Ménière's Syndrome or Disease: Time Trends in Management and Quality of Evidence Over the Last Two Decades.

OBJECTIVE: To evaluate the evidence and trends in published literature on the treatment of Ménière's syndrome or disease (MS/D) by comparing studies published in the last two decades. DATA SOURCES: A literature search was performed on AMED, EMBASE, HMIC, MEDLINE, PsycINFO, BNI, CINAHL, HEALTH BUSINESS ELITE, CENTRAL and Cochrane Ear, Nose and Throat disorders groups trials register using a combination of MeSH. The date of last search was October 2014. STUDY SELECTION AND DATA EXTRACTION: Two hundred five studies (104 in decade I and 101 in decade II) were evaluated to report trends in the management of this condition, the differing levels of evidence published for each treatment modality, evaluate whether the guidelines published by the AAOHNS-Committee on Hearing and Equilibrium had been correctly employed, and whether the randomized controlled trials (RCTs) were compliant with the CONSORT guidelines. RESULTS: The number of published RCTs almost tripled from decade I (1994-2003) to decade II (2004-2103). There was a significant decline in the use of surgical intervention (p = 0.013); however, the number of studies involving the use of intratympanic injection remained largely unchanged. There was a shift in the level of evidence in published studies; studies with level 1 evidence tripled from decade I to II (4.8 to 17.8%, respectively) (p = 0.03); however, compliance with the AAOHNS-CHE criteria for reporting treatment outcomes and the CONSORT checklist was still poor. CONCLUSION: Although the evidence base on published literature on MS/D has improved over the last decade with an increase in emphasis on RCTs and quality of life (QoL) studies, a significant number of studies failed to follow AAOHNS-CHE criteria for reporting treatment outcome and the CONSORT criteria for reporting RCTs.

Evaluation of round window accessibility to cochlear implant insertion.

Emphasis on hearing preservation has led to recognition of the round window membrane (RWM) as a portal for the cochlear implant electrode array. The St Thomas' Hospital (STH) classification was devised to evaluate the accessibility of RWM electrode insertion. The objectives of this study were: (1) to prospectively evaluate the STH classification in selecting the appropriate cochlear insertion route in "RWM-intentioned" cases, and (2) to ascertain if RWM accessibility differs from adults to children. This was a prospective cohort study of consecutive patients (adult and paediatric) undergoing cochlear implantation at a specialist auditory implant centre. Visibility of the RWM was graded according to the STH classification after an "optimal" posterior tympanotomy had been performed and any overhang of the bony round window niche removed without breaching the RWM. Most adult (89 %) and paediatric (78 %) cases had more than 50 % of the RWM exposed (Types I and IIa). Cases having less than 50 % of RWM exposed (Types IIb) or none exposed (Type III) were twice as common in children (p = 0.004). 96 % of Type I and 63 % of Type IIa cases underwent RWM insertion through a membranous cochleostomy. 71 % of Type IIb necessitated an extended membranous cochleostomy. All Type III cases required a conventional bony cochleostomy. When more than 50 % of RWM was visible (Types I and IIa), 88 % underwent a membranous cochleostomy. For "RWM-intentioned" cases, the STH classification can be a sensible method of relating RWM visibility/accessibility to the optimal route for insertion. This study also demonstrates that RWM insertion is more challenging in children.

Round window electrode insertion potentiates retention in the scala tympani.

CONCLUSIONS: The round window membrane (RWM)-intentioned approach is superior to the traditional bony cochleostomy (BC) approach in obtaining electrode placement within the scala tympani (ST). OBJECTIVE: Cochlear implant outcome is influenced by several factors, including optimal placement and retention of the electrode array within the ST. The present study aimed to assess whether the RWM route is superior to a traditional BC for placement and retention of the electrode array in the ST. METHODS: This was a prospective consecutive non-randomized comparison study. All patients were implanted with the Advanced Bionics 1J electrode array. The RWM approach (n = 32) was compared with a traditional BC group (n = 33). The outcome measure was the electrode position as judged within the scalar chambers at four points along the basal turn using postoperative computed tomography (CT). RESULTS: When the mean position scores were compared, the RWM-intentioned group had significantly more electrodes directed towards the ST compartment than the BC group (p < 0.001). The RWM electrodes achieved 94% ST retention compared with 64% for the BC group (p < 0.05). All electrodes stayed in the ST in the RWM group, whereas in the BC group 9% crossed from the ST to the scala vestibuli.

Cerebrospinal fluid rhinorrhea complicating septoplasty: a novel mechanism of injury.

Cerebrospinal fluid (CSF) rhinorrhea after a septoplasty procedure is very rare and potentially life-threatening. We present a case of iatrogenic postseptoplasty CSF rhinorrhea. To the best of our knowledge, only 2 other cases of CSF rhinorrhea complicating septoplasty have previously been reported. However, neither resolved in the manner that our case did, when spontaneous cessation of CSF rhinorrhea unexpectedly occurred upon removal of intranasal splints. We discuss the clinical importance of anatomic variations and potential causative mechanisms of CSF rhinorrhea during septoplasty. Our experience with this case suggests a mechanism of injury to the cribiform plate during septoplasty that has not been described previously.

Contralateral incipient posterior canal benign positional paroxysmal vertigo: complication after Epley maneuver.

BACKGROUND: Particle repositioning procedures give consistent results for the treatment of benign positional paroxysmal vertigo (BPPV). However, little consideration has been given to the possibilities of bilateral disease. OBJECTIVE/HYPOTHESIS: To report contralateral symptoms and signs suggestive of revealed or incipient BPPV as a complication of Epley maneuver. STUDY DESIGN: A prospective cohort of 198 cases over a period of 11 years. RESULTS: Ten (5.0%) developed contralateral symptoms and signs suggestive of revealed or incipient posterior canal BPPV within 2 weeks of treatment. CONCLUSION: This novel observation has not been previously described and may influence the strategy for future management of patients with BPPV. Particle repositioning maneuvers for the previously asymptomatic contralateral ear may need to be considered in a subset of patients with posterior canal BPPV who suffer contralateral symptoms after undergoing treatment for the original ear.

Catamenial pneumothorax: surgical repair of the diaphragm and hormone treatment.

Catamenial pneumothorax is defined as spontaneous pneumothoraces occurring within 72 h before or after onset of menstruation. It is rare but clinical index of suspicion should be high in ovulating women with spontaneous pneumothoraces. The mechanism is unclear but is thought to involve pre-existing or acquired diaphragmatic defects and endometrial implants. Traditional therapy involving hormonal treatment or surgical pleurodesis alone is associated with high rates of recurrence. A series of four patients with catamenial pneumothorax managed at our institution is presented to highlight the condition to various surgical specialties to whom it may present, and to emphasise the importance of both surgical and hormonal interventions in preventing recurrence. Each patient underwent video-assisted thoracoscopic inspection of the diaphragm, mechanical pleurodesis and, most importantly, repair of diaphragmatic defects with an artificial mesh. Surgical treatment was strictly followed by a course of gonadotrophin-releasing hormone analogue therapy in three patients, with no recurrence to date (longest follow-up 45 months). The fourth patient suffered a postoperative recurrence when hormonal treatment was delayed for 6 weeks, stressing the importance of hormonal treatment in conjunction with surgery.