Acute otitis externa: Consensus definition, diagnostic criteria and core outcome set development.

OBJECTIVE: Evidence for the management of acute otitis externa (AOE) is limited, with unclear diagnostic criteria and variably reported outcome measures that may not reflect key stakeholder priorities. We aimed to develop 1) a definition, 2) diagnostic criteria and 3) a core outcome set (COS) for AOE. STUDY DESIGN: COS development according to Core Outcome Measures in Effectiveness Trials (COMET) methodology and parallel consensus selection of diagnostic criteria/definition. SETTING: Stakeholders from the United Kingdom. SUBJECTS AND METHODS: Comprehensive literature review identified candidate items for the COS, definition and diagnostic criteria. Nine individuals with past AOE generated further patient-centred candidate items. Candidate items were rated for importance by patient and professional (ENT doctors, general practitioners, microbiologists, nurses, audiologists) stakeholders in a three-round online Delphi exercise. Consensus items were grouped to form the COS, diagnostic criteria, and definition. RESULTS: Candidate COS items from patients (n = 28) and literature (n = 25) were deduplicated and amalgamated to a final candidate list (n = 46). Patients emphasised quality-of-life and the impact on daily activities/work. Via the Delphi process, stakeholders agreed on 31 candidate items. The final COS covered six outcomes: pain; disease severity; impact on quality-of-life and daily activities; patient satisfaction; treatment-related outcome; and microbiology. 14 candidate diagnostic criteria were identified, 8 reaching inclusion consensus. The final definition for AOE was 'diffuse inflammation of the ear canal skin of less than 6 weeks duration'. CONCLUSION: The development and adoption of a consensus definition, diagnostic criteria and a COS will help to standardise future research in AOE, facilitating meta-analysis. Consulting former patients throughout development highlighted deficiencies in the outcomes adopted previously, in particular concerning the impact of AOE on daily life.

Imbalance Associated With Cisplatin Chemotherapy in Adult Cancer Survivors: A Clinical Study.

OBJECTIVE: This study investigated balance problems and vestibular function in adult cancer survivors who had completed cisplatin chemotherapy treatment. STUDY DESIGN: Observational cross-sectional study. SETTING: Tertiary care center. PATIENTS: Adult survivors of cancer who had completed cisplatin treatment. MAIN OUTCOME MEASURES: Patient-reported balance symptoms were evaluated by a semistructured clinical interview. Patients underwent bedside clinical tests including Dynamic Visual Acuity test, Modified Clinical Testing of Sensory Interaction and Balance (CTSIB-m), and vibration sense testing to detect peripheral neuropathy. The video Head Impulse Test (vHIT) of all semicircular canals was performed. RESULTS: Eleven of 65 patients (17%) reported some balance symptoms after cisplatin therapy, including vertigo, dizziness, unsteadiness, and falls. Vertigo was the most common balance symptom, reported by six patients (9.2%), and the clinical histories of these patients were consistent with benign paroxysmal positional vertigo. Three patients (5%) had abnormal results of the CTSIB-m test, and they were the same patients who reported falls. There was a significant association of peripheral neuropathy detected by vibration test and balance symptoms. All patients had normal vHIT results in all semicircular canals. CONCLUSIONS: Balance symptoms after cisplatin treatment occurred in 17% of adult cancer survivors. Patients with peripheral neuropathy were more likely to have balance symptoms. The CTSIB-m test is a useful bedside physical examination to identify patients with a high risk of fall. Though there was no vestibular dysfunction detected by the vHIT in cancer survivors after cisplatin therapy, benign paroxysmal positional vertigo was relatively prevalent in this group of patients.

Clinical Implications of Chloroquine and Hydroxychloroquine Ototoxicity for COVID-19 Treatment: A Mini-Review.

At this time of the COVID-19 pandemic, potentially effective treatments are currently under urgent investigation. Benefits of chloroquine and hydroxychloroquine for the treatment of COVID-19 infection have been proposed and clinical trials are underway. Chloroquine and hydroxychloroquine, typically used for the treatment of malaria and autoimmune diseases, have been considered for off-label use in several countries. In the literature, there are reports of ototoxic effects of the drugs causing damage to the inner ear structures, which then result in hearing loss, tinnitus, and/or imbalance. This mini-review represents a summary of the findings from a systematic search regarding ototoxicity of chloroquine and hydroxychloroquine in the published literature. The characteristics of sensorineural hearing loss and/or tinnitus after chloroquine or hydroxychloroquine treatment can be temporary but reports of persistent auditory and vestibular dysfunction exist. These are not frequent, but the impact can be substantial. Additionally, abnormal cochleovestibular development in the newborn was also reported after chloroquine treatment in pregnant women. The suggested dose of chloroquine for COVID-19 infection is considerably higher than the usual dosage for malaria treatment; therefore, it is plausible that the ototoxic effects will be greater. There are potential implications from this review for survivors of COVID-19 treated with chloroquine or hydroxychloroquine. Patient reports of hearing loss, tinnitus, or imbalance should be noted. Those with troublesome hearing loss, tinnitus and/or imbalance are encouraged to be referred for hearing evaluation and interventions once they are stable. Clinical trials of chloroquine or hydroxychloroquine should also consider including audiological monitoring in the protocol.

Audiovestibular clinician experiences and opinions about cisplatin vestibulotoxicity.

PURPOSE: Vestibulotoxicity associated with cisplatin chemotherapy is known to exist, but the extent, severity, and impact is unclear from the literature. This study explored knowledge, experiences, and opinions of audiovestibular professionals about cisplatin vestibulotoxicity. METHODS: An online survey was disseminated to clinicians working in the audiovestibular field. RESULTS: Ninety-three respondents participated in the survey. Most professionals were aware of potential vestibulotoxicity associated with cisplatin chemotherapy. Thirty-three percent of the respondents reported that they had seen patients with cisplatin vestibulotoxicity. Forty percent of them were confident in making the diagnosis and in managing the patient in this situation. The prevalence and impact of vestibulotoxicity including practicality of the assessment should be considered when designing an effective vestibulotoxicity screening protocol. CONCLUSION: This study provides a better understanding of cisplatin vestibulotoxicity from the perspectives of audiovestibular clinicians, which will underpin appropriate detection and management of the condition.

The efficacy of statins as otoprotective agents: A systematic review.

OBJECTIVE: This systematic review examined current literature, summarised research findings and identified research gaps regarding the efficacy of statins on audiological outcomes. METHODS: Systematic search of electronic databases and grey literature was performed. Eligibility criteria were the study of a statin drug with report of audiological outcomes such as hearing, tinnitus or balance in either human or animal studies. Data extraction and quality assessment were performed by two independently researchers. The characteristics of the study and research findings were collated and summarised. A narrative synthesis was conducted. Meta-analysis was not possible due to heterogeneity of the included studies. RESULTS: Analysis of searches yielded 17 studies meeting the criteria. Included studies had variable drug type and dosage, outcome measures and associated inner ear conditions. Most animal experiments showed promising audiological outcomes after statin treatment, demonstrated by the results of auditory brainstem response, distortion product otoacoustic emissions and inner ear histology. However, no clear effect can be discerned in human trials due to the mixed results, and heterogeneity in research methodology and quality. Audiological outcomes were not always correlated with cholesterol levels. CONCLUSIONS: Statins remain a potential candidate as otoprotective agents which warrant further investigation.

Intraoperative Monitoring of the Cochlear Nerve during Neurofibromatosis Type-2 Vestibular Schwannoma Surgery and Description of a "Test Intracochlear Electrode".

Objectives A decision on whether to insert a cochlear implant can be made in neurofibromatosis 2 (NF2) if there is objective evidence of cochlear nerve (CN) function post vestibular schwannoma (VS) excision. We aimed to develop intraoperative CN monitoring to help in this decision. Design We describe the intraoperative monitoring of a patient with NF2 and our stimulating and recording set up. A novel test electrode is used to stimulate the CN electrically. Setting This study was set at a tertiary referral center for skull base pathology. Main outcome measure Preserved auditory brainstem responses leading to cochlear implantation. Results Electrical auditory brainstem response (EABR) waveforms will be displayed from different stages of the operation. A cochlear implant was inserted at the same sitting based on the EABR. Conclusion Electrically evoked CN monitoring can provide objective evidence of CN function after VS excision and aid in the decision-making process of hearing rehabilitation in patients who will be rendered deaf.

Vestibulotoxicity Associated With Platinum-Based Chemotherapy in Survivors of Cancer: A Scoping Review.

Background: Cochleotoxicity following the treatment with platinum-based chemotherapy is well documented. The potential for vestibulotoxicity is still unclear. This scoping review examined the extent of current research literature, summarized research findings and identified research gaps regarding vestibular-related adverse effects associated with platinum-based chemotherapy in survivors of cancer. Methods: Inclusion criteria followed the PICO principles: Participants, adult, and pediatric cancer patients of any cancer type; Intervention, platinum-based chemotherapy (such as cisplatin, carboplatin, and oxaliplatin); Control, none or any; Outcomes, vestibular-related adverse effects. English language articles published since 1978 were retrieved. Seventy-five eligible studies were identified from a systematic literature search, and relevant data were charted, collated, and summarized. Results: Testing for vestibulotoxicity predominately featured functional evaluation of the horizontal semicircular canal using the caloric and rotational tests. The rate of abnormal vestibular function test results after chemotherapy administration varied from 0 to 50%. The results of objective testing did not always correspond to patient symptoms. There is tentative support for patients with pre-existing loss of vestibular function to be more likely to experience vestibular toxicity after dosing with cisplatin. Conclusions: A number of studies reported significant evidence of vestibular toxicities associated with platinum-based chemotherapy, especially cisplatin. This scoping review emphasizes that vestibular toxicity needs more attention and comprehensive evaluation. Specifically, studies that analyse cumulative dose of platinum-based chemotherapy, affected sites of lesion in vestibular end organs, and the correlation and temporal patterns of cochlear and vestibular toxicity are needed.

Growth Patterns of Residual Tumor in Preoperatively Growing Vestibular Schwannomas.

Objectives To analyze growth of residual vestibular schwannoma (VS) following incomplete tumor resection and determine the influence of residual location and size. Design Retrospective case note and scan review. Setting Tertiary skull base unit. Participants Patients with residual tumor following primary surgery for medium and large unilateral growing vestibular schwanomas between 2006 and 2009. Main Outcome Measures Location of residual VS and post-operative growth, comparing those with more (>5%) or less than 5% of tumor residual (<5%). Results Fifty-two patients had visible residual tumor left behind at surgery. Twenty had < 5% and 32 had > 5% residual. The residual growth rates were 38% overall, 20% in < 5%, and 50% in > 5% residuals. There was no significant difference in growth rates at different residual locations. Median follow-up was 6.4 years. Conclusions There is a greater risk of regrowth of residuals > 5%. All positions of residual tumor can regrow, and the preoperative tumor size plays a role in this. Further data is needed to confirm if residual tumor in the fundus is less likely to grow.

Are routine preoperative CT scans necessary in adult cochlear implantation? Implications for the allocation of resources in cochlear implant programs.

Our aim was to critically assess the influence of preoperative computed tomography (CT) scans on implantation decisions for adult cochlear implant candidates. The working hypothesis was that these routine scans might not provide critical additional information in most adult cochlear implant candidates. The charts of 175 adults with unilateral cochlear implantation were reviewed. Preoperative CT scan reports were audited, and scans with reported pathology were examined by an Otologist/ENT Surgeon. Clinic notes and multidisciplinary team meeting summaries were also analyzed to assess whether the results of the radiology report had influenced the decision to implant or the laterality of implantation. Twenty-five of the 175 scans (14.3%) showed an abnormality. Five of those 25 scans showed evidence of previous surgeries already known to the clinicians. Of the remaining 20 scans, 17 showed abnormalities, including wide vestibular aqueducts, Mondini deformities, and varying degrees of otospongiosis, the identification of which can be considered preoperatively helpful. Of the 175 scans, 3 (1.7%) demonstrated abnormalities that influenced the side of implantation or the decision to implant and, therefore, had an impact on treatment. We conclude that a preoperative CT scan seems to have an impact on treatment in only a small percentage of adult cochlear implantees. Hence, it may only need to be performed in patients with a history or clinical suspicion of meningitis or otosclerosis, if the individual was born deaf or became deaf before the age of 16, or if there are other clinical reasons to scan (e.g., otoscopic appearance). The related resources can be allocated to other facets of cochlear implant programs.

Developing a nurse-delivered frenulotomy service.

OBJECTIVES: Tongue tie (ankyloglossia) describes a short lingual frenulum that can lead to breastfeeding difficulties. It affects between 4% and 10% of infants and can be treated by frenulotomy. We developed a nurse-delivered frenulotomy service at a tertiary pediatric hospital and audited our results. STUDY DESIGN: Observational study. SETTING: Tertiary pediatric hospital. SUBJECTS AND METHODS: An outpatient tongue tie clinic was set up by an ear, nose, and throat consultant. Tongue tie division was undertaken using a standard technique without the need for anesthesia or analgesia, as per National Institute for Health and Care Excellence guidelines. Subsequently, a senior nurse was trained to undertake the clinic independently and saw most referrals. Patient satisfaction data were collected via questionnaires. RESULTS: Referrals to the service increased from 57 (2009) to 296 (2012). Outcome data from outpatient frenulotomy are discussed. Parent satisfaction measures were similar for both nurse- and doctor-delivered treatment. If all frenulotomies were undertaken in nurse-delivered clinics, a total of £3830 could have been saved in 2012, compared with the cost of doctor-delivered care. CONCLUSION: A nurse-delivered outpatient frenulotomy service is a safe and cost-effective method of delivering such care. We have demonstrated reduced costs and reduced waiting times without compromising patient satisfaction or the quality of care provided.

Management of tumors arising from the parapharyngeal space: A systematic review of 1,293 cases reported over 25 years.

OBJECTIVES: We present a systematic review of 1,252 lesions published in the past 25 years, the largest to date. We also include our own experience of 41 cases. DATA SOURCES: Our data sources were MEDLINE and Embase databases. REVIEW METHODS: A systematic review of the literature (1988-2014) was performed and data on histological diagnosis, presentation, surgical approach, and postoperative complications were reviewed. RESULTS: In total, 22 studies (including our own institution) revealed 82% of lesions were benign. The most common presentation was an intraoral mass (52%) followed by a cervical mass (48%), and the most common primary lesion was a pleomorphic adenoma (29%). Ninety-six percent of patients underwent surgery. The cervical approach was most frequently used (46%), and the most common complication was vagus nerve injury (13%). Within our institution, 5-year progression-free survival for benign and malignant disease was 93% and 61%, respectively (P = .196). CONCLUSIONS: A parapharyngeal space mass is an uncommon tumor and requires careful preoperative assessment. Definitive treatment is usually surgery, and these patients should be counseled appropriately about the potential for permanent cranial nerve deficits. LEVEL OF EVIDENCE: NA.

The Surgical Management of Tympanic Membrane Retraction Pockets Using Cartilage Tympanoplasty.

Evaluate the surgical treatment of tympanic membrane (TM) retractions with modified cartilage augmentation tympanoplasty. Retrospective review of subjects with Charachon stage II and III TM retractions who underwent modified cartilage augmentation tympanoplasty following excision of the retracted TM segment. Pre and postoperative symptoms and air-bone gaps were recorded. Forty two ears were included in the study. Twenty six ears were of stage II and 16 were stage III retractions. 35 (83 %) ears had ossicular erosion and cholesteatoma was found in 13 (31 %) ears, all in stage III retractions. Follow-up ranged 12-102 months. The air-bone gap (ABG) improved in 29 (76 %) and worsened in seven (19 %). Ears without cholesteatoma had a greater improvement in ABG. The results of our modified cartilage tympanoplasty technique are comparable to the published literature and should provide a safe and acceptable result. The high rate of cholesteatoma found preoperatively in stage III retractions advocates early surgical intervention.

Infection with 2009 H1N1 influenza virus primes for immunological memory in human nose-associated lymphoid tissue, offering cross-reactive immunity to H1N1 and avian H5N1 viruses.

Influenza is a highly contagious mucosal infection in the respiratory tract. The 2009 pandemic H1N1 (pH1N1) influenza virus infection resulted in substantial morbidity and mortality in humans. Little is known on whether immunological memory develops following pH1N1 infection and whether it provides protection against other virus subtypes. An enzyme-linked immunosorbent spot assay was used to analyze hemagglutinin (HA)-specific memory B cell responses after virus antigen stimulation in nose-associated lymphoid tissues (NALT) from children and adults. Individuals with serological evidence of previous exposure to pH1N1 showed significant cross-reactive HA-specific memory B cell responses to pH1N1, seasonal H1N1 (sH1N1), and avian H5N1 (aH5N1) viruses upon pH1N1 virus stimulation. pH1N1 virus antigen elicited stronger cross-reactive memory B cell responses than sH1N1 virus. Intriguingly, aH5N1 virus also activated cross-reactive memory responses to sH1N1 and pH1N1 HAs in those who had previous pH1N1 exposure, and that correlated well with the memory response stimulated by pH1N1 virus antigen. These memory B cell responses resulted in cross-reactive neutralizing antibodies against sH1N1, 1918 H1N1, and aH5N1 viruses. The 2009 pH1N1 infection appeared to have primed human host with B cell memory in NALT that offers cross-protective mucosal immunity to not only H1N1 but also aH5N1 viruses. These findings may have important implications for future vaccination strategies against influenza. It will be important to induce and/or enhance such cross-protective mucosal memory B cells.

Closure of minor tracheoesophageal fistulae with calcium hydroxlapatite.

OBJECTIVE: To demonstrate a novel technique for the closure of a pinhole tracheoesophageal fistula using Radiesse (calcium hydroxylapatite). METHODS: Two patients underwent closure of a persistent tracheoesophageal fistula with four quadrant injections of Radiesse around the fistulous tract. RESULTS: Both patients had their fistulas successful closed. The first patient died after 3 months due to lung metastasis. The second patient required a further attempt at closure with Radiesse injection and has been without a leak for 18 months at his last follow up appointment. CONCLUSION: We feel this is an acceptable minimally invasive method to close a persistent pinhole tracheoesophageal fistula after failed management with chemical cautery.

Audiovestibular factors influencing quality of life in patients with conservatively managed sporadic vestibular schwannoma.

OBJECTIVES: To measure the health-related quality of life (QoL) of patients undergoing conservative management of a vestibular schwannoma and to identify audiovestibular factors that influence health-related QoL. STUDY DESIGN: Cross-sectional case-control study. INTERVENTION: Adult patients undergoing conservative management of a sporadic vestibular schwannoma were identified from a prospectively updated database. Each patient was asked to complete a series of questionnaires, including the Short Form 36 health-related QoL instrument, the Hearing Handicap Inventory, the Tinnitus Handicap Inventory, and the Dizziness Handicap Inventory. The QoL data obtained were compared with UK normal data. Multiple linear regression was performed to identify audiovestibular factors influencing QoL. PATIENTS: Of 241 patients still undergoing conservative management, 165 completed the questionnaires. The mean age was 66.6 years. Mean duration of follow-up was 5.7 years. RESULTS: Physical component summary scores were significantly lower than those of the normal population. Mental component summary scores were significantly above the normal population. Regression analysis showed that dizziness handicap score and age were strong predictors of physical component summary (both p < 0.0001). Dizziness handicap score and tinnitus handicap score were significant predictors of mental component summary (p = 0.0004 and p = 0.027 respectively). However, the model only explained a small amount of the data, suggesting that there may be other factors influencing QoL. CONCLUSION: Dizziness is the most significant audiovestibular predictor of QoL in patients with vestibular schwannomas. Tinnitus also has an impact on mental QoL. Hearing loss does not seem to influence QoL. Other factors such as illness perception may have an important role to play in determining QoL.

Developmental changes in cochlear orientation--implications for cochlear implantation.

OBJECTIVES: To investigate changes in cochlear orientation with age and discuss the implications of any change with respect to cochlear implantation. STUDY DESIGN: Cross-sectional study of computed tomographic scans of the temporal bones in patients with no congenital abnormalities. PATIENTS: One hundred fifty-nine patients were included in the study, making a total of 318 ears. The age range was 9 months to 85 years. INTERVENTION: Axial computed tomographic scans showing the basal turn of the cochlea were identified. The angle of the basal turn of the cochlea was measured by drawing a line through the long axis of the basal turn and measuring its angle with a line drawn through the midsagittal plane. The patients were grouped according to age, and a 1-way analysis of variance was used to identify any statistically significant change in basal turn angulation. Interobserver and intraobserver errors were calculated and presented as repeatability coefficients. The basal turn angles of 3 difficult cases of cochlear implantation were related to the findings. RESULTS: The mean basal turn angle was 54.6 degrees (range, 46.8-63.8 degrees; standard deviation, 3.5). There was a statistically significant reduction in the angulation of the basal turn with increasing age (F = 10.1; p = 0.002). The majority of the change occurs between the ages of 11 and 15 years. The interobserver reliability coefficient was 4.8. The intraobserver reliability coefficient was 2.0. The 3 difficult cases had basal turn angles that were at the upper limit of the reference range. CONCLUSION: There is a statistically significant reduction in basal turn angulation relative to the midsagittal plane with increasing age. However, care should be taken in interpreting these results in light of the inherent error in the measuring technique, although the intraobserver repeatability coefficient was only 2.0. The more obtuse angulation of the basal turn in children may have implications for cochlear implantation.

Heart rate and blood pressure effects during caloric vestibular testing.

OBJECTIVES: To determine whether the caloric vestibular test causes significant changes in heart rate and mean arterial blood pressure. MATERIALS AND METHODS: Changes in heart rate and mean arterial blood pressure before and after caloric irrigation were compared with the degree of nystagmus (as measured by maximum slow phase velocity) and the patient's subjective dizziness (scored from 0 to 10). A cardiologist reviewed each patient's heart rate and mean arterial blood pressure changes. Patients' anxiety levels were also assessed. RESULTS: Eighteen patients were recruited. There were no adverse events in any patient. There were no overall significant differences between the heart rate and mean arterial pressure before and after each irrigation. There was a significant correlation between the maximum slow phase velocity and patients' subjective dizziness scores. CONCLUSION: Heart rate and mean arterial blood pressure are not significantly influenced by the caloric vestibular test. This preliminary study will enable patients with stable cardiovascular disease to be recruited for further risk determination.