Otology/Neurotology recommendations - Choosing Wisely campaign.

The Choosing Wisely Canada Campaign aims to raise awareness amongst physicians and patients regarding unnecessary tests and treatment. The otology/neurotology subspecialty group within the Canadian Society of Otolaryngology - Head & Neck Society developed a list of five common otologic presentations to help physicians deliver high quality effective care: (1) Don't order specialized audiometric and vestibular testing to screen for peripheral vestibular disease, (2) Don't perform computed tomography or blood work in the evaluation of sudden sensorineural hearing loss, (3) Don't perform auditory brain responses (ABR) in patients with asymmetrical hearing loss, (4) Don't prescribe oral antibiotics as first line treatment for patients with painless otorrhea associated with tympanic membrane perforation or tympanostomy tube, and (5) Don't perform particle repositioning maneuvers without a clinical diagnosis of posterior canal benign paroxysmal positional vertigo.

Auditory effects of autologous fat graft for TORP stabilization in the middle ear: a cadaveric study.

BACKGROUND: Total ossicular replacement prostheses (TORP) are often used to re-establish ossicular coupling of sound in an ear lacking a stapes supra-structure. The use of TORPs, however, is associated with a 2/3 five year failure rate due to their anatomic instability over time in the middle ear. The use of autologous fat to try and stabilize TORPs may improve long-term results with this challenging ossicular reconstruction technique. METHODS: A cadaveric temporal bone model was developed and laser Doppler vibrometry was used to measure and record round window membrane vibration in response to sound stimulation under the following conditions: normal middle ear, middle ear filled with fat, normal middle ear with TORP prosthesis, TORP prosthesis with fat around its distal end and TORP prosthesis with fat filling the middle ear. Fourteen temporal bones were used. RESULTS: There was a significant decrease in round window membrane velocity after filling the middle ear with fat in both the normal middle ear (- 8.6 dB; p < 0.0001) and prosthesis conditions (- 13.7 dB; p < 0.0001). However, there was no significant drop in round window membrane velocity associated with using fat around the distal end of the TORP prosthesis as compared to the prosthesis without fat condition (p > 0.05). CONCLUSIONS: Autologous fat around the distal end of a TORP prosthesis may not be associated with any additional hearing loss, as demonstrated in this cadaveric model. The additional hearing loss potentially caused by using fat to completely surround the prosthesis and fill the middle ear is probably not clinically acceptable at this time, especially given the unknown way in which the fat will atrophy over time in this context.

Is Hospitalization Necessary after Ear Surgery? A National Survey and Retrospective Review of Postoperative Events.

Objective First, to survey our national otolaryngology colleagues on their postoperative care habits (hospitalization vs day surgery) after elective middle ear surgery. Second, to evaluate the necessity of hospitalization and safety of day surgery after these procedures. Methods A national survey regarding postoperative habits after elective middle ear surgery was launched. Then, the cases of all patients having undergone these surgical procedures at our center between 2010 and 2016 were reviewed. They were divided into 2 groups: hospitalization and day surgery. Postoperative events during hospitalization and rate of consultation/readmission for day surgery were recorded. Results Heterogeneity in postoperative habits for most elective otologic surgery exists among otolaryngologists. For tympanoplasty, however, day surgery was uniformly favored. At our institution, 88.6% of hospitalization patients had no complications during their stay. Complications noted for others were nausea (7.2%), bleeding (3.1%), hematoma (0.5%), and sensorineural hearing loss (0.5%). In the day surgery group, 3.0% consulted within 48 hours following their procedure, and the readmission rate was 1.3%. Nausea was the only cause for readmission, and stapes surgery accounted for 100% of readmissions. Discussion Most elective middle ear surgery can be safely performed as day care. Hospitalization does not provide care that could not have been provided at home in the majority of cases. Overnight hospital stay may be considered for stapes surgery. Implications for Practice Day surgery for elective middle ear surgery is sufficient for most cases. Transferring these cases to day care should lower costs to our health care system and increase bed availability.

Symptom Resolution Rates of Posttraumatic versus Nontraumatic Benign Paroxysmal Positional Vertigo: A Systematic Review.

OBJECTIVE: To determine the rate of symptom resolution in patients with posttraumatic benign paroxysmal positional vertigo (BPPV) and to determine if it differs from resolution rates in patients with BPPV and without a history of head trauma. DATA SOURCES: Systematic review of the literature was performed using Medline, EMBASE, and Cochrane databases. English and French articles meeting inclusion criteria and published between 1946 and October 2014 were included. REVIEW METHODS: Data were independently extracted from the articles by 2 reviewers using data collection forms developed a priori. Inclusion and exclusion criteria were decided a priori. Studies were included if they reported on at least 1 case of posttraumatic BPPV (t-BPPV), reported on outcomes of all patients with t-BPPV, had a clearly defined inception point, and provided a clear diagnosis of BPPV (defined a priori by reviewers). RESULTS: A total of 3017 titles, 362 abstracts, and 67 articles were reviewed, from which 16 articles met inclusion criteria and underwent data extraction. There were a total of 207 patients with posttraumatic BPPV identified. Among the 207 patients, 151 (73%) had resolution of symptoms. The T-BPPV patients may have more multi-canal involvement and may require more repositioning maneuvers for resolution compared to patients with nontraumatic BPPV. CONCLUSIONS: Available evidence does not support the notion that symptom resolution rates in patients with posttraumatic BPPV are worse than those with nontraumatic BPPV. However, well-designed studies with adequate cohorts are lacking. Additional well-executed studies are needed to confirm this lack of difference in resolution rates.

Voluntary eardrum movement: a marker for tensor tympani contraction?

HYPOTHESIS: Voluntary eardrum movement (VEM) and resultant tympanometric changes reflect tensor tympani (TT) contraction. BACKGROUND: TT contraction has been hypothesized to cause symptoms of aural fullness, tinnitus, clicking, and even vertigo despite the lack of understanding of how it functions or what causes it to contract. Identifying tympanometric changes unique to TT contraction can provide a diagnostic tool for identifying its role in pathologic conditions. METHODS: Various tympanometric measurements were performed on human subjects who could voluntarily move their eardrums. These were compared with similar tympanometric measurements performed on cadaveric temporal bones while manually tensing the TT and stapedius muscles individually. RESULTS: Eight subjects (14 ears) who could cause VEM were identified. Compared with baseline, VEM resulted in significantly decreased middle ear compliance (p < 0.01) and middle ear pressure (p < 0.01) measurements. The compliance changes seen with VEM were larger than those seen with acoustically stimulated stapedius contraction. Finally, the direction of compliance change with VEM was dependent on the pressure applied to the external auditory canal (EAC), with compliance increasing with positive EAC pressure. This was not seen with stapedius contraction. These findings were reproduced using the cadaveric temporal bone model: larger compliance changes with pull on TT as compared with stapedius with neutral EAC probe pressure; change in direction of compliance changes with varying EAC probe pressure with TT pull, not with stapedius pull. CONCLUSION: TT contraction produces distinctive tympanometric findings that can be used to support its abnormal contraction in ears with symptoms compatible with TT syndrome.

Vocalization-induced stapedius contraction.

OBJECTIVE: To present a case of a patient with visible stapedius contraction on vocalization and to discuss the related literature. PATIENTS: A 51 year-old woman with a Type III myringostapediopexy due to chronic suppurative otitis media and an incidental finding of voice-induced movement of the stapes head. INTERVENTIONS: Otoendoscopy, pure tone and impedance audiometry, and modified stapedius reflex decay. MAIN OUTCOME MEASURE: Stapes head movement on otoendoscopy. RESULTS: Stapes head movement was seen endoscopically on vocalization but not on tympanometric measures. CONCLUSION: Visible stapedius contraction with vocalization is an uncommon phenomenon. Our understanding of the nonauditory pathways to stapedius is limited and requires further research.

Insights into horizontal canal benign paroxysmal positional vertigo from a human case report.

For horizontal canal benign paroxysmal positional vertigo, determination of the pathologic side is difficult and based on many physiological assumptions. This article reports findings on a patient who had one dysfunctional inner ear and who presented with horizontal canal benign paroxysmal positional vertigo, giving us a relatively pure model for observing nystagmus arising in a subject in whom the affected side is known a priori. It is an interesting human model corroborating theories of nystagmus generation in this pathology and also serves to validate Ewald's second law in a living human subject.

Otologic safety of manuka honey.

OBJECTIVE: To investigate the possible ototoxic effects of a 50% concentration of manuka honey in a chinchilla animal model. STUDY DESIGN: A prospective, controlled animal study. SETTING: The Research Institute of the Montreal Children's Hospital, McGill University Health Centre. SUBJECTS AND METHODS: Eight animals had myringotomy incisions in both ears. One ear was randomly assigned to receive the 50% manuka honey solution. The contralateral ear received saline and served as the control ear. OUTCOME MEASURES: Auditory brainstem evoked responses (ABRs) were measured bilaterally for a wide range of frequencies (between 8 and 25 kHz) before and 2 weeks after transtympanic manuka honey and saline application. The animals were sacrificed, and all cochleae were dissected out and processed for light and scanning electron microscopy (SEM). RESULTS: The measured ABR thresholds after the application of 50% concentration of manuka honey revealed severe ototoxicity in all honey-exposed ears. This was accompanied by gross physical changes and histologic evidence of hair cell toxicity on SEM and light microscopy. The control ears remained unchanged during the period of the experiment. CONCLUSION: Although 50% concentration of manuka honey is the proven concentration to have bactericidal properties against biofilms of Pseudomonas aeruginosa and Staphylococcus aureus, this concentration appeared to have caused severe or intense inflammatory changes that produced facial paralysis, vestibulotoxicity, and hearing loss.

Vocal cord adduction causing obstructive sleep apnea from vagal nerve stimulation: case report.

A recognized complication of vagal nerve stimulation is new or worsening sleep apnea. Its pathophysiology is not clearly understood. We report a patient with obstructive sleep apnea that was directly associated with vagal nerve stimulation causing recurring vocal cord adduction. Adjusting the stimulator settings resolved the problem.

Ablative free thyroxine to thyroglobulin ratio as a predictor of differentiated thyroid cancer recurrence.

BACKGROUND: Serum thyroglobulin (Tg), a widely used thyroid cancer marker, is limited at the time of ablation, unable to differentiate between diseased and normal residual tissue. OBJECTIVE: We evaluated the use of the ablation free thyroxine to thyroglobulin ratio (fT4:Tg) as a tumour-specific ratio for predicting persistence or recurrence in differentiated thyroid cancer. DESIGN: Retrospective chart review. SETTING: McGill University Health Centre. METHODS: Of 234 patients, 84 were analyzed after exclusion of those with anti-Tg antibodies, ablation Tg < or = 2, and follow-up < 3 months. Ablation thyroxine and Tg levels were recorded and patients were followed to detect recurrence. The relationship between the ablation fT4:thyroglobulin ratio and recurrence was evaluated. MAIN OUTCOME MEASURES: Hazards ratio (HR) for predictive fT4:Tg ratio cutoff value and disease-free survival based on the fT4:Tg ratio. RESULTS: Thirty-eight percent of patients developed recurrence: 8 pathologically proven and 24 suspected. Eighty-one percent of patients with recurrence had an fT4:Tg < 27%, in contrast to 23% of those without recurrence (HR 6.2; p < .001). Of all patients with fT4:Tg < 27%, 68% developed evidence of recurrence compared with 13% with fT4:Tg > or = 27% (p < .001). Recurrences in the fT4:Tg < 27% group occurred twice as early. CONCLUSION: Ablation fT4:Tg < 27% is predictive of recurrence and should be used to identify high-risk patients.