Coblation intracapsular tonsillectomy in a paediatric tertiary centre: Revision surgery rates over a nine-year period.

OBJECTIVES: Coblation intracapsular tonsillectomy (ICT) is increasingly being used in the paediatric population because of the rapid recovery and low rates of complications associated with it. There is, however, a risk of symptomatic regrowth with this technique. The objective of our study is to establish the rate of, and risks for, revision surgery over time in a major tertiary referral centre with a large cohort of paediatric Coblation ICT cases. METHODS: A retrospective review of all children (0-19 years) undergoing Coblation ICT from April 2013 to June 2022 was undertaken, using electronic databases and clinical records. Post-operative follow up was reviewed and revision cases were subsequently identified and examined. Statistical analysis was performed using a Chi-Squared test. RESULTS: 4111 patients underwent Coblation ICT during the studied period, with or without concomitant adenoidectomy. Of these, 135 (3.3 %) required revision tonsil surgery, primarily for recurrence of initial symptoms; two patients required two consecutive revision procedures (137 revision procedures in total). Eight-eight (n = 88) (64 %) of these were revised with a repeat Coblation ICT procedure and 49 (36 %) with bipolar diathermy extracapsular tonsillectomy (ECT) of remnant tonsil tissue. The revision rates after Coblation ICT declined steeply on a year-on-year basis since the commencement of this technique (from 10.6 % early on, to 0.3 % at the end of the study period P<0.001). A significantly higher revision rate was noted in children below the age of two at the time of primary surgery, compared to those older than two years of age (P<0.001). CONCLUSIONS: This study demonstrates real-world departmental revision rates over a nine-year period from the technique's commencement of use. With Coblation ICT, symptomatic re-growth occurs rarely, but may be clinically significant, with higher rates of recurrent symptoms seen in children under two years of age at the time of primary surgery. The revision rate apparently drops over time in parallel with overall experience of surgeons and formalised training.

Dizziness, psychological disorders and cognitive decline.

INTRODUCTION: Dizziness is a common disorder, particularly among the elderly population. Aim of this paper was to revise the current concepts surrounding the relationship between dizziness, psychological disorders and cognitive decline. EVIDENCE ACQUISITION: This is a PRISMA-compliant systematic review, including observational studies in people with dizziness. Database inception, Medline/Cochrane/Embase/Web of Science/Scopus/NHS evidence were searched until October 30, 2019. EVIDENCE SYNTHESIS: Overall 22 studies, and 65,730 participants were included. Eleven studies were cross-sectional, 7 cross-sectional controlled, 2 prospective case-control, 1 retrospective case series, and 1 cohort study. The persistence of vestibular impairment (for 6 months or more) was correlated to the presence of psychological disorders affecting patient's Quality of Life and causing social anxiety, particularly in some conditions such as Ménière's disease. Interestingly, vestibular loss has been also correlated to cognitive impairment, with certain vestibular dysfunctions reported to be more prevalent in cognitive impaired individuals. CONCLUSIONS: The current literature suggests that there is an association between vestibular function, psychological disorders and cognitive functions. The findings from this review could be useful in informing on the need for a multidimensional diagnostic and rehabilitative programs for patients with dizziness. More studies could explore the role of counseling or behavioral therapy with an aim to reduce the perceived dizziness-related disability.

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.

Coblation intracapsular tonsillectomy in children: A prospective study of 1257 consecutive cases with long-term follow-up.

OBJECTIVES: Intracapsular tonsillectomy (ICT) is increasingly adopted by paediatric centres worldwide due to its association with reduced pain, fast recovery and low risks of post-operative complications. Questions still surround its role in patients with recurrent tonsillitis, as well as tonsillar regrowth requiring revision surgery. DESIGN: Prospective consecutive case series from March 2013 to April 2020. SETTING: Tertiary paediatric ENT referral centre. PARTICIPANTS: Paediatric patients undergoing Coblation ICT, with or without adenoidectomy, for obstructive and/or infective indications. MAIN OUTCOME MEASURES: Health-Related Quality of Life (HRQL), analgesia requirement, post-operative haemorrhage rates, time to return to normal diet and activity or school/nursery, and parental satisfaction. We report revision surgery rates and identify predictive factors for revision surgery. RESULTS: A total of 1257 patients (median age 4.2 years) underwent Coblation ICT, with a median direct and implied follow-up of 101.5 and 1419 days, respectively. We noted significantly improved HRQL scores across all domains. Median analgesia requirement was six days, and no patients required a return to theatre for post-operative haemorrhage. The majority of patients were eating a normal diet within 24 hours and returned to normal activity/school within a week post-operatively. Revision surgery was required in 2.6% of cases, mainly due to recurrent obstructive symptoms from tonsillar regrowth. Being under two years old at initial surgery (OR 5.10), having severe OSA (OR 4.43) or severe comorbidities (OR 2.98) increased the risk of needing revision surgery. CONCLUSIONS: Long-term data demonstrate the efficacy and safety of Coblation ICT in paediatric patients across a range of indications.

Utilization of SEMAC-VAT MRI for Improved Visualization of Posterior Fossa Structures in Patients With Cochlear Implants.

OBJECTIVE: The number of cochlear implant (CI) users is ever increasing worldwide, as is the utilization of magnetic resonance imaging (MRI) as a key diagnostic modality for pathology of the brain and surrounding structures. Despite advances in MRI compatibility with CI, metal artefact remains a significant issue that needs to be addressed. We test our hypothesis that the slice encoding for metal artefact correction and view angle tilting (SEMAC-VAT) metal artefact reduction technique improves demonstration of posterior fossa structures on MRI in CI recipients. STUDY DESIGN: A retrospective case review. SETTING: A tertiary referral hearing implant and skull base center. INTERVENTIONS: Dedicated MRI of the posterior fossa using T1 spin echo post-gadolinium sequences with and without the application of SEMAC-VAT in CI recipients. MAIN OUTCOME MEASURES: Extent and severity of the artefact and visualization of surrounding anatomic structures with and without the application of SEMAC-VAT, allowing for direct comparison. RESULTS: Eight CI recipients with nine CI devices were analyzed. We noted a significant reduction in signal void and improved visibility of the ipsilateral hemisphere in every case. Penumbra size increased although there was improved visibility through the penumbra. There was improved visualization of key intracranial structures, such as the ipsilateral internal auditory canal, cerebellopontine angle, cerebellar hemisphere, and brainstem. CONCLUSIONS: Application of SEMAC-VAT produces a significant reduction in signal void and improved visualization of key structures within the temporal bone and posterior cranial fossa in patients with CIs without the need for removal of the internal magnet.

Which is the optimally defined vestibular cross-section to diagnose unilateral Meniere's disease with delayed post-gadolinium 3D fluid-attenuated inversion recovery MRI?

OBJECTIVES: Delayed post-gadolinium 3D fluid-attenuated inversion recovery (FLAIR) MRI is used to support a diagnosis of Ménière's disease (MD) with the ratio of the endolymphatic space (ES) to the sum of the endolymphatic and perilymphatic spaces (SEPS) on a cross-section through the vestibule being a key diagnostic criterion. It was hypothesised that the exact definition of the vestibular cross-section would influence the ES: SEPS ratio, its ability to diagnose MD, and its reproducibility. METHODS: Following institutional approval, 22 patients (five male, 17 female; mean age 52.1) with unilateral MD and delayed post-gadolinium 3D FLAIR MRI were retrospectively analysed. Two observers measured the ES and SEPS on predefined axial (superior and inferior) and sagittal vestibular cross-sections. Receiver operating characteristic (ROC) curves, Bland-Altman plots and intraclass correlation (ICC) were analysed for the ES:SEPS ratios. RESULTS: The area under the curve (AUC) was decreased for the ES:SEPS ratios on the superior axial section through the vestibule (AUC 0.737) compared to the inferior axial (AUC 0.874) and sagittal sections (AUC 0.878). The resulting optimal thresholds (sensitivities/specificities) were 0.21 (0.66/0.75), 0.16 (0.77/0.9) and 0.285 (0.75/0.96). The reproducibility was excellent for all measures with ICCs of 0.97, 0.98 and 0.99. CONCLUSION: Inferior axial or sagittal vestibular cross-sections are more accurate for the diagnosis of MD ears and have excellent reproducibility. ADVANCES IN KNOWLEDGE: The choice of vestibular cross-section influences both the ability to distinguish MD from asymptomatic contralateral ears, and the optimum threshold ES:SEPS value.

The Outcomes of Cochlear Implantation in Elderly Patients: A Single United Kingdom Center Experience.

OBJECTIVES: The average life expectancy in the United Kingdom is currently nearly 80 years for a newborn baby with nearly 15% of the population, by 2040, being >75 years old. Hearing impairment is a common disability in the elderly individual, and there have been significant drives to support this population to lead longer and healthier working lives. We aimed to assess the long-term audiological and health-related quality-of-life benefits of cochlear implants (CI) in elderly individuals. METHODS: A retrospective and cross-sectional study of patients who received a CI at ≥70 years. Data extracted included speech perception scores, adverse events, telephone use, and patient-reported outcome measures using the Glasgow Benefit Inventory questionnaire with a minimum of 12 months follow-up. RESULTS: Sixty-four patients aged ≥70 years received a unilateral CI. A significant improvement in speech perception scores in all conditions was noted with no significant difference between differing age groups. Glasgow Benefit Inventory scores showed a significant positive impact on patients' lives and their health status, with no significant difference between the differing age groups. CONCLUSIONS: Cochlear implantation is a safe and well-tolerated procedure in the elderly patients with significant improvements observed in audiological performance, health status, and social interactions.

Longitudinal economic analysis of Bonebridge 601 versus percutaneous bone-anchored hearing devices over a 5-year follow-up period.

OBJECTIVES: Percutaneous bone-anchored hearing devices (pBAHDs) are the most commonly used bone conduction implants (BCI). Concerns surround the long-term complications, notably skin-related, in patients with percutaneous abutments. The active transcutaneous BCI Bonebridge system can help avoid some of these pitfalls but is often considered a second-line option due to various factors including perceived increased overall costs. DESIGN: Longitudinal economic analysis of Bonebridge BCI 601 versus pBAHD over a 5-year follow-up period. SETTING: A specialist hearing implant centre. PARTICIPANTS: Adult patients (≥16 years) with conductive hearing loss, mixed hearing loss or single-sided deafness, who received a Bonebridge or pBAHD implant between 1/7/2013 and 1/12/2018 with a minimum 12-month follow-up. MAIN OUTCOME MEASURES: We compared the mean costs per implanted patient for both implants at 1, 3 and 5 years postoperative time points. Clinical effectiveness was evaluated using objective and patient-reported outcome measures. RESULTS: The mean total cost per patient of Bonebridge was significantly higher than pBAHD at 1-year post-implantation (£8512 standard deviation [SD] £715 vs £5590 SD £1394, P < .001); however, by 5-years post-implantation this difference was no longer statistically significant (£12 453 SD £2159 vs £12 575 SD £3854, P > .05). The overall cost convergence was mainly accounted for by the increased long-term complications, revision surgery rates and higher cost of the pBAHD external processor compared to Bonebridge. CONCLUSIONS: Long-term costs of Bonebridge to healthcare providers are comparable to pBAHDs, whilst offering lower complication rates, comparable audiological benefit and patient satisfaction. Bonebridge should be considered as a first-line BCI option in appropriate cases.

Tracheostomy, ventilatory wean, and decannulation in COVID-19 patients.

PURPOSE: COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes. METHODS: We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway. RESULTS: At the point of analysis, a median 21 days (IQR 15-28) post-tracheostomy and 39 days (IQR 32-45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48-61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO2 at tracheostomy ≥ 0.4 (HR 1.80; 95% CI 0.89-3.60; p = 0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78-4.45; p = 0.001) were independent variables associated with prolonged time to decannulation. CONCLUSION: Higher FiO2 at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.

The Influence of Hearing Aids on Balance Control: A Systematic Review.

AIM: To assess the current opinion on the effects of hearing loss treatment by hearing aids (HAs) and the benefits of HA use on imbalance. METHODS: PRISMA-compliant systematic review was done, including observational studies in patients affected by mild to severe sensorineural hearing loss with HAs, investigating the benefits of HAs on balance. Electronic searches were performed through Medline, Cochrane, Embase, Web of Science, and Scopus. RESULTS: A total of 200 patients in 8 studies were included in this systematic review. Four studies were cross-sectional, 3 cross-sectional controlled and 1 prospective nonrandomized study. Static and dynamic balance in the aided condition improved in patients assessed using clinical investigations including Romberg test and Functional Ambulation Performance/mini-BESTest, respectively. Variable outcomes were found measuring static and dynamic balance during the aided condition with objective tests (computerized posturography, Mobility Lab device). Improved quality of life outcomes and self-confidence were noted, while subjective measurements of balance had conflicting results. CONCLUSION: Although an improvement in balance in patients with HAs has been shown in certain conditions, the overall benefit is still unclear and it is only possible to speculate that HAs may also improve static, dynamic, or subjective perception of balance function in adults affected by hearing loss.

Timing of Tracheostomy for Prolonged Respiratory Wean in Critically Ill Coronavirus Disease 2019 Patients: A Machine Learning Approach.

OBJECTIVES: To propose the optimal timing to consider tracheostomy insertion for weaning of mechanically ventilated patients recovering from coronavirus disease 2019 pneumonia. We investigated the relationship between duration of mechanical ventilation prior to tracheostomy insertion and in-hospital mortality. In addition, we present a machine learning approach to facilitate decision-making. DESIGN: Prospective cohort study. SETTING: Guy's & St Thomas' Hospital, London, United Kingdom. PATIENTS: Consecutive patients admitted with acute respiratory failure secondary to coronavirus disease 2019 requiring mechanical ventilation between March 3, 2020, and May 5, 2020. INTERVENTIONS: Baseline characteristics and temporal trends in markers of disease severity were prospectively recorded. Tracheostomy was performed for anticipated prolonged ventilatory wean when levels of respiratory support were favorable. Decision tree was constructed using C4.5 algorithm, and its classification performance has been evaluated by a leave-one-out cross-validation technique. MEASUREMENTS AND MAIN RESULTS: One-hundred seventy-six patients required mechanical ventilation for acute respiratory failure, of which 87 patients (49.4%) underwent tracheostomy. We identified that optimal timing for tracheostomy insertion is between day 13 and day 17. Presence of fibrosis on CT scan (odds ratio, 13.26; 95% CI [3.61-48.91]; p ≤ 0.0001) and Pao2:Fio2 ratio (odds ratio, 0.98; 95% CI [0.95-0.99]; p = 0.008) were independently associated with tracheostomy insertion. Cox multiple regression analysis showed that chronic obstructive pulmonary disease (hazard ratio, 6.56; 95% CI [1.04-41.59]; p = 0.046), ischemic heart disease (hazard ratio, 4.62; 95% CI [1.19-17.87]; p = 0.027), positive end-expiratory pressure (hazard ratio, 1.26; 95% CI [1.02-1.57]; p = 0.034), Pao2:Fio2 ratio (hazard ratio, 0.98; 95% CI [0.97-0.99]; p = 0.003), and C-reactive protein (hazard ratio, 1.01; 95% CI [1-1.01]; p = 0.005) were independent late predictors of in-hospital mortality. CONCLUSIONS: We propose that the optimal window for consideration of tracheostomy for ventilatory weaning is between day 13 and 17. Late predictors of mortality may serve as adverse factors when considering tracheostomy, and our decision tree provides a degree of decision support for clinicians.

Defining appropriateness criteria for endoscopic sinus surgery in the management of adult dental implant patients with incidental maxillary sinus findings on conebeam computed tomography.

OBJECTIVES: Conebeam computed tomography (CBCT) imaging is commonly requested by dental implant surgeons, preoperatively, for patients being considered for dental implants. Incidental maxillary sinus findings often result in otolaryngology (ENT) referral for further assessment. CBCT findings include transient and benign mucosal changes that may not require any intervention and therefore unnecessarily delay implant surgery. We aim to define appropriateness criteria for ESS in the management of adult dental implant patients with incidental maxillary sinus findings on CBCT and provide guidance to both dental implant and ENT surgeons. DESIGN: The RAND/UCLA appropriateness methodology was used to develop and define the appropriateness criteria. SETTING: A virtual panel of 13 international experts in ESS. PARTICIPANTS: The expert panel completed two rounds of a modified Delphi ranking process for nine clinical scenarios, considering various factors affecting decision-making processes. MAIN OUTCOME MEASURES: To define appropriateness criteria for ESS in adult dental implant patients who have incidental maxillary sinus findings on CBCT. RESULTS: Patients with clinical symptoms and endoscopic findings of chronic rhinosinusitis together with an obstructed ostiomeatal complex (OMC) and concentric mucosal thickening of the ipsilateral maxillary sinus or pansinusitis were deemed appropriate candidates for ESS prior to their dental implant. ESS was not appropriate in asymptomatic patients with a patent OMC and mucosal thickening isolated to floor of the ipsilateral maxillary sinus. For uncertain scenarios, further discussion between dental implant and ENT surgeon should be considered. CONCLUSIONS: This study has developed and reported a list of appropriateness criteria to offer ESS in adult dental implant patients with incidental maxillary sinus findings on CBCT.

Intracapsular versus extracapsular dissection tonsillectomy for adults: A systematic review.

OBJECTIVES: Tonsillectomy is an extremely common ENT surgical procedure. There is a growing interest in the role of intracapsular dissection tonsillectomy (ICDT) due to reported reduced perioperative complications. We aim to compare the outcomes associated with ICDT versus traditional extracapsular dissection tonsillectomy (ECDT) in the adult population. METHODS: Systematic review of all randomized controlled trials (RCTs) comparing ICDT and ECDT for all indications in the adult population. Electronic searches performed through CENTRAL, PubMed, Ovid EMBASE, Web of Science, ClinicalTrials.gov, and WHO ICTRP. Review Manager 5.3 (RevMan 2014) was used to carry out the meta-analysis. RESULTS: Nine RCTs were included with a total of 11 reports with mean age of 23.9 years including 181 patients who received ICDT compared to 176 patients receiving ECDT. We found statistically significant reduced postoperative pain and analgesia requirement as well as a reduced rate of secondary postoperative bleeding in patients undergoing ICDT versus ECDT. There appears to be no significant difference in controlling recurrent tonsillitis between the ICDT and ECDT groups. CONCLUSION: Across the recorded outcomes we noted no clear benefit to performing ECDT over ICDT and evidence suggests high patient satisfaction with ICDT. Laryngoscope, 130:2325-2335, 2020.

Systematic review of cochlear implantation in CHARGE syndrome.

Objective: CHARGE syndrome presents with a collection of congenital anomalies affecting multiple organs. Ear and temporal bone anomalies, including hearing loss are highly prevalent. We present an aid to management of this challenging condition and report the strategies and outcomes of cochlear implantation. Methods: Systematic review of Medline, EMBASE, Web of Science, CENTRAL and clinicaltrials.gov was performed up to 21/10/2018 The review and meta-analysis of studies were performed according to the PRISMA statement. Patient demographics, comorbidity, anatomical factors, details of cochlear implantation and audiological outcome were extracted and summarized. Anatomical and surgical factors were evaluated by meta-analysis. Audiological outcomes reported were too heterogeneous for meta-analysis. All statistics were calculated with SPSS v23.0 (IBM, New York, USA). Results: Thirty-one studies reported 165 cochlear implants in 156 patients with CHARGE syndrome. Temporal bone and facial nerve anomalies were common. Discussion: The assessment and management of patients with CHARGE syndrome undergoing cochlear implantation is challenging. Outcomes may be affected by cochlear nerve deficiency, inner ear anomalies, and developmental delay. Surgery is almost invariably complicated by abnormal anatomy, and increased incidence of complications. Conclusion: A careful, case-by-case assessment of an individual's requirements within a multi-disciplinary setup is essential for achieving the best possible outcome.

Sleep in elite swimmers: prevalence of sleepiness, obstructive sleep apnoea and poor sleep quality.

OBJECTIVES: Limited data suggest that swimmers might be affected by poor quality of sleep significantly. The aim was to explore the prevalence of sleep disturbances in swimmers and possible link between rhinitis and sleep disturbance. METHODS: Study 1 was an observational case-control, questionnaire-based study involving 157 elite and non-elite swimmers, 36 non-swimming athletes and 50 controls. In study 2, we measured sleep quality and duration using actigraphy in 20 elite swimmers. We also looked for presence of sleep-disordered breathing using overnight pulse oximetry monitor. RESULTS: In study 1, we observed a significant difference in prevalence of excessive daytime sleepiness between groups of elite swimmers and controls. Pittsburgh Sleep Quality Index (PSQI) scores do not suggest that quality of sleep in group of swimmers is impaired. In study 2, we found that prevalence of obstructive sleep apnoea (OSA) in elite swimmers defined as oxygen desaturation index ≥5 was 30%. Analysis of actigraphy data revealed that on nights prior to training days, 'going to' bed time was significantly earlier and total sleep time was significantly reduced. CONCLUSION: Swimmers and non-swimming athletes suffer significantly more with excessive daytime sleepiness than healthy controls. In elite swimmers, this is likely linked to high prevalence of OSA. PSQI scores do not suggest that quality of sleep in group of swimmers is impaired, but actigraphy shows great variations between sleep pattern preceding training and rest day. This seems to be associated with early-morning sessions which can be a disruptive element of weekly sleep patterns.

Assessing Readability and Reliability of Online Patient Information Regarding Vestibular Schwannoma.

HYPOTHESIS: The aim of this study is to objectively assess the quality and readability of websites related to vestibular schwannomas. BACKGROUND: Patients are increasingly seeking information on confirmed or suspected diagnoses through the Internet. Clinicians are often concerned regarding the accuracy, quality, and readability of web-based sites. METHODS: Online information relating to vestibular schwannoma was searched using the three most popular search engines. The terms "acoustic neuroma" and "vestibular schwannoma" were used. The top 50 results from each site were assessed for readability using the Flesch-Kincaid Grade Level, Flesch Reading Ease Score, and the Gunning-Fog Index. Quality of website information was scored using the DISCERN tool. RESULTS: Of 300 search results analyzed, 58 separate appropriate websites were identified. The mean readability score using Flesch-Kincaid Grade Level was 10.27 (95% confidence interval [CI] 9.84-10.70). The mean Flesch Reading Ease Score was 48.75 (95% CI 46.57-50.92). The Gunning-Fog Index was 13.40 (95% CI 12.92-13.89). These scores equate to someone finishing secondary school/first year university student. DISCERN scores were highly variable but consistently demonstrated great variability in quality of information. CONCLUSION: Online patient information on vestibular schwannoma is highly variable in quality. Although there are a wide range of different websites easily available to patients on their condition and its treatment options, the information is written at a difficult level which may exceed the understanding level of many patients as it is written at a higher than average level of expected reading ability.

Subdural Hematoma: A Rare Adverse Complication From Bone-Anchored Hearing Aid Placement.

OBJECTIVE: Bone-anchored hearing aids (BAHA) are bone conduction hearing aids commonly implantated by Ear, Nose, and Throat surgeons. We present the first documented case of a subdural hematoma secondary to primary fixation of a BAHA. PATIENT: We present a 65-year-old male patient undergoing a left sided BAHA for bilateral chronic ear infections and difficulty wearing conventional hearing aids. The procedure was uneventful, however, the patient developed a postoperative large acute left temporoparietal intracerebral hematoma associated with an ipsilateral acute subdural hematoma. This required emergency transfer to the local tertiary neurosurgical center for a left decompressive craniotomy and evacuation of the hematoma. RESULTS: The patient required a prolonged stay on an intensive care unit and was eventually discharged to the community for on-going neurological rehabilitation. CONCLUSION: This is a rare and devastating complication BAHA surgery. Otologist, general ENT surgeons, and neurosurgeons should be aware of this life-threatening complication of BAHA surgery.

Assessment and management of orbital cellulitis.

Orbital cellulitis is a medical emergency requiring multidisciplinary team involvement. Early diagnosis and intervention is imperative to avoid serious complications. This article provides an evidence-based approach to the assessment and management of patients with orbital cellulitis.