Patient Self-Management of Benign Paroxysmal Positional Vertigo: Instructional Video Development and Preliminary Evaluation of Behavioral Outcomes.

IMPORTANCE: Benign paroxysmal positional vertigo of the posterior canal (PC-BPPV) is a common disorder that is diagnosed using the Dix-Hallpike test (DHT) and treated with the canalith repositioning maneuver (CRM). Patients often seek out information about BPPV self-management, but studies to develop and evaluate patient-centered instructional resources are limited. OBJECTIVE: To develop and preliminarily evaluate a patient-oriented PC-BPPV self-management instructional video. METHODS: We assembled a multidisciplinary team and used an iterative process to develop a theory-based instructional video for self-performing the DHT and CRM. We recruited individuals searching online for information about dizziness to complete a survey and review the video. Patients rated the video by scoring seven questions that measure behavioral intent to perform the DHT or CRM (attitudes/acceptability, perceived self-efficacy, and social norms) using a 10-point scale (higher scores = more favorable ratings). A multilevel linear regression model was used to determine the association of age, sex, race, and education with video ratings. RESULTS: Of the 771 participants who completed the survey, 124 (16%) also reviewed and evaluated the PC-BPPV instructional video. The video review participants were typically more than or equal to 55 years old (70%; 93/124), women (70%; 87/124), and White (70%; 88/124). These participants also generally reported acute-subacute and moderate-to-severe dizziness, and 60% (75/124) reported typical BPPV triggers. The median scores for the seven questions about attitudes/acceptability, self-efficacy, and social norms on the PC-BPPV instructional video were all more than or equal to 9 out of 10 with interquartile ratios that ranged from 7 to 9 at the 25th percentile to 10 at the 75th percentile. Female sex was the only demographic variable associated with higher video ratings (coefficient, 1.21, 95% CI 0.60-1.83). CONCLUSION: This study found that participants rated the PC-BPPV self-management video favorably on measures that contribute to behavioral intent to perform the DHT or CRM. The findings provide support that the video is appropriate to use in future studies that evaluate patient self-performance accuracy and outcomes.

Intraoperative Electrocochleography Correlates to Outcomes in Transmastoid and Middle Cranial Fossa Superior Semicircular Canal Dehiscence Repair.

OBJECTIVE: To determine the degree to which electrocochleography (ECoG) correlates with auditory and vestibular outcomes after repair of superior semicircular canal dehiscence (SSCD) via transmastoid (TM) and middle cranial fossa (MCF) approaches. STUDY DESIGN: Retrospective review. SETTING: Academic tertiary referral center. PATIENTS: Adults with SSCD who underwent repair between 2005 and 2019. INTERVENTION: Pre-, intra-, and postoperative ECoG. MAIN OUTCOME MEASURES: Patient-reported vestibular and auditory symptoms; pre-, intra-, and postoperative ECoG measures, dizziness handicap inventory (DHI) scores. RESULTS: Forty-six patients underwent SSCD repair (40 unilateral, six bilateral) between 2005 and 2019, including 24 MCF and 28 TM approaches. There were no differences in preoperative, intraoperative, or postrepair ECoG SP/AP values between the MCF and TM groups (p 0.12, 0.77, 0.58). Patients had subjective improvement in vestibular symptoms (or stable vestibular function in patients operated for predominantly auditory manifestations) with both approaches (MCF: 87.5%; TM: 92.3%; p 0.64). A successful outcome correlated with intraoperative SP/AP ratio normalization (p 0.0005). Similarly, DHI scores were similar in both groups preoperatively (p 0.66) and returned to their preoperative baseline postoperatively with both (p 0.52). Reported vestibular symptoms persisted or worsened more often in patients with migraine (66.6% vs. 28.9%, p 0.03), and with persistently abnormal ECoG measures, though the latter was not statistically significant in this population (38% vs. 15%, p 0.10). Patients had subjective improvement or stability in auditory symptoms using either approach (MCF: 96%; TM: 100%; p 0.62), also correlating with SP/AP ratio normalization (p 0.008). CONCLUSIONS: Correction of abnormal preoperative ECoG reliably correlates to patient symptom improvement after SSCD repair. No significant differences in postoperative outcomes were noted between patients undergoing TM versus MCF repair. Circumspection regarding the likelihood of an ideal outcome after SSCD repair should be exercised when counseling patients with concomitant migraine. DEFINE PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: It is not certain whether outcomes differ between the two dominant approaches for SSCD repair. Surgeons and patients would benefit from an intraoperative metric that reflects satisfactory plugging of SSCD. LEARNING OBJECTIVE: To highlight the reliability and unique utility of intraoperative ECoG and demonstrate the correlation between ECoG correction and symptom improvement for SSCD repair. DESIRED RESULT: To report subjective and objective outcomes following SSCD repair and encourage adoption of intraoperative ECoG monitoring. LEVEL OF EVIDENCE: Level V. INDICATE IRB OR IACUC: IRB review considers this study exempt (HUM00169949).

Auditory Outcomes Following Transmastoid and Middle Cranial Fossa Approaches for Superior Semicircular Canal Dehiscence Repair.

OBJECTIVE: To describe postoperative hearing outcomes following transmastoid (TM) and middle cranial fossa (MCF) approaches for semicircular canal dehiscence (SSCD) repair. STUDY DESIGN: Retrospective review. SETTING: Academic, tertiary referral center. PATIENTS: Adults with SSCD who underwent repair between 2005 and 2019. INTERVENTIONS: Pure tone audiometry pre- and postoperatively after SSCD repair. MAIN OUTCOME MEASURES: Change in air-bone gap (ABG) at 250 and 500 Hz, pure tone average (PTA), bone conduction (BC), and air conduction (AC) thresholds at 500, 1000, 2000, and 4000 Hz for patients undergoing TM and MCF approaches for SSCD repair. RESULTS: The average change in BC PTA for patients undergoing TM (n = 26) and MCF (n = 24) SSCD repair was not significantly different between the two groups. The first and final postoperative PTAs were recorded an average of 1.7 (range 0.30-3.0) and 29.1 (range 3.5-154) months postoperatively. For patients who underwent MCF repair, the average BC PTAs increased (+) by 2.2 dB HL (p 0.43) and 0.57 dB HL (p 0.88) at the first and final audiograms respectively compared to +1.27 dB HL (p 0.53) and a decrease (-) of 0.57 dB HL (p 0.63) for the TM group. The average changes in low frequency ABG for patients undergoing MCF repair were -4.7 dB (p 0.08) and -6.9 dB (p 0.15) at first and final audiograms respectively compared to -4.9 dB (p 0.06) and -4.1 dB (p 0.36) for patients who underwent TM repair. There was a high frequency hearing loss noted at 8000 Hz for the MCF (30.0 dB ±â€Š18.7 preop; 41.7 dB ±â€Š21.7 postop; p 0.01) and TM (32.1 dB ±â€Š23.2 preop; 44.3 dB ±â€Š29.6 postop; p 0.001) groups which persisted on long term follow up. CONCLUSIONS: Both TM and MCF approaches to SSCD repair can be performed with long-term preservation of hearing. ABGs were reduced in each treatment group but did not reach significance. A high frequency hearing loss (8000 Hz) may be expected with either approach.

Vestibular Physical Therapy and Fall Risk Assessment.

Vestibular physical therapy (VPT) is a specialized form of evidence-based therapy designed to alleviate primary (vertigo, dizziness, imbalance, gait instability, falls) and secondary (deconditioning, cervical muscle tension, anxiety, poor quality of life, fear of falling/fear avoidance behavior) symptoms related to vestibular disorders. This article provides an overview of VPT, highlighting various exercise modalities used to treat a variety of vestibular disorders. Patient safety and fall prevention are paramount; therefore, fall risk assessment and treatment are also addressed.

Rehabilitation for unilateral deafness - Narrative review comparing a novel bone conduction solution with existing options.

Patients with single sided deafness (SSD) struggle with sound localization and speech in noise. Existing treatment options include contralateral routing of signal (CROS) systems, percutaneous bone conduction hearing devices (BCHDs), passive transcutaneous BCHDs, active BCHDs, and cochlear implants. Implanted devices provide benefits in speech in noise compared to CROS devices. Percutaneous BCHDs transmit sound efficiently but have aesthetic drawbacks and skin complications. Scalp attenuation impacts passive transcutaneous BCHD performance. Active BCHDs overcome these issues and provide benefits for speech in noise. Cochlear implantation is the only existing option that restores binaural input but introduces electrical rather than acoustic stimuli to the deaf ear. Active BCHDs have been designed to maintain efficient sound transmission and avoid chronic skin irritation and cosmetic concerns that may occur with percutaneous BCHDs. Cochlear implantation may be a superior option for recently deafened SSD patients, though this requires further study. The duration of deafness, patient age and comorbidities, and a shared decision-making model among patients, surgeons, and audiologists should be considered in device selection. The aim of this manuscript is to review available devices, discuss surgical considerations for implantable devices, review available published results for speech in noise and sound quality with each device, and provide an overview to guide shared decision making for patients and providers. This review consolidates available literature and reviews experience with a newer active transcutaneous active BCHD available for use in the SSD population.

Intraoperative Auditory Brainstem Response Results Predict Delayed Sensorineural Hearing Loss After Middle Cranial Fossa Resection of Vestibular Schwannoma.

OBJECTIVE: To identify intraoperative neurophysiologic measures predictive of delayed progressive sensorineural hearing loss in the operative ear after a middle fossa approach (MCF) for resection of vestibular schwannoma (VS). STUDY DESIGN: Retrospective review. SETTING: Academic, tertiary referral center. PATIENTS: Subjects with vestibular schwannoma who underwent a MCF microsurgical resection of VS were analyzed for individuals whose hearing was initially preserved but subsequently developed progressive sensorineural hearing loss in the operative ear. Thirty-seven patients were identified for whom audiologic and neurophysiologic data was available. INTERVENTION: Intraoperative neurophysiologic changes will correlate with delayed sensorineural hearing loss in the operative ear. MAIN OUTCOME MEASURES: Audiometric evaluations, intraoperative electrocochleography (ECoG), and auditory brainstem response (ABR) measures. RESULTS: Twenty-five subjects experienced stable hearing or hearing loss in the operative ear comparable to the contralateral ear. Twelve subjects suffered a significant increase in the hearing asymmetry between ears. Deterioration in the amplitude of wave V of the ABR persisting at the close of tumor resection correlated with delayed sensorineural hearing loss in the operative ear (p 0.02, 5% mean improvement in the stable hearing group, versus a 14% decline with progressive asymmetry), but changes in ECoG or other auditory brainstem response parameters (p > 0.05) were not predictive. CONCLUSIONS: Persisting amplitude reduction of wave V of the intraoperative ABR best correlates with delayed progressive sensorineural hearing loss in the operative ear. Neither persistent changes in ECoG, other ABR parameters, nor transient changes, correlated with delayed progressive sensorineural hearing loss in the operative ear.

Aberrant AICA Injury During Translabyrinthine Approach.

OBJECTIVE: To define a complication of the translabyrinthine surgical approach to the posterior fossa related to a rare variant of the anterior inferior cerebellar artery (AICA) that penetrated into the petrous temporal bone. PATIENT: A healthy 59-year-old male with a unilateral sporadic vestibular schwannoma. INTERVENTION: The patient elected to undergo a translabyrinthine approach for resection of a vestibular schwannoma. An aberrant loop of AICA was encountered during the temporal bone dissection within the petrous portion of the temporal bone. OUTCOMES: The patient suffered a presumed ischemic insult resulting in a fluctuating ipsilateral facial paresis and atypical postoperative nystagmus. RESULTS: MRI demonstrated an ischemic lesion in the vascular distribution of the right anterior-inferior cerebellar artery, including the lateral portion of the right cerebellar hemisphere, middle cerebellar peduncle, and bordering the right cranial nerve VII nucleus. His functional recovery was excellent, essentially identical to the anticipated course in an otherwise uncomplicated surgery. CONCLUSIONS: This case highlights the irregular anatomy of the AICA as well as the importance of thorough neurological exams in the postsurgical lateral skull base patient.

Multicenter Clinical Investigation of a New Active Osseointegrated Steady-State Implant System.

OBJECTIVE: A new active transcutaneous bone conduction hearing implant system that uses piezoelectric technology has been developed: an active osseointegrated steady-state implant system (OSI). This was the first clinical investigation undertaken to demonstrate clinical performance, safety, and benefit of the new implant system. STUDY DESIGN AND SETTING: A multicenter prospective within-subject clinical investigation was conducted. PATIENTS: Fifty-one adult subjects with mixed and conductive hearing loss (MHL/CHL, n = 37) and single-sided sensorineural deafness (SSD, n = 14) were included. MAIN OUTCOME MEASURE: Audiological evaluations included audiometric thresholds, speech recognition in noise, and quiet. Hearing and health-related patient-reported outcomes (PROs; health utilities index [HUI], abbreviated profile of hearing aid benefit [APHAB], and speech, spatial of qualities of hearing scale [SSQ]), daily use, surgical and safety parameters were collected. RESULTS: Intra- and postoperative complications were few. One implant was removed before activation due to post-surgical infection. Compared with the preoperative softband tests, a significant improvement in speech recognition-in-noise was observed in the MHL/CHL group (-7.3 dB, p ≤ 0.0001) and the SSD group (-8.1 dB, p = 0.0008). In quiet, word recognition improved in the MHL/CHL group, most markedly at lower intensity input of 50 dB SPL (26.7%, p ≤ 0.0001). The results of all PROs showed a significant improvement with the new device compared with preoperative softband in the MHL/CHL group. In the SSD group significant improvements were observed in the APHAB and SSQ questionnaires. DISCUSSION: The results confirmed the clinical safety, performance, and benefit of this new treatment modality for subjects with CHL, MHL, and SSD.

Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial.

STUDY OBJECTIVE: We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits. METHODS: We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computed tomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews. RESULTS: We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program. CONCLUSION: These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.

An Educational Intervention for Acute Dizziness Care: A Randomized, Vignette-based Study.

IMPORTANCE: Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Strong evidence exists for diagnosing BPPV using the Dix-Hallpike Test (DHT) and treating it with the canalith repositioning maneuver (CRM). Despite this, both are infrequently used in the emergency department (ED). OBJECTIVE: As an early method to evaluate a BPPV-focused educational intervention, we evaluated whether an educational intervention improved ED provider performance on hypothetical stroke and BPPV cases delivered by vignette. DESIGN: A randomized, controlled, educational intervention study in ED physicians. The intervention aimed to promote the appropriate use of the DHT and CRM. A BPPV vignette, a stroke-dizziness (safety) vignette, and vignette scoring schemes (higher scores indicating more optimal care) used previously established vignette methodology. SETTING: We recruited participants at the exhibitor hall of an emergency medicine annual meeting. PARTICIPANTS: We recruited 48 emergency physicians. All were board certified or residency trained and board eligible. All were engaged in the active practice of emergency medicine. None were trainees. INTERVENTIONS: Intervention group: a narrated, educational presentation by computer followed by the clinical vignettes. CONTROL GROUP: Received no educational intervention and completed the clinical vignettes-intended to mirror current clinician practice. MAIN OUTCOME MEASURE: Primary endpoint: total score (out of 200 points) on a vignette-based scoring instrument assessing the performance of history, physical, and diagnostic testing on hypothetical stroke and BPPV cases. RESULTS: The efficacy threshold was crossed at the interim analysis. The intervention group had higher performance scores compared with controls (113.2 versus 68.6, p < 0.00001). BPPV and safety subscores were both significantly higher in the intervention group. Sixty-two percent of the intervention group planned to use the DHT versus 29% of controls. After the vignette described characteristic BPPV nystagmus, 100% of the intervention group planned to use the CRM versus 17% of controls. CONCLUSIONS AND RELEVANCE: The educational intervention increased provider performance in dizziness vignettes, including more frequent appropriate use of the DHT/CRM. These findings indicate the intervention positively influenced planned behavior. Future work is needed to implement and evaluate this intervention in clinical practice.

Implementation of evidence-based practice for benign paroxysmal positional vertigo: DIZZTINCT- A study protocol for an exploratory stepped-wedge randomized trial.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, and accounts for 8% of individuals with moderate or severe dizziness. BPPV patients experience substantial inconveniences and disabilities during symptomatic periods. BPPV therapeutic processes - the Dix-Hallpike Test (DHT) and the Canalith Repositioning Maneuver (CRM) - have an evidence base that is at the clinical practice guideline level. The most commonly used CRM is the modified Epley maneuver. The DHT is the gold standard test for BPPV and the CRM is supported by numerous randomized controlled trials and systematic reviews. Despite this, BPPV care processes are underutilized. METHODS/DESIGN: This is a stepped-wedge, randomized clinical trial of a multi-faceted educational and care-process-based intervention designed to improve the guideline-concordant care of patients with BPPV presenting to the emergency department (ED) with dizziness. The unit of randomization and target of intervention is the hospital. After an initial observation period, the six hospitals will undergo the intervention in five waves (two closely integrated hospitals will be paired). The order will be randomized. The primary endpoint is measured at the individual patient level, and is the presence of documentation of either the Dix-Hallpike Test or CRM. The secondary endpoints are referral to a health care provider qualified to treat dizziness for CRM and 90-day stroke rates following an ED dizziness visit. Formative evaluations are also performed to monitor and identify potential and actual influences on the progress and effectiveness of the implementation efforts. DISCUSSION: If this study safely increases documentation of the DHT/CRM, this will be an important step in implementing the use of these evidenced-based processes of care. Positive results will support conducting larger-scale follow-up studies that assess patient outcomes. The data collection also enables evaluation of potential and actual influences on the progress and effectiveness of the implementation efforts. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02809599 . The record was first available to the public on 22 June 2016 prior to the enrollment of the first patients in October 2016.

Preauricular Approach for Cholesteatoma Resection After Surgical Overclosure of the External Auditory Canal and Cochlear Implantation.

: Chronic suppurative otitis media can have long-term effects on hearing if not managed effectively. When combined with cholesteatoma the condition may require creation of an open mastoid cavity. Recurrence of cholesteatoma is a concern when cochlear implantation is performed with overclosure of the external auditory meatus. A 61-year-old female with recurrent cholesteatoma in this setting was treated using a preauricular approach to provide adequate visualization while preventing the need to remove the implant or risking injury to the internal components. This technique would be useful in similar patients to prevent morbidity from removal and reinsertion of a cochlear implant.

Immediate and Long-term Hearing Outcomes With the Middle Cranial Fossa Approach for Vestibular Schwannoma Resection.

OBJECTIVE: To analyze the immediate postoperative and long-term hearing outcome data in patients who have undergone hearing preservation attempts with the middle cranial fossa (MCF) approach for the resection of sporadic vestibular schwannoma. STUDY DESIGN: Retrospective review of a surgical patient cohort. SETTING: Tertiary academic referral center. PATIENTS: Adult patients with unilateral sporadic vestibular schwannoma. INTERVENTION: Surgical treatment with a MCF approach. MAIN OUTCOME MEASURE: Comparison of pre- and postoperative audiometric data in accordance with the 1995 and 2012 American Academy of Otolaryngology/Head and Neck Surgery guidelines on reporting hearing outcomes and with a word recognition score only scale. Long-term hearing outcome data were analyzed in the following postoperative groups: 3 to 5, 6 to 8, 9 to 11, and 12+ years after surgery. RESULTS: From 1999 to 2016, 174 patients underwent the MCF approach and 155 of them met inclusion criteria for analysis of hearing outcome data. Class A or B hearing was preserved in 70% of the entire cohort after recovery. Seventy-one patients with measurable hearing met criteria for long-term data analysis. The rate of American Academy of Otolaryngology/Head and Neck Surgery class A or B hearing preservation was 82% at 3 to 5 years and declined thereafter. The rate of word recognition score class I or II hearing preservation was 98% at 3 to 5 years and declined less rapidly thereafter. Patients with preoperative Class A hearing had significantly higher rates of successful hearing preservation at all postoperative intervals. CONCLUSION: Delayed hearing loss occurs in a progressively increasing fashion but speech understanding remains durable for a majority of patients whose hearing is initially preserved with the MCF approach.

Venous Diverticula Causing Pulsatile Tinnitus Treated With Coil Embolization and Stent Placement With Resolution of Symptoms: Report of Two Cases and Review of the Literature.

OBJECTIVE: To report two cases of pulsatile tinnitus caused by complex venous diverticula with successful treatment via coil embolization and stent placement followed by complete resolution of symptoms. We also review the literature pertaining to venous diverticula causing pulsatile tinnitus treated using endovascular techniques. PATIENTS: Two women patients, aged 27 and 29 years, presented to our institution with 3-month histories of pulsatile tinnitus. In each case, non-invasive imaging and conventional digital subtraction angiography (DSA) confirmed the presence of a complex right transverse-sigmoid sinus junction diverticulum. INTERVENTION: Both patients underwent stent-assisted coil embolization of the venous diverticula. MAIN OUTCOME AND RESULTS: Clinical and DSA follow-up at 6 and 12 months confirmed resolution of symptoms with obliteration of the venous diverticulum. We also performed a PubMed database search for the period January 1995 through June 2016 using the terms pulsatile tinnitus, venous aneurysm/diverticulum, stent-assisted coil embolization, and endovascular treatment and identified reports of 14 additional patients treated using endovascular techniques. CONCLUSIONS: Venous sinus diverticula causing pulsatile tinnitus can be successfully treated with stent-assisted coil embolization with complete resolution of clinical symptoms. This is in concordance with 13 case reports in the literature involving 14 patients with venous sinus diverticula treated using endovascular techniques.

Dizziness Symptom Type Prevalence and Overlap: A US Nationally Representative Survey.

BACKGROUND: The traditional approach to dizziness encourages providers to emphasize the type of dizziness. However, symptom types might substantially overlap in individual patients, thus limiting the clinical value of this approach. We aimed to describe the overlap of types of dizziness using a US nationally representative sample. METHODS: The 2008 US National Health Interview Survey was examined for prevalence and overlap of types of dizziness. The data were also separately examined among people who otherwise had typical features of traditionally vertigo-based disorders (ie, benign paroxysmal positional vertigo and Meniere's disease). Data analysis also included exploratory factor analysis. RESULTS: Twelve-month prevalence of problems with dizziness or balance was 14.8%, representing 33.4 million individuals. The mean number of dizziness symptoms was 2.4 (95% confidence interval [CI], 2.3-2.4), with 61.1% reporting more than one type. Of subjects who otherwise had typical features of traditionally vertigo-based disorders, the mean number of dizziness types was 3.1 (95% CI, 3.0-3.3), and only 24.6% (95% CI, 21.0%-28.7%) reported vertigo as the primary type. Exploratory factor analysis found that symptom types loaded onto a single factor without other clinical or demographic variables. CONCLUSIONS: Substantial overlap of dizziness types exists among US adults with dizziness. People otherwise having features of traditionally vertigo-based disorders also typically report multiple dizziness types and do not typically report vertigo as the primary type. Symptom types correlate more strongly with each other than with other clinical or demographic variables. These findings suggest that the traditional emphasis on dizziness types is likely of limited clinical utility.

Barriers and facilitators to ED physician use of the test and treatment for BPPV.

BACKGROUND: The test and treatment for benign paroxysmal positional vertigo (BPPV) are evidence-based practices supported by clinical guideline statements. Yet these practices are underutilized in the emergency department (ED) and interventions to promote their use are needed. To inform the development of an intervention, we interviewed ED physicians to explore barriers and facilitators to the current use of the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). METHODS: We conducted semi-structured in-person interviews with ED physicians who were recruited at annual ED society meetings in the United States. We analyzed data thematically using qualitative content analysis methods. RESULTS: Based on 50 interviews with ED physicians, barriers that contributed to infrequent use of DHT/CRM that emerged were (1) prior negative experiences or forgetting how to perform them and (2) reliance on the history of present illness to identify BPPV, or using the DHT but misattributing patterns of nystagmus. Based on participants' responses, the principal facilitator of DHT/CRM use was prior positive experiences using these, even if infrequent. When asked which clinical supports would facilitate more frequent use of DHT/CRM, participants agreed supports needed to be brief, readily accessible, and easy to use, and to include well-annotated video examples. CONCLUSIONS: Interventions to promote the use of the DHT/CRM in the ED need to overcome prior negative experiences with the DHT/CRM, overreliance on the history of present illness, and the underuse and misattribution of patterns of nystagmus. Future resources need to be sensitive to provider preferences for succinct information and video examples.

SLC44A2 single nucleotide polymorphisms, isoforms, and expression: Association with severity of Meniere's disease?

SLC44A2 was discovered as the target of an antibody that causes hearing loss. Knockout mice develop age related hearing loss, loss of sensory cells and spiral ganglion neurons. SLC44A2 has polymorphic sites implicated in human disease. Transfusion related acute lung injury (TRALI) is linked to rs2288904 and genome wide association studies link rs2288904 and rs9797861 to venous thromboembolism (VTE), coronary artery disease and stroke. Here we report linkage disequilibrium of rs2288904 with rs3087969 and the association of these SLC44A2 SNPs with Meniere's disease severity. Tissue-specific isoform expression differences suggest that the N-terminal domain is linked to different functions in different cell types. Heterozygosity at rs2288904 CGA/CAA and rs3087969 GAT/GAC showed a trend for association with intractable Meniere's disease compared to less severe disease and to controls. The association of SLC44A2 SNPs with VTE suggests that thrombi affecting cochlear vessels could be a factor in Meniere's disease.

Monothermal Caloric Screening Test Accuracy: A Systematic Review.

OBJECTIVE: To minimize discomfort, time, and costs, vestibular laboratories may perform monothermal caloric irrigations and discontinue testing if responses are symmetric. This systematic review aimed to determine the diagnostic accuracy of the monothermal caloric screening test (MCST) for unilateral vestibular dysfunction compared with bithermal caloric testing (BCT). DATA SOURCES: Ovid-MEDLINE, EMBASE, Scopus, Cochrane CENTRAL, and manual bibliographic searches. REVIEW METHODS: Inclusion criteria specified concurrent MCST and BCT performance and reporting of test measures (monothermal caloric asymmetry, unilateral weakness). The primary outcomes were between-measure correlation, sensitivity, and specificity. Meta-analysis was performed with hierarchical bivariate and univariate random-effects models. Heterogeneity was assessed with the I(2) statistic. RESULTS: Fifteen studies (n = 5572 participants) met inclusion criteria. Thresholds varied between studies. Asymmetries calculated by MCST and BCT were strongly correlated, but a subgroup analysis showed no correlation for those with mild unilateral weakness. The sensitivity and specificity of the MCST ranged from 0.54 to 1.00 and 0.25 to 0.96, respectively. Predictably, higher sensitivity resulted from lower cutoff points for the MCST, higher thresholds for the BCT, and additional test positivity criteria. Warm irrigations yielded higher sensitivity than cool. Studies excluding participants with severe unilateral weakness yielded lower sensitivity estimates. After pooling by threshold, temperature, and risk of bias, most performance estimates remained substantially heterogeneous (I(2) > 60%). CONCLUSION: Accuracy of the MCST is lacking precisely where it is needed most-at the border of normal and abnormal vestibular function. To guide clinical practice, research should include analysis of subgroups with varying levels of function and employ standardized testing parameters.

Otologic Hazards Related to Scuba Diving.

CONTEXT: As of 2015, more than 23 million scuba diver certifications have been issued across the globe. Given the popularity of scuba diving, it is incumbent on every physician to know and understand the specific medical hazards and conditions associated with scuba diving. EVIDENCE ACQUISITION: Sources were obtained from PubMed, MEDLINE, and EBSCO databases from 1956 onward and ranged from diverse fields including otologic reviews and wilderness medicine book chapters. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Otologic hazards can be categorized into barotrauma-related injuries or decompression sickness. CONCLUSION: When combined with a high index of suspicion, the physician can recognize these disorders and promptly initiate proper treatment of the potentially hazardous and irreversible conditions related to scuba diving.

Monothermal Caloric Screening to Improve Healthcare Value.

OBJECTIVES: To evaluate whether monothermal caloric screening can reduce the number of caloric irrigations required in the vestibular testing battery while maintaining diagnostic accuracy. DESIGN: Prospective controlled cohort study. Three hundred and ninety patients referred for vestibular testing at this tertiary referral health system over a 1-year period were evaluated; 24 patients met exclusion or failure criteria and 366 patients were included in the study. Population was 35.6% male; average age was 50.4 years old. Each patient underwent caloric testing using either warm or cool water irrigation initially and this data was used for monothermal screening data. All patients then completed bithermal binaural caloric testing to obtain the "gold standard" bithermal data for comparison. The sensitivity and specificity of monothermal cool or monothermal warm caloric tests were calculated using a receiver operating characteristic curve analysis. RESULTS: Using a monothermal interear difference threshold of 25%, warm monothermal screening had sensitivity of 98.0%, specificity of 91.3%, false negative rate of 2%, and false positive rate of 8.7%. Cool monothermal screening also had excellent sensitivity (92.3%) and specificity (95.3)%, with a false negative rate of 7.7%, and a false positive rate of 4.7%. The diagnosis associated with the single false negative warm monothermal caloric test was compensated vestibular paresis. In the study population, 71.9% had a negative monothermal screen; if the monothermal data were accepted, 2 fewer irrigations would have been performed resulting in an average saving of $264 (typical Medicare reimbursement for 2 irrigations) billed per patient screened as well as shortening the average testing battery by about 15 min. CONCLUSIONS: Warm monothermal caloric screening can reduce time and cost of vestibular testing while nearly matching the diagnostic accuracy of bithermal testing.