Treatment of Tinnitus Using Theta Burst Based Repetitive Transcranial Magnetic Stimulation-A Single Blinded Randomized Control Trial.

OBJECTIVE: To determine whether theta burst repetitive transcranial magnetic stimulation is an effective treatment for chronic tinnitus compared with a control stimulus. STUDY DESIGN: A two-arm, single-blind, randomized controlled trial comparing an active treatment group to a placebo control group. SETTING: Neurotology department of a tertiary referral center. PATIENTS: Forty new and existing patients with chronic unilateral or bilateral tinnitus were recruited from specialist hearing and balance clinics. INTERVENTIONS: The subjects were randomized into two groups representing the treatment and sham subcategories. Two 40 second trains, 15 minutes apart of transcranial stimulation was provided using a super rapid stimulator (2.2. Tesla, Magstim Inc., Wales, UK) using a circular delivery coil. Treatment was provided over 5 consecutive days. MAIN OUTCOME MEASURE: Tinnitus functional index (TFI) scores were recorded before treatment, immediately after treatment, 2 weeks, and at 4 weeks following treatment and compared. RESULTS: TFI scores were analyzed using the Shapiro-Wilk test and found to be normally distributed. A paired Student t test was then performed. Both the active treatment group and control group had a significant improvement in their TFI scores following treatment; however, there was no significant difference between active treatment and sham treatment groups. CONCLUSION: This study demonstrated a significant placebo effect following treatment with sham therapy and may suggest that repetitive transcranial magnetic stimulation does not have a therapeutic use in treating chronic tinnitus.

Intratympanic Steroid Use for Sudden Sensorineural Hearing Loss: Current Otolaryngology Practice.

OBJECTIVE: To investigate the current practice of intratympanic steroid (ITS) injection for sudden sensorineural hearing loss (SSNHL) in the United Kingdom and link the data with data from the United States and continental Europe. METHODS: A survey of 21 questions was distributed to members of the British Society of Otology using an online survey platform via ENT UK. Data obtained from UK otolaryngologists (n = 171) were integrated with previously published data from other countries, including the United States (n = 63) and continental Europe (n = 908). RESULTS: In the United Kingdom, 62% of responding otolaryngologists use ITS injection for SSNHL, while 38% do not. Of those using ITS, 59% use it as first-line treatment, either using it in conjunction with oral steroids (51%) or using it as monotherapy (8%). Of those that use ITS, a majority (83%) use it as salvage therapy when primary treatment with systemic steroids has failed, and similar results are found in the continental Europe and US surveys. The most commonly used preparation is dexamethasone. Responses to questions regarding treatment regimes used are enlightening and show considerable variation in the treatment regimes used within and between countries. CONCLUSIONS: There is a wide variation in practice with regards to ITS for SSNHL hearing loss in the United Kingdom, United States, and continental Europe. In the absence of protocols or definitive guidance from published literature, knowledge of contemporary practice may help guide or encourage reevaluation of clinical practice and will help guide the design of future clinical trials.

Clinical examination and management of the dizzy patient.

Dizziness is the commonest reason for a GP appointment over the age of 75 years and many dizzy patients will end up in hospital. This article introduces the range of vestibular disorders commonly seen in hospital practice with a symptom-based approach and discusses the range of treatments that might be considered.

The effect of electrode positioning on the ocular vestibular evoked myogenic potential to air-conducted sound.

OBJECTIVE: To assess the effect of electrode position on the amplitude and latency of ocular vestibular evoked myogenic potentials (oVEMPs) produced by air-conducted (AC) sound with a view to optimisation of the recording paradigm. METHODS: Eight otologically normal subjects (16 ears) were stimulated by 500 Hz AC tone bursts at 95 dBnHL; oVEMP traces were recorded below the eye contralateral to the acoustic stimulation. Five independent oVEMP measurements were recorded with the active electrode in equally spaced positions in the infra-orbital plane relative to a reference electrode positioned 2 cm below the lower lid in the orbital midline. These measurements included the accepted standard-montage in which the electrodes were positioned vertically above and below each other in the orbital midline. A further recording was made using a belly-tendon montage with reference to the inferior oblique muscle. RESULTS: Of the six recording paradigms tested the largest amplitude oVEMP response was found using the belly-tendon montage with an n10 average of 5.67 ± 3.42 µV (sd). This was significantly larger than the amplitude recorded using the standard-montage (p < 0.01). With the reference electrode in the orbital midline, the position of the active electrode in the infra-orbital plane was found to significantly alter the response magnitude. As the active electrode was moved laterally the response reduced in amplitude, however when moved medially the response polarity reversed indicating the existence of a null-point at which no response was present. CONCLUSIONS: The location of oVEMP recording electrodes significantly alters the response amplitude. Whilst the standard-montage provides a reasonable method for recording oVEMPs, the belly-tendon montage results in a significantly larger amplitude response. Furthermore medial and lateral variations in the position of the active electrode using the standard-montage significantly affect the magnitude and polarity of the response. SIGNIFICANCE: The standard-montage used for recording oVEMPs is sensitive to the placement of the active electrode. Small variations in position result in significant changes in the n(10) amplitude and this may account for the variability reported in the literature. Using the belly-tendon montage, larger amplitude responses can be elicited which may improve the robustness with which oVEMPs can be collected. However this enhancement in response amplitude must be balanced against the increased possibility of signal contamination from neighbouring extraocular muscles.

Altered frequency dynamics of cervical and ocular vestibular evoked myogenic potentials in patients with Ménière's disease.

OBJECTIVE: To measure the frequency dynamics of cervical and ocular vestibular evoked myogenic potentials in healthy subjects and patients with Ménière's disease. STUDY DESIGN: A prospective cohort study. SETTING: A university teaching hospital. SUBJECTS: Eight healthy volunteers (16 ears) and 12 adult patients with unilateral Ménière's disease (8 with definite disease and 4 with probable disease) by American Academy of Otolaryngology - Head and Neck Surgery diagnostic criteria. INTERVENTIONS: Cervical and ocular vestibular evoked myogenic potentials generated by tone bursts at 250, 500, 750, 1,000, 1,500, 2,000, 3,000, and 4,000 Hz were measured in both groups. MAIN OUTCOME MEASURES: The frequency sensitivity of both the cervical and ocular vestibular evoked myogenic potentials, as evaluated by p13-n23 and n10 amplitudes in healthy ears and in ears affected and not affected by Ménière's disease. RESULTS: Cervical and ocular vestibular evoked myogenic potentials were present in all ears tested. In the healthy volunteers, the acoustic stimulus frequency at which the response amplitudes were largest was 500 Hz. This shifted to higher frequencies in patients with definite Ménière's disease for both measurements, with the effect being more pronounced for ocular vestibular evoked myogenic potentials. The shift was less marked in the probable Ménière's group and was absent in the unaffected ears of the Ménière's patients. CONCLUSION: Ménière's ears display alterations in cervical and ocular vestibular evoked myogenic potentials tuning responses with changes in the latter being more prominent. These findings indicate that the disease process affects both the otolith organs but may have an enhanced effect on the utricle. We propose that this more dominant affect may relate to the anatomical configuration of the utricle.

TRANSDUCER FIELD IMAGING USING ACOUSTOGRAPHY.

A common current practice for transducer field mapping is to scan, point-by-point, a hydrophone element in a 2D raster at various distances from the transducer radiating surface. This approach is tedious, requiring hours of scanning time to generate full cross-sectional and/or axial field distributions. Moreover, the lateral resolution of the field distribution image is dependent on the indexing steps between data points. Acoustography is an imaging process in which an acousto-optical (AO) area sensor is employed to record the intensity of an ultrasound wavefield on a two-dimensional plane. This paper reports on the application of acoustography as a simple but practical method for assessing transducer field characteristics. A case study performed on a commercial transducer is reported, where the radiated fields are imaged using acoustography and compared to the corresponding quantities that are predicted numerically.

Feasibility study of complex wavefield retrieval in off-axis acoustic holography employing an acousto-optic sensor.

We propose and experimentally demonstrate a new method for complex-valued wavefield retrieval in off-axis acoustic holography. The method involves use of an intensity-sensitive acousto-optic (AO) sensor, optimized for use at 3.3 MHz, to record the acoustic hologram and a computational method for reconstruction of the object wavefield. The proposed method may circumvent limitations of conventional implementations of acoustic holography and may facilitate the development of acoustic-holography-based biomedical imaging methods.

Intraoral radiographic findings in acne calcification: a case report.

The authors present a case report of a 52-year-old Hispanic female who presented for a routine dental exam at the Arthur A. Dugoni School of Dentistry in San Francisco. Incidental findings of multiple, calcified acne vulgaris lesions were noted in the soft tissues of the cheek that were viewed in the periapical radiographs. The findings were confirmed by a clinical evaluation of the patient's skin and past history.

Use of TissuePatchDural™ in the closure of an iatrogenic fistula following posterior semicircular canal occlusion surgery for intractable benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is a common disorder caused by the dislocation of otoconia most commonly into the posterior canal. The primary symptoms are brief episodes of head-position related vertigo which may be accompanied by nausea and disequilibrium. BPPV is usually managed conservatively with excellent results, however in a small number of cases the symptoms can become persistent and incapacitating. The most common treatment in such cases involves the surgical occlusion of the canal. This procedure carries a small risk of post operative perilymph leakage via an iatrogenic fistula. In this paper we outline a case of a patient who developed a perilymph leak following occlusion surgery for intractable BPPV. We describe a novel surgical method that was used to close the fistula using a synthetic polymer based patch (TissuePatchDural90™), which has not been applied in the field of otology previously.

Emergency medical service providers' experience with family presence during cardiopulmonary resuscitation.

OBJECTIVE: To describe emergency medical service providers' experiences with family member presence during resuscitation, and to determine whether those experiences are similar within urban and suburban settings. METHODS: We conducted a personally distributed survey of a convenience sample of urban and suburban emergency medical service (EMS) providers presenting to two Midwestern Emergency Departments. Providers were questioned as to their experiences with resuscitating patients in the presence of family members. RESULTS: There were 128 respondents to the survey (59 urban and 69 suburban), of which 70.1% were EMT-Paramedics. No provider who was approached refused participation. Nearly all (122) had performed CPR in the presence of family members, with most (77%) performing greater than 20. Subjects averaged 12.3 years of experience. The majority of urban and suburban providers felt it was inappropriate for family to witness resuscitations (75.9% versus 60.3%, respectively; p=0.068). Many providers reported feeling uncomfortable with family presence (31.5% urban versus 44.8% suburban; p=0.136), and few preferred that family witness the resuscitation (13.2% urban versus 15.4 suburban; p=0.738). A minority of providers believed that family were better prepared to accept the death of the patient (37.0% urban versus 37.6% suburban; p=0.939). Approximately half felt comfortable providing emotional support (66.0% urban versus 53.7% suburban; p=0.173). Many felt that family caused a negative impact during resuscitation (53.7% urban and 36.8% suburban; p=0.061). Urban providers more often reported feeling threatened by family members during resuscitation (66.7% versus 39.7%; p=0.003), and felt that family often interfered with their ability to perform resuscitations (35.6% versus 16.4%, p=0.014). CONCLUSIONS: EMS providers have substantial experience with family witnessed resuscitations, are uncomfortable about their presence, and often must provide support for families. While urban providers tended to report more negative experiences and perceptions, there were minimal differences between the two groups.

Bone marrow progenitors are not the source of expanding oval cells in injured liver.

Liver progenitor/oval cells differentiate into hepatocytes and biliary epithelial cells, repopulating the liver when the regenerative capacity of hepatocytes is impaired. Recent studies have shown that hematopoietic bone marrow (BM) stem/progenitor cells can give rise to hepatocytes in diseased/damaged liver. One study has reported that BM cells can transdifferentiate into liver progenitor/oval cells, but it has not been proven that the latter can repopulate the liver. To answer this question, we have lethally irradiated female DPP4(-) mutant F344 rats and transplanted them with 50 million wild-type male F344 BM cells. One month after transplantation, the recipient BM was reconstituted with male hematopoietic cells, determined by quantitative polymerase chain reaction using primers for Y chromosome-specific sry gene. In addition, DPP4(+) cells, single or in clusters and predominantly in the periportal region, were detected in all liver sections of recipient rats. Animals were subjected to the following three different liver injury protocols for activation and expansion of oval cells: D-galactosamine, retrorsine/partial hepatectomy (Rs/PH), and 2-acetylaminofluorene/partial hepatectomy (2-AAF/PH). In all three models, prominent expansion and accumulation of cytokeratin 19-positive (CK-19(+)) oval cells was observed. However, most of the DPP4(+) clusters dispersed over time, and their total number decreased. Very few oval cells (less than 1%) showed double DPP4/CK-19 labeling. None of the small hepatocytic clusters in the Rs/PH or 2-AAF/PH model were comprised of DPP4(+) cells. These data demonstrate that the sources of oval cells and small hepatocytes in the injured liver are endogenous liver progenitors and that they do not arise through transdifferentiation from BM cells.