IL-17 and IFN-γ-producing respiratory tissue resident memory CD4†T cells persist for decades in adults immunized as children with whole cell pertussis vaccines.

The objective was to determine if antigen-specific tissue resident memory T (TRM) cells persist in respiratory tissues of adults immunized as children with whole cell pertussis (wP) or acellular pertussis (aP) vaccines. Mononuclear cells from tonsil or nasal tissue cells were cultured with Bordetella pertussis antigens and TRM cells quantified by flow cytometry. Adults immunized with wP vaccines as children had significantly more IL-17A and IFN-y-producing TRM cells that respond to B. pertussis antigens in respiratory tissues when compared with aP-primed donors. Our findings demonstrate that wP vaccines induce CD4 TRM cells that can persist in respiratory tissues for decades.

Bone-anchored hearing aids: Percutaneous versus transcutaneous attachments - a health economics comparison in paediatric patients.

INTRODUCTION: Bone anchored hearing aids (BAHA) are a useful support when conventional hearing aids are not suitable. The two types of attachment of the aid are onto a percutaneous abutment or a transcutaneous magnet. Anecdotally, the abutment requires more care, revision procedures and causes more infections than magnet-based devices. METHODS: A multicentre, retrospective review was conducted of all patients that underwent a BAHA since our programme began, identified through a prospectively maintained database of patients. Patients' charts were audited for outpatient clinic visits, skin complications and revision surgeries. Developmental delay was also recorded. Patients were censored if the hearing aid was removed, replaced or the patient reached 16 years old. Bilateral or reimplanted patients were recorded as separate implants. Statistical analysis was performed using SAS version 9.4. RESULTS: 150 implants were assessed over 126 patients: 115 transcutaneous and 35 percutaneous. Percutaneous patients had significantly more outpatient clinic attendances (Least square mean 4.19 vs. 1.39 p = 0.00), skin complications (mean 4.82 v 0.11 p = 0.00) and theatre visits (mean 2.8 vs. 1.03 p = 0.00) compared to transcutaneous patients. 77 implants were in patients that had developmental delay; having same made no significant difference to above outcomes. CONCLUSION: There is a significant difference in healthcare burden between percutaneous and transcutaneous systems in a paediatric population. The increased cost of the percutaneous implant to the healthcare system and inconvenience to the patient is cause to consider a transcutaneous system in the first instance.

Effectiveness of conventional versus virtual reality based vestibular rehabilitation in the treatment of dizziness, gait and balance impairment in adults with unilateral peripheral vestibular loss: a randomised controlled trial.

BACKGROUND: Unilateral peripheral vestibular loss results in gait and balance impairment, dizziness and oscillopsia. Vestibular rehabilitation benefits patients but optimal treatment remains unknown. Virtual reality is an emerging tool in rehabilitation and provides opportunities to improve both outcomes and patient satisfaction with treatment. The Nintendo Wii Fit Plus® (NWFP) is a low cost virtual reality system that challenges balance and provides visual and auditory feedback. It may augment the motor learning that is required to improve balance and gait, but no trials to date have investigated efficacy. METHODS/DESIGN: In a single (assessor) blind, two centre randomised controlled superiority trial, 80 patients with unilateral peripheral vestibular loss will be randomised to either conventional or virtual reality based (NWFP) vestibular rehabilitation for 6 weeks. The primary outcome measure is gait speed (measured with three dimensional gait analysis). Secondary outcomes include computerised posturography, dynamic visual acuity, and validated questionnaires on dizziness, confidence and anxiety/depression. Outcome will be assessed post treatment (8 weeks) and at 6 months. DISCUSSION: Advances in the gaming industry have allowed mass production of highly sophisticated low cost virtual reality systems that incorporate technology previously not accessible to most therapists and patients. Importantly, they are not confined to rehabilitation departments, can be used at home and provide an accurate record of adherence to exercise. The benefits of providing augmented feedback, increasing intensity of exercise and accurately measuring adherence may improve conventional vestibular rehabilitation but efficacy must first be demonstrated. TRIAL REGISTRATION: Clinical trials.gov identifier: NCT01442623.

International Pediatric Otolaryngology Group (IPOG) Consensus Recommendations: Congenital Cholesteatoma.

OBJECTIVE: To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of children who present with signs and symptoms of congenital cholesteatoma. METHODS: A two-iterative Delphi method questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group, on the preoperative work-up, the perioperative considerations, and follow-up. RESULTS: Twenty-two members completed the survey, in 14 tertiary-care center departments representing 5 countries. The main consensual recommendations were: a precise otoscopic description of the quadrants involved, extensive audiological workup (bilateral tonal, vocal audiometry, and BERA), and a CT scan are required. Facial nerve monitoring and a combination of microscope and telescope are recommended for surgical removal. Clinical and audiological follow-up should be pursued yearly for at least 5 years. First MRI follow-up should be done at 18 months postoperatively if the removal violated the matrix. MRI follow-up duration depends on the initial extent of the cholesteatoma. CONCLUSION: The goal of preoperative and follow-up consensus from International Pediatric Otolaryngology Group participants is to help manage infants and children with congenital cholesteatoma. The operative techniques may vary, and experienced surgeons must perform these procedures.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Hearing loss in the pediatric patient.

OBJECTIVE: To provide recommendations for the workup of hearing loss in the pediatric patient. METHODS: Expert opinion by the members of the International Pediatric Otolaryngology Group. RESULTS: Consensus recommendations include initial screening and diagnosis as well as the workup of sensorineural, conductive and mixed hearing loss in children. The consensus statement discusses the role of genetic testing and imaging and provides algorithms to guide the workup of children with hearing loss. CONCLUSION: The workup of children with hearing loss can be guided by the recommendations provided herein.

A simple and reliable predictor for an adequate laryngeal view with rigid endoscopic laryngoscopy.

OBJECTIVES: It is sometimes impossible to obtain an adequate laryngeal view during rigid endoscopic laryngoscopy. This may be due to a high tongue base. Our study seeks to determine a correlation between tongue base level and the adequacy of laryngeal view obtained with a 70-degree rigid endoscope. STUDY DESIGN AND SETTING: Over a period of 4 months, patients from a voice clinic were gathered and categorized into class I to III according to Mallampati et al (1985). Rigid laryngo-videostroboscopy was conducted to assess the larynx and the adequacy of the view was recorded. RESULTS: 74 patients were recruited. The number of adequate views were: class I = 18/20 (90%); class II = 20/33 (60.6%); class III = 7/21 (33.3%). chi 2 analysis demonstrated significance trend in all 3 classes. CONCLUSION: The level of the tongue base correlated well with the adequacy of laryngeal view obtained from a 70-degree rigid endoscope. This can be used to predict the success of obtaining adequate views during rigid laryngoscopy.

Genetic screening for deafness.

Genetic testing for deafness has become a reality. It has changed the paradigm for evaluating deaf and hard-of-hearing persons and will be used by physicians for diagnostic purposes and as a basis for treatment and management options. Although mutation screening is currently available for only a limited number of genes, in these specific instances, diagnosis, carrier detection, and reproductive risk counseling can be provided. In the coming years there will be an expansion of the role of genetic testing and counseling will not be limited to reproductive issues. Treatment and management decisions will be made based on specific genetic diagnoses. Although genetic testing may be a confusing service for the practicing otolaryngologist, it is an important part of medical care. New discoveries and technologies will expand and increase the complexity of genetic testing options and it will become the responsibility of otolaryngologists to familiarize themselves with current discoveries and accepted protocols for genetic testing.

The use of cortical evoked response audiometry in the assessment of noise-induced hearing loss.

OBJECTIVES: The study aims were to determine the incidence of exaggerated hearing thresholds in individuals complaining of noise-induced hearing loss (NIHL) as a result of impulse noise using cortical evoked response audiometry (CERA) and to identify any associated audiometric features. SETTING: We conducted an office-based study. STUDY DESIGN: In this prospective case series, 1154 males complaining of NIHL were assessed with pure tone audiometry; 673 had CERA. Pure tone averages (PTA) and hearing disability were calculated using the Irish and American Medical Association systems. A PTA of >10 dB worse than the CERA average was considered evidence of exaggerated thresholds. RESULTS: The mean PTA was 33 dB. Seventy-two percent had a hearing disability of an average of 26% when assessed by the Irish system. Fifty-four percent had a hearing disability of an average of 30% when assessed by the American Medical Association system. Twenty-six percent of subjects had exaggerated thresholds based on CERA. A binaural hearing threshold of >25 dB at 500 Hz had a sensitivity of 94% and a specificity of 59% for the detection of exaggerated thresholds. CONCLUSION: Exaggerated hearing thresholds are common. A hearing threshold of >25 dB at 500 Hz should be considered an indication for CERA testing.

Medical evaluation of pediatric hearing loss. Laboratory, radiographic, and genetic testing.

Specific investigations of pediatric hearing loss are based on the history, physical examination, and age of the patient. The radiographic investigation of choice is high-resolution CT of the temporal bone. Patients with a dilated vestibular aqueduct need to be investigated further for Pendred syndrome. Screening for mutations in connexin 26 has become increasingly available in many centers and should be performed in all cases of nonsyndromic hearing loss. It is important to understand the implications and pitfalls of genetic testing. Genetic counseling is necessary.

How to perform adequate nasal packing in posterior epistaxis with difficult access.

Inadequate nasal packing in the treatment of posterior epistaxis can result in an increase in patient morbidity and mortality, and also hospital expenditure. The presence of a septal spur or septal deviation anterior to the bleeding may prevent sufficient local pressure over the bleeding point with a ribbon gauze pack. A modified Jobson-Horne probe can be used to ensure a tight ribbon gauze application over the bleeding point behind the septal spur or deviation.

Transnasal endoscopic repair of choanal atresia in a tertiary care centre: a review of outcomes.

INTRODUCTION/AIM: Choanal atresia (CA) is an obliteration, in newborns, of the airway at the level of posterior nasal aperture resulting in absence of connection between the nasal cavity and the aerodigestive tract. It is rare, with incidence of 1 in 7000 live births. This review is aimed at assessing the factors influencing the outcome of transnasal endoscopic repair of CA in a tertiary referral children's hospital. MATERIAL/METHOD: A retrospective study was carried out between 2002 and 2009. 31 children; 14 boys and 17 girls, age range 1 day to 15 years, mean 23.4 months were included. Unilateral presentation was 19 (11 right, 8 left) and bilateral was 12. All patients had transnasal endoscopic repair under direct vision. Nasal stents were placed for varying duration (range 4-12 weeks) or nasopharyngeal airways (removed within 24h) were inserted at time of surgery. Patients were monitored for re-stenosis and revisions carried out as necessary, with a mean follow-up of 11.9 months. RESULTS: 54.7% (n=17) of patients had re-stenosis requiring revision surgery. Of these, 41.1% (n=7) had success after the 1st revision, 20% had success after the 2nd revision while 12.3% had success after the 3rd revision. One patient required more than four revisions. 80% of re-stenosis requiring revisions occurred in children who had surgery under 10 months of age and of these, approx. 42% were 1-week-old or younger. 57% of those who had stents for 4-6 weeks (n=15) had re-stenosis requiring revision while only 33.3% of those who either had no stents or had NP airways removed within 24h (n=16) had re-stenosis (P=0.019). The re-stenosis rate was comparable for those who had mitomycin (53%) versus those who did not (60%). CONCLUSION: Transnasal endoscopic repair of CA is effective and safe and provides the benefit of surgery under direct vision. Age 1 week or less was a predictive factor for re-stenosis. Intranasal stents was also associated with increased incidence of re-stenosis and the use of mitomycin C does not seem to have any significant effect on re-stenosis.

ABO blood type as a risk factor for secondary post-tonsillectomy haemorrhage.

INTRODUCTION: Blood type-O is associated with decreased expression of von Willebrand factor. Type-O patients suffer fewer thrombotic problems and may be more prone to haemorrhage. Secondary post-tonsillectomy haemorrhage is the most common severe complication of tonsillectomy. We propose that type-O blood may be over-represented in patients presenting with secondary bleeds. METHODS: We reviewed patients treated in the Royal Victoria Eye and Ear Hospital and the Midwestern Regional Hospital for secondary post-tonsillectomy haemorrhages from 2001 to 2006. RESULTS: Three-hundred and three patients suffered secondary post-tonsillectomy haemorrhages over the study period. Blood group data was available in 206 cases (68%). Sixty-three percent of patients studied were blood group O, compared with 55% of the general population (p=0.01). CONCLUSIONS: Blood group O is disproportionately represented in secondary post-tonsillectomy haemorrhage patients. Although we cannot demonstrate causality, this association suggests that patients with type-O blood are more likely to suffer from secondary bleeds following tonsillectomy.

A histological comparison of deep and superficial lobe pleomorphic adenomas of the parotid gland.

BACKGROUND: Excision of parotid superficial lobe pleomorphic adenomas requires removal of a surrounding cuff of normal parotid tissue. Less aggressive dissection in removing pleomorphic adenomas that occur in the deep lobe of the parotid gland does not seem to compromise prognosis in these patients. We attempted to define histologic characteristics, differentiating superficial and deep lobe tumors, in an attempt to explain this clinical phenomenon. METHOD: Thirty-one pleomorphic adenomas, 12 deep-lobe tumors, and 19 superficial lobe tumors were analyzed and compared, looking at tumor size, capsule thickness, penetration of tumor through capsule, and predominant cell types present. RESULTS: The superficial lobe tumors had significantly thinner capsules (p =.02). There was increased extracapsular extension of tumor in the superficial lobe group compared with the deep lobe group (79% and 58%, respectively). The tumors were larger in patients with deep lobe lesions (2.6 cm vs 3.6 cm). There was no difference in predominant cell types. CONCLUSIONS: The anatomic location of deep lobe tumors is a likely explanation for the histologic differences observed in this study. These important differences allow less aggressive dissection in deep lobe tumors without compromising prognosis.