Assessing risk of stroke after idiopathic sudden sensorineural hearing loss using data from general practice.

The cause of sudden sensorineural hearing loss (SSNHL) remains unknown in a significant number of cases, but vascular involvement in its pathophysiology has been proposed. Our study aimed to assess the incidence of stroke following idiopathic SSNHL (iSSNHL) and to evaluate associated cardiovascular risk factors and comorbidities. We extracted electronic medical record data from iSSNHL patients aged ≥ 50 years retrospectively from 84 general practices. Patients were matched for age, sex and general practice in a 1:4 ratio to controls. Primary outcome was the 5-years stroke risk following iSSNHL diagnosis. 480 iSSNHL cases could be matched to 1911 controls. The hazard ratio for iSSNHL compared with controls was 1.25 (95%CI 0.50-3.27; P = 0.646) for CVA (cerebrovascular accident) alone and 0.92 (95% CI 0.50-1.71; P = 0.804) for CVA and TIA (transient ischemic attack) combined. The hazard ratio for the interaction term between iSSNHL and age ≥ 60 years was 4.84 (95% CI 1.02-23.05; P = 0.048) for CVA and TIA combined. Patients with iSSNHL used antihypertensives and beta-blocking agents more frequently than controls (P = 0.006 and P = 0.022, respectively). In conclusion, no overall significant difference in the risk of stroke was observed, but the hazard ratio for stroke increased in iSSNHL patients aged 60 and older, suggesting potential vascular involvement in older subjects presenting with sudden sensorineural hearing loss.

Cardiovascular Risk Factors, Cerebral Small Vessel Disease, and Subsequent Risk of Stroke in Patients with Idiopathic Sudden Sensorineural Hearing Loss: Systematic Review and Meta-Analyses of the Current Literature.

Vascular involvement in the pathophysiology of idiopathic sudden sensorineural hearing loss (iSSNHL) has been previously proposed. The objective of this study was to perform a systematic review of the current literature and conduct meta-analyses to evaluate associations between cardiovascular risk factors, cerebral small vessel disease, and subsequent stroke after presentation with iSSNHL. Three systematic literature reviews and meta-analyses were conducted using PubMed, Embase, and CINAHL. All studies investigating associations between iSSNHL and the cardiovascular risk factors: body mass index (BMI), diabetes mellitus, hyperlipidemia, hypertension, medical history of myocardial infarction (MI), smoking, the degree of white matter hyperintensities, and incidence of stroke were included. Adhering to the PRISMA guidelines, two independent reviewers reviewed the articles and assessed risk of bias. The cardiovascular risk factors of abnormal BMI, diabetes, hypertension, total cholesterol, low-density lipoprotein cholesterol, and a medical history of MI were significantly associated with iSSNHL. The adjusted hazard ratio of a higher degree of white matter hyperintensities was 0.70 (95% CI 0.44, 1.12). Patients with iSSNHL showed a higher risk of stroke compared to controls, with hazard ratios ranging from 1.22 up to 4.08. Several cardiovascular risk factors are more frequently present in patients with iSSNHL than in the general population. The degree of white matter hyperintensities does not appear to be increased in patients with iSSNHL, while the risk of stroke following ISSNHL is increased. Prospective studies with larger study populations are needed to confirm the associations between generalized cardiovascular disease and iSSNHL and to assess whether these patients benefit from cardiovascular risk management to prevent future cardiovascular and cerebrovascular disease.

Idiopathic Labyrinthitis: Symptoms, Clinical Characteristics, and Prognosis.

BACKGROUND: Labyrinthitis is an inner ear disorder of unknown incidence, characterized by sudden hearing loss and concurrent vertigo. Cohort studies of patients diagnosed with labyrinthitis are nonexistent. This study aims to describe the clinical characteristics and prognosis of patients diagnosed with idiopathic labyrinthitis. METHODS: Patients with labyrinthitis in the absence of a clear viral, bacterial, or autoimmune pathogenesis were retrospectively identified from electronic patient files. Symptoms at presentation and results from vestibular testing were retrieved. The 9-item Vestibular Activity Avoidance Instrument, administered during follow-up interviews by telephone, was used to assess the presence of persistent balance problems and activity avoidance behavior. RESULTS: Sixty-one patients with idiopathic labyrinthitis were included. All patients had vestibular weakness at presentation. After a median of 61 months of follow-up (interquartile range 81), 72.5% of patients still experienced balance problems. Subjective hearing recovery only occurred in 20% of cases. CONCLUSION: Patients presenting in a tertiary dizziness clinic with idiopathic labyrinthitis have a poor prognosis for both hearing and balance function impairment. Prospective observational cohorts are required to establish objectifiable vestibular and audiological follow-up data.

Cerebral Small Vessel Disease in Elderly Patients with Sudden Sensorineural Hearing Loss.

BACKGROUND: The cause of sudden sensorineural hearing loss (SSNHL) is uncertain in a significant number of patients. A vascular etiology has been proposed because SSNHL increases the risk of developing a stroke. Cardiovascular risk factors can cause cerebral small vessel disease (CSVD). The presence of CSVD in turn raises the risk of stroke. AIM: The aim of this study was to compare the presence of CSVD and cardiovascular risk factors in elderly patients with idiopathic SSNHL (iSSNHL) to a control cohort. METHOD: Patients with iSSNHL of 50 years and older were compared with a control cohort with patients suspected of trigeminal neuralgia or vestibular paroxysmia. The primary outcome was the difference in the number of white matter hyperintensities using the ordinal Fazekas scale. Secondary outcomes were the presence of brain infarctions on MRI and the difference in cardiovascular risk factors. RESULTS: In the SSNHL cohort, Fazekas score 2 was most frequently seen compared with Fazekas 1 in the control cohort. The distribution of Fazekas scores did not differ significantly. The sum of the Fazekas scores were 13,925 and 14,042 for iSSNHL and controls, respectively ( p = 0.908). Brain infarctions were seen in 8 patients with iSSNHL (n = 118) and in 13 patients in the control cohort (n = 118) ( p = 0.361). None of the cardiovascular risk factors were more frequently seen in the iSSNHL cohort. CONCLUSION: Patients with iSSNHL did not exhibit more CSVD on MRI than controls. This result is in contrast with previous literature demonstrating a higher risk of stroke in patients with iSSNHL than in controls. A prospective analysis with a larger study population is therefore warranted.

Cerebral Small Vessel Disease in Elderly Patients With Menière's Disease.

Background: Menière's disease (MD) is an inner ear disease characterized by vertigo attacks, progressive hearing loss, tinnitus, and the sensation of aural fullness. Although the exact pathophysiology of MD is unknown, endolymphatic hydrops is considered to be its histopathological hallmark. It has been suggested that endolymphatic hydrops results from lowered perfusion pressure due to cardiovascular comorbidity. Cardiovascular risk factors can cause cerebral small vessel disease (CSVD), visible on MRI. The presence of CSVD in turn raises the risk of developing a stroke. Objectives: This study aimed to compare the presence of CSVD and cardiovascular risk factors in elderly patients with MD to a control cohort. Methods: Patients diagnosed with MD, aged 50 years and older, were retrospectively reviewed and compared with a control cohort. The primary outcome was the difference in CSVD on MRI imaging, which was assessed by the number of white matter hyperintensities using the ordinal Fazekas scale. The secondary outcome was the presence of brain infarctions on MRI. Results: A total of 111 patients with MD were compared with a control cohort of 111 patients. No difference in the degree of white matter hyperintensities (P = 0.890) was found between the MD and control cohort. Brain infarctions were seen in 8 of 111 patients with MD and 14 of 111 patients from the control cohort (P = 0.261). Conclusion: CSVD is not more frequently visible on MRI in elderly patients with MD than in controls. This result does not support hypoperfusion-induced ischemia in the pathophysiology of MD.

Cerebral Small Vessel Disease in Elderly Patients With Vestibular Neuritis.

Background: Acute audiovestibular loss is a neurotologic emergency of which the etiology is frequently unknown. In vestibular neuritis a viral genesis is expected, although there is insufficient evidence to support viruses as the only possible etiological factor. In sudden deafness, a vascular etiology has been proposed in elderly patients, since cardiovascular risk factors are more frequently present and a higher risk of developing a stroke was seen compared to the general population. So far, very little research has been carried out on vascular involvement in elderly patients with vestibular neuritis. Cardiovascular risk factors have a positive correlation with cerebral small vessel disease, visible as white matter hyperintensities, brain infarctions, microbleeds and lacunes on MRI. The presence of these characteristics indicate a higher risk of developing a stroke. Aim: We investigated whether elderly patients with vestibular neuritis have a higher prevalence of vascular lesions on MRI compared to a control cohort. Materials and Methods: Patients of 50-years and older, diagnosed with vestibular neuritis in a multidisciplinary tertiary referral hospital, were retrospectively reviewed and compared to a control cohort. The primary outcome was the difference in cerebral small vessel disease on MRI imaging, which was assessed by the number of white matter hyperintensities using the ordinal Fazekas scale. Secondary outcomes were the presence of brain infarctions on MRI and the difference in cardiovascular risk factors. Results: Patients with vestibular neuritis (N = 101) had a 1.60 higher odds of receiving a higher Fazekas score than the control cohort (N = 203) (p = 0.048), there was no difference in presence of brain infarctions (p = 1.0). Hyperlipidemia and atrial fibrillation were more common in patients experiencing vestibular neuritis. Conclusion: We found a positive correlation of white matter hyperintensities and VN which supports the hypothesis of vascular involvement in the pathophysiology of vestibular neuritis in elderly patients. Further prospective research is necessary to confirm this correlation.

Solitary iliac branch endoprosthesis placement for iliac artery aneurysms.

BACKGROUND: Isolated iliac artery aneurysms (IAAs), accounting for 2% to 7% of all abdominal aneurysms, are often treated with the use of iliac branched endografts. Although outside the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an endovascular aneurysm repair device, for the treatment of an isolated IAA. In the present study, we have described the outcomes of the use of the Gore iliac branched endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz), without the support of an infrarenal endovascular aneurysm repair device, for the exclusion of an isolated IAA. The present study was an international multicenter retrospective cohort analysis. METHODS: All the patients who had undergone treatment with a solitary IBE for IAA exclusion from January 11, 2013 to December 31, 2018 were retrospectively reviewed. The primary outcome was technical success. The secondary outcomes included mortality, intraoperative and postoperative complications, and reintervention. RESULTS: A total of 18 European and American centers participated, with a total of 51 patients in whom 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. No 30-day mortality occurred, with 98.1% patency of the internal and external iliac artery found at 24 months of follow-up. At 24 months of follow-up, 81.5% of the patients were free of complications and 90% were free of a secondary intervention. CONCLUSIONS: Treatment with a solitary IBE is a safe and, at midterm, an effective treatment strategy for selected patients with a solitary IAA.

Pulmonary complications and survival after elective infrarenal endovascular abdominal aneurysm repair in patients with documented chronic obstructive pulmonary disease.

BACKGROUND: Elective abdominal aortic aneurysm (AAA) repair is advocated in patients where risk of rupture exceeds the risks of peri-procedural morbidity and mortality. Chronic obstructive pulmonary disease (COPD) is a known risk factor for AAA and increased operative morbidity in general. Since literature on the correlation between the clinical classification of COPD and morbidity following endovascular infrarenal AAA repair (EVAR) is scarce, assessment per individual remains a challenge. OBJECTIVE: To analyse the pulmonary and all-cause morbidity and mortality in patients with documented COPD and relate this to their GOLD classification. METHODS: Sixty-eight patients with COPD, documented by a lung function test, who underwent elective EVAR between July 2002 and July 2018 were retrospectively reviewed. The primary endpoint was the incidence of 30-day pulmonary adverse events. Procedural characteristics, length of hospital stay, pulmonary and all-cause morbidity including major adverse events (MAEs) during follow-up and five-year survival divided per GOLD classification were the secondary endpoints. RESULTS: There was no statistically significant difference in the incidence of pulmonary adverse events between GOLD I/II and GOLD III/IV patients. There was neither procedural nor 30-day mortality in either group. Through 30 days and 1 year, there was no difference in pulmonary and all-cause morbidity between groups. Three MAEs occurred in the GOLD I/II group versus 2 MAE in the GOLD III/IV group during the first postoperative year. The five-year survival was 66.0%, 60.9% and 61.9% for patients with GOLD I, GOLD II and GOLD III, respectively. Three of four GOLD IV died within the first year after EVAR. CONCLUSION: EVAR can be safely performed in patients with COPD, with low 30-day morbidity and mortality rates. Although severe co-morbidity should be taken into account, EVAR seems to be justified in patients with COPD with a GOLD classification I, II or III. Further research should focus on optimising the pulmonary condition in patients selected for EVAR.

The effect of antibiotics on post-adenotonsillectomy morbidity in Tanzanian children: study protocol for a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Adenotonsillectomy is the most frequently performed operation in children worldwide. For decades, prophylactic antibiotics have been prescribed to limit postoperative complications. The effect of this antibiotic use has been refuted in a Cochrane Review. However, all reviewed studies were carried out in developed countries. In Tanzania, like many other developing countries with limited resources and a high burden of infectious diseases, postoperative antibiotic prescription is still very common to decrease the supposed higher postoperative morbidity. However, as a consequence of this widespread use of postoperative antibiotics, cross-resistance and risk of allergic side effects rise. Well-designed randomized controlled trials are needed to limit unnecessary antibiotic prescription and secondary antibiotic resistance. AIM: The aim of this study is to analyse the prophylactic role of postoperative antibiotics on morbidity following adenotonsillectomy in children in Tanzania. DESIGN: The double-blinded, randomized, placebo-controlled trial was set in northern Tanzania. Participating centres are the Department of Otolaryngology at Kilimanjaro Christian Medical Centre in Moshi and the Department of Paediatric Surgery at the Arusha Lutheran Medical Centre in Arusha. METHODS: Around 270 children aged 2-14 years, all scheduled for elective (adeno)tonsillectomy, will be included and assigned to receive either a standard regimen of 5 days of antibiotic prophylaxis or placebo after surgery. The primary outcomes are postoperative haemorrhage, fever and pain. Secondary outcomes are the time until normal diet is resumed, the time until normal activities are resumed and the occurrence of adverse events and microbial recolonization of the tonsillar beds. DISCUSSION: This study will enhance an increase of proper antimicrobial prescription in Tanzanian institutions as well as other resource-limited countries where prescription of antibiotics is still very common. In addition, it might augment current knowledge about surface and core tonsillar micro-organisms and sensitivity patterns. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR201905466349317. Retrospectively registered on 15 May 2019. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=8119.