon experience.

OBJECTIVE: Otologic trauma was the most common physical injury sustained after the April 15, 2013, Boston Marathon bombings. The goal of this study is to describe the resultant otologic morbidity and to report on early outcomes. STUDY DESIGN: Multi-institutional prospective cohort study. METHODS: Children and adults seen for otologic complaints related to the Boston Marathon bombings comprised the study population. Participants completed symptom assessments, quality-of-life questionnaires, and audiograms at initial and 6-month visits. Otologic evaluation and treatment, including tympanoplasty results, were reviewed. RESULTS: More than 100 patients from eight medical campuses have been evaluated for blast-related otologic injuries; 94 have enrolled. Only 7% had any otologic symptoms before the blasts. Ninety percent of hospitalized patients sustained tympanic membrane perforation. Proximity to blast (RR = 2.7, p < 0.01) and significant nonotologic injury (RR = 2.7, p < 0.01) were positive predictors of perforation. Spontaneous healing occurred in 38% of patients, and tympanoplasty success was 86%. After oral steroid therapy in eight patients, improvement in hearing at 2 and 4 kHz was seen, although changes did not reach statistical significance. Hearing loss, tinnitus, hyperacusis, and difficulty hearing in noise remain persistent and, in some cases, progressive complaints for patients. Otologic-specific quality of life was impaired in this population. CONCLUSION: Blast-related otologic injuries constitute a major source of ongoing morbidity after the Boston Marathon bombings. Continued follow-up and care of this patient population are warranted.

What an otolaryngologist should know about evaluation of a child referred for delay in speech development.

IMPORTANCE: Otolaryngologists are asked to evaluate children who a parent, physician, or someone else believes is slow in developing speech. Therefore, an otolaryngologist should be familiar with milestones for normal speech development, the causes of delay in speech development, and the best ways to help assure that children develop the ability to speak in a normal way. OBJECTIVE: To provide information for otolaryngologists that is helpful in the evaluation and management of children perceived to be delayed in developing speech. EVIDENCE ACQUISITION: Data were obtained via literature searches, online databases, textbooks, and the most recent national guidelines on topics including speech delay and language delay and the underlying disorders that can cause delay in developing speech. Emphasis was placed on epidemiology, pathophysiology, most common presentation, and treatment strategies. Most of the sources referenced were published within the past 5 years. RESULTS: Our article is a summary of major causes of speech delay based on reliable sources as listed herein. CONCLUSIONS AND RELEVANCE: Speech delay can be the manifestation of a spectrum of disorders affecting the language comprehension and/or speech production pathways, ranging from disorders involving global developmental limitations to motor dysfunction to hearing loss. Determining the cause of a child's delay in speech production is a time-sensitive issue because a child loses valuable opportunities in intellectual development if his or her communication defect is not addressed and ameliorated with treatment. Knowing several key items about each disorder can help otolaryngologists direct families to the correct health care provider to maximize the child's learning potential and intellectual growth curve.

A comparison of two methods for preventing cross-contamination when using flexible fiberoptic endoscopes in an otolaryngology clinic: disposable sterile sheaths versus immersion in germicidal liquid.

OBJECTIVES/HYPOTHESIS: To assess the efficacy of using a sterile sheath to prevent cross-contamination when using a fiberoptic nasopharnygolaryngoscope (FNPL) in an otolaryngology clinic. STUDY DESIGN: Prospective controlled trial. METHODS: All FNPLs were disinfected according to applicable current guidelines recommended by the US Center for Disease Control. Swabs were taken from multiple sites on 100 FNPLs for cultures to detect the presence of bacteria, viruses, or both. Each FNPL was then assigned to either the sheath alone (experimental) or germicidal immersion (control) group. After using an FNPL in a patient, swabs were again taken so that a comparison could be made in microbes on the scopes. Throughout the study, the steps in the disinfection process taken by medical assistants as they worked with the FNPLs were observed and recorded. RESULTS: Microbial counts on insertion shafts of FNLPs for the sheath and immersion groups were similar, with 1/50 versus 0/50, respectively. Time spent using the sheath method averaged 89 seconds, whereas immersion in the germicidal liquid took 14 minutes. No breaches in adherence to applicable protocols were observed. CONCLUSIONS: Using an individually packaged disposable sterile sheath on a FNLP prevents microbes from adhering to the shaft of the scope, thus providing a reasonably safe method of avoiding the transmission of infection from one patient to the next patient when using an FNLP successively in multiple patients in an otolaryngology clinic.

Hearing loss.

For physicians treating patients with sensorineural hearing loss, therapy is directed more toward helping the patient cope with the loss of hearing rather than offering various medical or surgical interventions. Accordingly, for the patient with sensorineural hearing loss, the care plan is usually more directed toward palliation than toward cure. This article views hearing loss not only as a physiologic deficit, but as the loss of an important aspect of overall communication skill that can have far reaching emotional and psychologic effects on the patient, the family, and those who surround patients in their daily lives. In this article the authors offer strategies for managing the patient who is losing or who has lost hearing.

Analysis of recurrent angiotensin converting enzyme inhibitor-induced angioedema.

OBJECTIVE/HYPOTHESIS: A known risk for patients taking angiotensin converting enzyme-inhibitors (ACE-Is) is angioedema that can involve the face, lips, oral cavity, and larynx. Such upper airway obstruction may be severe enough to require an emergency department visit or even necessitate prompt airway intervention. Once a patient has had an episode of ACE-inhibitor induced angioedema (AIIA), certainly a thrust of continuing case management would be to avoid the occurrence of subsequent episodes of AIIA that potentially can be life-threatening. Nevertheless, recurrent episodes of AIIA do occur. This study aims to characterize a patient's risk for recurrent AIIA, determine the cause for repeat episodes of AIIA and recommend steps to be taken to minimize the recurrence of AIIA. STUDY DESIGN: Retrospective study. METHODS: A retrospective chart review of all patient encounters at our medical center between January 1, 1991 and December 30, 2005 with a diagnosis of angioedema was performed. The documented etiology of the angioedema, comorbidities, and documentation of an "allergy" to ACE-I were noted. Observations regarding risk factors for recurrent AIIA were made. RESULTS: Recurrent AIIA occurred in 23 patients with a recurrence rate of 6.2%. Risk factors for recurrence were categorized as patient factors, physician factors, or systems factors. Physician error with failure to document in the medical record, the suspicion of AIIA, and failure to consider risk in prescribing ACE-I after an episode of angioedema had occurred were the most common causes of recurrent AIIA. CONCLUSIONS: Angioedema can cause life-threatening airway compromise yet patients with a history of one episode of AIIA are at risk for a subsequent episode. Physicians can modify clinical practices to avert the potentially life-threatening side effects of ACE-inhibitors in patients with a prior episode of AIIA.

Cervical tuberculosis: a decision tree for protecting healthcare workers.

OBJECTIVES/HYPOTHESIS: The clinical presentation of cervical tuberculosis (TB) is a unique challenge to the otolaryngologist. To minimize the risk of nosocomial transmission, otolaryngologists must suspect the diagnosis and be familiar with recommendations for TB prevention. STUDY DESIGN: Scientific review. METHODS: We review current literature and recent changes in TB prevention strategies including the Centers for Disease Control and Prevention "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." RESULTS: Nosocomial transmission may occur from either unrecognized pulmonary disease or from aerosolization of tubercle bacilli during diagnostic procedures. History of prior TB infection, residence in a country where TB is endemic, close contact with a TB patient, or positive tuberculin skin test should raise suspicion of cervical TB. Physical examination findings may include painless, unilateral cervical lymphadenopathy. Children and human immunodeficiency virus infected patients present unique challenges, as these groups may have atypical presentations. When cervical TB is suspected, the provider should always screen for pulmonary and laryngeal disease. Fine needle aspiration with polymerase chain reaction or culture may accurately identify cervical TB. In rare cases, excisional biopsy may be required. CONCLUSIONS: To facilitate interpretation and rapid diagnosis while minimizing risk to health care providers, we provide a decision tree based on new federal guidelines and the clinical experience of a team of infectious disease specialists and otolaryngologists.

Emerging therapies for the treatment and prevention of otitis media.

Otitis media is one of the most common disorders occurring in children, and there is growing concern that bacteria are quickly becoming resistant to antimicrobials. As a result, global antibiotic treatment is no longer the standard of care and treatment of otitis media has changed dramatically in the last decade. In addition to new antimicrobials currently in development, the effects of the pneumococcal conjugate vaccine are just beginning to be understood. Furthermore, new surgical techniques are for the first time being tested as alternatives for tympanostomy tubes for recurrent acute otitis media. This review discusses current and emerging otitis media therapeutics, with particular attention to acute otitis media. Topics include antimicrobial use, antimicrobial resistance, effects of vaccination and new surgical techniques.

Hearing loss in Wegener's granulomatosis.

OBJECTIVE: To describe the frequency, type, and clinical course of hearing loss in Wegener's granulomatosis and assess hearing loss as an indicator of disease activity. STUDY DESIGN, SETTING, AND PATIENTS: Retrospective cohort review of all patients with Wegener's granulomatosis seen in 1 year at an academic medical center. MAIN OUTCOME MEASURES: Hearing loss documented by pure-tone audiogram. RESULTS: Thirty-six patients were included in the analysis: 20 men and 16 women, with a mean age of 55.5 years (range, 22-87 yr); 30 (83%) were antineutrophil cytoplasmic autoantibodies-positive, and the mean disease duration was 47 months (range, 2-196 mo). Twenty patients (56%) had documented hearing loss: there were 17 (47%) cases of sensorineural hearing loss and 12 (33%) cases of conductive hearing loss. Seven of 12 cases of conductive hearing loss improved with immunosuppressive treatment of Wegener's granulomatosis, 2 worsened, and 3 remained stable. Of 17 cases of sensorineural hearing loss, 3 improved, 4 worsened, and 10 remained stable. Seven patients had hearing loss requiring amplification. Five of 35 (14%) patients had established hearing loss months to years before diagnosis of Wegener's granulomatosis. Hearing loss occurred both on initial presentation and with disease relapse. The rates of conductive hearing loss (38%) and sensorineural hearing loss (31%) were also high in the subset of patients 65 years of age or younger and without history of noise exposure. CONCLUSIONS: Both sensorineural hearing loss and conductive hearing loss are common in Wegener's granulomatosis, may result in significant morbidity, and may precede the diagnosis of Wegener's granulomatosis by years. Both types of hearing loss in patients with Wegener's granulomatosis may be used as an indicator of disease. These data suggest that it may be appropriate to obtain screening audiograms in all patients with newly diagnosed or relapsing Wegener's granulomatosis.

Clinical practice guideline: Otitis media with effusion.

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline "Otitis Media With Effusion in Young Children," which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children aged 1 to 3 years with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media (AOM). The subcommittee made recommendations that clinicians should (1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME; (2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk; and (3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown). The subcommittee also made recommendations that (4) hearing testing be conducted when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; (5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; and (6) when a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that (1) population-based screening programs for OME not be performed in healthy, asymptomatic children and (2) antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that (1) tympanometry can be used to confirm the diagnosis of OME and (2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child. The subcommittee made no recommendations for (1) complementary and alternative medicine as a treatment for OME based on a lack of scientific evidence documenting efficacy and (2) allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children older than 12 years because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Modern management of acute otitis media.

Although recent clinical trials suggest that conjugate vaccination will be less effective for the prevention of AOM than for IPD, these trials have demonstrated impressive reductions in the incidence of AOM due to invasive and antibiotic-resistant pneumococcal serotypes. These data suggest that if serotype replacement does occur in immunized children, the causative agents are likely to be less virulent than vaccine strains. Furthermore, a recent cost-effectiveness analysis projected that immunization of healthy infants with the heptavalent conjugate vaccine could prevent over one million episodes of AOM and 12,000 cases of invasive pneumococcal disease. Because significant reductions have been demonstrated in the incidence of frequently recurrent AOM, children with the worst disease stand to benefit most from vaccination. Based on data currently available, however, the conjugate vaccine is not going to eradicate AOM. Consequently, there will continue to be a need to scrutinize the threshold for prescribing antibiotics. In addition, there will be an ongoing need for surgery in some cases of recurrent AOM and persistent OME.