High Dose of Intratympanic Steroids for Sudden Sensorineural Hearing Loss Salvage.

OBJECTIVE: Intratympanic (IT) steroid administration for sudden sensorineural hearing loss is offered as salvage to patients who failed systemic steroid treatment. Our objective was to study the audiometric and clinical outcomes of patients given salvage therapy with high-dose IT steroids instilled via ventilation tube. STUDY DESIGN: Retrospective case review. SETTING: Academic secondary medical center. PATIENTS: One hundred three patients >18 years of age with sudden sensorineural hearing loss who failed systemic steroids and received IT treatment between 2010 and 2018. INTERVENTION: Following ventilation tube insertion, 1 ml of 10 mg/ml dexamethasone was instilled, twice daily, for 7 days. OUTCOME MEASURES: Hearing assessment immediately before and after treatment. Tinnitus and vertigo complaints and risk factors were also retrieved. RESULTS: Tinnitus had improved in 53 (52%) patients, vertigo in 4 (4%), and aural fullness sensation in 56 (55%) (p < 0.001, p = 0.344, p < 0.001, respectively). The mean pure-tone threshold difference across frequencies following treatment was between 0 and 6 dB. A significant improvement was observed at 250, 500, 1000 Hz (p < 0.001 in all), and at 2000 Hz (p = 0.035). No significant difference was found at 4000 and 8000 Hz (p = 0.055, p = 0.983 respectively). Mean pure-tone average improvement of 4.5 dB was detected in 61 (59%) patients (p = 0.001). The mean speech discrimination score improved by 7% (p = 0.001). Four (22%) diabetic and nine (20%) hypertensive patients had pure-tone average ≥10 dB improvement (p = 0.759, p = 0.852 respectively). CONCLUSION: Although more than half of the patients improved clinically, the significance of the slight audiometric improvement should be weighed against the treatment protocol's complications.

Pediatric neck abscesses: No increase in methicillin-resistant Staphylococcus aureus.

INTRODUCTION: Recent studies from Western countries showed an increased incidence rate of methicillin-resistant Staphylococcus aureus (MRSA) isolated from pediatric neck abscesses cultures. We sought to examine the microbiology and antibiotic susceptibility of such samples over a 10-year period, and particularly of Staphylococcus aureus (SA), in order to determine whether a similar trend exists in our institution. METHODS: A retrospective chart review of children ≤18 years that underwent needle aspiration or surgical drainage of neck abscesses, including suppurative lymphadenitis, retropharyngeal abscesses, and parapharyngeal abscesses was conducted between 1/1/06-31/12/15. RESULTS: Sixty-two children were identified with a male predominance (34, 55%). The median age was 2 years. There were 37 (60%) suppurative lymphadenitis, 15 (24%) parapharyngeal abscess, and 10 (16%) retropharyngeal abscess cases. Twenty-nine (47%) children received antibiotic treatment prior to admission, most commonly ß-lactam agents. Of them, 15 (52%) had positive cultures, including 7 (47%) with SA. On admission, 45 (73%) children had already received amoxicillin-clavulanate. Of those who did not improve, 16 (26%) received ceftriaxone and clindamycin. Twenty-one (38%) cultures were negative. The most common isolated bacteria were SA in 13 (24%), Streptococcus pyogenes in 7 (13%), and Streptococcus viridians group in 9 (16%). Of the SA isolates, there was only 1 (8%) case of MRSA; however, there were 4 (31%) clindamycin-resistant SA isolates. CONCLUSION: Unlike previously published data, there was no increase in MRSA incidence at our institution. However, the high prevalence of clindamycin-resistant SA was in line with previous reports. These findings should be considered when starting empirical therapy in pediatric neck abscesses.

Computerized dynamic posturography for evaluating dizziness in patients with scarred orbital content.

Our objective was to assess the capability of computerized dynamic posturography (CDP) to evaluate dizziness in blind patients who lack corneoretinal potential. We performed a retrospective analysis of 2 young blind subjects with intraorbital scarring who complained of dizziness and underwent CDP. Tests were carried out at our center for balance disorders using the NeuroCom's EquiTest System version 4.0. CDP demonstrated vestibular dysfunction and revealed it to be severe. We conclude that CDP can serve as a potentially reliable tool for assessing dizziness in blind patients who have no corneoretinal potential.

Hyperbaric oxygen therapy can improve post concussion syndrome years after mild traumatic brain injury - randomized prospective trial.

BACKGROUND: Traumatic brain injury (TBI) is the leading cause of death and disability in the US. Approximately 70-90% of the TBI cases are classified as mild, and up to 25% of them will not recover and suffer chronic neurocognitive impairments. The main pathology in these cases involves diffuse brain injuries, which are hard to detect by anatomical imaging yet noticeable in metabolic imaging. The current study tested the effectiveness of Hyperbaric Oxygen Therapy (HBOT) in improving brain function and quality of life in mTBI patients suffering chronic neurocognitive impairments. METHODS AND FINDINGS: The trial population included 56 mTBI patients 1-5 years after injury with prolonged post-concussion syndrome (PCS). The HBOT effect was evaluated by means of prospective, randomized, crossover controlled trial: the patients were randomly assigned to treated or crossover groups. Patients in the treated group were evaluated at baseline and following 40 HBOT sessions; patients in the crossover group were evaluated three times: at baseline, following a 2-month control period of no treatment, and following subsequent 2-months of 40 HBOT sessions. The HBOT protocol included 40 treatment sessions (5 days/week), 60 minutes each, with 100% oxygen at 1.5 ATA. "Mindstreams" was used for cognitive evaluations, quality of life (QOL) was evaluated by the EQ-5D, and changes in brain activity were assessed by SPECT imaging. Significant improvements were demonstrated in cognitive function and QOL in both groups following HBOT but no significant improvement was observed following the control period. SPECT imaging revealed elevated brain activity in good agreement with the cognitive improvements. CONCLUSIONS: HBOT can induce neuroplasticity leading to repair of chronically impaired brain functions and improved quality of life in mTBI patients with prolonged PCS at late chronic stage. TRIAL REGISTRATION: ClinicalTrials.gov NCT00715052.

Role of computerized dynamic posturography in evaluating sinugenic vertigo.

OBJECTIVES: Vertigo associated with rhinosinusitis has seldom been reported, and the pathophysiologic mechanism is still vague. Our aim was to evaluate sinugenic vertigo with computerized dynamic posturography (CDP) and suggest a possible pathophysiologic mechanism. METHODS: We conducted a prospective study of 16 patients with a clinical and radiologic diagnosis of rhinosinusitis made between January 2007 and December 2008. All patients underwent CDP on the first 2 days after diagnosis. Patients with abnormal CDP results and/or complaints of vertigo underwent follow-up CDP when healthy. RESULTS: Five patients complained of a new onset of vertigo. The CDP demonstrated a combined disorder in 3 of them, even though the vestibular signs were intact. On follow-up examination, all 3 patients were asymptomatic, and the follow-up CDP values were normal. CONCLUSIONS: We report a surprising 20% prevalence of sinugenic vertigo associated with abnormal results on CDP. Our results might possibly indicate that the somatosensory system of the paranasal sinuses plays a major role in the pathophysiologic mechanism of sinugenic vertigo.

Tonsillectomy vs. partial tonsillectomy for OSAS in children--10 years post-surgery follow-up.

BACKGROUND: Today, obstructive hypertrophic tonsils are completely resected to remove the obstruction. Since tonsillar tissue has important protective characteristics, it is more logical to resect only the obstructive tonsillar tissue and leave remnants in the tonsillar beds, thereby presuming to preserve the immunological function of the tonsillar tissue. However, it is as yet unclear whether or not rehypertrophy of this remnant of the tonsils and/or tonsillitis reoccur in the long-term. OBJECTIVES: To evaluate the remnants of the tonsils 10-14 years post-tonsillotomy in children who suffered from obstructive sleep apnea syndrome (OSAS) due to obstructive tonsils. METHODS: We conducted a retrospective study, telephone survey and selective physical examination of 33 children who had obstructive hypertrophic tonsils (suffered from OSAS due to hypertrophic tonsils), and underwent tonsillotomy (TT) at Assaf Harofeh Medical Center between July 1990 and April 1993, and compared them with a group of 16 children treated by tonsillectomy (TE) for the same diagnosis. RESULTS: No statistically significant difference was found between the TT and TE groups in all parameters compared: non-obstructing tonsils recurred (97% vs. 87%); snoring (3% vs. 12.5%); recurrent tonsillitis (6% vs. 6.25%); and recurrent obstruction and unilateral enlargement (3% vs. 12.5%). CONCLUSIONS: TT is as effective as TE for the long-term treatment of children suffering from OSAS due to hypertrophic tonsils.

Postural control in patients with severe idiopathic scoliosis: a prospective study.

Thirty-one patients with severe adolescent idiopathic scoliosis were evaluated preoperatively by computerized dynamic posturography. Curve type, magnitude and spine balance were measured radiographically. In four girls, a very mild vestibular dysfunction was observed on the sensory organization analysis, and three of them had a horizontal shift of more than 2 cm; a disbalance was observed in only three other patients among the 27 patients with normal posturography. These results suggest that abnormalities in the sensory systems are not involved in the etiology of severe adolescent idiopathic scoliosis. The vestibular dysfunction detected in the four patients was most probably the result of disbalance and not the cause of the disease.

Accuracy and consistency of fine-needle aspiration biopsy in the diagnosis and management of solitary thyroid nodules.

BACKGROUND: Fine-needle aspiration biopsy has been well established as a diagnostic technique for selecting patients with thyroid nodules for surgical treatment, thereby reducing the number of unnecessary surgical procedures in cases of non-malignant tumors. OBJECTIVES: To evaluate the sensitivity, specificity, accuracy, and positive and negative predictive values of FNAB in cases of a solitary thyroid nodule. METHODS: The preoperative FNAB results in 170 patients who underwent thyroidectomy due to a solitary thyroid nodule were compared retrospectively with the final postoperative pathologic diagnoses. RESULTS: In cases of a solitary thyroid nodule, FNAB had a sensitivity of 79%, specificity of 98.5%, accuracy of 87%, and positive and negative predictive values of 98.75% and 76.6% respectively. All cases of papillary carcinoma diagnosed by FNAB proved to be malignant on final histology, while 8 of 27 cases of follicular adenoma detected by preoperative FNAB were shown to be malignant on final evaluation of the surgical specimen. CONCLUSIONS: FNAB cytology reduces the incidence of thyroidectomy since this method has excellent specificity and sensitivity and a low rate of false-negative results. It proved to be cost-effective and is recommended as the first tool in the diagnostic workup in patients with thyroid nodules.

Removal of sinonasal tumors by the endonasal endoscopic approach.

BACKGROUND: The external approach is the golden standard for sinonasal tumor removal but is associated with several side effects, including facial scars, intracranial and extracranial complications, a long hospitalization period and high costs. Endoscopic sinus surgery enables resection of benign and selected malignant sinonasal tumors and has the advantages of no facial scars, better functional and structural preservation of the sinonasal complex, minimal trauma to surrounding tissue, a shorter hospitalization stay and lower costs. OBJECTIVES: To evaluate the advantages and limitations of endoscopic resection of benign and malignant sinonasal tumors, their recurrence and complication rates. METHODS: The medical and radiology records of 56 patients who underwent endonasal endoscopic resection of benign and malignant sinonasal tumors between 1996 and 2003 were retrospectively reviewed. Tumors located in the center of the nose and sinuses were endoscopically resected. RESULTS: Six cases of malignant tumor and 50 cases of benign tumor underwent resection by ESS. One of the patients with malignant tumor died, the remainder showing no evidence of disease on follow-up of 3-60 months (mean 26.8 months). Inverted papilloma was the most common benign tumor (40 patients). Seven patients (18%) had recurrence followed by endonasal resection. No major complications were recorded. Hospitalization stay was 2-7 days (mean 3.6 days). CONCLUSIONS: Endoscopic resection of benign sinonasal tumors that are centrally located in the nose and sinuses should be considered before the external approach is used. In very carefully selected cases of malignant tumors ESS is oncologically acceptable, but more experience is needed for discerning the indications for endoscopic resection of malignant tumors. The complication rate for endoscopic resection is low, there are no facial scars, hospitalization stay is short, and costs are low.

Hearing loss after direct blunt neck trauma.

OBJECTIVE: To report for the first time hearing impairment resulting from blunt neck trauma. STUDY DESIGN: Retrospective chart review of clinical, pure tone, and speech audiometric findings. The first obtained within 3 months and the follow-up ones between 6 and 12 months after injury. Three representative examples are given. PATIENTS: Eighty-three patients (166 ears) who reported hearing impairment after blunt neck trauma. RESULTS: Twenty of the 166 ears (12%) had normal hearing and 137 ears (81.3%) showed an acoustic trauma-like hearing impairment. Eight ears (4.8%) had a hearing loss of at least 30 dB in the speech frequencies (500-2,000 Hz) and two ears (1.2%) had additional impairment in the higher frequencies. Only one ear (0.8%) had a conductive hearing loss. No speech discrimination score was poorer than 80%. Forty-six subjects (55.4%) reported tinnitus. CONCLUSIONS: Blunt neck trauma, like whiplash injury, may cause objectively measurable hearing impairment.

Is there a relation between acoustic trauma or noise-induced hearing loss and a subsequent appearance of Ménière's Disease? An epidemiologic study of 17245 cases and a review of the literature.

OBJECTIVE: To explore whether acute acoustic trauma or noise-induced hearing loss may cause the later development of Ménière's Disease. STUDY DESIGN: Retrospective search of a military medical data bank. SETTING: Medical records of 17245 Israel Defense Force veterans who were recognized as being disabled as a result of acoustic trauma or noise-induced hearing loss. PATIENTS: Eleven cases of late-onset Ménière's Disease were retrieved from these files. MAIN OUTCOME MEASURES: Documented symptoms and audiograms. RESULTS: Eleven of the 17425 veterans appeared to have typical Ménière's Disease. Their symptoms included attacks of vertigo, lasting between half an hour and a few hours and no more than 24 hours; the sensation of aural fullness; and tinnitus accompanied by a fluctuating or permanent low-tone hearing loss. Four of the 11 patients had a documented previous noise-induced hearing loss, and the remaining 7 had experienced acute acoustic trauma. The Ménière's Disease was bilateral in three cases. The average period between the first documented hearing loss and the onset of Ménière's Disease was 15.8 years (standard deviation, +/- 6.6 years). This yielded a prevalence of 1.9:100000 of Ménière's Disease in a population with acoustic trauma or noise-induced hearing loss-a figure comparable to that in the general population. CONCLUSIONS: No support was found for the hypothesis that Ménière's Disease may be causally related to previous acoustic trauma or noise-induced hearing loss.

Inferior turbinectomy in children.

BACKGROUND: Inferior turbinectomy on patients of all ages is a controversial procedure. Its effect on children has been reported little in the literature and the few studies that are available involved relatively older children, i.e., >10 years old. Nasal obstruction caused by extensive hypertrophy of the inferior turbinates is not an uncommon observation in the pediatric population. The clinical manifestations might present as snoring, noisy breathing, mouth breathing, and, possibly, sleep apnea. METHODS: In this study, we followed 227 children <10 years of age who underwent inferior turbinectomy (27 children also underwent a revision of an earlier adenoidectomy), of whom 179 children had significant relief of nasal obstruction at the 1-year follow-up. RESULTS: Nocturnal breathing was reported to be more regular and otherwise improved in the 36 children with a suspected history of sleep apnea. Forty-two of 47 children who had thick nasal secretions and did not respond to antibiotic therapy before the operation had significant relief postoperatively. Postoperative complications were few and their number did not exceed that of adults. CONCLUSIONS: A complete inferior turbinectomy should be considered in children <10 years of age who have hypertrophied inferior turbinates that cause major interference with nasal breathing.

Dynamics of sensorineural hearing loss after head trauma.

OBJECTIVE: To estimate the temporal endpoint of permanent sensorineural hearing loss after head trauma. STUDY DESIGN: Retrospective observational case study. PATIENTS: In patients with sensorineural hearing loss caused by head trauma, 1,741 ears were studied. MAIN OUTCOME MEASURE: A follow-up survey of audiograms in patients with sensorineural hearing loss after head trauma was performed for up to 4 years from the date of injury. Each patient's audiograms were compared according to a severity score that specifically classified hearing loss that was associated with acoustic trauma. RESULTS: Either improvement or deterioration of the early posttrauma hearing loss occurred during the first year after head trauma. Thereafter, hearing levels could be expected to remain stationary. CONCLUSION: Fluctuation in hearing after head trauma may take place within the first year after trauma, after which the associated hearing loss should be considered to be stabilized.