High-frequency spinal cord stimulation (10 kHz) alters sensory function and nerve fiber density in painful diabetic neuropathy: a pilot prospective open-label study.

OBJECTIVE: Spinal cord stimulation at 10 kHz has provided effective pain relief and improved function in painful diabetic peripheral neuropathy. This study aims to confirm the clinical outcomes for 10-kHz spinal cord stimulation treatment of painful diabetic peripheral neuropathy and explore its impact on objective quantitative measures of nerve pathology and function. METHODS: This single-academic center, prospective, open-label, observational study examined the pain relief success of 10-kHz spinal cord stimulation in patients >18 years of age with diabetic peripheral neuropathy. Patients underwent skin biopsies to measure intra-epidermal nerve fiber densities and corneal confocal microscopy measurements before implantation and at the 3-, 6-, and 12-month follow-up visits. Numerical rating scale for pain, visual analog scale, neuropathy pain scale, Short Form-36, and Neuropen (pin prick and monofilament) assessments were also conducted. RESULTS: Eight patients met the criteria and were enrolled in the study. A successful trial was achieved in 7 subjects, and 6 completed the study. Significant pain relief (P < .001) was achieved at all follow-up visits. Neurological assessments showed reduced numbers of "absent" responses and increased "normal" responses from baseline to 12 months. Both proximal and distal intra-epidermal nerve fiber densities were higher at 12 months than at baseline (P < .01). Confocal microscopy measurements showed a steady increase in nerve density from baseline (188.8% increase at 12 months; P = .029). CONCLUSIONS: We observed pain relief and improvements in sensory function after stimulation that were accompanied by increases in lower-limb intra-epidermal nerve fiber density and corneal nerve density. Further evaluation with a blinded and controlled study is needed to confirm the preliminary findings in this study.

Factors Influencing Access to Cochlear Implantation in Deaf and Hard-of-Hearing Children in Southern California.

OBJECTIVE: To determine the epidemiologic relationship of family demographics and educational resources with parental knowledge of and willingness for their children to receive cochlear implantation (CI) for deaf and hard-of-hearing (DHH) children. METHODS: A total of 213 parents of DHH children were surveyed at local schools, specialized camps, and clinics in Southern California. Data on parents were solicited, including income, insurance status, education level, hearing status, primary language, and motivations towards CI. RESULTS: Sixty-six surveys were included in the analysis. Three of these patients had already undergone CI, thus of the 63 children without CI, 59% had been presented with the option of CI by a healthcare professional and 27% were willing to have their child undergo CI. Willingness for children to undergo CI was statistically higher in families with an annual income less than $15,000 or more than $75,000 (p = 0.02), and children enrolled in specialized schools for DHH (p = 0.02). The leading reasons for unwillingness to undergo CI were risks of surgery (17%) and discouragement from others (14%). CONCLUSION: A significant gap exists between the number of CI candidates and families and willingness to undergo CI. The difference could be related to socioeconomic status and the patient's school type. This underscores the importance of parental education through the use of a multi-disciplinary team to ensure all hearing rehabilitation options are explained.

Anatomical Look Into OnabotulinumtoxinA Injection for Chronic Migraine Headache.

BACKGROUND AND OBJECTIVES: While existing studies about onabotulinumtoxinA for chronic migraines have focused on injection location and appropriate dosing, little consideration has been given to patient body habitus and its potential impact on efficacy. We hypothesized that with increasing patient body mass index (BMI) there would be more subcutaneous fat separating targeted muscle groups from the skin surface, such that standard 0.5-inch needles used in existing protocols may not allow intramuscular injection. This may have implications for treatment planning. METHODS: Anatomically normal computed tomography scans of the head, neck, and face were randomly selected. Subjects were stratified into 4 groups based on BMI, with 30 patients in each group. Four standardized locations were chosen to obtain measurements from the skin surface to the underlying muscle fascia, including (1) frontalis, (2) temporalis, (3) semispinalis capitis, and (4) trapezius. RESULTS: Median depth for the temporalis was 12.65 mm (Q1 = 9.32 mm, Q3 = 15.08 mm) for the BMI greater than 35 kg/m group. Median depth for the semispinalis capitis was 13.77 mm (Q1 = 10.3 mm, Q3 = 15.7 mm) for the BMI 30 to 35 kg/m group, and 14.75 mm (Q1 = 11.00, Q3 = 17.00 mm) for the BMI greater than 35 kg/m group. Median depth for the trapezius was 13.95 mm (Q1 = 10.18 mm, Q3 = 19.00 mm) for the BMI greater than 35 kg/m group. These medians exceeded the length of the standard 0.5-inch (12.-mm) needle used in existing protocols. CONCLUSIONS: Our study demonstrates that with increasing BMI there is a greater distance between the skin surface and the muscle fascia of muscles that are targeted for injection in standard chronic migraine botulinum toxin injection protocols. Because of this, patient body habitus may be an important factor in injection technique.

A feasible repetitive transcranial magnetic stimulation clinical protocol in migraine prevention.

OBJECTIVE: This case series was conducted to determine the clinical feasibility of a repetitive transcranial magnetic stimulation protocol for the prevention of migraine (with and without aura). METHODS: Five patients with migraines underwent five repetitive transcranial magnetic stimulation sessions separated in 1- to 2-week intervals for a period of 2 months at a single tertiary medical center. Repetitive transcranial magnetic stimulation was applied to the left motor cortex with 2000 pulses (20 trains with 1s inter-train interval) delivered per session, at a frequency of 10 Hz and 80% resting motor threshold. Pre- and post-treatment numerical rating pain scales were collected, and percent reductions in intensity, frequency, and duration were generated. RESULTS: An average decrease in 37.8%, 32.1%, and 31.2% were noted in the intensity, frequency, and duration of migraines post-repetitive transcranial magnetic stimulation, respectively. A mean decrease in 1.9±1.0 (numerical rating pain scale ± standard deviation; range: 0.4-2.8) in headache intensity scores was noted after the repetitive transcranial magnetic stimulation sessions. CONCLUSION: The tested repetitive transcranial magnetic stimulation protocol is a well-tolerated, safe, and effective method for migraine prevention.

Facial nerve hemangioma: a case report.

Although hemangiomas are relatively common in the head and neck, those that originate in the facial nerve are extremely rare. These benign tumors have the potential to compress or invade the adjacent facial nerve and thereby produce facial paralysis and other associated symptoms. We present a case of facial nerve hemangioma in a 15-year-old girl that initially manifested as unilateral facial weakness. We also discuss the diagnostic imaging and management options.

Systematic assessment of noise amplitude generated by toys intended for young children.

OBJECTIVE: To systematically evaluate the noise generated by toys targeted for children and to compare the results over the course of 4 consecutive holiday shopping seasons. STUDY DESIGN: Experimental study. SETTING: Academic medical center. SUBJECTS AND METHODS: During 2008-2011, more than 200 toys marketed for children older than 6 months were screened for loudness. The toys with sound output of more than 80 dBA at speaker level were retested in a soundproof audiometry booth. The generated sound amplitude of each toy was measured at speaker level and at 30 cm away from the speaker. RESULTS: Ninety different toys were analyzed. The mean (SD) noise amplitude was 100 (8) dBA (range, 80-121 dBA) at the speaker level and 80 (11) dBA (range, 60-109 dBA) at 30 cm away from the speaker. Eighty-eight (98%) had more than an 85-dBA noise amplitude at speaker level, whereas 19 (26%) had more than an 85-dBA noise amplitude at a 30-cm distance. Only the mean noise amplitude at 30 cm significantly declined during the studied period (P < .001). There was no significant difference in mean noise amplitude of different toys specified for different age groups. CONCLUSION: Our findings demonstrate the persistence of extremely loud toys marketed for very young children. Acoustic trauma from toys remains a potential risk factor for noise-induced hearing loss in this age group, warranting promotion of public awareness and regulatory considerations for manufacture and marketing of toys.

Efficacy of commercial earplugs in preventing water intrusion during swimming.

OBJECTIVE: To evaluate and compare the efficacy of commercially available earplugs in preventing water intrusion in healthy individuals. STUDY DESIGN: Experimental study. SETTING: Tertiary care medical center. SUBJECTS AND METHODS: Ten subjects (20 ears) were assessed. After insertion of the earplugs, subjects underwent 3 standardized head-wetting protocols, including (1) surface swimming for 10 minutes, which entailed no head submersion and moderate splashing; (2) head submersion at a 90-cm depth for 20 seconds with their head upright; and (3) head submersion at a 90-cm depth with head tilted 90 degrees left and then tilted 90 degrees right for 10 seconds on each side to apply vertical pressure. Color change of a wetness indicator was used to determine water intrusion after each protocol. The same protocol was repeated for all 9 earplugs. RESULTS: Water intrusion was observed in 44%, 67%, and 88% of ears after surface swimming, horizontal submersion, and vertical submersion, respectively. The results revealed a significant difference in the waterproofing qualities of the various types of earplugs. The soft silicone type (Pillow Soft) earplug had the lowest rate of water penetration during all 3 protocols (P < .001). The difference between the most effective earplugs, Pillow Soft and Aquaseal, were only significant during the horizontal submersion protocol (P = .008). CONCLUSION: Water intrusion occurred even with the use of earplugs. The intrusion was more significant with horizontal or vertical head submersion. The soft silicone Pillow Soft earplug was the most effective earplug for preventing water intrusion in surface swimming.

Noise-induced hearing threshold shift among US adults and implications for noise-induced hearing loss: National Health and Nutrition Examination Surveys.

The objective of this study was to estimate the prevalence and evaluate the associated risk factors of the noise-induced hearing threshold shift (NITS) in the US adult population based on the National Health and Nutrition Examination Surveys (NHANES). The study population consisted of 5,418 individuals aged 20-69 years who had complete audiologic data from the NHANES database. Stringent criteria were used to define NITS. Prevalence of unilateral, bilateral, and total NITS and their association with several socio-demographic and hearing-related factors were evaluated. The prevalence of unilateral, bilateral, and total NITS was 9.4, 3.4 and 12.8%, respectively. Prevalence of bilateral NITS was higher in subjects with older age, male gender, white (non-Hispanic) and Hispanic ethnicities, education level less than or equal to high school diploma, married/living with partner status, Mexico as country of birth, service in armed forces, smoking history, diabetes, and different kinds of noise exposure. Odds of NITS were only higher in older people, males, and smokers. This study provides comprehensive information on the prevalence of NITS in the US adult population and its associated risk factors. More targeted interventions may be done for educational, preventative, and screening purposes.

A novel method to determine standardized anatomic dimensions of the osseous external auditory canal.

OBJECTIVE: To introduce a novel method for measuring the dimensions of the osseous external auditory canal (OEAC) on computed tomographic images of the temporal bone. STUDY DESIGN: Radiology case series. SETTING: Tertiary care medical center. PATIENTS: A retrospective review of high-resolution computed tomographic images of the temporal bones of 69 patients (120 ears) between the ages of 5 and 85 years (mean, 29.1 yr) was performed. MAIN OUTCOME MEASURES: Using a novel method to measure dimensions of the OEAC in the parasagittal planes, 6 defined dimensions as well as length and shape of the OEAC were studied at the annulus, midcanal, and the border of the bony cartilaginous junction. RESULTS: There was no statistically significant difference in OEAC dimensions between the male and female subjects or patients with and without a history of chronic otitis media within similar age groups. The length of the OEAC was significantly different between age groups of 5 to 12 and older than 13 years. The 6 defined dimensions were statistically different between the age groups of 5 to 8 years and older. These dimensions were not statistically different between the age groups of 9 to 12, 13 to 18, and older than 18 years. The most prevalent shape of the OEAC was conical (64%). CONCLUSION: Standardized anatomic dimensions of the OEAC provide important measurements for design of novel in-the-canal hearing aids and specialized earplugs and assist in defining average sizes for canalplasty procedures.

Stereotactic radiosurgery for vestibular schwannomas: a survey of current practice patterns of neurotologists.

OBJECTIVE: To evaluate the use of radiation by neurotologists practicing in the United States as a treatment modality for vestibular schwannomas (VSs). STUDY DESIGN: Cross-sectional survey. METHODS: We surveyed 302 members of the American Neurotology Society to assess the number of VS seen, the frequency with which radiation is used as a treatment modality, radiation training and experience, the impact of tumor size and patient age on treatment decisions, and radiation dose ultimately used by neurotologists. RESULTS: Responses were received from 43% (132/302) of surveyed neurotologists; of the respondents, 42% (54/132) perform stereotactic radiation. Approximately 58% (30/54) of those use gamma knife, and 44% (24/54) use Cyberknife; 36.7% of VS patients seen by neurotologists received radiation. On average, 6 additional neurotologists per year begin treating VS with stereotactic radiation. Academic and private neurotologists showed significant differences (p < 0.05) between new VS patients per year, years in practice, and maximum tumor size recommended for radiation. The most common barrier to using radiation was prevention by a neurosurgical or radiation oncology service. Neurotologists use radiation to treat other cranial base tumors as well, most commonly glomus tumors or meningiomas, and 64% of respondents irradiate neurofibromatosis Type 2. Total radiation dose and fractionation were variable. CONCLUSION: Neurotologists are increasingly choosing to treat VS with stereotactic radiation. There seem to be significant differences between academic and private neurotologists' practice characteristics. Not all neurotologists strictly adhere to the consensus statement by the International RadioSurgery Association with regard to radiation dosing and tumor size limits.

Personality types of otolaryngology resident applicants as described by the Myers-Briggs Type Indicator.

OBJECTIVE: To assess the personality types of applicants to a single otolaryngology residency program using the Myers- Briggs Type Indicator. The personality types were compared with those of the general population and with physicians in other medical specialties. STUDY DESIGN: Cross-sectional survey. SETTING: University hospital. SUBJECTS AND METHODS: A personality survey was emailed to 327 resident physician applicants over 2 consecutive years (2008- 2009). Analysis was accomplished by calculating prevalence estimates. RESULTS: Of the 327 anonymous surveys, 137 were completed (response rate = 42%). The Introverted/Sensing/Thinking/ Judging personality type was the most prevalent (14.6%), representing 13% of the general population. Prospective applicants displayed mostly Extroverted (E; 58%), Sensing (S; 54%), Thinking (T; 62%), and Judging (J; 61%) personality traits. Of the 16 personality types, statistically significant differences were found between otolaryngology resident applicants and the general population only for the Extroverted/Sensing/Thinking/ Perceiving (P = .002) personality type after correcting for multiple comparisons. The Intuitive (N; 46%) and Feeling (F; 38%) types correlated closely with the reported personality types of those individuals in non­primary care specialties, 47% and 28%, respectively. Extroverted (E) and Thinking (T) individuals appeared to prefer surgical specialties, which occurred in 58% and 62% of the applicants, respectively. There were no significant differences between male and female applicants. CONCLUSION: This study examines the personality types of medical students applying to an otolaryngology residency. The results support a highly structured, data-driven teaching preference among applicants. These results may allow for a better understanding of the personalities of medical students who are interested in otolaryngology.

Optical coherence tomography of cholesteatoma.

OBJECTIVES: To image cholesteatoma using optical coherence tomography (OCT) and correlate the results with clinical findings and conventional observations obtained using binocular microscopy and histology. OCT is a high-resolution optical imaging modality that generates cross-sectional images of turbid media, such as tissue with resolution approaching that of light microscopy. OCT relies on intrinsic differences in tissue optical properties for image contrast. STUDY DESIGN: In vivo prospective clinical study. SETTING: University Medical Center. PATIENTS: Patients with cholesteatoma undergoing otologic surgery. INTERVENTION: Using a commercial OCT imaging system, we obtained cross-sectional images (resolution, approximately 10 microm; depth penetration, approximately 1 mm) of cholesteatomas. MAIN OUTCOME MEASURES: Images are obtained by raster scanning a single mode fiber across the interior of the probe. The imaging probe is sterilized and inserted into the middle ear or mastoid under microscopic guidance, and still images of the middle ear or mastoid mucosa and cholesteatoma when present were obtained. RESULTS: OCT images of cholesteatomas demonstrate differences in signal intensity, which are distinct from those of normal or inflamed middle ear/mastoid mucosa. Identification of keratin in cholesteatoma, even if very thin, distinguished it from inflamed mucosa. CONCLUSION: This is the first study that systematically used OCT to image cholesteatoma during otologic surgery. Cholesteatomas can be distinguished from normal or inflamed adjacent mucosa.