Persistence of Non-Vertigo Symptoms in Meniere Disease During Remission - A Preliminary Report.

BACKGROUND: Though the absence of vertigo in Meniere disease is often interpreted as remission, patient-centered subjective assessment of quality of life remains the best indicator of such remission. STUDY OBJECTIVE: To assess the presence and severity of aural pressure/tinnitus, hearing loss, unsteadiness, nausea and vomiting in MD patients during remission. SETTING: Urban tertiary care referral hospital in a developing country. METHODOLOGY: Consecutive patients with diagnosis of Definite Meniere were selected from the Balance and Dizziness Clinic of National Hospital Abuja for the study. Quality of life assessment was carried out using 3 validated tools - Modified MD-POSI, Vertigo Symptom Scale and Tinnitus Handicap Inventory (THI). Patients were included only when they have been vertigo free for at least 4 weeks. Pure tone audiometry was carried out in those with subjective hearing loss at recruitment and 4 weeks later. RESULTS: A total of 26 patients completed the study. All had cinnarizine for acute vertigo control and Betahistine for maintenance of vertigo control. There was female preponderance (17:9). The age range was 32-56 years. The duration of MD ranges from 4 months to 12 years. The total and subscale MD-POSI scores for "between attacks" significantly correlated with hearing, unsteadiness and tinnitus/pressure when compared to during attack. 69.2 per cent of participants experienced symptoms of unsteadiness during remission. 13/26 of participants reported persistent, though less annoying tinnitus that poorly correlated with THI score during remission. CONCLUSION: Our study showed that significant non-vertigo symptoms affect the quality of life during remission. Perhaps there is need to properly define, in future studies, what constitutes remission in patients with MD.

10 years of Vertigo Clinic at National Hospital Abuja, Nigeria: what have we learned?

The clinician's major role in management of the dizzy patient involves determining what dizziness is vertigo, and what vertigo is of central or peripheral origin. These demand attention to details of history, otolaryngological workup including vestibular assessment, and often use of diagnostic and management algorithms. There is paucity of published reports of the management outcomes of peripheral vestibular diseases from Africa. Two tertiary care otologist-led dedicated vertigo clinics are located in Abuja, Nigeria. A prospective, non-randomized study of patients presenting with features of peripheral vestibular diseases attending the National Hospital Abuja Nigeria (between May 2005 and April 2014) and CSR Otologics Specialist Clinics (May 2010 to April 2014) was carried out. Both institutions adopted the same diagnostic and management protocols. Data extracted from anonymized databases created for this study include age, sex, vertigo duration (acute <12 weeks, chronic >12 weeks), dizziness handicap inventory score at presentation and at subsequent visits, otological and vestibular findings, ice-water caloric testing results, other investigation outcomes, treatments offered and outcomes. 561/575 (97.5 %) of the cases recorded had peripheral vestibular disease. The male-to-female ratio was 290:271. The mean age of the subjects was 44.7 years. Duration of vertigo at presentation was acute in 278 subjects and chronic in 283 subjects. Identifiable clinical diagnostic groups include BPPV (n = 200), Meniere's disease (n = 189), cervicogenic vertigo (n = 35), labyrinthitis (n = 32), Migraine-associated vertigo (MAV) (n = 32), cholesteatoma/perilymph Fistula (n = 10), climacteric vertigo (n = 8) and unclassified vertigo (n = 55). Migraine-associated vertigo recorded the highest DHI score (95 % CI 75 ± 4.3), followed by cholesteatoma/perilymph fistula (95 % CI 72 ± 6.1) and labyrinthitis (95 % CI 62 ± 1.9). Pure tone audiometry (95 % CI 67.3 ± 3.43), followed by thyroid function tests (95 % CI 66.7 ± 23.55) and ice-water caloric testing (95 % CI 59.7 ± 2.69) were investigations with the highest yields. 86.5 % of cases were treated by either vestibular suppressant medications alone (n = 285) and/or particle repositioning maneuver (n = 200) with improvement in vertigo control (95 % CI 63.63 to 74.37 % and 62.59 to 75.41 %, respectively). Peripheral vestibular diseases constitute majority of cases of self-reported vertigo seen in our setting. Migraine-associated vertigo seen in our setting all have peripheral vestibular signs. Dedicated vertigo clinics could significantly improve the diagnostic and treatment yield in a resource-constrained setting like ours. Most cases can be managed using non-operative measures.

Chronic rhinosinusitis: correlation of symptoms with computed tomography scan findings.

INTRODUCTION: Symptomatology, nasal endoscopy and Computerised Tomographic (CT) scan have been used to diagnose chronic rhinosinusitis. The value of disease severity score in the assessment of chronic rhinosinusitis has not been well investigated. Hence, this study aims to correlate the pre-operative symptom severity score as well as overall disease severity score of patients with chronic rhinosinusitis with CT scan scores. METHODS: This is a prospective study of 60 patients diagnosed clinically with chronic rhinosinusitis. Each patients ubjectively assessed his/her presenting symptoms and severity of disease on a visual analogue scale. The patients had CT scan of the paranasal sinuses which were graded and scored using Lund-Mackay grading system. The correlation study between severity of symptoms/disease severity and CT scores was performed. The level of statistical significance was considered at p<0.05 and confidence interval at 95%. RESULTS: All patients had more than one symptom with mean symptom severity scores highest for nasal discharge and nasal obstruction. There was a significant correlation between CT scores and nasal discharge (r=-0.132; p=0.03)and nasal obstruction (r=0.193; p=0.049). No correlation with other symptoms. There was no correlation between the overall disease severity scores and the Lund-Mackay CT scores (r=0.195; p=0.6). CONCLUSION: This study showed that CT scan scores can help clinicians to predict severity of symptom for nasal obstruction and discharge but not for other symptoms of chronic rhinosinusitis. However, there was no association of CT score with the overall disease severity score.

Postauricular advancement fascio-cutaneo-periosteal flap for closure of mastoid cutaneous fistula.

BACKGROUND: Postauricular cutaneous mastoid fistula (PCMF) is a rare complication of chronic suppurative otitis media, may also complicate ear surgery and, very rarely, has been reported to complicate congenital cholesteatoma. Few authors have given descriptions of techniques of closure, with majority agreeing on the difficulty in managing such fistula due to the necrotic nature of the margin. SETTING: A tertiary care urban referral hospital in a developing economy. METHODOLOGY: A new technique of closure of PCMF is described. This technique utilizes the postauricular fascio-cutaneo-periosteal advancement flap with Burow's triangles following excision of the fistula margin. Details of this technique are described. RESULTS: Two women with cholesteatoma, aged 33 and 41 years, were successfully managed using this technique. The first case was diagnosed with right ear cholesteatoma with automastoidectomy and persistent discharging cutaneous mastoid fistula and had completion of canal wall-down mastoidectomy with postoperative cleaning of the mastoid cavity. The mastoid cutaneous fistula persisted postoperative despite conservative treatment and was treated using this technique 14 months postsurgery with successful outcome. The second case with left attic cholesteatoma extending to the mastoid antrum had canal wall-up mastoidectomy with limited atticotomy, but developed persistent mastoid cutaneous fistula 4 months postoperative and was treated with this technique. She had delayed wound healing but the fistula eventually closed. Both cases have been followed up for 24 and 18 months respectively with no recurrence. CONCLUSION: Postauricular advancement flap is effective for closure of persistent cutaneous mastoid fistula.

Allergy history as a predictor of early onset adenoids/adenotonsillar hypertrophy among Nigerian children.

BACKGROUND: Previous reports have established the association of allergy with adenoidal and tonsillar hypertrophy, and adenotonsillar hypertrophy is a well known co-morbid factor in patients with allergic rhinitis. Very little is known about the association of history of allergy with timing of first presentation in adenotonsillitis patients. SETTING: Tertiary care urban referral hospital. STUDY DESIGN: Descriptive analysis of prospectively collected data. METHODS: All cases which had adenotonsillectomy carried out between September 2005 and September 2012 at National Hospital Abuja that met the selection criteria were recruited and analyzed on the basis of family history of allergy in first degree relatives, clinical history of allergic rhinitis, asthma and atopic dermatitis. RESULT: Total of 434 cases were recruited. Mean age was 5 years (range 9 months-15 years, std. dev. 3.535). 56% of participants were aged 3 years and below. 22, 15, and 16% of participants aged 3 years and below had family history of allergy, allergic rhinitis and atopic dermatitis respectively compared to 6, 4 and 4% for participants aged above 3 years. The mean age at onset of symptoms is 7.59, 10.32, and 13.62 months for participants with family history of allergy, clinical allergic rhinitis and atopic dermatitis respectively and 23.890 months for participants with no history of atopy or allergy. Family history of allergy significantly predicts onset of symptoms before age 6 months (OR 7.59, 95% CI 4.74-12.12, P<0.0001). CONCLUSIONS: Family history of allergy and presence of clinical allergic or atopic dermatitis are related to early onset of symptoms in Nigerian children with adenoids/adenotonsillar hypertrophy.

Characterisitics and maskability of self-reported tinnitus in adult Nigerians.

BACKGROUND: Tinnitus or noise perception with no identifiable acoustic origin is a perplexing symptom to sufferers as well as to otolaryngologists saddled with managing such patients. With most studies from the continent focusing on etiologies and clinical types, there is paucity of information on psychoacoustic properties of tinnitus among Africans. SETTING: Tertiary care otolaryngology clinics in Abuja. OBJECTIVE: To determine characteristics and maskability of tinnitus seen in adult Nigerians who self-report tinnitus as the main presenting symptom. METHODS: A prospective study involving 100 adult Nigerians seen at two specialist Otorhinolaryngology clinics in Abuja - National Hospital Abuja and CSR Otologics Specialist Clinics, Abuja between January 2008 and June 2014. Clinical and audiological history and findings were captured in the study protocol. Participants were then assessed to determine Tinnitus pitch match, loudness match, mask ability and minimum masking level as well as residual inhibition. RESULTS: 100 participants aged 24 - 58 years were assessed. Male to female ratio was 1:1.4. Tinnitus was sudden in onset in 24%, and gradual in 76%, involved the right ear in 32%, left ear in 38% and both ears in 30%. 48% of participants have other symptoms apart from tinnitus, and 32% were on other medications known to induce tinnitus. 16% of participants gave history of exposure to significant loud sound. Only 16% of participants have significant otoscopic findings. Tinnitus abated with carotid pressure in 64%, with extra ocular muscle movement in 16%, with teeth clenching in 32%, with neck movement in 28%, and with movement of arms or legs in 8%. The mean difference in hearing threshold of ear with and without tinnitus was 12.09 dB HL. Tinnitus pitch match was 4 KHz in 44%, 3 KHz in 24%, and 2 KHz in 32%, while mean tinnitus loudness match was 41.24 dB SL. Tinnitus was maskable in 88% of subjects, with a residual inhibition of 2 to 76 seconds. CONCLUSION: Majority of adult Nigerians that self-report tinnitus have maskable tinnitus, and this should be considered when considering hearing augmentation for those with associated impaired hearing.

Subjective and objective outcomes of tympanoplasty surgery at National Hospital Abuja, Nigeria 2005-2009.

The objective of this study is to determine the subjective and objective outcomes of tympanoplasty surgery carried out in patients with otitis media and to identify factors responsible for these outcomes. The study setting is tertiary care urban referral hospital in a developing economy and the study methodology is a prospective analysis of patients with diagnosis of chronic suppurative otitis media that had tympanoplasty with or without mastoidectomy between May 2005 and September 2009 at National Hospital Abuja. Subjects were evaluated for age, sex, size and site of perforation, status of operated ear(s) (dry/discharging), status of the contralateral ear, surgical technique, subjective and objective pre-operative and post-operative hearing scores, average post-operative follow-up time, and post-operative complications, and results were statistically analyzed. A total of 45 patients (51 ears) were operated. Age distribution was 8-52 years. Type 1 tympanoplasty was done in 41 patients and Type 3 in 4 patients. Seven of the patient had concomitant mastoid surgery (cortical mastoidectomy). 3/51 of the cases had discharging ears at surgery. 16/45 of the patients (19/51 ears) had cartilage graft tympanoplasty, while 29/45 (32 ears) had temporalis fascia tympanoplasty. 15/16 of the cartilage group as well as 26/29 of the fascia group reported subjective hearing improvement, whilst the actual graft take was 12/16 of the cartilage group and 23/29 of the fascia group. Objective hearing improvement was observed in all of the cartilage as well as 26/29 of the fascia group. This study confirms success of tympanoplasty among Nigerians, and recommends that subjective hearing assessment should form part of indicators for success following tympanoplasty.