Recognizing bisphosphonate-induced ear osteonecrosis in primary care: a case report.

INTRODUCTION: Medication-related ear canal osteonecrosis (MRECO) is a growing concern linked to prolonged anti-resorptive medication use. Despite primary care providers being key prescribers of these medications, there is limited information about MRECO in primary care literature. This article presents a case of bisphosphonate-induced osteonecrosis of the external auditory canal (EAC), emphasizing the vital role of primary care providers in identifying this rare yet significant side effect of anti-resorptive medication. MAIN SYMPTOMS AND CLINICAL FINDINGS: A 65-year-old female, on long-term alendronic acid for osteoporosis, presented to primary care with a 2-year history of left-sided ear blockage and itchiness. Despite prolonged topical treatment for ear wax, symptoms persisted, leading to an Otolaryngology referral. Microsuction revealed exposed bone in the left EAC. DIAGNOSES, INTERVENTIONS, AND OUTCOMES: A computed tomography scan confirmed bony erosion of the left EAC, and in the absence of other osteonecrosis risk factors, bisphosphonate-induced osteonecrosis was diagnosed. Management involved bisphosphonate discontinuation, regular aural toilet, and topical treatment, achieving complete ear canal epithelialisation within 6 months. CONCLUSION: MRECO, a rare complication of anti-resorptive therapy, is anticipated to rise with increasing antiresorptive medication use in the ageing population. Unexplained ear symptoms in those with a history of current or prior anti-resorptive therapy should raise clinical concern, prompting evaluation for exposed bone in the EAC. Raising awareness of MRECO among primary care providers is crucial for early diagnosis and timely management.

Diffusion-Weighted Magnetic Resonance Imaging of Cholesteatoma Using PROPELLER at 1.5T: A Single-Centre Retrospective Study.

PURPOSE: The purpose of this study was to evaluate the sensitivity, specificity, and positive and negative predictive values of the diffusion-weighted periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) technique in the detection of cholesteatoma at our institution with surgical confirmation in all cases. METHODS: A retrospective review of 21 consecutive patients who underwent diffusion-weighted PROPELLER magnetic resonance imaging (MRI) on a 1.5T MRI scanner prior to primary or revision/second-look surgery for suspected cholesteatoma from 2009-2012 was performed. RESULTS: Diffusion-weighted PROPELLER had a sensitivity of 75%, specificity of 60%, positive predictive value of 86%, and negative predictive value of 43%. In the 15 patients for whom the presence or absence of cholesteatoma was correctly predicted, there were 2 cases where the reported locations of diffusion restriction did not correspond to the location of the cholesteatoma observed at surgery. CONCLUSION: On the basis of our retrospective study, we conclude that diffusion-weighted PROPELLER MRI is not sufficiently accurate to replace second look surgery at our institution.

Differences in perception of hearing handicap between cochlear implant users and their spouses.

OBJECTIVES/HYPOTHESIS: To examine the relationship between patient and proxy ratings of health-related quality of life (HRQL) in patients with cochlear implants. STUDY DESIGN: Prospective survey. METHODS: Eighty-two adult cochlear implant recipients and their spouses/partners were asked to complete the Nijmegen Cochlear Implant Questionnaire (NCIQ) and the Hearing Participation Scale (HPS) that were mailed to them. RESULTS: For the NCIQ, there were 38 useable responses from recipients and 31 useable responses from the partners. There were 27 paired and useable questionnaires (i.e., from both the recipient and his/her partner). For the HPS, there were 42 useable responses from recipients and 36 useable responses from the partners. Of these, there were 35 paired questionnaires. There was good agreement between partners and patients with both the HPS (r = 0.62) and the NCIQ (r = 0.80). There was a significant statistical difference in the scoring of the Basic Sound Perception subscale between the two groups (P = .039), with spouses under-rating performance in this subscale. CONCLUSIONS: For patients with cochlear implants, patients' partners corroborate patients' self-reported HRQL. In cases in which patients have sensory impairment, there may be an additional role for proxy ratings of HRQL to give a more complete assessment of functional limitations.

Predicting thyroxine requirements following total thyroidectomy.

OBJECTIVE: Optimal thyroxine replacement following total thyroidectomy is critical to avoid symptoms of hypothyroidism. The aim of this study was to determine the best formula to determine the initiated replacement dose of levothyroxine immediately following total thyroidectomy. DESIGN: Prospective study. All patients were initiated on 100 µg levothyroxine and titrated to within the reference range for TSH and free T4. Correlations to height, weight, age, lean body mass (LBM), body surface area (BSA) and body mass index (BMI) were calculated. PATIENTS: One hundred consecutive adult patients underwent total thyroidectomy for non-malignant disease. MEASUREMENTS: Comparison between three methods of levothyroxine dose prediction, aiming for a levothyroxine dose correct to within 25 µg of actual dose required. RESULTS: Correlations were seen between levothyroxine dose and patient age (r=-0.346, P<0.01), bodyweight (r=0.296, P<0.01), LBM (r=0.312, P<0.01), BSA (r=0.319, P<0.01) and BMI (r=0.172, P<0.05). A regression equation was calculated (predicted levothyroxine dose=[0·943 × bodyweight] + [-1.165 × age] + 125.8), simplified to (levothyroxine dose= bodyweight - age + 125) pragmatically. Initiating patients empirically on 100 µg post-operatively showed that 40% of patients achieved target within 25 µg of their required dose; this increased to 59% when using a weight-only dose calculation (1.6 µg/kg) and to 72% using the simplified regression equation. CONCLUSIONS: A simple calculated regression equation gives a more accurate prediction of initiated levothyroxine dose following total thyroidectomy, reducing the need for outpatient attendance for dose titration.