Comparing the use of high dose to standard dose corticosteroids for the treatment of sudden sensorineural hearing loss in adults - A systematic review.

OBJECTIVE: Idiopathic sudden sensorineural hearing loss (SSNHL) is typically treated with systematic or intratympanic corticosteroids. Current ENT-UK guidelines suggest treatment with a dose of oral prednisolone 1mg/kg/day for 7 days then tapered over a further 5 days. However, there is no consensus on the effectiveness of corticosteroids for idiopathic SSNHL and no universally accepted optimal regime. The objective of this systematic review was to examine the effect of high dose versus standard dose corticosteroids in the management of idiopathic SSNHL. METHODS: A systematic review was performed of all published data related to patients with idiopathic SSNHL who were treated acutely with high dose corticosteroid therapy. Articles were included that reported data on high dose, or comparing standard dose to high dose, oral or intravenous corticosteroid therapy for the treatment of patients with idiopathic sudden sensorineural hearing loss. Articles where patients received only combination treatment with intra-tympanic steroid were excluded. Risk of bias was assessed using the ROBINS-I tool and the ROB-2 tool. RESULTS: Six studies were included in the analysis, representing 919 patients. Two prospective single-arm studies of patients with SSNHL treated with a high dose steroid regime found mean hearing level improved (79.5dB to 42.3dB) and 45.8% of idiopathic patients had complete recovery of hearing. Three retrospective case-series comparing high dose to standard dose regimes found a significantly greater improvement in hearing level (38.3dB vs. 48.8dB, P = 0.042), a greater mean absolute hearing gain (44.4dB vs. 15.1dB) and a significantly higher rate of functionally relevant recovery (35.7% vs. 7.4%, P = 0.035) in patients treated with high dose regimes. The single included prospective randomised trial found no statistically significant difference in mean hearing level or speech discrimination score between patients treated with high dose pulse steroids or a standard dose regime. CONCLUSIONS: Our systematic review found the reported outcomes in the literature in this area to be mixed, with some studies suggesting a greater degree of hearing recovery with a high dose regime but others suggesting no difference. The overall quality of the available evidence was deemed to be low, with the studies at moderate risk of bias.

Follow-up care after grommet insertion in children: Review article.

BACKGROUND: Grommet insertion is a common procedure in children. A lengthy otolaryngology follow-up can have an adverse impact on clinic waiting times, new patient appointment availability, and pecuniary disadvantage for the hospital. OBJECTIVE OF REVIEW: To consolidate research and opinion concerning follow-up care following grommet insertion in a pediatric population. SEARCH STRATEGY: The literature between January 1990 and September 2015 was searched on MEDLINE (Ovid), Google Scholar, PubMed and Web of Science databases. RESULTS: Guidelines and consensus of opinion from the United States advocate that an initial post-operative review should take place within 4 weeks, and subsequent appointments every 6 months until grommet extrusion. Recent audit reports from the United Kingdom have shown that some groups arrange their first post-operative review at 3 months, and subsequent appointments vary considerably from no further follow-up to up to 24 months. Up to 75% of follow-up appointments were scheduled despite normal audiometry and clinical findings after grommet insertion, suggesting a large cohort of patients may undergo unnecessary specialist clinic reviews. General practioners (GP), audiologists or specialist nurses are potential alternative providers of regular reviews to ensure normal hearing thresholds and an adequate tympanic membrane healing course. CONCLUSION: Follow-up schedules are largely driven by consensus of opinion. A significant number of follow-up appointments in otolaryngology clinic appear to be redundant. Recently attention has been drawn to earlier discharge from otolaryngology clinic with subsequent follow-up in less resource and cost intensive clinics coordinated by GPs, audiologist or nurses, which may help alleviate some outpatient workload on acute hospital trusts.

Outcome of bone-anchored hearing aids for single-sided deafness: a prospective study.

CONCLUSION: The bone-anchored hearing aid (BAHA) system can offer significant benefits to patients with single-sided deafness (SSD), primarily by lifting the head shadow effect. OBJECTIVE: To evaluate the efficacy of BAHA for SSD by comparing pre- and postoperative speech, spatial and qualities of hearing scale (SSQ) scores. METHODS: This was a prospective study conducted within a tertiary auditory implant department. The inclusion criteria were unilateral profound hearing loss with normal or mild high frequency hearing loss in the hearing ear (pure tone average better than or equal to 25 dBHL measured at 0.5, 1, 2 and 3 kHz) and subjective benefits reported by patients following a home trial with a BAHA Softband. Patients who met the above criteria and opted for surgery were asked to complete the SSQ questionnaire. The postoperative SSQ response was collected after at least 6 months of consistent BAHA usage. RESULTS: This study included 25 adult patients (mean age at implantation 57.5 years). There was a statistically significant improvement in the average SSQ score in all three sections of the questionnaire with the use of the BAHA. Our patients experienced most marked benefits in speech hearing in challenging listening situations. All patients remain consistent users and there has been no explantation to date.

A systematic review of diffusion-weighted magnetic resonance imaging in the assessment of postoperative cholesteatoma.

OBJECTIVE: A systematic review to determine whether the diffusion-weighted (DW) magnetic resonance imaging scan can reliably detect residual or recurrent cholesteatoma after mastoid surgery. DESIGN: A systematic review. DATA SOURCES: Databases including EMBASE, MEDLINE, CINAHL, Web of Science, and Cochrane Review were searched for studies published without language restriction from the start of the databases. Additional studies were identified from cited references. SELECTION CRITERIA: Initial search identified 402 publications, of which 16 studies met the inclusion criteria for the systematic review. The DW imaging (DWI) scan was used to detect residual or recurrent cholesteatoma and subsequent second-look surgery was performed to correlate the findings. REVIEW METHODS: Studies were assessed for their selection of patients for radiologic investigations, imaging parameters, and subsequent surgery. Outcome measures included sensitivity, specificity, positive and negative predictive values of the DWI, and the incidence and size of residual or recurrent cholesteatoma. RESULTS: Two different modalities of DWI sequences have been described. Eight studies with 225 patients analyzed echo-planar imaging (EPI) and 8 studies with 207 patients described the "non-EPI" scanning techniques. Non-EPI parameters are more reliable in identifying residual or recurrent cholesteatoma with sensitivity, specificity, and positive and negative predictive values of 91%, 96%, 97%, and 85%, respectively. CONCLUSION: The available evidence suggests that non-EPI such as half-Fourier acquisition single-shot turbo spin echo sequences are more reliable in identifying residual or recurrent cholesteatoma. This is a promising radiologic investigation; however, we think further studies are required with more patients and long-term results to establish its place as an alternative to a second-stage surgery after canal wall up surgery.

Hypopharyngeal perforation during endoscopic ultrasound treated by primary repair.

BACKGROUND: An endoscopic ultrasound scan is a common procedure used to diagnose conditions of the upper gastrointestinal tract. We present a case of hypopharyngeal perforation complicating endoscopic ultrasound scan treated with primary surgical repair. METHODS AND RESULTS: A 62-year-old woman underwent an endoscopic ultrasound scan for investigation of a pancreatic lesion. A high esophageal perforation occurred during the procedure. She underwent emergency repair of this perforation via an external approach. Unfortunately her recovery was complicated by a pleural effusion which required a chest drain. She made a complete recovery, which was confirmed with a barium swallow. DISCUSSION: Upper esophageal perforation is a rare complication of an endoscopic ultrasound scan and, to our knowledge, there have been no reported cases of hypopharyngeal perforation. The risk factors, incidence, and management of perforations are reviewed. Early recognition of hypopharyngeal perforation is important and, in selected cases, immediate repair of the defect can lead to a good result.

Diffusion-weighted magnetic resonance imaging in the management of cholesteatoma.

Diffusion-weighted (DW) MRI has recently increasingly gained popularity in the diagnosis of post-operative cholesteatoma. The aim of this study is to prospectively evaluate the usefulness of echo-planar imaging (EPI) for the diagnosis of residual cholesteatoma. Fifty patients underwent DW-EPI before surgery. Fifteen patients had a scan before their first surgery and 35 patients underwent neuroimaging prior to their second look surgery. In the first preoperative group of 15 patients, DW-EPI confirmed cholesteatoma in all the patients. In the post-operative group DW-EPI identified or excluded cholesteatoma correctly in 29 out of 35 patients. Our study has demonstrated a sensitivity of 83% and specificity of 82% of DW-EPI for the diagnosis of residual cholesteatoma. DW-EPI can be a value imaging modality and may help the surgeon in selecting patients for revision surgery.

Idiopathic intracranial hypertension in otolaryngology.

Idiopathic intracranial hypertension (IIH) is defined as increased intracranial pressure in the absence of intracranial mass or obstructive hydrocephalus. Over 80% of patients are overweight women. IIH is usually encountered in the neurology and ophthalmology practise as headaches, visual disturbance and papilloedema are the characteristic features of this syndrome. Patients with IIH also experience tinnitus, hearing loss, balance disturbance, cerebrospinal fluid (CSF) otorrhoea or rhinorrhoea and in some cases these otorhinological symptoms can be presenting features of this syndrome. IIH is also associated with obstructive sleep apnoea. Otolaryngologists should be familiar with this important condition as it can manifest a variety of symptoms that are more frequently seen in their clinics. Sometimes otolaryngologists may be involved in the surgical management of this condition, such as repair of CSF rhinorrhoea or otorrhoea or endoscopic optic nerve decompression. The aim of this review article is to familiarise the otolaryngologists with the important features of this unusual syndrome which may remain unrecognised in the otolaryngology practice.

Intraoperative dilated pupil during nasal polypectomy.

In endoscopic sinus surgery, it is often desirable to prepare the nasal mucosa with a nasal decongestant to minimise blood loss and enhance the operative field during surgery. A widely used commercially available preparation for such a purpose is a solution containing 5% Lidocaine Hydrochloride and 0.5% Phenylepherine Hydrochloride. We report a case of a unilateral dilated pupil occurring during nasal polypectomy. A dilated pupil during sinus surgery is associated with an intraorbital injury but many commonly used nasal decongestive agents can also cause mydriasis and this knowledge may prevent some anxiety for the unwary ENT surgeon undertaking sinonasal surgery.

Does epinephrine infiltration in septoplasty make any difference? A double blind randomised controlled trial.

Infiltration of lignocaine with epinephrine is used with cocaine in septoplasty, in attempt to improve haemostasis and thereby improve the surgical field. This practice is widespread despite the lack of evidence to support its efficacy in the literature. Thirty patients undergoing septoplasty were randomised into two groups -- one in whom infiltration was performed with lignocaine (2%) with adrenaline (1:80,000) and a control group who received lignocaine (2%). Both groups of patients received intranasal application of cocaine paste prior to surgery. The surgeon and anaesthetist were blinded to the contents of the infiltration. The operative field was rated by the surgeon, and the blood loss calculated. No significant difference was demonstrated in blood loss or surgical field between the groups. However there was significant rise in systolic blood pressure in patients who received epinephrine. The use of epinephrine with cocaine paste does not improve haemostasis or surgical field. As the use of epinephrine is associated with cardiac arrhythmias, the authors suggest that combined use of cocaine paste and epinephrine infiltration should be avoided in septal surgery.

Surgical findings and long-term hearing results in 3,050 stapedotomies for primary otosclerosis: a prospective study with the otology-neurotology database.

OBJECTIVE: To evaluate with a new otologic database the results of primary stapes surgery for otosclerosis with up to 14 years of follow-up in a consecutive series of 2,525 patients operated on by the same surgeon with the same technique (stapedotomy and vein graft interposition) and to provide online access to the complete data of this study for the reviewers. To study the effect of specific operative findings (obliterative otosclerosis and simultaneous malleus ankylosis) and age at the time of surgery on the long-term outcome. STUDY DESIGN: Prospective clinical study using a new computerized otologic database. SETTING: : Tertiary referral center. PATIENTS: Two thousand five hundred twenty-five patients who underwent 3,050 stapedotomies for otosclerotic stapes fixation were enrolled in this study from January 1991 to December 2004. Separate analyses were made for two unique pathologies (92 cases of obliterative otosclerosis and 19 cases of simultaneous malleus ankylosis) diagnosed during surgery and for patients in two age brackets (or=65 yr [302 patients]). INTERVENTION: Stapedotomy with vein graft interposition and reconstruction with either a Teflon piston, a bucket handle prosthesis, or a total prosthesis. MAIN OUTCOME MEASURES: Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap (ABG), bone-conduction thresholds, and air-conduction thresholds were all assessed. Postoperative audiometry was performed at 3, 6, 9, 12, 18, and 24 months and then annually for 14 years. RESULTS: Overall, the postoperative ABG was closed to 10 dB in 94.2% of cases. The mean four-frequency postoperative ABG was 1.7 dB compared with 25.6 dB preoperatively. The mean four-frequency bone-conduction thresholds were unchanged postoperatively. A significant postoperative sensorineural hearing loss (SNHL; >15 dB) was seen in 0.5% of cases in this series. Postoperative ABG was achieved to within 10 dB in 95% of cases of obliterative otosclerosis and in 64.7% of cases of simultaneous malleus ankylosis. A significant postoperative SNHL (>15 dB) was seen in 4.8% of cases of obliterative otosclerosis and was not observed in any cases of simultaneous malleus ankylosis. Postoperative ABG was achieved to within 10 dB in 93.5% of cases in the pediatric series and in 94.5% of cases in the senior series. A significant postoperative SNHL (>15 dB) was seen in 0.7% of cases in the senior group but was not observed in the children. CONCLUSION: Using a new otologic database, our series confirms that stapedotomy with vein graft interposition for otosclerotic stapes fixation is a safe and successful treatment for long-term hearing improvement. The deterioration in hearing with time after stapedotomy did not exceed the rate of hearing loss because of presbyacusis. Therefore, argon laser stapedotomy with vein graft interposition is our preferred surgical technique in the treatment of otosclerosis. Obliterative otosclerosis and simultaneous malleus ankylosis may be encountered during stapedotomy. Our study shows that reasonable success rates can still be expected in these situations. Stapedotomy results in the elderly and in children are comparable to those obtained in patients of other groups of age undergoing surgery for otosclerosis without an increased risk for complications.