Impact of Patient Frailty on Speech Recognition and Quality of Life Outcomes in Adult Cochlear Implant Users.

OBJECTIVE: The process of cochlear implantation (CI) and subsequent post-cochlear implant care is extensive and can be difficult to navigate for patients considered medically frail. This study investigates potential impact of patient frailty on speech recognition and quality of life outcomes after CI. STUDY DESIGN: Retrospective review of a prospectively maintained database. SETTING: Tertiary cochlear implant center. PATIENTS: Three hundred seventy adults undergoing CI for traditional bilateral hearing loss indication. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Comparison of pre-CI to 12-month post-CI change in consonant-nucleus-consonant phoneme/words, AzBio sentences in quiet/+10SNR, and Cochlear Implant Quality of Life (CIQOL)-35 Profile domain and global scores based on degree of patient frailty as assessed using the five-factor modified frailty index and Charlson Comorbidity Index. RESULTS: The average age at implantation was 65.4 years (±SD, 15.7; 19-94 years). Overall, there were minimal to absent and nonsignificant differences in speech recognition outcomes (consonant-nucleus-consonant phoneme/words, and AzBio sentences +10SNR) based on pre-CI patient frailty. The exception was less improvement in AzBio quiet sentence score in patients noted to be severely frail based on Charlson Comorbidity Index (57.1% vs. 35.2%, d = 0.7 [0.3, 1]). Similar findings were observed for CIQOL-35 Profile domain and global scores where no associations were found other than decreased improvement in the social domain in patients noted to be severely frail (21.7 vs. -0.3, d = 1 [0.4, 1.7]). CONCLUSIONS: Although some differences in outcomes were noted based on cochlear implant user frailty, these were small and isolated to only a few outcome measures. Therefore, assuming the patient is medically safe for surgery, preoperative frailty should not dissuade clinicians from recommending CI.

Pathogenesis and Etiology of Ménière Disease: A Scoping Review of a Century of Evidence.

IMPORTANCE: Ménière disease is a rare chronic benign disorder of the inner ear with a natural history of multiple clinical phenotypes of variable severity and a tendency to burnout with time. Although multiple treatment modalities have been shown to improve the disease process-some adversely affecting cochleovestibular function-it remains uncertain whether one, several separate, or a combination of pathophysiologic mechanisms affect the disease process. A scoping review of the evidence underlying proposed pathophysiologic mechanisms of Ménière disease is needed to determine which processes are most likely to be etiopathogenic factors. OBSERVATIONS: Of the 4602 relevant articles found through Embase, Ovid, and PubMed, 444 met inclusion criteria. The most common reported causes of Ménière disease were autoimmune or immune-mediated, genetic, or structural dysfunction of the inner ear. During the study period from inception to March 2021, etiologic theories shifted from structural dysfunction to autoimmune and genetic causes of Ménière disease. CONCLUSIONS AND RELEVANCE: This scoping review found that Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years whose most commonly reported causes were structural dysfunction, immunologic damage, and genetic susceptibility. Recent studies have examined how autoinflammatory processes and vestibular migraine may be associated with Ménière disease. Large heterogeneity among studies may be explained by historical differences in the clinical understanding of the disease, as well as evolving intervention methodologies and practitioner expertise. Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years; therefore, future studies of reliable biomarkers of endolymphatic hydrops and real-time imaging are warranted to improve understanding and treatment.

Impact of Treatment for Nasal Cavity Disorders on Sleep Quality: Systematic Review and Meta-analysis.

OBJECTIVE: To determine the impact of treatment for patients with nasal obstruction secondary to allergic rhinitis (AR) and nasal septal deviation (NSD) on sleep quality. DATA SOURCES: Primary studies were identified though PubMed, Scopus, Cochrane Library, and Web of Science. REVIEW METHODS: A systematic review was performed by querying databases for articles published through August 2020. Studies were included that reported on objective sleep parameters (apnea-hypopnea index) and sinonasal and sleep-specific patient-reported outcome measures: Rhinoconjunctivitis Quality of Life Questionnaire, Nasal Obstruction Symptom Evaluation, Epworth Sleepiness Scale (EpSS), and Pittsburgh Sleep Quality Index (PSQI). RESULTS: The database search yielded 1414 unique articles, of which 28 AR and 7 NSD studies were utilized for meta-analysis. A total of 9037 patients (8515 with AR, 522 with NSD) were identified with a mean age of 35.0 years (35.3 for AR, 34.0 for NSD). Treatment for AR and NSD significantly improved subjective sleep quality. For AR, the EpSS mean difference was -1.5 (95% CI, -2.4 to -0.5; P = .002) and for the PSQI, -1.7 (95% CI, -2.1 to -1.2; P < .00001). For NSD, the EpSS mean difference was -3.2 (95% CI, -4.2 to -2.2; P < .00001) and for the PSQI, -3.4 (95% CI, -6.1 to -0.6; P = .02). CONCLUSION: Subjective sleep quality significantly improved following treatment for AR and NSD. There were insufficient data to demonstrate that objective metrics of sleep quality similarly improved.

Laryngeal Electromyographic Findings in a Cohort of Recalcitrant Chronic Neurogenic Cough Patients.

OBJECTIVES: To evaluate the laryngeal electromyography findings of bilateral thyroarytenoid muscles in 10 patients with chronic, intractable coughing. METHODS: This is a retrospective cohort case series. Clinical records were reviewed for demographic information, symptoms, and findings on bilateral laryngeal EMG for 10 patients referred for chronic coughing. RESULTS: All thyroarytenoid muscles tested demonstrated electromyographic evidence of neuropathy, with signs of denervation and reinnervation. There was reduced recruitment in all 20 thyroarytenoid muscles studied. In addition, polyphasic motor units were seen in all thyroarytenoid muscles, with increased amplitude in 18 of 20 thyroarytenoid muscles and increased duration in 17 of 20 thyroarytenoid muscles. Additionally, there was electromyographic evidence of synkinesis in 19 of 20 thyroarytenoid muscles studied, a sign of aberrant reinnervation. CONCLUSION: Patients with intractable coughing, despite numerous modalities of treatment, potentially have bilateral neuropathy of the recurrent laryngeal nerves suggesting the potential peripheral as well as central neuropathic changes as the etiology.

A Trigger Reduction Approach to Treatment of Paradoxical Vocal Fold Motion Disorder in the Pediatric Population.

OBJECTIVES: Paradoxical vocal fold motion disorder (PVFMD), or induced laryngeal obstruction (ILO), is a clinical phenomenon characterized by inappropriate adduction of the true vocal folds during inspiration. The resultant episodes of acute respiratory distress marked by exercise-induced cough, inspiratory stridor, throat tightness, and shortness of breath are often misattributed to asthma despite normal pulmonary function testing results. Although the pathogenesis of the disease remains unclear, the etiology is likely multifactorial with an inflammatory, neurological, and psychiatric basis. Our trigger reduction approach, consisting of a plant-based, Mediterranean-style diet to treat laryngopharyngeal reflux and sinus toilet, aims to dampen the peripheral neuronal hyperexcitability of the laryngopharyngeal tissues that is hypothesized to contribute to this disorder. The primary objective of the present study was to assess for therapeutic efficacy by analyzing pre- and post-treatment subjective scores using four validated indices: Voice Handicap Index (VHI), Reflux Symptom Index (RSI), Dyspnea Index (DI), and Cough Severity Index (CSI). METHODS: A retrospective chart review of all patients age ≤18 years seen by the senior author between 2012 and 2018 who reported laryngeal spasm (J35.5) as a presenting complaint with no underlying organic diagnosis that otherwise explained the symptom identified the study cohort. Patients were excluded if another cause of their laryngeal spasm was identified or their medical records were incomplete. RESULTS: Of 80 patients, 24 met the criteria. The most frequent presenting symptom was exercise-induced dyspnea (79%). Of the four measured indices, only a change in DI (P = 0.024) met statistical significance. Of 24 patients, 18 (75%) demonstrated a reduction in DI following our treatment protocol. Using reduction in DI as a continuous variable to assess response, the patient cohort experienced a 4.62 (95% confidence interval [CI]: 0.65-8.6) mean point reduction. Using the eight-point reduction (improvement) in DI as an accepted clinical response to treatment, 8 of 24 patients (33%) experienced a clinically relevant response. Changes in CSI (P = 0.059), RSI (P = 0.27), and VHI (P = 0.25) did not meet statistical significance. Of 24 patients, 8 (33%), 11 (46%), and 7 (29%) demonstrated a reduction in CSI, RSI, and VHI following our trigger reduction protocol, respectively. The patient cohort experienced a mean point reduction of 1.8 (95% CI: -0.1 to 3.7), 1.3 (95% CI: -1.1 to 3.7), and 1.3 (95% CI: -1.0 to 3.6) in CSI, RSI, and VHI, respectively. CONCLUSIONS: Paradoxical vocal fold motion disorder is a multifactorial disease that poses diagnostic and therapeutic challenges. Early diagnosis and treatment are critical to ensure patient safety, satisfaction, and reduction in health care costs, as mistreatment with asthma pharmacotherapy, intubation, or tracheostomy may exacerbate their dyspnea and lead to preventable hospitalizations. Our results demonstrate that a trigger reduction approach consisting of a plant-based, Mediterranean-style diet and sinus toilet alone may not achieve a clinically meaningful response in the majority of patients. However, given their favorable safety profile, our therapeutic regimen, along with respiratory retraining therapy, may provide symptom relief for selected patients who would otherwise continue to suffer.

Characterization of dysphagia following anterior cervical spine surgery.

BACKGROUND: Post-operative dysphagia is one of the most common complications of anterior cervical spine surgery (ACSS). OBJECTIVE: Examine post-operative structural and physiologic swallowing changes in patients with dysphagia following ACSS as compared with healthy age and gender matched controls. METHODS: Videofluoroscopic swallow studies of adults with dysphagia after ACSS were retrospectively reviewed. Seventy-five patients were divided into early (≤2 months) and late (> 2 months) post-surgical groups. Modified Barium Swallow Impairment Profile (MBSImP), Penetration-Aspiration Scale (PAS) scores, and pharyngeal wall thickness (PWT) metrics were compared. RESULTS: Significant differences were identified for all parameters between the control and early post-operative group. MBSImP Pharyngeal Total (PT) scores were greater in the early group (Interquartile Range (IQR) = 9-14, median = 12) versus controls (4-7, 5, P < 0.001) and late group (0.75-7.25, 2, P < 0.001). The early group had significantly higher maximum PAS scores (IQR = 3-8, median = 7) than both the control group (1-2, 1, P < 0.001) and late post-operative group (1-1.25, 1, P < 0.001). PWT was significantly greater in the early (IQR = 11.12-17.33 mm, median = 14.32 mm) and late groups (5.31-13.01, 9.15 mm) than controls (3.81-5.41, 4.68 mm, P < 0.001). CONCLUSION: Dysphagic complaints can persist more than two months following ACSS, but often do not correlate with validated physiologic swallowing dysfunction on VFSS. Future studies should focus on applications of newer technology to elucidate relevant deficits.