Google Trends Analysis of Otologic Symptom Searches Following COVID-19.

Introduction: COVID-19 infection was accompanied by otologic symptoms, a pattern that was captured early by Google Trends. The objective of this study is to investigate searches for otologic symptoms and identify correlations with the pandemic onset. Materials and Methods: Search interest for otologic symptoms was gathered using Google Trends from two years before and two years following the pandemic start date. A two-tailed Mann-Whitney U test was used to identify significant changes and effect size. Results: In total, search interest for 14 terms was collected, with significant changes identified in 11. Six terms showed increased search interest, with the most significant rises observed for headache (r=0.589, p<0.001), dizziness (r=0.554, p<0.001), and tinnitus (r=0.410, p<0.001). Search interest decreased for five terms, with the most notable declines found in searches for migraine headache (r=0.35, p<0.001) and phonophobia (r=0.22, p=0.002). No significant changes were seen in ear pressure (p=0.142), neck pain (p=0.935), and sudden hearing loss (p=0.863) searches. Conclusion: COVID-19 infection is often accompanied otologic symptoms and holds a diagnostic role. Fluctuating search interest may be attributed to a true increase in cases, media trends, or people's desires to stay informed. Google Trends robustly captured trends in search interest and presented itself as a valuable epidemiological tool.

Conservative Management of Acute Sports-Related Concussions: A Narrative Review.

This review explores the application of the conservative management model for pain to sports-related concussions (SRCs), framing concussions as a distinct form of pain syndrome with a pathophysiological foundation in central sensitization. Drawing parallels with proven pain management models, we underscore the significance of a proactive approach to concussion management. Recognizing concussions as a pain syndrome allows for the tailoring of interventions in alignment with conservative principles. This review first covers the epidemiology and controversies surrounding prolonged concussion recovery and persistent post-concussion symptoms (PPCS). Next, the pathophysiology of concussions is presented within the central sensitization framework, emphasizing the need for early intervention to mitigate the neuroplastic changes that lead to heightened pain sensitivity. Five components of the central sensitization process specific to concussion injuries are highlighted as targets for conservative interventions in the acute period: peripheral sensitization, cerebral metabolic dysfunction, neuroinflammation, glymphatic system dysfunction, and pain catastrophizing. These proactive interventions are emphasized as pivotal in accelerating concussion recovery and reducing the risk of prolonged symptoms and PPCS, in line with the philosophy of conservative management.

Reply to Theodorou et al. Comment on "Umemoto et al. Management of Migraine-Associated Vestibulocochlear Disorders. Audiol. Res. 2023, 13, 528-545".

We thank the authors for their insightful and thoughtful commentary on our recent publication [...].

A Novel Technique of Reduction Meatoplasty for Correction of Very Large Meatus from a Previous Canal Wall-Down Mastoidectomy.

OBJECTIVE: To evaluate the efficacy of reduction meatoplasty, a novel technique aiming to improve the usage of molded hearing aids and ear plugs in patients undergoing mastoid obliteration of a previous canal wall-down (CWD) mastoidectomy, complicated with a very large meatus. PATIENTS: Twenty-six patients from a tertiary care neurotology clinic with a very large meatus from a previous CWD mastoidectomy, who were unable to use molded hearing aids or ear plugs for water protection. INTERVENTION: Reduction meatoplasty after mastoid obliteration (cartilage strips and bone pate) of the CWD mastoidectomy. The procedure involves removing a wedge of skin and underlying soft tissue superiorly in the meatus. MAIN OUTCOME MEASURES: Reduction in meatus size, enabling usage of hearing aids and ear plugs. RESULTS: Twenty-six patients underwent mastoid obliteration and reduction meatoplasty to reduce meatus size. Patients were followed up for an average of 22 months postoperation. After operation, the meatus size was significantly reduced in all patients, enabling usage of over-the-counter ear plugs. In addition, all six patients with hearing aids could use standard occlusive hearing aid domes without requiring molded hearing aids. No patients showed symptoms of chronic infection in the mastoid cavity during the follow-up period. CONCLUSIONS: Results of reduction meatoplasty showed significant improvements in functionality of the external auditory meatus, indicating that this technique is effective in reducing meatus size and improving the normal meatal anatomy after mastoid obliteration.

Migraine management for the otolaryngologist.

Objective: To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine. Methods: Narrative review of available literature. Results: Migraine disorder can be described as a spectrum of otologic manifestations, with vestibular migraine now recognized with fully-fledged diagnostic criteria. Otologic manifestations are theorized to be due, in part, to trigeminal innervation of the inner ear structures and calcitonin gene-related peptide (CGRP) expression within the labyrinth. Patients can experience vertigo, aural fullness, enhanced tinnitus, and hearing loss without the characteristic migraine headache, leading to under recognition of these symptoms as migraine-related. Meniere's disease, mal de débarquement syndrome, persistent postural perceptual dizziness, and recurrent benign paroxysmal positional vertigo have close associations to migraine and may exist on the migraine spectrum. Migraine treatment consists of two goals: halting acute attacks (abortive therapy) and preventing attacks (prophylactic therapy). Abortive medications include triptans, corticosteroids, anti-histamines, and anti-emetics. Pharmacologic prophylaxis in conjunction with lifestyle modifications can decrease frequency and severity of symptoms and include tricyclic antidepressants, calcium channel blockers, anti-epileptic medications, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, beta-blockers, gepants, and monoclonal antibodies to CGRP. Promising evidence is emerging regarding the ability of migraine medications to positively treat the various otologic symptoms of migraine. Conclusion: Migraine disorder manifesting with primarily cochleovestibular symptoms can be challenging to diagnose and manage for practicing clinicians. Patients with various vestibulopathies that are closely related to migraine may benefit from migraine treatment. Lifestyle choices and prophylactic medications are key to satisfactorily preventing acute migrainous attacks and improve function.

Cogan Syndrome: A Case Study and Review of the Literature.

Cogan syndrome is an autoimmune disease characterized by vestibular symptoms, bilateral sensorineural hearing loss, and inflammatory ocular manifestations, which may be accompanied by systemic vasculitis. We herein present the case of a patient with bilateral sensorineural hearing loss who presented with pain over her cochlear implantation incision site. She was later found to have evidence of ocular disease and underlying vasculitis leading to a diagnosis of Cogan syndrome.

Triamcinolone Injection for Cochlear Implant Magnet Adherence Issues.

OBJECTIVES: To evaluate the effectiveness of triamcinolone injections in treating external magnet displacement in cochlear implant (CI) patients with adhesions problems of their processor. PATIENTS: We present seven CI patients with magnet adhesion issues who presented to our tertiary care neurotology clinic. None of the patients had a history of head trauma, postimplant MRI, or surgery in the head and neck other than the cochlear implantation. INTERVENTION: Triamcinolone 40 mg/mL injected subcutaneously at the CI magnet site. MAIN OUTCOME MEASURE: Reduction of scalp thickness and successful magnet retention. RESULTS: Our cohort consisted of seven patients (eight implant sites) of which five were overweight or obese. The temporoparietal scalp thickness measured on preoperative CT scans varied between 8.4 and 15.9 mm. Initial conservative measures such as hair shaving at the magnet site, using a headband, and increasing magnet strength failed in all patients. After receiving triamcinolone injections at the CI receiver site, six out of seven patients (seven out of eight CI sites) were able to use their processor again without the need for a headband for an average of 9.55 hours/day. The average number of injections required for each patient was 2.57 (SD = 2.18), median (range) = 1 (1-7). One patient required a flap thinning surgery but showed no improvement even after flap thinning. None of the patients showed skin irritation, breakdown, ulceration, necrosis, or magnet exposure during follow-up period. CONCLUSIONS: The significant improvement in CI retention shows that triamcinolone injections are effective in making the subcutaneous tissue thinner and allowing magnet retention.

Management of Migraine-Associated Vestibulocochlear Disorders.

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

Meniere's disease is a manifestation of migraine.

PURPOSE OF REVIEW: To discuss the theory that Meniere's disease (MD) is a variation of otologic migraine rather than an isolated inner ear condition. RECENT FINDINGS: In contrast to the approximately 12% of the general population suffering from migraine headaches, 51-60% of patients with MD experience migraine headaches. While pathognomonic for MD, endolymphatic hydrops has also been identified in patients with vestibular migraine. Treatment with the integrative neurosensory rehabilitation approach (diet and lifestyle changes, magnesium and riboflavin supplementation, and when needed, prophylactic medication) to treat the underlying migraine process has been highly effective in patients with MD. SUMMARY: MD can be understood as a manifestation of migraine such that patients with MD can be effectively treated with migraine therapies.

Correlation Between Laterality of Hearing Loss and Migraine Features in Menière's Disease.

OBJECTIVES: The objective of this study is to understand whether the hearing loss laterality in Menière's disease (MD) correlates with migraine symptoms laterality such as headache, neck stiffness, and otalgia. METHODS: We performed a retrospective review of prospectively obtained data on patients presenting between September 2015 and October 2021 with definite or probable MD. A custom-designed, comprehensive questionnaire was used to identify patients' migraine-related symptoms. The clinical and audiometric data were used to diagnose patients with definite or probable MD using criteria set by the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: In total, 113 patients with definite or probable MD were included in the study. The mean age of the patients was 60 ± 15 years with no gender predominance (49.6% male and 50.4% female). A total of 57 (50%) patients were presented with headaches. Among the migraine headache cohort, headache and otalgia were on the same side as the MD ear affected by hearing loss. In addition, in patients who present with otalgia as the primary feature of headache, otalgia was more likely to be on the same side as the ear affected by the hearing loss. CONCLUSIONS: The high prevalence of migraine symptoms on the same side of the ear affected by MD among this cohort could suggest a shared pathophysiology in both MD and migraine, possibly involving migraine-related changes in both the cochlea and vestibule.

A proposed association between subjective nonpulsatile tinnitus and migraine.

Objective: Tinnitus is defined as the perception of sound in the absence of an external source. We propose the hypothesis that migraine can cause exacerbation of tinnitus in some patients. Methods: English literature from PubMed has been reviewed. Results: Studies have reported a high prevalence of cochlear symptoms in patients with migraine headaches and up to 45% of tinnitus patients have been shown to concomitantly suffer from migraine. Both conditions are thought to stem from central nervous system disturbances, involving disruption of the auditory and trigeminal nerve pathways. One proposed mechanism of this association is the modulation of sound sensitivity by trigeminal nerve activation of the auditory cortex during migraine attacks, resulting in tinnitus fluctuation in some patients. Increased brain and inner ear vascular permeability resulting from trigeminal nerve inflammation, can also cause observed headache and auditory symptoms. Tinnitus and migraine also share a number of symptom triggers including stress, sleep disturbances, and dietary factors. These shared features may help explain promising results of migraine therapies for the treatment of tinnitus. Conclusion: Given the complex association between tinnitus and migraine, further investigation is needed to identify the underlying mechanisms and determine the optimal treatment strategies for managing migraine-related tinnitus patients.

Audiometric Validation of a Smart Watch Decibel Meter.

This diagnostic study assesses the performance of the Apple Watch Noise application in comparison with a class 1 sound level meter.

Treatment of Stapedial Myoclonus as a Migraine-Related Phenomenon.

OBJECTIVE: To describe a case series of patients with stapedial myoclonus (SM) whose conditions improved after prophylactic migraine treatment. PATIENTS: We present seven cases of SM reported from a tertiary care neurotology clinic. All seven patients reported SM triggers similar to those of migraine headaches and suffered from concomitant headaches and/or vertigo, and were thus treated with a standard migraine protocol used at this neurotology clinic. INTERVENTION: Prophylactic migraine treatment. MAIN OUTCOME MEASURES: Reduction or resolution of SM. RESULTS: In this series, seven patients with SM were included. Six of seven subjects were male (86%), with a mean age at presentation of 44 years. Four patients noted significant improvement in their symptoms, with a reduced frequency, duration, and intensity of their symptoms with the migraine regimen. Three patients experienced complete resolution of SM with their migraine treatment. CONCLUSION: We report that treatment with prophylactic migraine treatment can provide long-term relief for patients with SM, which may suggest an etiological association between migraine and SM as well as a possible treatment for SM.

Tympanostomy tube placement for pressure-sensitive vertigo.

Objective: To evaluate tympanostomy tube placement in patients with pressure-sensitive vertigo. Methods: Retrospective case series. Results: Six patients with pressure-sensitive vertigo reported resolution of their vertigo and other vestibular symptoms after placement of the tympanostomy tubes. All recurrences of symptoms were due to either extrusion or plugging of the tubes. All patients fulfilled the criteria for vestibular migraine. None of the patients had superior canal dehiscence on imaging or precedent event that triggered the problem, and all had a negative fistula test. Conclusion: Tympanostomy tube placement should be considered in selected patients with vertigo exacerbated by seemingly small changes in atmospheric pressure (e.g., just prior to thunderstorms, air travel, or travel to the mountains). By eliminating the capability of the tympanic membrane to sense changes in pressure with a tube, patients with pressure-induced vertigo (in the absence of perilymph fistula or superior canal dehiscence) may have relief of their symptoms.

Selective Neural Electrical Stimulation of an Injured Facial Nerve Using Chronically Implanted Dual Cuff Electrodes.

Facial nerve (FN) injury can lead to debilitating and permanent facial paresis/paralysis (FP), where facial muscles progressively lose tone, atrophy, and ultimately reduce to scar tissue. Despite considerable efforts in the recent decades, therapies for FP still possess high failure rates and provide inadequate recovery of muscle function. In this pilot study, we used a feline model to demonstrate the potential for chronically implanted multichannel dual-cuff electrodes (MCE) to selectively stimulate injured facial nerves at low current intensities to avoid stimulus-induced neural injury. Selective facial muscle activation was achieved over six months after FN injury and MCE implantation in two domestic shorthaired cats (Felis catus). Through utilization of bipolar stimulation, specific muscles were activated at significantly lower electrical currents than was achievable with single channel stimulation. Moreover, interval increases in subthreshold current intensities using bipolar stimulation enabled a graded EMG voltage response while maintaining muscle selectivity. Histological examination of neural tissue at implant sites showed no appreciable signs of stimulation-induced nerve injury. Thus, by selectively activating facial musculature six months following initial FN injury and MCE implantation, we demonstrated the potential for our neural stimulator system to be safely and effectively applied to the chronic setting, with implications for FP treatment.

Approaches to Mitigate Mitochondrial Dysfunction in Sensorineural Hearing Loss.

Mitochondria are highly dynamic multifaceted organelles with various functions including cellular energy metabolism, reactive oxygen species (ROS) generation, calcium homeostasis, and apoptosis. Because of these diverse functions, mitochondria are key regulators of cell survival and death, and their dysfunction is implicated in numerous diseases, particularly neurodegenerative disorders such as Alzheimer's Disease, Parkinson's Disease, and Huntington's Disease. One of the most common neurodegenerative disorders is sensorineural hearing loss (SNHL). SNHL primarily originates from the degenerative changes in the cochlea, which is the auditory portion of the inner ear. Many cochlear cells contain an abundance of mitochondria and are metabolically highly active, rendering them susceptible to mitochondrial dysfunction. Indeed, the causal role of mitochondrial dysfunction in SNHL progression is well established, and therefore, targeted for treatment. In this review, we aim to compile the emerging findings in the literature indicating the role of mitochondrial dysfunction in the progression of sensorineural hearing loss and highlight potential therapeutics targeting mitochondrial dysfunction for hearing loss treatment.

Use of a Novel Clinical Decision-Making Tool in Vestibular Schwannoma Treatment.

OBJECTIVE: To determine the usefulness of a personalized tool and its effect on the decision-making process for those with vestibular schwannoma (VS). STUDY DESIGN: Prospective study. SETTING: Single institution, academic tertiary care lateral skull base surgery program. PATIENTS: Patients diagnosed with VS. INTERVENTIONS: A comprehensive clinical decision support (CDS) tool was constructed from a previously published retrospective patient-reported data obtained from members of the Acoustic Neuroma Association from January to March 2017. Demographic, tumor, and treatment modality data, including associated side effects, were collected for 775 patients and integrated in an interactive and personalized web-based tool. MAIN OUTCOME MEASURES: Pre- and posttool questionnaires assessing the process of deciding treatment for VS using a decisional conflict scale (DCS) and satisfaction with decision (SWD) scale were compared. RESULTS: A pilot study of 33 patients evaluated at a single institution tertiary care center with mean ± SD age of 63.9 ± 13.5 years and with average tumor size of 7.11 ± 4.75 mm were surveyed. CDS implementation resulted in a mean ± SD total DCS score decrease from 43.6 ± 15.5 to 37.6 ± 16.4 ( p < 0.01) and total SWD score increase from 82.8 ± 16.1 to 86.2 ± 14.4 ( p = 0.04), indicating a significant decrease in decisional conflict and increase in satisfaction. CONCLUSIONS: Implementing a decision-making tool after diagnosis of VS reduced decisional conflict and improved satisfaction with decision. Patients considered the tool to be an aid to their medical knowledge, further improving their comfort and understanding of their treatment options. These findings provide a basis for developing predictive tools that will assist patients in making informed medical decisions in the future.

Migrainous Vertigo, Tinnitus, and Ear Symptoms and Alternatives.

Migraine headaches frequently coexist with vestibular symptoms such as vertigo, motion sickness, and gait instability. Migraine-related vasospasm can also damage the inner ear, which results in symptoms such as sudden sensorineural hearing loss and resultant tinnitus. The pathophysiology of these symptoms is not yet fully understood, and despite their prevalence, there is no universally approved management. This review summarizes the data on complementary and integrative medicine in treating patients with migrainous ear disorders.

Cholesteatoma With Cochlear Fistula and Carotid Dehiscence.

Cholesteatomas are non-neoplastic, invasive lesions created by the accumulation of keratinized squamous epithelium in the temporal bone. If left untreated, its expansion may cause local destruction of the surrounding structures, eventually leading to inner ear fistula, dehiscence of tegmen and possible intracranial pathology, and facial nerve paralysis. Surgical resection is the mainstay of curative treatment. We hereby present a case of a giant cholesteatoma in a 62-year-old patient who presented with a right-sided hemifacial spasm with later paralysis who was treated with botulinum toxin injection by a neurologist. CT scan imaging showed a very large cholesteatoma with involvement of the carotid canal, cochlea, and geniculate ganglion. The patient underwent transmastoid and subarcuate approach for resection which led to marked improvement of her symptoms.