Virtual clinic for hearing loss and non-pulsatile tinnitus: initial experience of 210 cases.

OBJECTIVE: Patients with hearing loss and tinnitus face lengthy waits to be seen in the ENT clinic. SHOEBOX Audiometry is an iPad-based, audiometric screening tool. A virtual hearing loss and non-pulsatile tinnitus clinic involving an ENT specialist virtually assessing cases based on the SHOEBOX audiogram, a patient symptom questionnaire and the primary care referral letter were implemented. This service evaluation explored the outcomes of the virtual clinic in reducing the need for a face-to-face ENT appointment. METHOD: This was a retrospective service evaluation of the first six months of the virtual hearing loss and non-pulsatile tinnitus clinic. RESULTS: A total of 210 patients were included: 34.8 per cent (73) were discharged without requiring audiologist assessment or an ENT appointment, 51.9 per cent (109) required formal audiological assessment, 36.7 per cent (77) required imaging and only 13.8 per cent (29) required a face-to-face ENT appointment. CONCLUSION: A virtual hearing loss and non-pulsatile tinnitus clinic minimised the number of patients requiring a traditional face-to-face clinic appointment within ENT.

Somnoplasty for simple snoring--a pilot study.

A prospective pilot study was conducted to investigate the efficacy of radiofrequency thermal ablation (RFTA) of the soft palate to treat simple snoring. Ten consecutive, consenting patients were recruited following history, examination, Epworth scoring, sleep nasendoscopy and full polysomnography. All the patients received two treatments of three lesional RFTA of the soft palate under local anaesthesia, using the Somnus S2 generator. Each treatment was separated by 6 weeks. Patients completed a questionnaire which used visual analogue scales to score pain during the procedure as well as the postoperative period. Snoring was also scored on visual analogue scales by both the patient and the partner. Objective assessment was based on full polysomnography 3 months after the second treatment. Sixty per cent of patients subjectively reported improvement in snoring. Objectively, only 30% showed improvement in duration of snoring (38-48% better) with no change in intensity. There was high patient acceptability of the procedure.

Pneumocephalus--an unreported risk of Valsalva's manoeuvre following cochlear implantation.

We describe a case of pneumocephalus as an unusual early postoperative complication following cochlear implantation. The aetiology of this condition we attribute to the patient's habit of 'ear popping' using Valsalva's manoeuvre.

A century of eighth nerve surgery.

STUDY DESIGN: A scholarly review of over 70 original papers from the late 19th and early 20th centuries. RESULTS: Although many neurotologists consider vestibular nerve section to be a recent innovation, eighth nerve division dates back to the dawn of intracranial surgery. Although surgery of peripheral nerves (e.g., repair after injury) is ancient, intracranial nerve surgery began in the latter part of the 19th century with fifth nerve division for tic douloureux. By analogy, it was reasoned that hyperactivity of the eighth nerve (initially tinnitus and later vertigo) could be relieved by dividing this nerve. In 1898, Fedor Krause (1856-1937) of Berlin attempted the first eighth nerve section. This patient, as did many during this era, died shortly after the operation. Most of the survivors had facial palsy. These innovative early surgeons used a variety of approaches, including the suboccipital, middle fossa, and transtemporal routes. After an initial burst of excitement during the first decade of the century, poor results led to few procedures being performed through the second and third decades. Throughout this era, there was much debate about the relative merits of labyrinthectomy (introduced by Milligan and Lake in 1904) as opposed to eighth nerve division. In the late 1920s, the prolific Walter E. Dandy (1886-1946) of Baltimore repopularized eighth nerve section and ultimately performed 607 procedures between 1927 and 1946. Although Dandy achieved a high vertigo control rate and reduced the mortality rate to <1%, he had a high rate of facial nerve weakness (9.1% transient, 4.2% permanent). Remarkably, the latter outcome was never published in his numerous papers on the subject, but was first revealed in a 1951 retrospective survey, which appeared some 5 years after his death. Selective division of the vestibular fibers was introduced by Kenneth G. McKenzie (1892-1963) of Toronto in 1931. At least 11 sizable series appeared in the literature before the introduction of microsurgical vestibular nerve section by William F. House (b. 1923) of Los Angeles in 1960. CONCLUSIONS: The introduction and progressive refinement of eighth nerve section played a central role in the evolution of operative neurotology. Many of the most vigorous debates of recent years (e.g., the choice of operative route, the optimal site of division, and the relative role of inner ear surgery vs. nerve surgery) have antecedents in the controversies of the distant past.

Primary malignant melanoma of the cerebellopontine angle.

BACKGROUND: Malignant tumors of the cerebellopontine angle are very rare, accounting for less than 1% of lesions at this site. These may be primary or secondary tumors of the temporal bone, central nervous system (CNS), or leptomeninges. Malignant melanoma is uncommon, accounting for 1.5% of all types of malignant tumors. Metastatic melanoma is a frequent cause of CNS metastasis, often with leptomeningeal spread. Primary leptomeningeal melanoma is, however, rare and even more so at the cerebellopontine angle. The prognosis for CNS malignant melanoma is generally very poor. PATIENT: The authors describe the case of a 29-year-old woman with unilateral hearing loss and facial paresis. Magnetic resonance imaging (MRI) demonstrated a mass that was thought to be an acoustic neuroma but was seen to involve the cochlea as well as the internal auditory meatus and cerebellopontine angle. The lesion was subsequently excised completely by a trans-labyrinthine approach, with facial nerve preservation, and was shown on histologic examination to be a malignant melanoma. Further comprehensive investigation did not reveal a primary extracranial site or any sign of CNS spread. The clinical features of this case, including the radiologic and histologic findings, are described, and literature concerning management is reviewed.

Appropriate use of the day care unit for rigid endoscopy of the upper aerodigestive tract.

There is increasing pressure for more day surgery to be undertaken in the health service. In this retrospective study of 325 rigid upper aerodigestive tract endoscopies performed in the Day Care Unit of The Royal National Throat Nose and Ear Hospital, London, there were no post-discharge complications and only four patients required admission, none were, in our opinion, the direct result of day case rigid endoscopy. In our unit, the day case rate for microlaryngeal surgery is 44.8%, showing that rates significantly higher than published national rates of 17.1% (1993/1994) are achievable. We conclude that day case microlaryngeal surgery and diagnostic rigid endoscopy of the upper aerodigestive tract is safe if performed by suitably qualified staff in dedicated specialist units with patients selected according to existing day case criteria.

Barotraumatic fracture of the stapes footplate.

We present a rare case in which barotrauma led to fracture of the stapes footplate and perilymph fistula, resulting in sudden severe sensorineural hearing loss and tinnitus. Surgical repair in this case resulted in excellent hearing recovery. The aetiology and management of inner ear barotrauma and stapes injury is discussed. We believe that early exploration and repair of suspected perilymph fistulae optimises hearing recovery.

Punctate diathermy of the soft palate: a new approach in the surgical management of snoring.

We present our experiences in the surgical management of 21 snorers, utilizing a new approach designed to stiffen the palatal musculature, without compromising its function. This was achieved by using a punctate pattern of intrapalatal diathermy to achieve fibrosis within the palate and hence the requisite stiffening. The initial results of this procedure are encouraging showing a subjective improvement in snoring in 85.7 per cent of patients and an increase in sleeping in the same room as their partner every night, from 14.3 per cent pre-operatively to 57.1 per cent post-operatively.

Surgical presentations of Ehlers-Danlos syndrome type IV. A case report.

The case of a 28 year old man with Ehlers-Danlos syndrome (EDS) type IV is presented. He had the typical facies of this disorder, thin skin with atrophic scars and bruised easily. He suffered with congenital clubbed feet, heavy blood loss and poor wound healing following a traumatic compound fracture of the right leg, recurrent spontaneous pneumothoraces for which a pleurectomy was performed, two episodes of vascular rupture following minor trauma, one managed conservatively and the other surgically, and one episode of massive spontaneous vascular rupture which was fatal. In this report we highlight the surgical nature of the presenting complications of EDS type IV and demonstrate the hazards of surgical management. We conclude that, when possible, conservative management is preferable.