Menière's disease treated by grommet insertion.

INTRODUCTION: Menière's disease (MD) is an uncommon cause of sudden profound vertigo. A variety of medical and surgical treatments have been used to manage this condition. This study reviewed the outcomes of patients treated with grommet insertion and transtympanic steroid injection. METHODS: Patients diagnosed with MD between 2007 and 2017 were identified, and case notes and audiological data were retrieved for those managed by grommet (ventilation tube) insertion with and without transtympanic steroid injection. RESULTS: Thirty-three patients were identified as being diagnosed with MD. Grommet insertion resulted in cessation or improvement of attacks in 91% of cases. The mean follow-up duration was 33.8 months (median: 29 months). The mean hearing threshold across the low frequencies improved from 57.2dBHL to 49.4dBHL (p=0.031). Following the intervention, improved tinnitus was reported in 80% of cases. Twelve patients (36%) reported aural fullness prior to grommet insertion; all reported improved symptoms following the procedure. CONCLUSIONS: Early grommet insertion with transtympanic steroid injection, combined with customised vestibular physiotherapy, may provide an alternative first-line strategy for MD, preventing further true MD attacks. In some patients, it may significantly improve hearing thresholds.

Assessing the Unterberger test: introduction of a novel smartphone application.

BACKGROUND: Peripheral vestibular function is commonly assessed using the Unterberger test. Patients are asked to march on the spot and their extent of rotation is recorded. The sensitivity of this test depends on an assessor accurately estimating the degree of rotation. This study therefore aimed to compare observer estimates with a smartphone application (DplusR Balance) that accurately records rotation. METHOD: Twenty-five participants were asked to estimate the degree of rotation in 10 successive Unterberger tests performed by a volunteer. RESULTS: The average difference between estimated and application recorded extent of rotation was 30°. CONCLUSION: Assessors poorly estimate the degree of rotation in this clinical test, to an extent sufficient to affect clinical interpretation and diagnosis. We recommend the use of this application or alternative methods to record the degree of rotation in patients.

Hearing outcomes following primary malleostapedial rotation ossiculoplasty in patients undergoing modified radical mastoidectomy.

INTRODUCTION: Treatment of cholesteatoma consists of either excision or exteriorisation of disease. Approaches have traditionally included a radical or modified radical mastoidectomy and combined approach tympanoplasty. Hearing thresholds following a modified radical mastoidectomy alone have been reported as poor. We assessed hearing outcomes in patients undergoing a primary malleostapedial reconstruction combined with their open cavity surgery. METHODS: All patients undergoing open cavity mastoidectomy with primary malleostapedial rotation ossiculoplasty between 2009 and 2013 were identified. Case notes were reviewed, and demographic data, recurrence rate and audiometry were recorded. RESULTS: Twenty-one patients were identified. The age range was 10-65 years. There was no evidence of recurrence of cholesteatoma. The mean postoperative air-bone gap was 20dBHL, 23dBHL, 10dBHL and 27dBHL at 0.5kHz, 1kHz, 2kHz and 4kHz respectively. Excluding cases consistent with a postoperative ossicular discontinuity (n=3), the mean postoperative air-bone gap was 15dBHL, 19dBHL, 8dBHL and 26dBHL at 0.5kHz, 1kHz, 2kHz and 4kHz respectively. CONCLUSIONS: The improvement in hearing thresholds demonstrated in this cohort of patients supports the use of this form of ossiculoplasty in those undergoing open cavity procedures. This would also suggest that the subsequent use of hearing aids in these patients would require less amplification and therefore provide superior hearing outcomes. As hearing loss remains a significant concern following modified radical mastoidectomy, we suggest an open cavity with primary malleostapedial rotation ossiculoplasty as a viable alternative to modified radical mastoidectomy alone, in selected cases.

The contribution of hearing to normal balance.

INTRODUCTION: Normal balance relies on three sensory inputs: vision, proprioception and the peripheral vestibular system. This study assessed hearing change and postural control in normal subjects. MATERIALS AND METHODS: Postural control in 20 normal volunteers was assessed using a Nintendo Wii gaming console and balance board. Each subject was tested standing upright for 30 seconds in a clinic room and a soundproof room with their eyes open, eyes closed, whilst standing on and off foam, and with and without ear defenders. RESULTS: There was significantly more postural sway in the following subjects: those standing with their eyes closed vs those with eyes open (normal room, p = 0.0002; soundproof room, p = 0.0164); those standing on foam with eyes open vs those standing normally with eyes open (in both rooms; p < 0.05); those standing with eyes open in a soundproof room vs a normal room (p = 0.0164); and those standing on foam in a soundproof room with eyes open and wearing ear defenders vs those in the same circumstances but without ear defenders. CONCLUSION: Our results suggest that this method provides a simple, inexpensive tool for assessing static postural control. Whilst it is recognised that visual input and proprioception play a central role in maintaining posture, our findings suggest that ambient sound and hearing may also have a significant influence.

The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study.

UNLABELLED: Individuals with vestibular dysfunction may experience visual vertigo (VV), in which symptoms are provoked or exacerbated by excessive or disorientating visual stimuli (e.g. supermarkets). VV can significantly improve when customized vestibular rehabilitation exercises are combined with exposure to optokinetic stimuli. Virtual reality (VR), which immerses patients in realistic, visually challenging environments, has also been suggested as an adjunct to VR to improve VV symptoms. This pilot study compared the responses of sixteen patients with unilateral peripheral vestibular disorder randomly allocated to a VR regime incorporating exposure to a static (Group S) or dynamic (Group D) VR environment. Participants practiced vestibular exercises, twice weekly for four weeks, inside a static (Group S) or dynamic (Group D) virtual crowded square environment, presented in an immersive projection theatre (IPT), and received a vestibular exercise program to practice on days not attending clinic. A third Group D1 completed both the static and dynamic VR training. Treatment response was assessed with the Dynamic Gait Index and questionnaires concerning symptom triggers and psychological state. At final assessment, significant between-group differences were noted between Groups D (p=0.001) and D1 (p=0.03) compared to Group S for VV symptoms with the former two showing a significant 59.2% and 25.8% improvement respectively compared to 1.6% for the latter. Depression scores improved only for Group S (p=0.01) while a trend towards significance was noted for Group D regarding anxiety scores (p=0.07). CONCLUSION: Exposure to dynamic VR environments should be considered as a useful adjunct to vestibular rehabilitation programs for patients with peripheral vestibular disorders and VV symptoms.

Ear, nose and throat day-case surgery at a district general hospital.

INTRODUCTION: In 2000, The NHS Plan in the UK set a target of 75% for all surgical activity to be performed as day-cases. We aim to assess day-case turnover for ENT procedures and, in particular, day-case rates for adult and paediatric otological procedures together with re-admissions within 72 h as a proxy measure of safety. PATIENTS AND METHODS: Retrospective collection of data (procedure and length of stay) from the computerised theatre system (Galaxy) and Patient Information Management System (PIMS) of all elective patients operated over one calendar year. The setting was a district general hospital ENT department in South East England. All ENT operations are performed with the exception of oncological head and neck procedures and complex skull-base surgery. RESULTS: Overall, 2538 elective operations were performed during the study period. A total of 1535 elective adult procedures were performed with 74% (1137 of 1535) performed as day-cases. Of 1003 paediatric operations, 73% (730 of 1003) were day-cases. Concerning otological procedures, 93.4% (311 of 333) of paediatric procedures were day-cases. For adults, we divided the procedures into major and minor, achieving day-case rates of 88% (93 of 101) and 91% (85 of 93), respectively. The overall day-case rate for otological procedures was 91% (528 of 580). Re-admission rates overall were 0.7% (11 of 1535) for adults and 0.9% (9 of 1003) for paediatric procedures. The most common procedure for re-admission was tonsillectomy accounting for 56% of all adult re-admissions and 78% of paediatric re-admissions. The were no deaths following day-case procedures. DISCUSSION: ENT surgery is well-suited to a day-case approach. UK Government targets are attainable when considering routine ENT surgery. Day-case rates for otology in excess of targets are possible even when considering major ear surgery.

How we do it: diagrammatic recording of tympanomastoid procedures.

Accurate documentation of the operative findings of tympanomastoid procedures is essential for effective patient management and to satisfy the growing demands of clinical audit. Due to the three-dimensional complexity of the middle ear, it is difficult to represent graphically. Consequently, most surgeons only describe subjectively their operative, otological findings. We present for the first time a simple middle ear template which provides an objective tool to improve the recording of tympanomastoid procedures.

Paediatric rhabdomyosarcoma of the ear and temporal bone.

The objective of the present study was to review the presentation, management, outcome and morbidity of paediatric patients presenting to a single centre with rhabdomyosarcoma of the ear and temporal region. All patients diagnosed with rhabdomyosarcoma of the ear and temporal region between 1980 and 2000 were entered into this retrospective study. Fourteen patients were identified. The median age at presentation was 4.5 years with a mean time of onset of symptoms to diagnosis of 21 weeks. In many patients, the presentation mimicked that of chronic otitis media, delaying diagnosis. Histological subtype was embryonal in 13 patients and alveolar in 1. All patients underwent multimodality treatment. The 5-year disease-free survival rate was 81%. Regional post-treatment morbidity included chronic aural discharge (6/14), facial palsy (8/14), growth disturbance (4/14) and maxillo-facial deformity occurring in four children. From the results, we conclude that these patients should usually present to an ENT surgeon who should keep the diagnosis in mind when dealing with children with chronic otitis media as early diagnosis with referral to a specialist multidisciplinary team will optimize the chance of survival. Discharge, hearing loss and aural polyp, although commonly because of chronic otitis media, should prompt urgent investigation and biopsy, particularly if associated with facial palsy, lymphadenopathy or an obvious mass.

Removal of migrating pectus bars by video-assisted thoracoscopy.

Surgical correction of pectus excavatum deformity with the use of a metal bar strut provides a good cosmetic result with a low complication rate. Reports of pectus bar migration are rare but we report three cases of bar migration which required thoracoscopic removal.