Laser-Assisted Control of Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Systematic Review.

BACKGROUND AND OBJECTIVES: Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, causes recurrent mucous membrane hemorrhage, especially epistaxis. In this systematic review, we discuss the efficacies of the three most common laser photocoagulation treatments for HHT-related epistaxis. STUDY DESIGN/MATERIALS AND METHODS: A systematic literature search was conducted in PubMed and MEDLINE from database inception to March 2019. Studies reporting epistaxis outcomes following argon, neodymium-doped yttrium aluminum garnet (Nd:YAG), and diode laser photocoagulation for HHT were included. χ2 and Barnard's exact tests were utilized to detect differences in reduced epistaxis frequency and intensity rates. RESULTS: Fifteen out of 157 published studies met our eligibility criteria, spanning a collective 362 patients. Argon, Nd:YAG, and diode laser therapy reduced epistaxis frequency in 90.4%, 88.9%, and 71.1% of patients, respectively, and reduced epistaxis intensity in 87.8%, 87.2%, and 71.1% of patients, respectively. Diode laser photocoagulation significantly underperformed in both outcome measurements when compared with argon (frequency: P = 0.005; intensity: P = 0.034) and Nd:YAG (frequency: P = 0.012; intensity: P = 0.041). There was no significant difference between argon and Nd:YAG in reducing HHT epistaxis frequency (P = 0.434) or intensity (P = 0.969). Categorizing HHT patients by clinical severity demonstrated a higher rate of improvement in the mild-moderate group compared with the severe group in both argon (P < 0.001) and Nd:YAG (P < 0.001) therapeutic methods. While no significant differences were found in rates of improved epistaxis outcomes between argon and Nd:YAG in mild-moderate HHT patients (frequency: P = 0.061; intensity: P = 0.061), Nd:YAG demonstrated greater rates of reduction in epistaxis frequency (P = 0.040) and intensity (P = 0.028) than argon among severe HHT patients. CONCLUSIONS: HHT is a lifelong disease, plaguing patients with debilitating epistaxis. Intranasal laser photocoagulation of telangiectasias using argon or Nd:YAG laser therapy can yield improved epistaxis outcomes compared with diode laser photocoagulation. In severe cases of HHT, Nd:YAG laser therapy provides greater improvements in epistaxis outcomes than argon photocoagulation. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Visual consequences of electronic reader use: a pilot study.

BACKGROUND: With the increasing prevalence of electronic readers (e-readers) for vocational and professional uses, it is important to discover if there are visual consequences in the use of these products. There are no studies in the literature quantifying the incidence or severity of eyestrain, nor are there clinical characteristics that may predispose to these symptoms with e-reader use. PURPOSE: The primary objective of this pilot study was to assess the degree of eyestrain associated with e-reader use compared to traditional paper format. The secondary outcomes of this study were to assess the rate of eyestrain associated with e-reader use and identify any clinical characteristics that may be associated with the development of eyestrain. METHODS: Forty-four students were randomly assigned to study (e-reader iPAD) and control (print) groups. Participant posture, luminosity of the room, and reading distance from reading device were measured during a 1-h session for both groups. At the end of the session, questionnaires were administered to determine symptoms. RESULTS: Significantly higher rates of eyestrain (p = 0.008) and irritation (p = 0.011) were found among the iPAD study group as compared to the print 'control' group. The study group was also 4.9 times more likely to report severe eyestrain (95 % CI [1.4, 16.9]). No clinical characteristics predisposing to eyestrain could be identified. CONCLUSIONS: These findings conclude that reading on e-readers may induce increased levels of irritation and eyestrain. Predisposing factors, etiology, and potential remedial interventions remain to be determined.

False-Positive Cholesteatomas on Non-Echoplanar Diffusion-Weighted Magnetic Resonance Imaging.

OBJECTIVES: To investigate false-positive findings on non-echoplanar (non-EPI) diffusion-weighted magnetic resonance imaging (DWI) in patients under surveillance post-cholesteatoma surgery. STUDY DESIGN, SETTING, SUBJECTS, AND METHODS: A retrospective review was performed on patients diagnosed with cholesteatoma who underwent surgical resection and were then followed by serial non-EPI DWI using half-Fourier acquisition single-shot turbo spin echo (HASTE) sequence. All patients had at least two annual follow-up imaging studies. RESULTS: False-positive findings were identified in four patients. The size of the suspected lesions was 4 to 12 mm. Otoendoscopy was used during all primary cases and Argon laser was used in one case. In all cases, the entire cholesteatoma was removed, and no residual disease was detected at the end of the procedures. One patient underwent revision surgery but only cartilage graft was found in the area of concern. All patients had stable or resolved hyperintense areas in the subsequent HASTE sequences. CONCLUSION: False positive findings can occur with non-EPI DWI MRI and patients need to be counseled accordingly before revision surgery. Decreasing intensity and dimension of a suspected lesion and a positive finding in an area other than the location of the initial cholesteatoma may favor a false positive. If a false positive finding is suspected when the surgeon is confident of complete resection of the cholesteatoma, an MRI can be repeated in 6 to 12 months to assess changes in the dimension and intensity of the area of concern. Cartilage grafts may cause restricted diffusion on DWI sequences.

Risk Recall of Complications Associated with Vestibular Schwannoma Treatment.

OBJECTIVE: To assess the risk recall of complications among patients who underwent different vestibular schwannoma (VS) treatments. STUDY DESIGN: Patients with VS completed a voluntary and anonymous survey. SETTING: Survey links were distributed via the Acoustic Neuroma Association (ANA) website, Facebook, and email list. SUBJECTS AND METHODS: Surveys were distributed to ANA members from January to March 2017. Of the 3200 ANA members with a VS diagnosis at the time of survey distribution, 789 (25%) completed the survey. RESULTS: Subjects reported the following incidence of posttreatment complications: imbalance (60%), hearing issues (51%), dry eyes (30%), headache (29%), and facial weakness (27%). Overall, 188 (25%) recalled remembering all the risks associated with their treatment. Among those in the surgical cohort (52%) who experienced balance issues, facial weakness, cerebrospinal fluid leak, meningitis, and stroke, 73%, 91%, 77%, 67%, and 33% claimed recall of these associated risks. Among those in the radiosurgery cohort (28%) who experienced balance issues, facial weakness, and hydrocephalus, 56%, 52%, and 60% recalled discussions of those risks. Patients with higher-level education (P = .026) and those who underwent surgery (P = .001) had a significantly higher risk recall ratio, while sex, age, and tumor size were not significant contributing factors. CONCLUSION: Not all patients with VS who experienced treatment complications recalled remembering those risks being discussed with them. Patients with higher education and those who underwent surgery had a better recall of risks associated with different treatment modalities. The risk recall ratio of patients experiencing complications ranged 33% to 91%, suggesting an opportunity for decision-making and discussion improvement.

Tympanic Membrane and Ossicular-Sparing Modified Lateral Temporal Bone Resection.

A modified lateral temporal bone resection (mLTBR) is a unique technique that spares the tympanic membrane (TM) and ossicles in select patients with squamous cell carcinoma (SCCa). The records of 5 patients with SCCa of the temporal bone with negative frozen-section biopsy at the tympanic annulus were reviewed. The mean follow-up time for the patients was 29.2 months. One patient received postoperative radiation due to cervical nodal extracapsular spread. All patients were recurrence free as of the most recent follow-up (range, 8-50 months). Postoperative audiometry demonstrated an average conductive hearing loss of 9 dB (range, 0-17 dB). The mLTBR with sparing of the TM can be an effective alternative to the traditional lateral temporal bone resection (LTBR) with better hearing results for patients with SCCa involving the bony external auditory canal. In the short term, oncologic results of mLTBR appear equivalent to the LTBR. However, long-term follow-up is needed for >5-year outcomes.

Transcanal Micro-Osteotome Only Technique for Excision of Exostoses.

OBJECTIVES: To evaluate the outcomes and complications of transcanal excision of exostoses using micro-osteotomes, without a postauricular incision or the use of the drill. STUDY DESIGN: A retrospective chart review of patients undergoing exostoses excision. SETTING: Tertiary Care Medical Center. SUBJECTS AND METHODS: All of the patients underwent surgical removal of the exostoses using only a 1 or 2 mm micro-osteotomes. Patients were followed postoperatively and associated complications were evaluated. RESULTS: One-hundred thirty-eight ears in 106 patients were treated for obstructive exostosis. The average age of patients was 43 ± 16 years. Of these, 99 were man (93%) and 7 were woman (7%). A majority of the patients (84%, n = 89) had 90 to 100% obstruction of the ear canal. Complete ear canal healing was observed in 80% of patients by 3 weeks. All but one patient had healed by 6 weeks postoperatively. There were 9 (6.5%) slit tympanic membrane perforations that healed with intraoperative gelfoam or fascia myringoplasty. One patient had an anterior canal mobilization which required Xeroform packing for 3 weeks for stabilization. There were no postoperative vertigo, facial paresis, conductive/sensorineural hearing loss, soft tissue stenoses, and no skin grafting required. CONCLUSIONS: This is the first study to report a series of patients performing solely a transcanal approach using micro-osteotomes for removing exostoses. Results indicate that it is a safe procedure with low complication rate and expeditious healing. Patients with 100% obstruction can have this procedure performed with no significant increase in morbidity.

Migraine features in patients with Meniere's disease.

OBJECTIVES/HYPOTHESIS: To better understand the features of migraine in Meniere's disease (MD). STUDY DESIGN: Retrospective review of prospectively obtained surveys in an outpatient clinic of a tertiary medical center. METHODS: Detailed questionnaires on headaches and dizziness were given to consecutive patients presenting with dizziness. The responses were verified by the clinician with the patient. The data, in addition to the clinical history and audiogram, were used to diagnose patients with migraine headaches and MD using criteria set by the International Headache Society (IHS) and the American Academy of Otolaryngology-Head and Neck Surgery, respectively. The prevalence of migraine-like symptoms in those patients with MD, who did not fit the diagnostic criteria for migraine, was evaluated. RESULTS: Thirty-seven patients with definite MD were included. There was a predominance of females (female/male:26/11). Mean age of patients was 52 ± 14 years. Nineteen patients (51%) had migraine headaches. Fifteen patients fulfilled the criteria for definite vestibular migraine. Of those who did not fulfill the IHS migraine criteria, a majority had characteristics such as a family history of migraine, visual motion sensitivity, or lifelong motion sickness that were highly suggestive of a migraine disorder. CONCLUSIONS: A majority of patients with MD have migraine headaches as defined by the IHS. Sensitivity to visual motion, light and sound, head motion, smells, weather changes, or medication was present in 95% of all patients with definite MD and 82% of non-IHS migraine MD patients. This may suggest that MD may be an atypical variant of migraine.

Estimation of Nasal Tip Support Using Computer-Aided Design and 3-Dimensional Printed Models.

IMPORTANCE: Palpation of the nasal tip is an essential component of the preoperative rhinoplasty examination. Measuring tip support is challenging, and the forces that correspond to ideal tip support are unknown. OBJECTIVE: To identify the integrated reaction force and the minimum and ideal mechanical properties associated with nasal tip support. DESIGN, SETTING, AND PARTICIPANTS: Three-dimensional (3-D) printed anatomic silicone nasal models were created using a computed tomographic scan and computer-aided design software. From this model, 3-D printing and casting methods were used to create 5 anatomically correct nasal models of varying constitutive Young moduli (0.042, 0.086, 0.098, 0.252, and 0.302 MPa) from silicone. Thirty rhinoplasty surgeons who attended a regional rhinoplasty course evaluated the reaction force (nasal tip recoil) of each model by palpation and selected the model that satisfied their requirements for minimum and ideal tip support. Data were collected from May 3 to 4, 2014. RESULTS: Of the 30 respondents, 4 surgeons had been in practice for 1 to 5 years; 9 surgeons, 6 to 15 years; 7 surgeons, 16 to 25 years; and 10 surgeons, 26 or more years. Seventeen surgeons considered themselves in the advanced to expert skill competency levels. Logistic regression estimated the minimum threshold for the Young moduli for adequate and ideal tip support to be 0.096 and 0.154 MPa, respectively. Logistic regression estimated the thresholds for the reaction force associated with the absolute minimum and ideal requirements for good tip recoil to be 0.26 to 4.74 N and 0.37 to 7.19 N during 1- to 8-mm displacement, respectively. CONCLUSIONS AND RELEVANCE: This study presents a method to estimate clinically relevant nasal tip reaction forces, which serve as a proxy for nasal tip support. This information will become increasingly important in computational modeling of nasal tip mechanics and ultimately will enhance surgical planning for rhinoplasty. LEVEL OF EVIDENCE: NA.

Postoperative Complications and Readmission Rates Following Surgery for Cerebellopontine Angle Schwannomas.

OBJECTIVE: To investigate the 30-day postoperative complication, readmission, and reoperation rates following surgery for cerebellopontine angle (CPA) schwannomas. STUDY DESIGN: Cross-sectional analysis. SETTING: National surgical quality improvement program dataset (NSQIP) 2009 through 2013. PATIENTS: All surgical cases with an International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis code of 225.1, benign neoplasms of cranial nerves, and one of the following current procedural terminology (CPT) codes, were included: 61616, 61526, 61530, and 61520. INTERVENTION(S): Surgical resection as indicated by the CPT codes above. MAIN OUTCOME MEASURE(S): Demographics, comorbidities, 30-day postoperative complications, readmission rate, and reoperation rate. RESULTS: Overall, 404 cases were identified, of which 42.6% were men. The average age was 51 years. Comorbidities were present in 45.3%. NSQIP-tracked complications occurred in 9.7% of patients. Most common complications were wound infections including surgical-site infection and wound dehiscence (11 patients, 2.7%), sepsis (10 patients, 2.5%), blood loss (nine patients, 2.2%), and deep vein thrombosis (DVT; seven patients, 1.7%). Mortality occurred in four patients (1.0%). The complication rate was statistically higher in patients with comorbidities versus those without (10.2% versus 4.1%, p = 0.04). Patients with complications were more likely to undergo reoperation (2.5% with versus 4.1% without, p = 0.001). Unplanned readmissions occurred in 41 cases (10.1%) and reoperations occurred in 23 patients (5.7%). CONCLUSIONS: Most common NSQIP-tracked complications in excision of CPA neoplasms are infections, sepsis, blood loss, and deep vein thrombosis (DVT). Further, investigation of patients with unplanned readmission and reoperation are warranted. Neurotologists need to take an active role in the data to be gathered in the NSQIP database as it relates to vestibular schwannomas.

Evaluation of Reported Malignant Transformation of Vestibular Schwannoma: De Novo and After Stereotactic Radiosurgery or Surgery.

OBJECTIVE: To critically analyze each reported case of malignant transformation of vestibular schwannoma (VS) after either stereotactic radiosurgery (SRS) or microsurgery (MS). DATA SOURCES: We searched the Pubmed/Medline database using the relevant key words vestibular schwannoma, acoustic neuroma, malignant, transformation, radiation, induced, stereotactic, radiosurgery, malignancy, GammaKnife, and CyberKnife and combinations thereof. STUDY SELECTION: Inclusion criteria for malignant transformation of VS after SRS included histopathology of initially benign VS, subsequent histopathology confirming malignant VS, reasonable latency period between malignancy and benign diagnoses. DATA EXTRACTION: A neurotologist and a skull base neurosurgeon independently assessed each case report for quality, entry, exclusion criteria, and comparability of extracted data. DATA SYNTHESIS: We calculated median age, latency times, and survival times for each case report. RESULTS: Malignant transformation has been documented to occur after either SRS or MS. Eight cases were included that showed histopathologic evidence of malignant transformation after SRS and MS. Four cases of malignant transformation were included that demonstrated malignant transformation after MS only. Malignant transformation of VS can also occur de novo, and de novo malignant VSs are also encountered, which can confound a causal inference from either SRS or MS. Eighteen cases of primary malignant VS were included. Studies that were identified but not included in the review are summarized and tabulated. We found 12 studies of malignant transformation associated with NF2. CONCLUSION: The potential mechanism leading to malignant transformation of VS seems more obvious for SRS and is less understood for MS. Given a low incidence of de novo malignant schwannoma, the possibility that these are spontaneous events in either setting cannot be ruled out. Risk of malignant transformation of VS after either SRS or MS is not zero; however, the magnitude of this risk is probably minimal based on the evidence from eight histopathologically confirmed cases.

Congenital anomalies of the incudostapedial joint.

OBJECTIVE: To describe congenital anomalies of the incudostapedial joint (ISJ) and to discuss the possible unique embryogenesis of the ISJ based on the two anomalies that were encountered. SETTING: Tertiary care medical center. SUBJECTS AND METHODS: Retrospective review of the medical records of all patients with ISJ anomalies. RESULTS: Four patients presented with congenital hearing loss. Upon further workup, we observed a preserved incudostapedial joint (ISJ) with deficiencies of the incus and stapes in three cases. Our fourth case demonstrated the inverse pattern of the congenital anomalies in which the ISJ was missing with an intact proximal incus and stapes crura. Three patients opted for surgical intervention with improvement in hearing. One case preferred hearing amplification over surgery. CONCLUSION: Isolated ISJ malformations are uncommon potential causes of congenital conductive hearing loss. Although numerous patterns of ossicular anomalies have been reported in the literature, our case series is the first to demonstrate both the absence of the ISJ in one patient and the presence of the ISJ in the presence of missing stapes crura and incus body in other patients. Though limited by the small number of cases, the inverse relationship of the single case compared to the three other cases, suggests a possible independent embryological development pathway for the ISJ. Therefore, an embryological explanation of the defects should be considered. Additionally, surgical intervention can improve hearing outcomes for patients with isolated ISJ anomalies.

Curved adjustable fiberoptic laser for endoscopic cholesteatoma surgery.

OBJECTIVE: To determine whether endoscopic cholesteatoma removal can be performed efficiently and safely using a curved fiberoptic-based laser. BACKGROUND: Angled instruments are required in endoscopic ear surgery to access recesses of the middle ear without extra drilling. Lasers are effective at ablating visible and microscopic cholesteatoma matrix and removing granulation tissue. STUDY DESIGN: Retrospective case review from 2006 to 2013. SETTING: Single tertiary care center. PATIENTS: Patients who underwent cholesteatoma surgery with otoendoscopy. INTERVENTION: Residual cholesteatoma that could not be reached by conventional microinstruments was identified using an endoscope. This residual cholesteatoma was ablated in a contactless manner using a fiberoptic-based curved laser carrier with an argon laser. The laser tip through the carrier probe has a 45-degree curve, and the length of the tip is adjustable, allowing it to be used in recesses or around corners, such as in the sinus tympani, around the stapes suprastructure, in the oval window, or in the Eustachian tube orifice. MAIN OUTCOME MEASURES: Presence or absence of residual cholesteatoma after laser ablation and complications. RESULTS: In 7 cases, the fiberoptic curved laser was used to ablate cholesteatoma completely with no injury to surrounding structures and with no evidence of recidivism with a mean follow-up period of 19 months. There were no cases of sensorineural hearing loss or perilymphatic fistula. CONCLUSION: The curved laser probe allows for precise removal of cholesteatoma endoscopically.

Loudness and acoustic parameters of popular children's toys.

OBJECTIVE: This project was conducted to evaluate the loudness and acoustic parameters of toys designed for children. In addition, we investigated whether occluding the toys' speaker with tape would result in a significant loudness reduction; thereby potentially reducing the risk of noise induced hearing loss. METHODS: Twenty-six toys were selected after an initial screening at two national retailers. Noise amplitudes at 0.25, 0.5, 1, 2, 4, and 8kHz were measured using a digital sound level meter at a distance of 0 and 30cm. The toys' speakers were then occluded using adhesive tape and the same acoustic parameters were re-measured. RESULTS: Mean maximum noise amplitude of the toys at 0cm and 30cm was 104dBA (range, 97-125dBA) and 76dBA (range, 67-86dBA), respectively. Mean maximum noise amplitude after occlusion at 0cm and 30cm distances was 88dBA (range, 73-110dBA) and 66dBA (range, 55-82dBA), respectively, with a p-value <0.001. CONCLUSIONS: Proper use of the loudest toys at a distant of 30cm between the speaker and the child's ear will likely not pose a risk of noise-induced hearing loss. However, since most toys are used at closer distances, use of adhesive tape is recommended as an effective modification to decrease the risk of hearing loss.

Vestibular Schwannoma Excision in Sporadic versus Neurofibromatosis Type 2 Populations.

OBJECTIVE: To understand the differences in characteristics of neurofibromatosis type 2 (NF2) and sporadic patients with surgically excised vestibular schwannomas in the state of California. STUDY DESIGN: Cross-sectional. SETTING, SUBJECTS, AND METHODS: The records of all patients who underwent vestibular schwannoma excision between 1997 and 2011 were extracted from the California Hospital Inpatient Discharge Databases (CHIDD). NF2 cases were identified using ICD-9-CM diagnosis code 237.72, neurofibromatosis, type 2. All other cases were recoded as sporadic. Trends in total number and population-adjusted rates (per 1 million California residents) of surgery, demographics, hospital case volume, state of residency, complications, length of stay, total charges, expected source of payment, and disposition were examined. RESULTS: Vestibular schwannoma (VS) excision was performed on 7017 patients, of which 464 patients (6.6%) had NF2. The population-adjusted surgery rate declined from 11.8 to 6.2 (P < .001) for sporadic cases and from 0.3 to 0.2 (P = .01) for NF2 cases over the study period. NF2 was associated with younger age (mean, 32.9 vs 51.3), higher rate of other complications (8.8% vs 4.4%) and facial nerve complications (32.3% vs 16.8%), higher total charges (median $70,106 vs $46,395), longer stay (median 5 vs 4), and high volume hospitals (80.4% vs 48.8%) (all P < .001). CONCLUSION: The surgery rates for vestibular schwannoma excision for both sporadic and NF2 patients have declined, but the decline is more prominent for sporadic cases. NF2 patients tend to be younger and have a longer hospitalization and possibly higher corresponding hospital charges compared to patients with sporadic VS.