Symptoms Underestimate the Presence of Obstructive Sleep Apnea in Patients with Spontaneous Cerebrospinal Fluid Leaks of the Temporal Bone.

OBJECTIVE: To determine the severity of symptoms and degree of obstructive sleep apnea (OSA) in patients with spontaneous cerebrospinal fluid (sCSF) leaks of the temporal bone given the known association between sCSF leaks and OSA. STUDY DESIGN: Retrospective case review. SETTING: Ambulatory clinics in tertiary referral centers. PATIENTS: Polysomnogram testing in 34 consecutive patients who had been diagnosed with sCSF leaks of the temporal bone was examined. Diagnosis of sCSF leak was defined as biochemically confirmed CSF from middle ear fluid with no other obvious source. INTERVENTION: Diagnostic. MAIN OUTCOMES MEASURES: Patient characteristics (age, sex, body mass index, Epworth Sleepiness Scale score, presence of hypoxia, overnight change in blood pressure, and apnea hypopnea index [AHI]) were recorded. Diagnosis of OSA was defined as mild when AHI ≥5 and <15/h, moderate when AHI ≥15 and <30/h, and severe when AHI ≥30/h. RESULTS: Of the 34 patients, 28 (82%) had a confirmed diagnosis of OSA. There was a male predisposition in those with OSA, and 17 of 28 (61%) were male. A majority were overweight, and the mean body mass index was 30.1 (SD, 4.8; range, 23.2-40) kg/m2. The mean severity of OSA was moderate, and the mean AHI was 28.7 (SD, 21.9; range, 5.4-92.8). Of the 28 patients, 13 with OSA (46%) had Epworth Sleepiness Scale scores higher than 8, suggesting that many were asymptomatic for excessive daytime sleepiness at the time of presentation. CONCLUSION: OSA is highly prevalent among patients with sCSF leaks of the temporal bone. Patients with sCSF leaks irrespective of symptoms of OSA should undergo formal polysomnogram testing.

Spontaneous cerebrospinal fluid leaks of the temporal bone - clinical features and management outcomes.

OBJECTIVE: METHODS: A retrospective cohort study over seven-years from 2013 to 2020 was conducted at five tertiary referral centres. Patients identified with biochemically confirmed spontaneous cerebrospinal fluid leaks of the temporal bone manifesting as middle ear fluid with no other obvious cause were included. Demographics (age, gender, body-mass-index), symptomatology, past medical history, examination, investigation (biochemical and radiological), management and outcomes were recorded. RESULTS: 90 adult patients with spontaneous cerebrospinal fluid otorrhoea were identified. Right sided leaks were most common (58%), and a majority of the cohort overweight (mean body-mass-index = 29.2 kg/m2). Unilateral hearing loss was the commonest presenting symptom (81%). Two patients presented to hospital with meningitis presumed secondary to spontaneous cerebrospinal fluid otorrhoea. Over half (54%) of patients were observed who tended to be older (mean age of 71 years vs 62 years) whilst the remainder underwent surgical repair with middle-fossa craniotomy the most common approach (87%). Eight patients managed surgically had recurrent leaks (21%). CONCLUSIONS: This is one of the largest cohorts of spontaneous cerebrospinal fluid otorrhoea reported in the literature and reiterates the importance for clinicians to have a high index of suspicion for this condition in patients presenting with a unilateral middle ear effusion, especially in those who are overweight. Surgical intervention carries a risk of recurrence and further studies are needed to determine the risk of intra-cranial infection in order to guide management.

Patient satisfaction after conversion from warfarin to direct oral anticoagulants for patients on extended duration of anticoagulation for venous thromboembolism - The SWAN Study.

BACKGROUND: Warfarin is an anticoagulant medication proven effective in the initial treatment and secondary prevention of venous thromboembolism. Anti-Xa direct oral anticoagulants are alternatives to warfarin; however there is limited data assessing satisfaction after switching from warfarin to an anti-Xa direct oral anticoagulant in patients for treatment of venous thromboembolism. OBJECTIVES: To assess medication satisfaction in patients requiring anticoagulation for venous thromboembolism after conversion from warfarin to an anti-Xa direct oral anticoagulant. METHODS: A retrospective cohort study with prospective assessment of satisfaction and review of adverse events following anti-Xa direct oral anticoagulant replacement of warfarin for treatment of venous thromboembolism. Out of 165 patients who had switched from warfarin to rivaroxaban or apixaban from an outpatient haematology practice, 126 patients consented for a survey of patient's relative satisfaction of anti-Xa direct oral anticoagulant therapy compared with previous warfarin therapy using the Anti-Clot Burden and Benefits Treatment Scale and SWAN Score. RESULTS: The mean Anti-Clot Burden and Benefits and SWAN Score was 93% (56/60) and 83% (24.8/30) respectively reflecting high satisfaction with anti-Xa direct oral anticoagulants. 120 patients stated preference for anti-Xa direct oral anticoagulants over warfarin. Leading perceptions driving this was the reduction in frequency of medical contact and fewer bleeding side effects. Thirteen patients (10.3%) experienced an adverse event after the anti-Xa direct oral anticoagulant switch (majority were non-major bleeding) but most remained on anti-Xa direct oral anticoagulant treatment after management options were implemented with continued high satisfaction scores. CONCLUSIONS: Patient satisfaction with anti-Xa direct oral anticoagulant therapy for the treatment and prevention of venous thromboembolism after switching from warfarin in routine clinical practice appeared high. Improved patient convenience including reduced frequency of medical contact and fewer unpredictable side effects were perceived as significant advantages of anti-Xa direct oral anticoagulants compared to warfarin.

Supraglottic laryngeal sarcoidosis masquerading as supraglottitis.

Sarcoidosis is a rare multisystem disorder of unknown aetiology characterised by non-caseating granulomas in involved organs; it is a diagnosis of exclusion. Laryngeal involvement affects only 0.5%-5% of those with sarcoidosis. It is an uncommon but important cause of supraglottic inflammation and oedema and should be considered in the differential diagnosis in patients with supraglottitis. This case describes a 30-year-old man who presented with stridor and shortness of breath. Flexible nasendoscopic examination revealed a grossly oedematous, pale pink, diffusely hypertrophied epiglottis. Surgical biopsy revealed non-caseating granulomatous inflammation. In the context of exclusion of hepatitis, anti-neutrophil cytoplasmic antibody (ANCA) positivity, malignancy and mycobacterial infection, the diagnosis of supraglottic laryngeal sarcoid was made. He is being treated with azathioprine immunosuppression with symptomatic improvement.

Non-invasive fungal sinusitis resulting in multiple cranial nerve neuropathies.

A 33-year-old man presented to the emergency department with a right-sided facial paralysis and maxillary division (V2, trigeminal nerve) paraesthesia. He had been suffering with upper respiratory tract symptoms in the preceding 2 months, including rhinorrhoea, fever and headache. The patient was otherwise fit and immunocompetent. Urgent radiological investigation revealed extensive fungal sinusitis with sphenoid sinus dehiscence and skull base osteitis. The patient underwent emergency endoscopic sinus surgery revealing concretions and debris in the ethmoid and sphenoid sinuses. He was commenced on systemic antifungal therapy and made a full recovery with resolution of his cranial neuropathies. The fungus Schizophyllum commune was isolated and is a rare cause of fungal sinusitis, but with the potential for invasive disease in immunosuppressed individuals.

Clear cell chondrosarcoma of the larynx.

Chondrosarcomas represent a group of malignant tumours composed of cells producing cartilage, and clear cell chondrosarcomas (CCC) represent a variant of these. A rare case of a laryngeal CCC is presented. The patient was a 70-year-old man who presented with a 6-week history of throat pain, worsening dysphonia and a lump in the neck. Examination revealed a level 3 neck mass and positron emission tomography imaging revealed a metabolically active right laryngeal mass. Biopsies revealed a cartilaginous neoplasm. The patient underwent total laryngectomy, and the pathology confirmed CCC of the larynx. Chondrosarcomas are the most common type of sarcoma in the larynx but the CCC variant is rare. CCC are usually low-grade tumours affecting long bones, with a male predominance. Less than six cases have been described in the literature affecting the larynx. Management of these malignancies is complete surgical excision given the high risk of local recurrence.

Improvement in lung function following medialisation thyroplasty in a postbilateral lung transplant patient.

A 59-year-old man underwent external medialisation thyroplasty for his left unilateral vocal cord paralysis (UVCP) secondary to recent thoracic surgery. The patient had undergone bilateral lung transplant for idiopathic pulmonary fibrosis and was referred to the ear, nose and throat surgical team with new-onset voice hoarseness. Examination confirmed left UVCP, and after failing conservative management a decision was made to perform external medialisation thyroplasty. Following an uneventful procedure, the patient's phonation returned to normal, and remarkably on spirometry there was evidence of significant improvement in lung function. Despite case series demonstrating subjective improvement in respiration, this is the first documented case, to our knowledge, of significant improvement in spirometry following this procedure.

Predicting sequential bilateral cochlear implantation performance in postlingually deafened adults; A retrospective cohort study.

OBJECTIVE: To identify which preoperative patient characteristics influence sequential bilateral cochlear implantation performance and to create a statistical model that predicts benefit. DESIGN: Multicentre retrospective cohort study. SETTING: All patients were operated in four academic teaching hospitals in Perth, Australia, and followed up by audiologists of the Ear Science Institute Australia. PARTICIPANTS: A total of 92 postlingually deafened adult patients who had undergone sequential cochlear implantations between 19 June 1990 and 14 March 2016 were included. Patients were excluded if the 12-month follow-up consonant-nucleus-consonant (CNC) phoneme score was missing. MAIN OUTCOME MEASURE: The effect of 18 preoperative factors on the CNC phoneme score in quiet (at 65 dB SPL) with the second cochlear implant (CI2) one year after implantation. RESULTS: Two factors were positively correlated to speech understanding with CI2: Wearing a hearing aid (HA) before receiving CI2 (r = 0.46, P = 0.00) and the maximum CNC phoneme score with the first CI (CI1) (r = 0.21, P = 0.05). Two factors were negatively correlated: the length of hearing loss before CI2 in the second implanted ear (r = -0.25, P = 0.02) and preoperative pure tone average (PTA) (0.5, 1, 2 kHz) before CI2 in the second implanted ear (r = -0.27, P = 0.01). The following model could be created: predicted CNC phoneme score with CI2 (%) = 16 + (44 * HA use before CI2 (yes)) - (0.22 * length of hearing loss before CI2 (years)) + (0.23 * CNC phoneme score with CI1 (%)). Because the effect of HA use before implantation played such a major role, we also created a model after exclusion of the HA factor: Predicted CNC phoneme score with CI2 (%) = 82 - (0.17 * length of hearing loss before CI2 (years)) - (0.27 * PTA in second implanted ear before CI2 (0.5, 1, 2 kHz)) + (0.20 * CNC phoneme score with CI1 (%)). CONCLUSION: Advanced age or a long interval between implantations does not necessarily lead to poor CI2 results. Patients who are successful HA users before CI2, who have a low PTA before CI2, a high CNC phoneme score with CI1 and a limited length of hearing loss before CI2, are likely to be successful CI2 recipients.

Predicting Sequential Cochlear Implantation Performance: A Systematic Review.

This systematic review of the literature reveals which pre-operative factors affect sequential cochlear implantation outcomes in adults. The findings can help health care prof-essionals provide evidence-based advice on the expected benefits from a second cochlear implant (CI). We searched PubMed, EMBASE, and the Cochrane database from November 1977 to August 26, 2017, using the terms "sequential cochlear implantation"; the most frequently cited predictors for unilateral cochlear implantation performance and other potential predictors for sequential implantation outcome; and "speech perception," "localization" as well as synonyms of all of the above. Ten studies were included. The effects of age, duration of hearing loss, time between implantations, preoperative hearing, etiology of hearing loss, hearing aid use and duration of follow-up on sequential cochlear implantation performance were studied. The literature has shown that duration of deafness, age at onset of deafness, etiology of hearing loss, and preoperative speech perception score are (inversely) related to unilateral cochlear implantation outcome in adults. One would expect that these factors would also affect sequential bilateral implantation outcome. However, the best available evidence to date shows that advanced age, a long duration of deafness, or a long interval between implantations should not be considered negative factors when considering sequential bilateral cochlear implantation.