What is the current status of care by neuro-otology specialists in Switzerland-A national survey.

Background: Vertigo and dizziness are frequent presenting symptoms in the emergency department and in outpatient centers. While the majority of dizzy patients are evaluated by primary care physicians, specialists are often involved in the diagnostic workup. We aimed to gain more insights into the role of specialists in the care of dizzy patients. Materials and methods: Board-certified neurologists and ear-nose-throat (ENT) physicians working in Switzerland were invited to participate in an online survey. Descriptive statistical analyses were performed, and prospectively defined hypotheses were assessed using correlation analyses. Results: All 111 participating specialists (neurologists = 62; ENT specialists = 49) were familiar with testing for posterior canal benign paroxysmal positional vertigo (BPPV), and 66% regularly applied provocation maneuvers for suspected lateral canal BPPV. Reposition maneuvers for posterior (99%) and lateral (68%) canals were frequently performed. ENT physicians were familiar with lateral canal BPPV repositioning maneuvers significantly more often than neurologists (84 vs. 56%, p ≤ 0.012). Specialists strongly agreed that performing the head impulse test (86%) and looking for deficient eccentric gaze holding (82%) are important. Compared to neurologists, significantly fewer ENT physicians indicated ordering brain MRI in acutely dizzy patients (OR = 0.33 [0.16-0.067], p = 0.002) and physical therapy in patients with acute (50 vs. 20%, p = 0.005) or episodic/chronic dizziness (78 vs. 50%, p = 0.003). Conclusion: We found substantial differences in the care of dizzy patients by neurologists and ENT physicians. This underlines the need for a standardized, guideline-oriented diagnostic workup and treatment across specialties. Dedicated training for performing lateral canal BPPV repositioning maneuvers should be prioritized for neurologists. Similarly, physical therapy should be considered more often by ENT physicians.

Needs and supporting tools for primary care physicians to improve care of patients with vertigo and dizziness: a national survey.

Background: The diagnostic workup and treatment decisions for vertigo or dizziness in primary care can be challenging due to the broad range of possible causes and limited time and expertise of physicians. This can lead to delays in treatment and unnecessary tests. We aimed to identify the unmet needs of primary care physicians (PCPs) and strategies to improve care for dizzy patients. Materials and methods: An online survey was conducted among board-certified PCPs in Switzerland to explore needs in caring for dizzy patients and potential educational approaches. Results: Based on responses from 152 participating PCPs, satisfaction and confidence were higher in diagnosing (82%) and treating (76%) acute dizziness compared to episodic/chronic cases (63 and 59%, respectively). Younger PCPs had lower diagnostic yield and confidence. Areas for improvement in specialist interactions included communication between physicians (23%/36%; always/often true), shorter waiting times for consultations (19%/40%), more detailed feedback (36%/35%), and consistent patient back referrals (31%/30%). PCPs expressed interest in hands-on courses, workshops, practical guidelines, web-based algorithms, and digital tools such as printed dizzy diaries and apps for follow-up. Conclusion: Enhanced dialog between PCPs and specialists is crucial to address the most common unmet needs. Reducing waiting times for referrals and providing clear instructions to specialists for triage are essential. The findings from this survey will guide the development of tools to improve the diagnosis and treatment of dizzy patients. Younger PCPs, who face higher diagnostic uncertainty, should be prioritized for educational approaches such as hands-on courses, workshops, and practical recommendations.

What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey.

Background: Vertigo and dizziness are among the most frequent presenting symptoms in the primary care physicians' (PCPs) office. With patients facing difficulties in describing their complaints and clinical findings often being subtle and transient, the diagnostic workup of the dizzy patient remains challenging. We aimed to gain more insights into the current state of practice in order to identify the limitations and needs of the PCPs and define strategies to continuously improve their knowledge in the care of the dizzy patient. Materials and methods: Board-certified PCPs working in Switzerland were invited to participate in an online survey. A descriptive statistical analysis was performed, and prospectively defined hypotheses were assessed using regression analyses. Results: A vast majority of participating PCPs (n = 152) were familiar with the key questions when taking the dizzy patient's history and with performing provocation/repositioning maneuvers when posterior-canal benign paroxysmal positional vertigo (BPPV) was suspected (91%). In contrast, strong agreement that performing the alternating cover test (21%), looking for a spontaneous nystagmus with fixation removed (42%), and performing the head-impulse test (47%) were important was considerably lower, and only 19% of PCPs were familiar with lateral-canal BPPV treatment. No specific diagnosis could be reached in substantial fractions of patients with acute (35% [25; 50%], median [inter-quartile range]) and episodic/chronic (50% [40; 65.8%]) dizziness/vertigo. Referral to specialists was higher in patients with episodic/chronic dizziness than in acutely dizzy patients (50% [20.3; 75] vs. 30% [20; 50]), with younger PCPs (aged 30-40 years) demonstrating significantly increased odds of referral to specialists (odds ratio = 2.20 [1.01-4.81], p = 0.048). Conclusion: The assessment of dizzy patients takes longer than that of average patients in most primary care practices. Many dizzy patients remain undiagnosed even after a thorough examination, highlighting the challenges faced by PCPs and potentially leading to frequent referrals to specialists. To address this, it is crucial to promote state-of-the-art neuro-otological examination and treatment techniques that are currently neglected by most PCPs, such as "HINTS" and lateral-canal BPPV treatment. This can help reduce referral rates allowing more targeted treatment and referrals.

Olfactory Dysfunction: Etiology, Diagnosis, and Treatment.

BACKGROUND: Disorders of the sense of smell have received greater attention because of the frequency with which they occur as a symptom of SARS-CoV-2 infection. Olfactory dysfunction can lead to profound reduction in quality of life and may arise from many different causes. METHODS: A selective literature review was conducted with consideration of the current version of the guideline issued by the Association of the Scientific Medical Societies in Germany. RESULTS: The cornerstones of diagnosis are the relevant medical history and psychophysical testing of olfactory function using standardized validated tests. Modern treatment strategies are oriented on the cause of the dysfunction. While treatment of the underlying inflammation takes precedence in patients with sinunasal dysosmia, olfactory training is the primary treatment option for other forms of the disorder. The prognosis is determined not only by the cause of the olfactory dysfunction and the patient's age, but also by the olfactory performance as measured at the time of diagnosis. CONCLUSION: Options for the treatment of olfactory dysfunction are available but limited, depending on the cause. It is therefore important to carry out a detailed diagnostic work-up and keep the patient informed of the expected course and prognosis.

What neuro-otology specialists need for better care of dizzy patients: a national survey.

Background: A substantial fraction of dizzy patients are assessed by neurologists and ear-nose-throat (ENT) physicians. With the differential diagnosis being broad and often different specialties involved, we aimed to assess the interaction with generalists from the specialists' perspective to identify limitations and needs and to define strategies for improvement in patient care and education by the specialist. Methods: One hundred eleven board-certified neurologists (n = 62) and ENT physicians (n = 49) working in Switzerland participated in an online survey. Here, we focused on limitations faced in the diagnostic workup and treatment of the dizzy patient and potential strategies to improve the standard of care and the interaction between generalists and specialists. Descriptive statistical analyses were performed. We hypothesized that those specialists applying modern concepts in history-taking and bedside examination techniques reach a specific diagnosis more often and request fewer referrals. Results: Specialists indicated higher confidence in reaching a specific diagnosis for patients presenting with acute dizziness than episodic/chronic dizziness (80% vs. 60%) at the first consultation. Knowledge of the timing-and-trigger concept [odds ratio (OR) = 0.81 (0.67-0.98), p = 0.034], as well as of subtle oculomotor/vestibular signs [OR = 0.80 (0.68-0.94), p = 0.007] was predictive of the self-reported probability of reaching a specific diagnosis in patients with episodic/chronic dizziness, while no such differences were observed in the care of acutely dizzy patients. Further referrals of acutely dizzy patients were significantly higher in neurologists than in ENT physicians (17% vs. 10%, p < 0.001) and in specialists located in the Latin part of Switzerland [OR = 2.84 (1.63-4.93), p < 0.001], while this was not the case for patients with episodic/chronic dizziness. Identified unmet needs included regular communication between physicians (27%/53%; always/often true) and sufficiently detailed information on the previous workup from the referrals (27%/53%). Specialists expressed most interest in hands-on courses/workshops, webinars, and practical guidelines for education. Conclusion: In our survey, bedside state-of-the-art assessments were key in reducing the fraction of unclear dizzy cases. Several gaps were identified that should be addressed. Specifically, referring physicians should provide more comprehensive details regarding urgency, prior diagnostics, and treatment. Specifically, when promoting the knowledge of neurologists and ENT physicians, this should be preferentially done by offering a combination of hands-on courses and webinars.

[Smarter medicine in Otorhinolaryngology - Top 5 List]. / Smarter Medicine in der ORL.

Smarter medicine in Otorhinolaryngology - Top 5 List Abstract. Many diseases or symptoms with a high prevalence in the population, such as vertigo / dizziness, tinnitus, or sinusitis, but also nasal bone fractures and otitis externa, lead to a high number of visits to the physicians due to their frequency alone. Often, conventional X-rays (sinusitis, nasal bone fractures) or - in cases of vertigo and tinnitus - magnetic resonance imaging are ordered for further diagnostic clarification even though the benefit of theses is not generally given according to the current state of knowledge. The indication for imaging can be set much more restrictive after critical review of these clinical conditions without reducing the quality of treatment. The same applies to the usage of systemic antibiotics in uncomplicated otitis externa, which can be reduced without any problems. The extensive discussion of these issues within the Society of Otorhinolarnygology (SGORL) formed the basis for the creation of the Top 5 -list with its recommendations which are presented in detail below.

Clinical Olfactory Working Group consensus statement on the treatment of postinfectious olfactory dysfunction.

BACKGROUND: Respiratory tract viruses are the second most common cause of olfactory dysfunction. As we learn more about the effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with the recognition that olfactory dysfunction is a key symptom of this disease process, there is a greater need than ever for evidence-based management of postinfectious olfactory dysfunction (PIOD). OBJECTIVE: Our aim was to provide an evidence-based practical guide to the management of PIOD (including post-coronavirus 2019 cases) for both primary care practitioners and hospital specialists. METHODS: A systematic review of the treatment options available for the management of PIOD was performed. The written systematic review was then circulated among the members of the Clinical Olfactory Working Group for their perusal before roundtable expert discussion of the treatment options. The group also undertook a survey to determine their current clinical practice with regard to treatment of PIOD. RESULTS: The search resulted in 467 citations, of which 107 articles were fully reviewed and analyzed for eligibility; 40 citations fulfilled the inclusion criteria, 11 of which were randomized controlled trials. In total, 15 of the articles specifically looked at PIOD whereas the other 25 included other etiologies for olfactory dysfunction. CONCLUSIONS: The Clinical Olfactory Working Group members made an overwhelming recommendation for olfactory training; none recommended monocycline antibiotics. The diagnostic role of oral steroids was discussed; some group members were in favor of vitamin A drops. Further research is needed to confirm the place of other therapeutic options.

Assessment of odor hedonic perception: the Sniffin' sticks parosmia test (SSParoT).

Qualitative olfactory dysfunction is characterized as distorted odor perception and can have a profound effect on quality of life of affected individuals. Parosmia and phantosmia represent the two main subgroups of qualitative impairment and are currently diagnosed based on patient history only. We have developed a test method which measures qualitative olfactory function based on the odors of the Sniffin' Sticks Identification subtest. The newly developed test is called Sniffin' Sticks Parosmia Test (SSParoT). SSParoT uses hedonic estimates of two oppositely valenced odors (pleasant and unpleasant) to assess hedonic range (HR) and hedonic direction (HD), which represent qualitative olfactory perception. HR is defined as the perceivable hedonic distance between two oppositely valenced odors, while HD serves as an indicator for overall hedonic perception of odors. This multicenter study enrolled a total of 162 normosmic subjects in four consecutive experiments. Cluster analysis was used to group odors from the 16-item Sniffin' Sticks Identification test and 24-additional odors into clusters with distinct hedonic properties. Eleven odor pairs were found to be suitable for estimation of HR and HD. Analysis showed agreement between test-retest sessions for all odor pairs. SSparoT might emerge as a valuable tool to assess qualitative olfactory function in health and disease.

Self-reported mini olfactory questionnaire (Self-MOQ): A simple and useful measurement for the screening of olfactory dysfunction.

OBJECTIVES: Olfactory dysfunction is a common problem. However, too little attention has been paid to questionnaires used to evaluate quantitative olfactory dysfunction. Therefore, the current study aimed to develop a simple self-reported Mini Olfactory Questionnaire (Self-MOQ) for the screening of quantitative olfactory dysfunction in clinical practice. METHODS: Two hundred and eighty-five patients who had subjective complaints of olfactory disorder participated. The Sniffin' Sticks test score was used to define functional anosmia, hyposmia, or normosmia. We assessed the factor structure as well as internal consistency, convergent validity, and discrimination performance. RESULTS: The results showed that the final version of the Self-MOQ included only one factor with five items. The Self-MOQ has a good internal reliability (Cronbach's α = 0.84) and validity (r = -0.60, P < 0.001). The receiver operating characteristic analyses indicated that the Self-MOQ as compared to a visual analogue scale (VAS) is an effective measure for discriminating normosmic from hyposmic/anosmic patients, anosmic patients, and hyposmic patients. CONCLUSION: The Self-MOQ is a simple, reliable and valid questionnaire to screen olfactory dysfunction in clinical practice that appears to be superior to the use of VASs but does not replace olfactory testing. LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.

Influence of external ear occlusion on food perception.

PURPOSE: The present study aimed to explore if food perception can be influenced by sound mastication level when the external ear canal was occluded. METHODS: Fifty-nine adults (38 women) with normal hearing, smell, and taste participated in the study. They tasted five crispy and five soft food items over two sessions: one with and one without an earplug inserted in the external ear canal. Participants were asked to rate freshness and taste of the food as well as their willingness to eat more of it and how much they usually like this kind of food. The sound pressure level related to the food mastication was recorded with a probe microphone placed in the external ear canal. RESULTS: Compared to the open ear canal condition, levels of the mastication sounds were higher when the participants had their ears occluded, as well as for crispy than for soft food. Regarding food freshness, food appreciation, and willingness to eat more of the same food, there was no significant difference concerning food type, ear condition, and sex. For soft foods, men rated their usual liking of this food higher when they were wearing ear plugs compared to the opened condition. CONCLUSION: Plugging the ear canals led to increased mastication sound levels. Participants did not seem to consider these additional acoustic cues when they rated food freshness, food appreciation, and willingness of eating the specific food. Only men seemed to take these cues into account when they rated their habit consumption of soft food.

Among Early Appearing Non-Motor Signs of Parkinson's Disease, Alteration of Olfaction but Not Electroencephalographic Spectrum Correlates with Motor Function.

Olfactory decline is a frequent and early non-motor symptom in Parkinson's disease (PD), which is increasingly used for diagnostic purposes. Another early appearing sign of PD consists in electroencephalographic (EEG) alterations. The combination of olfactory and EEG assessment may improve the identification of patients with early stages of PD. We hypothesized that olfactory capacity would be correlated with EEG alterations and motor and cognitive impairment in PD patients. To the best of our knowledge, the mutual influence of both markers of PD-olfactory decrease and EEG changes-was not studied before. We assessed the function of odor identification using olfactory "Screening 12 Test" ("Sniffin' Sticks®"), between two samples: patients with PD and healthy controls (HC). We analyzed correlations between the olfactory function and demographical parameters, Unified Parkinson's Disease Rating Scale (UPDRS-III), cognitive task performance, and spectral alpha/theta ratio (α/θ). In addition, we used receiver operating characteristic-curve analysis to check the classification capacity (PD vs HC) of olfactory function, α/θ, and a combined marker (olfaction and α/θ). Olfactory capacity was significantly decreased in PD patients, and correlated with age, disease duration, UPDRS-III, and with items of UPDRS-III related to gait and axial rigidity. In HC, olfaction correlated with age only. No correlation with α/θ was identified in both samples. Combined marker showed the largest area under the curve. In addition to EEG, the assessment of olfactory function may be a useful tool in the early characterization and follow-up of PD.

[Olfactory disorders ­ history, classification and implications]. / Riechstörung.

Smell disorders are common and can be found in 3 ­ 5 % of the population under 65 years. With growing age these numbers increase up to 50 % and more. Qualitative disorders which cannot be measured are differentiated from quantitative disorders. Self-assessment of olfactory function is rather poor therefore olfactory testing is mandatory in cases of patients complaining about an olfactory disorder. Olfactory screening smell tests are available for orientation, however, for detailed testing or in cases of a pathological screening test an extensive psychophysical olfactory test battery such as the Sniffin' Sticks Test battery should be used. According to the result of the test battery olfactory function can be qualified as norm, hyp- or anosmic. Additionally, in cases of medicolegal questions, olfactory evoked potentials can be recorded. Smell disorders are classified according to the history, clinical and endoscopic examination of the nose. Imaging techniques such as magnetic resonance imaging (MRI) or computertomography may contribute to classify the disorder. Sinunasal olfactory disorders are considered to be the most common ones. If the etiology remains unclear a neurological examination has to be performed in order to rule out a concomitant neurodegenerative disease. Olfactory disorders in the elderly might have to be considered as a sign of a reduced regeneration capacity in general being depicted in an increase in overall mortality in affected subjects.

Long-term follow-up of posttraumatic olfactory disorders.

OBJECTIVE: This study aims to determine the long-term recovery rate of posttraumatic olfactory disorders and to evaluate whether a lateralized disorder influences recovery. METHOD: Olfactory function of 67 patients with posttraumatic olfactory disorders were examined twice using the `Sniffin` Sticks` test battery. Olfactory function was classified based on composite TDI (Threshold, Discrimination and Identification) score. Subjective impairment was rated by visual analogue scale ranging from 0 to 10. RESULTS: First and second examinations were conducted an average of 16.7 months and 74 months after trauma, respectively. From first to second examination, mean TDI score of the better nostril increased significantly, the number of patients with anosmia of the better nostril decreased, and number of hyposmic and normosmic patients increased. Subjective impairment decreased. Neither age, sex, nor side differences between nostrils affected improvement. CONCLUSION: After the follow-up period, in 27% of the patients the TDI score improved ≥ 6 points score and subjective impairment decreased. A follow-up period of more than 2 years is recommended.

A study about the frequency of taste disorders.

Although 5% of the general population exhibit a functional anosmia, little is known about the frequency of gustatory disorders. Whenever taste function has been tested within large sociodemographic studies, so far only short test versions were applied making the interpretation difficult. Using two psychophysical taste tests, the validated "taste strips" and suprathreshold taste solutions of the four basic tastes sweet, sour, salty and bitter we investigated 761 healthy subjects within the age range of 5-89 years. Prior to testing, all subjects rated their taste function. According to testing with the taste strips, 5.3% scored below the result considered as hypogeusia. All four taste sprays were correctly identified by 82.3% of all subjects. Results of the two taste tests correlated positively (r = 0.33, p < 0.001), and there was a significant negative correlation between age and test results. However, we never observed complete ageusia. Misinterpretations of tastes were surprisingly common. In summary, hypogeusia was present in 5% while complete ageusia seems to be very rare, in contrast to misinterpretations of tastes.

The course of olfactory deficits in patients with Parkinson's disease--a study based on psychophysical and electrophysiological measures.

OBJECTIVES: Patients with Parkinson's disease (PD) commonly show olfactory deficits in the early stages of the disease. These deficits can be verified psychophysically or electrophysiologically using olfactory event-related potentials (OERP). While psychophysical olfactory function in PD patients can improve over time, the course of OERPs in PD has not yet been investigated. METHODS: Olfactory function was investigated twice in 19 patients at 5-year intervals. Psychophysical tests included the "Sniffin' Sticks" test battery. In addition, OERPs were recorded in response to two odors on each side (phenyl-ethyl-alcohol: 40% (v/v), H(2)S, 6ppm). OERPs were evaluated regarding existence (yes/no). Average disease duration at follow-up was 9.0 years and the average Hoehn and Yahr score (disease stage) was 2.2. RESULTS: Psychophysically, 1 patient was normosmic, 14 were hyposmic, and 4 were functionally anosmic at the initial visit. Re-examination revealed 1 normosmic, 9 hyposmic, and 8 functionally anosmic patients. Mean olfactory function decreased significantly in all patients. OERPs were initially existent in 3 out of 19 patients. At follow-up, OERPs were no longer present in these patients, but were detectable in 3 other patients. CONCLUSIONS: Overall, mean olfactory function decreased, although improvements were observed at the individual level. We confirmed previous findings regarding psychophysical follow-up results. Electrophysiological measures showed a pattern of fluctuation in olfactory function comparable to that of the psychophysical results. These fluctuations do not seem to predict the course of the disease.

Olfactory testing in clinical settings - is there additional benefit from unilateral testing?

In clinical settings, olfactory testing is usually performed bilaterally; thus, unilateral olfactory loss may go unnoticed. The aims of this study were to evaluate 1) whether patients presenting with self-reported olfactory disorders demonstrate significant side differences in odour perception, depending on the prevalance of measured unilateral disorder, and 2) to evaluate the existing testing procedure. In 518 patients presenting with olfactory disorders, olfactory testing was performed using the "Sniffin' Sticks" test battery (consisting of a threshold, discrimination, and odour identification test) examining each nostril separately. According to the history and results from the clinical examination, olfactory disorders were classified as related to trauma, sinunasal disease, upper respiratory tract infection (URTI), tumour, congenital, idiopathic, and other. A difference of three or more points in one of the subtests or six or more points in the composite olfactory test score was considered a side difference. In almost one quarter of all presenting patients (23.4%), a side difference was detected. To not to miss lateralized disorders, we recommend testing each nostril separately. Depending on the presence or absence of a significant difference, testing then can be continued birhinally or separately for each nostril.

Olfactory impairment predicts brain atrophy in Parkinson's disease.

Olfactory dysfunction is a frequent nonmotor symptom in idiopathic Parkinson's disease (PD) and may be considered as an early clinical feature of the disease preceding motor symptoms by years. According to recent neuropathological staging concepts, impaired olfaction is assumed to indicate an early pathological process and might be associated with structural changes in the brain. A morphometric analysis of magnetic resonance images [voxel-based morphometry (VBM)] was used to investigate gray matter atrophy related to psychophysically measured scores of olfactory function in early PD patients (n = 15, median Hoehn and Yahr stage 1.5), moderately advanced PD patients (n = 12, median Hoehn and Yahr stage 2.5), and age-matched healthy controls (n = 17). In PD patients, but not in controls, cortical atrophy in olfactory-related brain regions correlated specifically with olfactory dysfunction. Positive correlations between olfactory performance and gray matter volume were observed in the right piriform cortex in early PD patients and in the right amygdala in moderately advanced patients. The results provided first evidence that olfactory dysfunction in PD is related to atrophy in olfactory-eloquent regions of the limbic and paralimbic cortex. In addition, olfactory-correlated atrophy in these brain regions is consistent with the assumption that olfactory impairment as an early symptom of PD is likely to be associated with extranigral pathology.

Swallowing is differentially influenced by retronasal compared with orthonasal stimulation in combination with gustatory stimuli.

Identical stimuli are processed differently when presented ortho- or retronasally. In contrast to orthonasal olfaction, retronasal odorant perception is strongly associated with flavor and food intake, which is usually followed by swallowing. Along with other stimuli, gustatory stimuli are known to influence the swallowing reflex. It was therefore the aim of present study to examine whether retronasal olfaction, in combination with simultaneous gustatory stimuli, influences swallowing in a manner different from that of orthonasal olfaction. Fifty normosmic and normogeusic subjects took part in the study. A sweet taste (glucose, delivered via an intraoral taste dispenser) was presented simultaneously with vanillin, a food-like odor, either ortho- or retronasally at random using a computer-controlled olfactometer. Ultrasound imaging of the mouth floor was recorded on videotape to continuously monitor swallowing activity. After retronasal stimulation, swallowing occurred significantly faster (7.49 vs. 9.42 s; P < 0.001) and also took place more frequently compared with swallowing after orthonasal stimulation (1.38 times vs. 1.14 times; P < 0.001). These results show that a food-like odorant presented retronasally in combination with a congruent taste stimulus can influence swallowing. Whether these results can be assigned to other, unfamiliar, unpleasant nonfood-like odors has yet to be determined.