The prognostic value and pathophysiologic significance of three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) magnetic resonance imaging in idiopathic sudden sensorineural hearing loss: A systematic review and meta-analysis.

BACKGROUND: The underlying pathophysiology of idiopathic sudden sensorineural hearing loss (ISSNHL) is still unknown. However, an increasing number of observational studies report intralabyrinthine signal alterations in patients with ISSNHL using three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) magnetic resonance imaging (MRI). These findings warrant a meta-analysis. OBJECTIVE OF REVIEW: To conduct a meta-analysis assessing the value of 3D-FLAIR MRI in identifying possible underlying labyrinthine pathophysiologic mechanisms and prognostication in patients with ISSNHL. SEARCH STRATEGY: Two reviewers independently searched the Pubmed, Embase and Cochrane Library from inception until October 10, 2018 and evaluated eligibility based on titles and abstracts of all retrieved studies. All studies reporting on 3D-FLAIR imaging in ISSNHL were included. Subsequently, the full text of eligible studies were evaluated. EVALUATION METHOD: Adhering to the MOOSE guideline, two independent reviewers extracted data, assessed risk of bias and evaluated the relevance and quality of evidence. Data on the number of patients and events were extracted and hearing levels were converted to standardised mean differences (SMD) for conducting meta-analyses. Random effects models for meta-analyses were applied. RESULTS: Eight observational studies met our inclusion criteria (n = 638 patients). In 29%, high signal intensity was found on 3D-FLAIR imaging, suggesting labyrinthine pathology (labyrinthitis [79%], intralabyrinthine haemorrhage [21%]). High signal intensity on 3D-FLAIR was associated with poorer hearing (SMD: 14 dB, 95% CI 5.67-22.94) and vertigo (RR: 1.92, 95% CI 1.16-3.17) at baseline. Multivariate analyses demonstrated that patients with high 3D-FLAIR signal intensity had 21 dB lower final hearing pure-tone averages (SMD: 21 dB, 95% CI 9.08-33.24). CONCLUSIONS: Three-dimensional fluid-attenuated inversion recovery MR imaging can identify an underlying labyrinthine condition in up to 29% of patients with sudden hearing loss in whom previously no cause could be identified. Their final pure-tone averages are more than 20 dB worse than 3D-FLAIR-negative patients, suggesting more severe labyrinthine damage. Findings such as these may contribute to our understanding of pathophysiologic mechanisms of ISSNHL.

An unusual instance of stridor: airway obstruction from a nasogastric tube knot in a 1-month old infant.

We report a 1 month old infant with a spontaneously knotted nasogastric tube. Attempted removal of the nasogastric tube was unsuccessful, prompting further investigation. Plain radiographs revealed a large, multi-looped knot impacted in the nasopharynx and oropharynx. The tube was subsequently removed through the mouth under general anesthesia without complication, revealing a large, impressive knot of the distal end of the nasogastric tube.

Surgical Coaching: Patient Perspectives Regarding Surgeon Coaches in the Operating Room.

BACKGROUND: Surgical coaching programs have been introduced as platforms for ongoing professional development amongst independently practicing surgeons. While there is a plethora of evidence regarding the effectiveness of surgical coaching for practicing staff surgeons, patients' opinions regarding surgical coaching are largely unknown. OBJECTIVES: To determine patients' baseline attitudes and opinions about the hypothetical situation of their treating surgeon having a surgical coach present during their upcoming operation, and to determine patients' baseline knowledge and prior exposure to surgical coaching. DESIGN AND SETTING: This study was conducted at a tertiary hospital in Vancouver, Canada. Patients on the surgical waitlist of 2 independently practicing Otolaryngologists within the subspeciality of Neurotology were invited to participate in the study. Participants engaged in a semi-structured interview to discuss their opinions and knowledge of physician coaches and to learn about surgical coaching. The interview was conducted based on a pre-set script. RESULTS: Of the 100 patients approached, 70 consented to participate. Forty-three (61%) participants identified as female, and the mean age was 56±15 years. Initially, 84% of participants (n = 59) consented to the hypothetical presence of a surgical coach. Post-discussion, this number increased to 95.7% (n = 67, p = 0.04). Prior participant exposure to coaching related to employment, education, athletics, or music was high (90%, n = 63). Younger participants between 25 and 45 years of age were more amenable to the presence of a surgical coach compared to participants >66 years of age (p = 0.01). After the interview, 55 (79%) participants were interested in learning more about surgical coaching. CONCLUSION: Many patients were unaware of the rationale and importance of surgical coaching programs for practicing staff surgeons. Most patients, especially younger patients, were amenable to the presence of a surgical coach during their surgery, and this number increased in all age categories with patient education about surgical coaching.

Risk of Stroke and Myocardial Infarction After Sudden Sensorineural Hearing Loss: A Meta-Analysis.

OBJECTIVES/HYPOTHESIS: The pathophysiology of idiopathic sudden sensorineural hearing loss (ISSNHL) is still unknown, but labyrinthine artery infarction has been proposed. The objective of this study was to perform a systematic review and conduct a meta-analysis assessing the risk of developing stroke and myocardial infarction after presentation with ISSNHL. METHODS: A systematic literature review was conducted using Pubmed, Embase, Web of Science, and Cochrane Libraries. All studies investigating an association between ISSNHL and stroke and/or myocardial infarction (MI) were included. Adhering to the MOOSE guideline, two independent reviewers extracted data, assessed risk of bias, and evaluated the relevance and quality of evidence. RESULTS: Three observational studies evaluating the risk of stroke in ISSNHL were included (n = 6,521 patients). All individual study results indicated an increased relative risk of stroke after ISSNHL (unadjusted relative risk range 1.21-1.63). Pooled adjusted hazard ratios revealed a 1.42-fold increased risk of stroke after ISSNHL (hazard ratio [HR] 1.42; 95% confidence interval [CI] 1.15-1.75, I2 = 55%). Subgroup analysis of one study demonstrated that the increased risk is only present in adults aged above 50 years (HR 1.23; 95% CI 1.07-1.42). Five observational studies evaluating the risk of MI in patients with ISSNHL were included (n = 61,499 patients). Pooled analyses demonstrated that ISSNHL was not associated with MI (HR 1.08, 95% CI 0.87-1.34). CONCLUSION: ISSNHL may be an independent risk factor for the subsequent development of stroke especially in a subgroup of elderly patients. More studies are needed to confirm this association and to assess whether such patients would benefit from cardiovascular risk assessment and management to prevent future strokes. Laryngoscope, 131:1369-1377, 2021.

Quality Indicators for the Diagnosis and Management of Menière's Disease.

OBJECTIVE: Menière's disease (MD) is a clinical disorder that often provides challenges in diagnosis and management. High-quality evidence to guide care providers is sparse, which can result in significant practice variations. Quality indicators (QIs) are one method that can be used to standardize and measure accepted care practices to improve healthcare quality and patient outcomes. Here, we developed practical, high-yield QIs that serve to measure and inform the quality of care provided to patients with MD. STUDY DESIGN: Modified RAND Corporation University of California, Los Angeles appropriateness methodology for QI development. SETTING: Multicenter nine-member expert panel. PATIENTS: NA. INTERVENTIONS: NA. MAIN OUTCOME MEASURE: Final QIs deemed appropriate measures of quality care with agreement by the expert panel. RESULTS: Twenty-seven candidate indicators were identified after literature review. After the first round of evaluations, the panel agreed on three candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss disagreements. Two agreed-upon QIs were revised during this discussion before final evaluations. The expert panel ultimately agreed upon five QIs as appropriate measures of high-quality care after completing final evaluations and reviewing updated literature. The five quality indicators measure audiometric documentation, minimization of electrocochleography, use of intratympanic dexamethasone, use of intratympanic gentamycin, and rate of labyrinthectomy/vestibular neurectomy in refractory MD patient. CONCLUSIONS: This study proposes five QIs that cover key aspects of care for MD, such as accurate diagnosis and management options including initial destructive therapies. These QIs can serve multiple purposes, the most important of which is to galvanize quality improvement initiatives.

Quality Indicators for the Diagnosis and Management of Sudden Sensorineural Hearing Loss.

OBJECTIVE: Sudden sensorineural hearing loss (SSNHL) is an ideal entity for quality indicator (QI) development, providing treatment challenges resulting in variable or substandard care. The American Academy of Otolaryngology-Head and Neck Surgery recently updated their SSNHL guidelines. With SSNHL demonstrating a large burden of illness, this study sought to leverage the updated guidelines and develop QIs that support quality improvement initiatives at an individual, institutional, and systems level. METHODS: Candidate indicators (CIs) were extracted from high-quality SSNHL guidelines that were evaluated using the Appraisal of Guidelines for Research and Evaluation II tool. Each CI and its supporting evidence were summarized and reviewed by a nine-member expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND Corporation-University of California, Los Angeles appropriateness methodology. RESULTS: Fifteen CIs were identified after literature review. After the first round of evaluations, the panel agreed on 11 candidate indicators as appropriate QIs with 2 additional CIs suggested for consideration. An expert panel meeting provided a platform to discuss areas of disagreement before final evaluations. The expert panel subsequently agreed upon 11 final QIs as appropriate measures of high-quality care for SSNHL. CONCLUSION: The 11 proposed QIs from this study are supported by evidence and expert consensus, facilitating measurement across a wide breadth of quality domains. With the recently updated SSNHL guidelines, and a greater focus on quality improvement opportunities, these QIs may be used by healthcare providers for targeted quality improvement initiatives.

Guidance for otolaryngology health care workers performing aerosol generating medical procedures during the COVID-19 pandemic.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for Coronavirus disease 2019 (COVID-19) has a predilection for infecting the mucosa of the upper and lower airways. Otolaryngologists and supporting health care workers (HCWs) are particularly at high risk of becoming infected while treating patients as many in-office procedures and surgeries are Aerosol Generating Medical Procedures (AGMP). Based on a review of the literature and various guidelines, recommendations are made to mitigate the risk to health care workers of becoming infected with SARS-CoV-2 while providing clinical care. RECOMMENDATIONS: During the COVID-19 pandemic all elective and non-time sensitive Otolaryngology procedures should be deferred to mitigate the risk of transmission of infection to HCWs. For non-AGMPs in all patients, even COVID-19 positive patients Level 1 PPE (surgical mask, gown, gloves and face shield or goggles) is sufficient. If local prevalence is favourable and patients are asymptomatic and test negative for SARS-CoV-2, Level 1 PPE can be used during short duration AGMPs, with limited risk of infected aerosol spread. For AGMPs in patients who test positive for SARS-CoV-2 a minimum of Level 2 PPE, with adequate protection of mucosal surfaces, is recommended (N95/FFP2 respirator, gown, double gloves, goggles or face shield and head cover). For long duration AGMPs that are deemed high-risk in COVID-19 positive patients, Level 3 PPE can provide a higher level of protection and be more comfortable during long duration surgeries if surgical hoods or PAPRs are used. It is recommended that these procedures are performed in negative pressure rooms, if available. It is essential to follow strict donning and doffing protocols to minimize the risk of contamination. CONCLUSIONS: By following strict infection prevention recommendations, the risk of HCWs becoming infected with SARS-CoV-2 while treating patients can be minimized. As the COVID-19 pandemic evolves rapidly, these recommendations should serve as guidance and need to be interpreted based on local factors and availability of healthcare resources.

Cost-effectiveness of School Hearing Screening Programs: A Scoping Review.

OBJECTIVE: School hearing screening is a public health intervention that can improve care for children who experience hearing loss that is not detected on or develops after newborn screening. However, implementation of school hearing screening is sporadic and supported by mixed evidence to its economic benefit. This scoping review provides a summary of all published cost-effectiveness studies regarding school hearing screening programs globally. At the time of this review, there were no previously published reviews of a similar nature. DATA SOURCES: A structured search was applied to 4 databases: PubMed (Medline), Embase, CINAHL, and Cochrane Library. REVIEW METHODS: The database search was carried out by 2 independent researchers, and results were reported in accordance with the PRISMA-ScR checklist and the JBI methodology for scoping reviews. Studies that included a cost analysis of screening programs for school-aged children in the school environment were eligible for inclusion. Studies that involved evaluations of only neonatal or preschool programs were excluded. RESULTS: Four of the 5 studies that conducted a cost-effectiveness analysis reported that school hearing screening was cost-effective through the calculation of incremental cost-effectiveness ratios (ICERs) via either quality- or disability-adjusted life years. One study reported that a new school hearing screening program dominated the existing program; 2 studies reported ICERs ranging from 1079 to 4304 international dollars; and 1 study reported an ICER of £2445. One study reported that school-entry hearing screening was not cost-effective versus no screening. CONCLUSION: The majority of studies concluded that school hearing screening was cost-effective. However, significant differences in methodology and region-specific estimates of model inputs limit the generalizability of these findings.

The Effect of Unilateral Vestibular Loss on Standing Balance During Postural Threat.

OBJECTIVE: Vestibular deficit patients have an increased fall risk and fear of falling. Postural threat, known to increase balance-related fear and anxiety, influences vestibular gains during quiet standing in young healthy adults. The current study examined whether there is a similar relationship for peripheral unilateral vestibular loss (UVL) patients in comparison to age-matched healthy controls (HC). SETTING: University laboratory. STUDY DESIGN: Prospective laboratory study. PATIENTS AND CONTROLS: Eleven UVL patients, nine with vestibular neurectomy. Eleven aged-matched HCs. MAIN OUTCOME MEASURES: Subjects stood on a hydraulic lift placed at two heights: low (0.8 m, away from the edge) and high (3.2 m, at the edge). Amplitude (root mean square), mean power frequency (MPF), and mean position were analyzed for center of foot pressure (COP) and 90% ranges for angle amplitude and velocity for trunk sway. RESULTS: Group interactions were strongest for anterior-posterior (AP) COP and trunk pitch angle. AP lean away from the edge was greater in HCs than UVLs. HCs, but not UVLs had a decrease in root mean square AP COP with height. Trunk pitch sway was changed similarly. Both groups had increased trunk pitch velocity at height. Changes with height were less for roll: MPF of lateral COP increased with height for UVLs with no changes for HCs, and trunk roll amplitude decreased for both groups. CONCLUSIONS: This report provides evidence for a differential effect of height induced postural threat on balance control between UVLs and HCs presumably due to the reduced vestibular-spinal gain in UVL subjects.

Systematic Review and Network Meta-analysis of Cognitive and/or Behavioral Therapies (CBT) for Tinnitus.

OBJECTIVE: To evaluate the efficacy of cognitive and/or behavioral therapies in improving health-related quality of life (HRQOL), depression, and anxiety associated with tinnitus. DATA SOURCES: EMBASE, MEDLINE, PubMed, PsycINFO, and the Cochrane Registry were used to identify English studies from database inception until February 2018. STUDY SELECTION: Randomized controlled trials (RCTs) comparing cognitive and/or behavioral therapies to one another or to waitlist controls for the treatment of tinnitus were included. DATA EXTRACTION: Quality and risk were assessed using GRADE and Cochrane's Risk of Bias tool respectively. DATA SYNTHESIS: Pairwise meta-analysis (12 RCTs: 1,144 patients) compared psychological interventions to waitlist controls. Outcomes were measured using standardized mean differences (SMDs) and 95% confidence intervals (CI). I and subgroup analyses were used to assess heterogeneity. Network meta-analysis (NMA) (19 RCTS: 1,543 patients) compared psychological therapies head-to-head. Treatment effects were presented by network diagrams, interval plots, and ranking diagrams indicating SMDs with 95% CI. Direct and indirect results were further assessed by inconsistency plots. CONCLUSIONS: Results are consistent with previously published guidelines indicating that CBT is an effective therapy for tinnitus. While guided self-administered forms of CBT had larger effect sizes (SMD: 3.44; 95% CI: -0.022, 7.09; I: 99%) on tinnitus HRQOL, only face-to-face CBT was shown to make statistically significant improvements (SMD: 0.75; 95% CI: 0.53, 0.97; I: 0%). Guided self-administered CBT had the highest likelihood of being ranked first in improving tinnitus HRQOL (75%), depression (83%), and anxiety (87%), though statistically insignificant. This NMA is the first of its kind in this therapeutic area and provides new insights on the effects of different forms of cognitive and/or behavioral therapies for tinnitus.

Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology - head and neck surgery during the COVID-19 pandemic.

BACKGROUND: Aerosol generating medical procedures (AGMPs) present risks to health care workers (HCW) due to airborne transmission of pathogens. During the COVID-19 pandemic, it is essential for HCWs to recognize which procedures are potentially aerosolizing so that appropriate infection prevention precautions can be taken. The aim of this literature review was to identify potential AGMPs in Otolaryngology - Head and Neck Surgery and provide evidence-based recommendations. METHODS: A literature search was performed on Medline, Embase and Cochrane Review databases up to April 3, 2020. All titles and abstracts of retrieved studies were evaluated and all studies mentioning potential AGMPs were included for formal review. Full text of included studies were assessed by two reviewers and the quality of the studies was evaluated. Ten categories of potential AGMPs were developed and recommendations were provided for each category. RESULTS: Direct evidence indicates that CO2 laser ablation, the use of high-speed rotating devices, electrocautery and endotracheal suctioning are AGMPs. Indirect evidence indicates that tracheostomy should be considered as potential AGMPs. Nasal endoscopy and nasal packing/epistaxis management can result in droplet transmission, but it is unknown if these procedures also carry the risk of airborne transmission. CONCLUSIONS: During the COVID-19 pandemic, special care should be taken when CO2 lasers, electrocautery and high-speed rotating devices are used in potentially infected tissue. Tracheal procedures like tracheostomy and endotracheal suctioning can also result in airborne transmission via small virus containing aerosols.

Post-Traumatic Dizziness: Clinical and Medicolegal Aspects.

Subjective complaints of dizziness after mild-to-moderate traumatic brain injury are common. Alterations in the mode of injury have changed the presentation symptoms. Evolutions in neuroimaging challenge conventional concepts regarding lack of evidence of injury following mild head trauma and provide hope for elucidating the site of lesion in patients with post-traumatic balance symptoms. Yet the vestibular clinician must maintain a healthy level of suspicion regarding potential exaggeration of symptoms and disability in patients with a financial incentive. Unique conditions warrant particular attention by the vestibular clinician, including chronic traumatic encephalopathy, catastrophization, and persistent postural and perceptual dizziness. The clinical significance of abnormalities, particularly on vestibular-evoked myogenic potential testing, needs to be better defined prior to their widespread application in the medical legal arena. The role of the medical expert is to provide opinion on matters requiring special knowledge to assist the court in reaching its findings. As such, this chapter provides an update on recent advances to consider in patients with dizziness after trauma.

Vestibular Neuritis: Recent Advances in Etiology, Diagnostic Evaluation, and Treatment.

Purpose of Chapter: This chapter highlights the recent advances in etiology, diagnostic evaluation, and management of vestibular neuritis (VN). Recent Findings: The viral hypothesis has been strengthened with new evidence as the main etiology of VN. Recent evidence indicates that bedside oculomotor findings play a critical role in differentiating VN from stroke. The implementation of cervical and ocular vestibular evoked myogenic potential, and video head impulse test in vestibular function testing has made it possible to diagnose selective damage of the vestibular nerves. The management of the acute phase of VN is primarily medical, while long-term treatment is designed to improve vestibular compensation. Summary: VN is clearly defined as an important viral inner ear disorder.

Subjective and objective vestibular changes that occur following paediatric cochlear implantation: systematic review and meta-analysis.

OBJECTIVE: Cochlear implantation can result in post-operative vestibular dysfunction of unknown clinical significance. The objective of this study was to characterize the presence, magnitude, and clinical significance of vestibular dysfunction that occurs after pediatric cochlear implantation. DATA SOURCES: The databases Embase, Medline (OvidSP), and PubMed were used. Only articles published in English were included. Grey literature and unpublished sources were also reviewed. STUDY SELECTION: Articles published from 1980 until the present which documented pre-operative and post-operative vestibular testing on children under the age of 18 were used. DATA EXTRACTION: Parameters that were assessed included number of patients, pre- and post-operative vestibular-evoked myogenic potentials (VEMPs), head impulse testing (HIT), calorics, and posturography, timing of pre- and post-operative testing, symptomatology, and other demographic data such as etiology of the hearing loss. DATA SYNTHESIS: Ten articles were included. Relative risk values evaluating the effect of cochlear implantation on vestibular function were calculated for VEMPs and caloric testing due to the availability of published data. I2 values were calculated and 95% confidence intervals were reported. Separate analyses were conducted for each individual study and a pooled analysis was conducted to yield an overall relative risk. Assessment on risk of bias in individual studies and overall was performed. CONCLUSION: Pediatric cochlear implantation is associated with a statistically significant decrease in VEMP responses post-operatively (RR 1.8, p < 0.001, I2 91.86, 95%CI 1.57-2.02). Similar results are not seen in caloric testing. Insufficient data is available for analysis of HIT and posturography. Further studies are necessary to determine the effect of cochlear implantation on objective vestibular measures post-operatively and whether any changes seen are clinically relevant in this population.

Otology/Neurotology recommendations - Choosing Wisely campaign.

The Choosing Wisely Canada Campaign aims to raise awareness amongst physicians and patients regarding unnecessary tests and treatment. The otology/neurotology subspecialty group within the Canadian Society of Otolaryngology - Head & Neck Society developed a list of five common otologic presentations to help physicians deliver high quality effective care: (1) Don't order specialized audiometric and vestibular testing to screen for peripheral vestibular disease, (2) Don't perform computed tomography or blood work in the evaluation of sudden sensorineural hearing loss, (3) Don't perform auditory brain responses (ABR) in patients with asymmetrical hearing loss, (4) Don't prescribe oral antibiotics as first line treatment for patients with painless otorrhea associated with tympanic membrane perforation or tympanostomy tube, and (5) Don't perform particle repositioning maneuvers without a clinical diagnosis of posterior canal benign paroxysmal positional vertigo.

A systematic review examining the effects of therapeutic radioactive iodine on ovarian function and future pregnancy in female thyroid cancer survivors.

BACKGROUND: For women with differentiated thyroid carcinoma (DTC), the effect of radioactive iodine (RAI) therapy on gonadal and reproductive function is an important consideration. OBJECTIVE AND METHODS: We systematically reviewed controlled studies examining the gonadal and reproductive effects of RAI therapy in women and adolescents surviving DTC. We searched nine electronic databases. All abstracts and papers were independently reviewed by two reviewers. RESULTS: After reviewing 349 unique citations and 61 full-text papers, 16 papers including data from 3023 women or adolescents with DTC were included. All studies were observational, with no long-term randomized control trial data. The age at first RAI treatment varied from 8 to 50 years and the cumulative activities of RAI administered for treatment varied from 30 to 1099 mCi. Transient absence of menstrual periods occurred in 8-27% of women within the first year after RAI, particularly in older women. In addition, RAI-treated women experienced menopause at a slightly younger age than women not treated with RAI. In the first year after RAI therapy, several studies reported increased rates of spontaneous and induced abortions. However, RAI treatment for DTC was generally not associated with a significantly increased risk of long-term infertility, miscarriage, induced abortions, stillbirths, or offspring neonatal mortality or congenital defects. CONCLUSIONS: In female survivors of DTC, there is little observational evidence to suggest important adverse effects of RAI treatment on gonadal function, fertility or pregnancy outcomes beyond 12 months, with the exception of a possible slightly earlier age of menopause.

A systematic review of the gonadal effects of therapeutic radioactive iodine in male thyroid cancer survivors.

BACKGROUND: For patients with well-differentiated thyroid carcinoma (WDTC), the gonadal effects of radioactive iodine (RAI) therapy is an important consideration. OBJECTIVE AND METHODS: We systematically reviewed the controlled studies examining the gonadal effects of RAI therapy in male WDTC survivors. We searched in nine electronic databases. All abstracts and papers were independently reviewed by two reviewers. RESULTS: After reviewing 334 abstracts and 59 full-text papers, seven papers were included. In longitudinal studies examining the effect of single primary RAI dose activities of 594 mCi. Cumulative RAI dose correlated with FSH measurements at long-term follow-up. In one study, approximately one in eight men experienced oligospermia 1 year after RAI therapy. Rates of infertility, pregnancy loss and offspring congenital malformation were not elevated, but studies were limited by small size and self-reported outcomes. CONCLUSIONS: Abnormalities in testicular function are common within several months of a single therapeutic dose of RAI for WDTC. Biochemical abnormalities usually resolve within 18 months after administration of a single activity of < 150 mCi of RAI. The risk of persistent gonadal dysfunction is increased after repeated or high cumulative RAI activities. Controlled, prospective studies, with long-term follow-up, examining male gonadal and offspring effects of RAI therapy are needed.

A closer look at subjective caloric sensations: Is there more to vertigo than spinning?

BACKGROUND: There is a prevailing opinion that spinning sensations signify a peripheral vestibular pathology while non-spinning sensations are not of vestibular origin. OBJECTIVES: 1) Characterize the subjective sensations reported by patients during caloric testing. 2) Assess if the sensation was correlated with the peak slow phase velocity (SPV). METHODS: Retrospective chart review at a Canadian adult tertiary-quaternary care balance centre for patients undergoing diagnostic caloric testing between December 2014 and September 2015. RESULTS: Of 163 patients included, 122 had normal calorics and 41 demonstrated unilateral weakness. Spinning/rotatory movements were the most commonly reported sensations (55-70%). No sensation was reported among 10-20% of patients. Other non-rotatory sensations were reported 20-25% of the time. Both lack of sensation and other sensations were more likely to be correlated with SPVs that were significantly lower than those associated with spinning/rotating sensations. However, 18% of patients with normal calorics and robust SPVs with warm irrigation still reported non-spinning sensations. CONCLUSIONS: During caloric irrigation, subjective sensations other than spinning and rotating are reported 20-25% of the time and these tend to be associated with lower peak SPV. Non-spinning vertigo is not uncommon as a subjective description of vestibular sensation even in normal patients with strong SPVs.

Shared decision making and decisional conflict in the Management of Vestibular Schwannoma: a prospective cohort study.

BACKGROUND: Patients with vestibular schwannomas (VS) are faced with complex management decisions. Watchful waiting, surgical resection, and radiation are all viable options with associated risks and benefits. We sought to determine if patients with VS experience decisional conflict when deciding between surgery or non-surgical management, and factors influencing the degree of decisional conflict. METHODS: A prospective cohort study in two tertiary ambulatory skull-base clinics was performed. Patients with newly diagnosed or newly growing vestibular schwannomas were recruited. Patients were given a demographic form and the decisional conflict scale (DCS), a validated measure to assess the degree of uncertainty when making medical decisions. The degree of shared decision making (SDM) experienced by the patient and physician were assessed via the SDM-Q-10 and SDM-Q-Doc questionnaires, respectively. Non-parametric statistics were used. Questionnaires and demographic information were correlated with DCS using Spearman correlation coefficient and Mann-Whitney U. Logistic regression was performed to determine factors independently associated with DCS scores. RESULTS: Seventy-seven patients participated (55% female, aged 37-81 years); VS ranged in size from 2 mm-50 mm. Significant decisional conflict (DCS score 25 or greater) was experienced by 17 (22%) patients. Patients reported an average SDM-Q-10 score of 86, indicating highly perceived level of SDM. Physician and patient SDM scores were weakly correlated (p = 0.045, Spearman correlation coefficient 0.234). DCS scores were significantly negatively correlated with a decision to pursue surgery, presence of a trainee, and higher SDM-Q-10 score. DCS was higher with female gender. Using logistic regression, the SDM-Q-10 score was the only variable associated with significantly reduced DCS. CONCLUSIONS: About one fifth of patients deciding how to manage their vestibular schwannoma experienced a significant degree of decisional conflict. Involving the patients in the process through shared decision-making significantly reduced the degree of uncertainty patients experienced.