Intratympanic corticosteroids for Ménière's disease.

BACKGROUND: Ménière's disease is a condition that causes recurrent episodes of vertigo, associated with hearing loss and tinnitus. Corticosteroids are sometimes administered directly into the middle ear to treat this condition (through the tympanic membrane). The underlying cause of Ménière's disease is unknown, as is the way in which this treatment may work. The efficacy of this intervention in preventing vertigo attacks, and their associated symptoms, is currently unclear. OBJECTIVES: To evaluate the benefits and harms of intratympanic corticosteroids versus placebo or no treatment in people with Ménière's disease. SEARCH METHODS: The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 September 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs in adults with a diagnosis of Ménière's disease comparing intratympanic corticosteroids with either placebo or no treatment. We excluded studies with follow-up of less than three months, or with a cross-over design (unless data from the first phase of the study could be identified).  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) change in hearing, 6) change in tinnitus and 7) other adverse effects (including tympanic membrane perforation). We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included 10 studies with a total of 952 participants. All studies used the corticosteroid dexamethasone, with doses ranging from approximately 2 mg to 12 mg.  Improvement in vertigo Intratympanic corticosteroids may make little or no difference to the number of people who report an improvement in their vertigo at 6 to ≤ 12 months follow-up (intratympanic corticosteroids 96.8%, placebo 96.6%, risk ratio (RR) 1.00, 95% confidence interval (CI) 0.92 to 1.10; 2 studies; 60 participants; low-certainty evidence) or at more than 12 months follow-up (intratympanic corticosteroids 100%, placebo 96.3%; RR 1.03, 95% CI 0.87 to 1.23; 2 studies; 58 participants; low-certainty evidence). However, we note the large improvement in the placebo group for these trials, which causes challenges in interpreting these results.  Change in vertigo Assessed with a global score One study (44 participants) assessed the change in vertigo at 3 to < 6 months using a global score, which considered the frequency, duration and severity of vertigo. This is a single, small study and the certainty of the evidence was very low. We are unable to draw meaningful conclusions from the numerical results. Assessed by frequency of vertigo Three studies (304 participants) assessed the change in frequency of vertigo episodes at 3 to < 6 months. Intratympanic corticosteroids may slightly reduce the frequency of vertigo episodes. The proportion of days affected by vertigo was 0.05 lower (absolute difference -5%) in those receiving intratympanic corticosteroids (95% CI -0.07 to -0.02; 3 studies; 472 participants; low-certainty evidence). This is equivalent to a difference of approximately 1.5 days fewer per month affected by vertigo in the corticosteroid group (with the control group having vertigo on approximately 2.5 to 3.5 days per month at the end of follow-up, and those receiving corticosteroids having vertigo on approximately 1 to 2 days per month). However, this result should be interpreted with caution - we are aware of unpublished data at this time point in which corticosteroids failed to show a benefit over placebo. One study also assessed the change in frequency of vertigo at 6 to ≤ 12 months and > 12 months follow-up. However, this is a single, small study and the certainty of the evidence was very low. Therefore, we are unable to draw meaningful conclusions from the numerical results. Serious adverse events Four studies reported this outcome. There may be little or no effect on the occurrence of serious adverse events with intratympanic corticosteroids, but the evidence is very uncertain (intratympanic corticosteroids 3.0%, placebo 4.4%; RR 0.64, 95% CI 0.22 to 1.85; 4 studies; 500 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: The evidence for intratympanic corticosteroids in the treatment of Ménière's disease is uncertain. There are relatively few published RCTs, which all consider the same type of corticosteroid (dexamethasone). We also have concerns about publication bias in this area, with the identification of two large RCTs that remain unpublished. The evidence comparing intratympanic corticosteroids to placebo or no treatment is therefore all low- or very low-certainty. This means that we have very low confidence that the effects reported are accurate estimates of the true effect of these interventions. Consensus on the appropriate outcomes to measure in studies of Ménière's disease is needed (i.e. a core outcome set) in order to guide future studies in this area, and enable meta-analysis of the results. This must include appropriate consideration of the potential harms of treatment, as well as the benefits. Finally, we would also highlight the responsibility that trialists have to ensure results are available, regardless of the outcome of their study.

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.

Fatal Bacterial Meningitis Possibly Associated with Substandard Ceftriaxone--Uganda, 2013.

The burden of disease from bacterial meningitis is highest in low-income countries (1). Early initiation of antibiotic therapy is important in reducing the risk for mortality. Current treatment guidelines recommend the use of an expanded-spectrum cephalosporin (cefotaxime or ceftriaxone) (2), but these therapies increasingly are limited by drug resistance, and are threatened by the proliferation of substandard and falsified medicines (3,4). In February 2013, a case of bacterial meningitis following a middle ear infection was diagnosed in an adolescent at the Mulago National Referral Hospital in Kampala, Uganda. Once-daily treatment with 2 g of intravenous ceftriaxone administered according to guidelines failed, and the patient died. To determine whether the patient's treatment failure and subsequent death might be related to the ceftriaxone product administered, a sealed vial similar to the one administered to the patient was analyzed at the University of Ottawa, Canada, and was found to contain only 0.455 g of the drug, not 1 g as stated by the manufacturer. This would have resulted in subtherapeutic dosing. Substandard medicines are a global problem that disproportionately affects low-income countries, leading to fatal consequences and promoting the emergence of drug resistance (4).

Time-Driven Activity Based Costing of an Annual Canadian Cochlear Implant Program.

OBJECTIVE: To define the cost necessary to run an adult cochlear implant (CI) program, including assessment, subsequent implantation, and follow from the Canadian provincial government perspective. STUDY DESIGN: Time-driven activity based costing (TDABC) of a CI program. SETTING: Adult provincial CI referral center. METHODS: Clinical scenario pathways were developed and verified with stakeholders. TDABC was then applied to all steps involved in the pathway. Costing was based on all patients referred to the CI program in 2019. All costs were calculated in Canadian (and American) dollars as of 2023. RESULTS: This is the first TDABC model of a CI program to the authors knowledge. In 2019, 296 referrals were placed to our CI program and 154 were surgical candidates. The calculated total annual cost for patients referred in 2019 was $4.542 million ($3.365 million USD), or $29,511 ($21,865 USD) per patient implanted. The largest cost contributors to patient cycles were surgical day costs ($23,164 [$17,185 USD] for unilateral, $43,356 [$32,165 USD] for bilateral), switch-on day costs ($1068 [$791 USD] for unilateral, $1511 [$1120 USD] for bilateral), and audiological assessment costs ($692 [$512 USD]). The highest single cost on the pathway was due to the actual CI device when used. Across other patient steps, the highest costs were related to labor. CONCLUSION: This TDABC evaluation of a CI program found the annual cost required to meet all referrals was $4.542 million ($3.365 million USD), or $29,511 ($21,865 USD) per patient implanted. The highest single-cost was associated with the CI device itself.

IGF-1 Mediated Neuroprotective Effects of Olfactory-Derived Mesenchymal Stem Cells on Auditory Hair Cells.

IMPORTANCE: Mesenchymal stem cells (MSCs) have the capability of providing ongoing paracrine support to degenerating tissues. Since MSCs can be extracted from a broad range of tissues, their specific surface marker profiles and growth factor secretions can be different. We hypothesized that MSCs derived from different sources might also have different neuroprotective potential. OBJECTIVE: In this study, we extracted MSCs from rodent olfactory mucosa and compared their neuroprotective effects on auditory hair cell survival with MSCs extracted from rodent adipose tissue. METHODS: Organ of Corti explants were dissected from 41 cochlea and incubated with olfactory mesenchymal stem cells (OMSCs) and adipose mesenchymal stem cells (AMSCs). After 72 hours, Corti explants were fixed, stained, and hair cells counted. Growth factor concentrations were determined in the supernatant and cell lysate using Enzyme-Linked Immunosorbent Assay (ELISA). RESULTS: Co-culturing of organ of Corti explants with OMSCs resulted in a significant increase in inner and outer hair cell stereocilia survival, compared to control. Comparisons between both stem cell lines, showed that co-culturing with OMSCs resulted in superior inner and outer hair cell stereocilia survival rates over co-culturing with AMSCs. Assessment of growth factor secretions revealed that the OMSCs secrete significant amounts of insulin-like growth factor 1 (IGF-1). Co-culturing OMSCs with organ of Corti explants resulted in a 10-fold increase in IGF-1 level compared to control, and their secretion was 2 to 3 times higher compared to the AMSCs. CONCLUSIONS: This study has shown that OMSCs may mitigate auditory hair cell stereocilia degeneration. Their neuroprotective effects may, at least partially, be ascribed to their enhanced IGF-1 secretory abilities compared to AMSCs.

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.

Content Validity of a High-Fidelity Surgical Middle Ear Simulator: A Randomized Prospective International Multicenter Trial.

OBJECTIVE: After demonstration of face validity of a surgical middle ear simulator (SMS) previously, we assessed the content validity of the simulator with otolaryngology residents. STUDY DESIGN: Multicenter randomized prospective international study. SETTING: Four academic institutions. METHODS: Novice participants were randomized into control, low-fidelity (LF), and high-fidelity (HF) groups. Control and LF produced 2 recordings from 2 attempts, and HF produced 4 recordings from 10 attempts, with trials 1, 4, 7, and 10 used for scoring. Three blinded experts graded videos of the simulated stapedectomy operation using an objective skills assessment test format consisting of global and stapedotomy-specific scales. RESULTS: A total of 152 recordings from 61 participants were included. Baseline characteristics did not differ significantly between groups. Depending on the step of the operation, inter-rater reliability ranged from 24 to 90%. For LF and HF, years of training was significantly associated with improved scores in certain objective skills assessment test subparts. HF outperformed the control group on stapes and global scores ( p < 0.05). The HF group demonstrated improvement in global score over trials, but plateaued after four trials. Scores varied greatly for participants from different institutions in certain operative steps, such as transecting incudostapedial joints, likely due to differences in instrumentation and time elapsed since manufacture. CONCLUSION: Practice with SMS led to better performance in both global and stapes-specific scores. Further studies are needed to examine construct validity and to create otology-appropriate grading systems. Variables like instrumentation and decline in flexibility of the simulator after 12 months greatly affect performance on the simulator.

Intratympanic steroids for Ménière's disease or syndrome.

BACKGROUND: Ménière's disease is a disorder characterised by hearing loss, tinnitus and disabling vertigo. The use of intratympanic steroids to reduce the severity of these symptoms has been gaining popularity. OBJECTIVES: To assess the effectiveness of intratympanic steroids on the frequency and severity of attacks of vertigo, on chronic symptoms such as tinnitus, imbalance and hearing loss, and on the progression of these symptoms in patients with definite Ménière's disease or syndrome, as defined by the AAO-HNS Committee. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 13 January 2011. SELECTION CRITERIA: Randomised controlled trials of intratympanic dexamethasone versus placebo in patients with Ménière's disease. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial risk of bias and extracted data. We contacted study authors for further information where possible. MAIN RESULTS: A single trial containing 22 patients, with a low risk of bias was included. This trial found that after 24 months, compared with placebo, the use of intratympanic dexamethasone demonstrated a statistically significant improvement in vertigo as defined by a respective improvement in functional level (90% versus 42%), class (82% versus 57%), change in Dizziness Handicap Inventory scores (60.4 versus 41.3) and mean vertigo subjective improvement (90% versus 57%). The treatment regime described by the authors involved daily injections of dexamethasone solution 4 mg/ml for five consecutive days. These results were clinically significant. No complications were reported. AUTHORS' CONCLUSIONS: The results of a single trial provide limited evidence to support the effectiveness of intratympanic steroids in patients with Ménière's disease. This trial demonstrated a statistically and clinically significant improvement of the frequency and severity of vertigo measured 24 months after the treatment was administered. It is important to note that there were a few aspects of the study which we were unable to clarify with the study authors.

Use of auditory evoked potentials with electrical stimulation at the round window niche pre-operatively on a brain-injured patient: A case study.

OBJECTIVES: To highlight the effectiveness of using PS testing in conjunction with electrically evoked auditory evoked potentials (eAEPs) to help guide treatment plans in patients with limited behavioural responses. METHODS: Case report on a 59-year-old male with traumatic brain injury. Electrophysiological measurements in conjunction with PS were performed. RESULTS: eAEPs were obtained up to the thalamo-cortical region, supporting the viability of a CI in the non-implanted ear. DISCUSSION & CONCLUSION: Use of PS in conjunction with electrically evoked auditory evoked potentials can provide valuable information to guide clinical decisions regarding implantation.

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.

Wideband reflectance in normal Caucasian and Chinese school-aged children and in children with otitis media with effusion.

OBJECTIVES: Wideband reflectance (WBR) is a middle ear analysis technique that quantifies frequency-specific sound conduction over a wide range of frequencies. One shortcoming of WBR is that there is limited normative data, particularly for pediatric populations and children with middle ear pathology. The goals of this study were to establish normative WBR data for early school-aged children; to determine whether WBR differs significantly between Caucasian and Chinese children, male and female children, and children and adults (experiment 1); and to compare the normative pediatric WBR data with the WBR data obtained from children with abnormal middle ear conditions (experiment 2). DESIGN: WBR was measured from 78 children with normal middle ear status with an average age of 6.15 yrs and 64 children with abnormal middle ear status with an average age of 6.34 yrs. Control group subjects and subjects without previously diagnosed middle ear pathology were recruited from eight elementary schools in the Greater Vancouver Area. Subjects with known middle ear pathology were recruited through the British Columbia Children's Hospital Otolaryngology department. Middle ear effusion (MEE) was identified in one of the two ways. In the British Columbia Children's Hospital group, MEE was diagnosed by a pediatric otolaryngologist (OTL) using pneumatic otoscopy and video otomicroscopy. These cases (21 ears) were classified as OTL confirmed. Subjects who were assessed through screenings at their elementary schools and suspected to have MEE based on audiological test battery results including elevated air conduction thresholds, flat low- and high-frequency tympanograms, and absent transient-evoked otoacoustic emissions were classified as not OTL confirmed (21 ears). Data were statistically analyzed for effects of gender, ethnicity (Caucasian versus Chinese), age (child versus adult), and middle ear condition. WBR equipment used for this study was from Mimosa Acoustics (RMS-system, version 4.03). Data were averaged in one-third octave bands collected from 248 frequencies ranging from 211 to 6000 Hz. RESULTS: Control group subject data (experiment 1) revealed no effects of gender or ear, and their interactions with frequency were not significant. There was a significant interaction between ethnicity (Caucasian versus Chinese) and frequency. Chinese children had lower energy reflectance (ER) values over the mid-frequency range. ER was significantly different between pediatric data and previously collected adult data. Diseased group ER was significantly different among all four middle ear conditions (normal, mild negative middle ear pressure, severe negative middle ear pressure, and MEE) (experiment 2). The overall test performance of ER was objectively evaluated using receiver operating characteristic (ROC) curve analyses; it was compared across frequencies averaged in one-third octave bands. Statistical comparison of the area under ROC (AUROC) plots revealed that ER above 800 Hz (except for ER at 6300 Hz) had better test performance in distinguishing normal middle ear status from MEE compared with ER at 630 and 800 Hz. Although not statistically different from other frequencies between 800 and 5000 Hz, ER at 1250 Hz had the largest AUROC curve (sensitivity of 96% and specificity of 95%) and was selected for further analysis. Comparison of AUROC curves between WBR at 1250 Hz and static admittance at 226-Hz probe tone frequency revealed significantly better test performance for WBR in distinguishing between healthy ears and MEE. CONCLUSIONS: A preliminary set of normative ER data have been generated for a pediatric population between the ages of 5 and 7 yrs, which were significantly different from previously gathered normative adult ER data. In this study, pediatric normative data were warranted for testing children, but ethnic-specific norms were not required to detect middle ear pathology and changes in middle ear status. WBR shows promise as a clinical diagnostic tool for measuring the mechanoacoustic properties of the middle ear and the changes that result in the presence of negative middle ear pressure or MEE.

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.

Differential Recovery in Early- and Late-Onset Delayed Facial Palsy Following Vestibular Schwannoma Resection.

BACKGROUND: Delayed facial palsy (DFP) after resection of vestibular schwannomas (VS) is worsening of facial nerve function after an initially normal postoperative result. OBJECTIVE: To characterize different types of DFP, compare recovery rates, and review of series of outcomes in patients following resection of VS. METHODS: Between 2001 and 2017, 434 patients (51% female) with VS underwent resection. We categorized the patients who developed facial palsy into groups based on timing of onset after surgery, immediate facial palsy (IFP), early-onset DFP (within 48 h), and late-onset DFP (after 48 h). Introduction of facial nerve motor-evoked potentials (fMEP) in 2002 and a change of practice utilizing perioperative minocycline in 2005 allowed for historical analysis of these interventions. RESULTS: Mean age of study cohort was 49.1 yr (range 13-81 yr), with 19.8% developing facial palsy. The late-onset DFP group demonstrated a significantly faster recovery than the early-onset DFP group (2.8 ± 0.5 vs 47 ± 8 wk, P < .0001), had prolonged latency to palsy onset after initiating perioperative minocycline (7.3 vs 12.5 d, P = .001), and had a nonsignificant trend towards faster recovery from facial palsy with use of minocycline (2.6 vs 3.4 wk, P = .11). CONCLUSION: Given the timings, it is likely axonal degeneration is responsible for early-onset DFP, while demyelination and remyelination lead to faster facial nerve recovery in late-onset DFP. Reported anti-apoptotic properties of minocycline could account for the further delay in onset of DFP, and possibly reduce the rate and duration of DFP in the surgical cohort.

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.

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.

American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Foundation Guide to Enhance Otologic and Neurotologic Care During the COVID-19 Pandemic.

: This combined American Neurotology Society, American Otological Society, and American Academy of Otolaryngology - Head and Neck Surgery Foundation document aims to provide guidance during the coronavirus disease of 2019 (COVID-19) on 1) "priority" of care for otologic and neurotologic patients in the office and operating room, and 2) optimal utilization of personal protective equipment. Given the paucity of evidence to inform otologic and neurotologic best practices during COVID-19, the recommendations herein are based on relevant peer-reviewed articles, the Centers for Disease Control and Prevention COVID-19 guidelines, United States and international hospital policies, and expert opinion. The suggestions presented here are not meant to be definitive, and best practices will undoubtedly change with increasing knowledge and high-quality data related to COVID-19. Interpretation of this guidance document is dependent on local factors including prevalence of COVID-19 in the surgeons' local community. This is not intended to set a standard of care, and should not supersede the clinician's best judgement when managing specific clinical concerns and/or regional conditions.Access to otologic and neurotologic care during and after the COVID-19 pandemic is dependent upon adequate protection of physicians, audiologists, and ancillary support staff. Otolaryngologists and associated staff are at high risk for COVID-19 disease transmission based on close contact with mucosal surfaces of the upper aerodigestive tract during diagnostic evaluation and therapeutic procedures. While many otologic and neurotologic conditions are not imminently life threatening, they have a major impact on communication, daily functioning, and quality of life. In addition, progression of disease and delay in treatment can result in cranial nerve deficits, intracranial and life-threatening complications, and/or irreversible consequences. In this regard, many otologic and neurotologic conditions should rightfully be considered "urgent," and almost all require timely attention to permit optimal outcomes. It is reasonable to proceed with otologic and neurotologic clinic visits and operative cases based on input from expert opinion of otologic care providers, clinic/hospital administration, infection prevention and control specialists, and local and state public health leaders. Significant regional variations in COVID-19 prevalence exist; therefore, physicians working with local municipalities are best suited to make determinations on the appropriateness and timing of otologic and neurotologic care.

Holiday review. How random is the toss of a coin?

BACKGROUND: The toss of a coin has been a method used to determine random outcomes for centuries. It is still used in some research studies as a method of randomization, although it has largely been discredited as a valid randomization method. We sought to provide evidence that the toss of a coin can be manipulated. METHODS: We performed a prospective experiment involving otolaryngology residents in Vancouver, Canada. The main outcome was the proportion of "heads" coin tosses achieved (out of 300 attempts) by each participant. Each of the participants attempted to flip the coin so as to achieve a heads result. RESULTS: All participants achieved more heads than tails results, with 7 of the 13 participants having significantly more heads results (p

Energy reflectance and tympanometry in normal and otosclerotic ears.

OBJECTIVE: The major goal of this study was to examine differences in the middle ear mechano-acoustical properties of normal ears and ears with surgically confirmed otosclerosis using conventional and multifrequency tympanometry (MFT) as well as energy reflectance (ER). Second, we sought to compare ER, standard tympanometry, and MFT in their ability to distinguish healthy and otosclerotic ears examining both overall test performance (sensitivity and specificity) and receiver- operating characteristic analyses. DESIGN: Sixty-two normal-hearing adults and 28 patients diagnosed with otosclerosis served as subjects. Tympanometric data were gathered on a clinical immittance machine, the Virtual 310 equipped with a high-frequency option. Two of the parameters, static admittance and tympanometric width, were measured automatically at a standard 226 Hz frequency. The remaining two parameters, resonant frequency and frequency corresponding to admittance phase angle of 45 degree (F45 degrees ), were derived from MFT, multicomponent tympanometry, using a mathematical approach similar to the method used in GSI Tympstar Version 2. ER data were gathered using Mimosa Acoustics (RMS-system v4.0.4.4) equipment. RESULTS: Analyses of receiver-operating characteristic plots confirmed the advantage of MFT measures of resonant frequency and F45 degrees over the standard low-frequency measures of static admittance and tympanometric width with respect to distinguishing otosclerotic ears from normal ears. The F45 degrees measure was also found to be the best single index for making this distinction among tympanometric parameters. ER less than 1 kHz was significantly higher in otosclerotic ears than normal ears. This indicates that most of the incident energy below 1 kHz is reflected back into the ear canal in otosclerotic ears. ER patterns exceeding the 90th percentile of the normal ears across all frequencies correctly identify 82% of the otosclerotic ears while maintaining a low false alarm rate (17.2%); thus, this measure outperforms the other individual tympanometric parameters. Combination of ER and F45 degrees were able to distinguish all otosclerotic ears. Correlations and the individual patterns of test performance revealed that information provided by ER is supplemental to the information provided by conventional and MFT with respect to distinguishing otosclerotic ears from normal ears. CONCLUSION: The present findings show that the overall changes of ER across frequencies can distinguish otosclerotic ears from normal ears and from other sources of conductive hearing loss. Incorporating ER in general practice will improve the identification of otosclerotic ears when conventional tympanometry and MFT may fail to do so. To further improve the false alarm rate, ER should be interpreted in conjunction with other audiologic test batteries because it is unlikely that signs of a conductive component, including abnormal middle ear muscle reflex and ER responses, would be observed in an ear with normal middle ear function.