Association between Cannabis Use and Tinnitus in US Adults.

OBJECTIVE: Assess the association between cannabis use and tinnitus in a nationally representative sample of US adults. STUDY DESIGN: Cross-sectional. SETTING: Population-based. PATIENTS: Adults aged 20 to 59 years who participated in 2011 to 2012 and 2015 to 2016 National Health and Nutrition Examination Survey (NHANES) with available data on tinnitus, audiometry, and substance use. INTERVENTION: None. MAIN OUTCOME MEASURE: Tinnitus, demographic information, and medical history were obtained from NHANES questionnaires. Tinnitus was defined as bothersome tinnitus in the past year. Cannabis use was categorized as never use, low-volume use (1-2 pipes/joints per day), and high-volume use (3+ pipes/joints per day). Multivariable regression models with interaction and mediation analyses were conducted. Sampling weights were incorporated to yield results generalizable to the US population. RESULTS: Tinnitus prevalence was significantly higher among high-volume cannabis users (odds ratio [OR], 20.5%; 95% confidence interval [CI], 16.0-26.0%]) and low-volume users (OR, 17.0%; 95% CI, 14.3-20.0%) than nonusers (OR, 12.0%; 95% CI, 10.4-13.9%). High-volume cannabis use was significantly associated with tinnitus relative to nonusers in multivariable models adjusting for demographics, cardiovascular factors, hearing loss, noise exposure, and depression (OR, 2.05; 95% CI, 1.1-3.9). Tinnitus severity was comparable among high volume, low volume, and noncannabis users. There was no significant mediation or interaction of depression affecting the association between cannabis use and tinnitus. CONCLUSIONS: Bothersome tinnitus prevalence was significantly higher among cannabis users relative to nonusers. High-volume cannabis use was independently associated with tinnitus in a multivariable model accounting for relevant factors including depression. Future study is warranted to elucidate the impact of various levels of cannabis use on tinnitus.

Physician satisfaction with telemedicine and in-person visits in otolaryngology.

OBJECTIVES: To investigate the differential factors associated with physician satisfaction between telemedicine and in-person visits in otolaryngology. METHODS: Study data included 646 telemedicine and 365 in-person encounters delivered from May-June 2020 at a tertiary center outpatient setting. Encounter-specific physician satisfaction was rated by 15 otolaryngologists using Provider Satisfaction Questionnaire (range 0-100) consisted of 5 items (patient needs addressed, patient involvement, adequacy of information given, quality of emotion support provided, and general interaction satisfaction). A multivariable linear mixed-effects model was used to explore patient demographic and clinical factors associated with physician satisfaction. RESULTS: Physician satisfaction scores for telemedicine and in-person visits were 83.0 [95 % CI: 77.0-88.9] and 88.1 [95 % CI: 82.5-93.6], respectively. Among telemedicine visits, physician satisfaction scores were significantly higher for follow-up (vs. new), videoconference (vs. telephone) encounters, and English-speaking patients in a multivariable model. New encounters had significantly lower satisfaction subdomain scores for adequacy of information given to the patient (ß = -4.7 [95 % CI: -7.3 to -2.0], p = 0.001) and addressing the needs of the patient among telemedicine visits (ß = -4.1, [95 % CI: -7.1 to -1.1], p = 0.007) while there were no differences in satisfaction scores between new vs follow-up visits among in-person visits. For non-English speaking patients, the physician satisfaction scores were significantly lower for subdomain scores assessing active patient participation (ß = -13.1, [95 % CI: -13.1 to -17.4], p < 0.001) and emotional support given to the patient (ß = -7.8, [95 % CI: -11.0 to -4.5], p < 0.001) for telemedicine visits. CONCLUSIONS: Telemedicine has been broadly adopted as an alternative option to deliver care in otolaryngology since COVID-19 pandemic. Appropriate triaging based on patient and encounter characteristics may enhance physician satisfaction and overall experiences with telemedicine. Further efforts are needed to provide adequate interpretation and videoconference services during telemedicine visits.

Congenital duplicated incus in the mastoid cavity.

Many congenital ossicular chain malformations exist, usually involving ossicular deformities, fixation, absence, or discontinuity. Duplication of ossicles has not been reported, much less a duplicated ossicle located in the mastoid. We present a case of a patient who had a duplicated incus in the mastoid antrum.

An Exploration of Online Support Community Participation Among Patients With Vestibular Disorders.

OBJECTIVES/HYPOTHESIS: To formally document online support community (OSC) use among patients with vestibular symptoms and gain an appreciation for the perceived influence of participation on psychosocial outcomes and the impact on medical decision-making. STUDY DESIGN: Self reported internet-based questionnaire. METHODS: The Facebook search function was paired with a comprehensive list of vestibular diagnoses to systematically collect publicly available information on vestibular OSCs. Next, a survey was designed to gather clinicodemographic information, OSC characteristics, participation measures, perceived outcomes, and influence on medical decision-making. The anonymous instrument was posted to two OSCs that provide support for patients with general vestibular symptoms. RESULTS: Seventy-three OSCs were identified with >250,000 cumulative members and >10,000 posts per month. The survey was completed by 549 participants, a cohort of primarily educated middle-aged (median = 50, interquartile range 40-60), non-Hispanic white (84%), and female (89%) participants. The participants' most cited initial motivation and achieved goal of participants was to hear from others with the same diagnosis (89% and 88%, respectively). Daily users and those who reported seeing ≥5 providers before receiving a diagnosis indicated that OSC utilization significantly influenced their requested medical treatments (72% daily vs. 61% nondaily, P = .012; 61% <5 providers vs. 71% ≥5 providers P = .019, respectively). Most participants agreed that OSC engagement provides emotional support (74%) and helps to develop coping strategies (68%). Membership of ≥1 year was associated with a higher rate of learned coping skills (61% membership <1-year vs. 71% ≥1-year P = .016). CONCLUSIONS: The use of OSCs is widespread among vestibular diagnoses. A survey of two OSCs suggests these groups provide a significant source of peer support and can influence users' ability to interface with the medical system. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1835-1842, 2022.

Prevalence of Tinnitus and Associated Factors Among Asian Americans: Results From a National Sample.

OBJECTIVES: A previous study demonstrated low rates of high-frequency hearing loss and noise exposure among Asian Americans (AAs). This study examined the prevalence of tinnitus and associated factors among AAs using the first nationally representative sample of AAs. STUDY DESIGN: Cross-sectional analysis of a national health survey. METHODS: We analyzed data from the 2011 to 2012 National Health and Nutritional Examination Survey, during which 3,669 participants aged 20 to 69 years completed questionnaires on tinnitus (AA participants, n = 530). Tinnitus was defined as bothersome ringing lasting 5 minutes or more in the past 12 months. Prevalence of any tinnitus in the past 12 months was calculated incorporating sampling weights. Logistic regression was used to examine the associations with relevant factors. RESULTS: The prevalence of any tinnitus was 6.6% (95% confidence interval [CI]: 4.5-8.6) among AAs, significantly lower than the prevalence among the overall population at 16.5% (95% CI: 14.3-18.8]. After adjusting for audiometric hearing loss and demographics, AAs were less likely to report any tinnitus than whites (odds ratio [OR] = 0.43 [95% CI: 0.24-0.75]), blacks (OR = 0.60 [95% CI: 0.37-0.95]), and Hispanics (OR = 0.60 [95% CI: 0.45-0.78]). Rates of tinnitus were not different from whites or blacks once comorbidities, noise exposure, and depression were taken into account. Among AAs, reporting exposure to work-related noise (OR = 2.92 [95% CI: 1.15-7.41]) and having a major depressive disorder (OR = 6.45 [95% CI: 1.15-36.12]) were significant factors associated with tinnitus in a multivariate model. CONCLUSIONS: The prevalence of tinnitus is significantly lower among AAs in comparison to other racial groups. Noise exposure and depression were significant factors associated with tinnitus among AAs. LEVEL OF EVIDENCE: 2b Laryngoscope, 2020.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) Executive Summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the "Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)." To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed emphasize diagnostic accuracy and efficiency, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing, and increasing the appropriate therapeutic repositioning maneuvers. An updated guideline is needed due to new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).

Objective This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV. Purpose The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV. Action Statements The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

Comparison of the gaze stabilization test and the dynamic visual acuity test in unilateral vestibular loss patients and controls.

OBJECTIVE: Compare the dynamic visual acuity test (DVAT) and gaze stabilization test (GST) in patients with unilateral vestibular loss (UVL) and healthy control subjects using a novel computerized testing system prototype. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary academic referral laboratory. PATIENTS: Seventeen UVL patients (median age 62 yr) with bithermal caloric asymmetry (≥49%) or ablative surgery and 17 control subjects (median age 57 yr). INTERVENTION(S): Diagnostic. MAIN OUTCOME MEASURE(S): Comparison of DVAT and GST results during self-generated sinusoidal head movements using transient unpredictable target presentations less than 95 milliseconds in duration. RESULTS: UVL patients had significantly higher DVAT scores toward the lesioned side compared with controls (p = 0.001) and the non-lesioned side (p = 0.003), but the non-lesioned side was not significantly different from controls (p = 0.157). When comparing GST scores, UVL patients required a slower head velocity to maintain visual acuity with movement toward the lesioned side compared with controls (p < 0.001) and the non-lesioned side (p = 0.004). In addition, UVL patients had significantly lower scores toward the non-lesioned side (p = 0.002) compared to controls. ROC curve analysis identified optimal thresholds for abnormal test results to discriminate the lesioned side from controls. A DVAT score greater than or equal to 0.3 ΔlogMAR provided 65% sensitivity and 88% specificity while a GST score less than or equal to 95 degrees/s provided 71% sensitivity and 100% specificity. When GST results were normal, adding DVAT increased overall sensitivity to 88% with 88% specificity. CONCLUSIONS: Both GST and DVAT demonstrated reduced gaze stabilization toward the lesioned side in the patient group compared with normal controls. Performing GST first and utilizing DVAT when GST was normal provides optimal identification of patients with vestibular dysfunction.

An open label study to evaluate the safety and efficacy of intratympanic golimumab therapy in patients with autoimmune inner ear disease.

OBJECTIVE: To evaluate the safety and efficacy of intratympanically injected golimumab (GLM), a TNF-α inhibitor, as a steroid-sparing agent for patients with steroid-dependent autoimmune inner ear disease (AIED). STUDY DESIGN: Open label. SETTING: Tertiary referral center. PATIENTS: Ten patients with steroid-dependent AIED were enrolled in Stage 2. The average patient age at enrollment was 59, with an average of 12.5 years from the start of bilateral hearing loss symptoms. The average dose of daily prednisone at the start of injections was 18 mg. INTERVENTION: Intratympanic injection of GLM. MAIN OUTCOME MEASURE: Hearing loss progression (treatment failure) was defined as either an increase in pure-tone thresholds by frequency or a decrease in word recognition score. RESULTS: There were no serious adverse events. Five of seven per-protocol subjects experienced stable pure-tone thresholds in the injected ear, whereas 4 had stable word recognition scores. Two subjects experienced an improvement in word recognition scores. The results support the hypothesis that GLM may be a promising treatment. CONCLUSIONS: The TNF-α inhibitor GLM stabilized hearing in 3 of 7 per-protocol subjects with AIED and allowed a complete tapering off of prednisone in those 7 subjects. Studies with larger samples sizes are warranted.

The transcriptome of utricle hair cell regeneration in the avian inner ear.

Sensory hair cell loss is the major cause of hearing and balance disorders. Mammals are incapable of sustained hair cell regeneration, but lower vertebrates can regenerate these mechano-electrical transducers. We present the first comprehensive transcriptome (by mRNA-Seq) of hair cell regeneration in the chick utricle. We provide pathway and pattern annotations and correlate these with the phenotypic events that occur during regeneration. These patterns are surprisingly synchronous and highly punctuated. We show how these patterns are a new resource for identifying components of the hair cell transcriptome and identify 494 new putative hair-cell-specific genes and validate three of these (of three tested) by immunohistochemical staining. We describe many surprising new components and dynamic expression patterns, particularly within NOTCH signaling. For example, we show that HES7 is specifically expressed during utricle hair cell regeneration and closely parallels the expression of HES5. Likewise, the expression of ATOH1 is closely correlated with HEYL and the HLH inhibitory transcription factors ID1, ID2, and ID4. We investigate the correlation between fibroblast growth factor signaling and supporting cell proliferation and show that FGF20 inhibits supporting cell proliferation. We also present an analysis of 212 differentially expressed transcription factor genes in the regenerative time course that fall into nine distinct gene expression patterns, many of which correlate with phenotypic events during regeneration and represent attractive candidates for future analysis and manipulation of the regenerative program in sensory epithelia and other vertebrate neuroepithelia.

Translabyrinthine resection of neurofibromatosis type 2 associated vestibular and facial schwannomas, repair of facial nerve, and placement of auditory brainstem implant.

We present video of gross-total resection of a large cerebellopontine angle tumor consisting of both vestibular and facial schwannoma components via the translabyrinthine route in a patient with neurofibromatosis type 2. The facial nerve is reconstructed using a greater auricular nerve graft, and an auditory brainstem implant is placed. Prior to surgery the patient had no facial nerve function on the operative side and had lost useful hearing. He also had usable vision only on the ipsilateral side and had contralateral vocal cord paralysis. The video can be found here: http://youtu.be/IOkEND-0vhI .

Practical guide to understanding multivariable analyses, Part B: conjunctive consolidation.

Conjunctive consolidation, one method of multivariable analysis by arranging data into clusters, is intuitive and transparent. An unexpected consequence in writing this article was the discovery of just how useful it is in critically analyzing articles and in designing new projects. It has stimulated a fresh understanding as to the value of multivariable thinking in all clinical research. This article is organized into the sequential steps for performing conjunctive consolidation for critically analyzing an article of interest and for completing the process, pending all required data are available. Investigators, particularly those who perform clinical research, should consider conjunctive consolidation as a valuable method of multivariable analysis with which to report data.

Practical guide to understanding multivariable analyses: Part A.

Multivariable analyses are complex statistical methods to evaluate the impact of multiple variables on outcomes of interest. Books have been written on each of these methods detailing the mathematical and statistical objectives and processes. However, we have found very little in the way of brief reports that help the nonstatistically trained physician obtain a basic understanding of multivariable analyses in order to have some understanding of the increasing literature using these methods. This work is organized in 2 parts. This article, Part A, addresses the "big 4" algebraic methods of multivariable analysis. The primary focus of Part A is to present a brief "primer" to help the reader understand the methods and uses; it expressly avoids the many details of statistical assumptions, calculations, and myriad branching alternatives. Part B will concentrate on conjunctive consolidation and will focus on enough information to allow the interested reader to actually perform the analysis. For the statistical scholar, we have included references to several voluminous serious works.

Practical guide to choosing an appropriate data display.

The primary objective of graphing research data is to communicate key information visually in a rapid, accurate, and concise way. Graphs might be considered visual take-home lessons of the major point(s) of the manuscript. In choosing a graph, it is tempting to concentrate only on ways of illustrating summary statements characterizing the group(s). However, individual patients are unique, and their characteristics or outcomes may not be predicted by a group summary. Consequently, if possible, graphs should demonstrate individual responses as well as group summaries. "Graphical literacy," "graphical excellence," and "graphical acumen" are achievable with work and collaboration. To produce a well-designed graph, a combination of by-subject detail and overall results should be the goal within the same illustration. The practice gap addressed in this article is that little attention from authors, reviewers, editors, and publishers seems to be paid to graphical literacy. The purpose of this article is to present some practical guidelines for choosing or evaluating more appropriate data displays.

A practical guide to surveys and questionnaires.

Surveys with questionnaires play a vital role in decision and policy making in society. Within medicine, including otolaryngology, surveys with questionnaires may be the only method for gathering data on rare or unusual events. In addition, questionnaires can be developed and validated to be used as outcome measures in clinical trials and other clinical research architecture. Consequently, it is fundamentally important that such tools be properly developed and validated. Just asking questions that have not gone through rigorous design and development may be misleading and unfair at best; at worst, they can result in under- or overtreatment and unnecessary expense. Furthermore, it is important that consumers of the data produced by these instruments understand the principles of questionnaire design to interpret results in an optimal and meaningful way. This article presents a practical guide for understanding the methodologies of survey and questionnaire design, including the concepts of validity and reliability, how surveys are administered and implemented, and, finally, biases and pitfalls of surveys.

A practical guide to understanding Kaplan-Meier curves.

In 1958, Edward L. Kaplan and Paul Meier collaborated to publish a seminal paper on how to deal with incomplete observations. Subsequently, the Kaplan-Meier curves and estimates of survival data have become a familiar way of dealing with differing survival times (times-to-event), especially when not all the subjects continue in the study. "Survival" times need not relate to actual survival with death being the event; the "event" may be any event of interest. Kaplan-Meier analyses are also used in nonmedical disciplines. The purpose of this article is to explain how Kaplan-Meier curves are generated and analyzed. Throughout this article, we will discuss Kaplan-Meier estimates in the context of "survival" before the event of interest. Two small groups of hypothetical data are used as examples in order for the reader to clearly see how the process works. These examples also illustrate the crucially important point that comparative analysis depends upon the whole curve and not upon isolated points.

A practical guide to understanding systematic reviews and meta-analyses.

A systematic review is a transparent and unbiased review of available information. The published systematic review must report the details of the conduct of the review as one might report the details of a primary research project. A meta-analysis is a powerful and rigorous statistical approach to synthesize data from multiple studies, preferably obtained from a systematic review, in order to enlarge the sample size from smaller studies to test the original hypothesis and/or to generate new ones. The objective of this article is to serve as an easy to read practical guide to understand systematic reviews and meta-analyses for those reading them and for those who might plan to prepare them.

A practical guide for understanding confidence intervals and P values.

The 95 percent confidence interval about the mean demarcates the range of values in which the mean would fall if many samples from the universal parent population were taken. In other words, if the same observation, experiment, or trial were done over and over with a different sample of subjects, but with the same characteristics as the original sample, 95 percent of the means from those repeated measures would fall within this range. This gives a measure of how confident we are in the original mean. It tells us not only whether the results are statistically significant because the CI falls totally on one side or the other of the no difference marker (0 if continuous variables; 1 if proportions), but also the actual values so that we might determine if the data seem clinically important. In contrast, the P value tells us only whether the results are statistically significant, without translating that information into values relative to the variable that was measured. Consequently, the CI is a better choice to describe the results of observations, experiments, or trials.