Cost-effectiveness analysis of a non-contrast screening MRI protocol for vestibular schwannoma in patients with asymmetric sensorineural hearing loss.

PURPOSE: We aimed to determine if a non-contrast screening MRI is cost-effective compared to a full MRI protocol with contrast for the evaluation of vestibular schwannomas. METHODS: A decision tree was constructed to evaluate full MRI and screening MRI strategies for patients with asymmetric sensorineural hearing loss. If a patient were to have a positive screening MRI, s/he received a full MRI. Vestibular schwannoma prevalence, MRI specificity and sensitivity, and gadolinium anaphylaxis incidence were obtained through literature review. Institutional charge data were obtained using representative patient cohorts. One-way and probabilistic sensitivity analyses were completed to determine CE model threshold points for MRI performance characteristics and charges. RESULTS: The mean charge for a full MRI with contrast was significantly higher than a screening MRI ($4089 ± 1086 versus $2872 ± 741; p < 0.05). The screening MRI protocol was more cost-effective than a full MRI protocol with a willingness-to-pay from $0 to 20,000 USD. Sensitivity analyses determined that the screening protocol dominated when the screening MRI charge was less than $4678, and the imaging specificity exceeded 78.2%. The screening MRI protocol also dominated when vestibular schwannoma prevalence was varied between 0 and 1000 in 10,000 people. CONCLUSION: A screening MRI protocol is more cost-effective than a full MRI with contrast in the diagnostic evaluation of a vestibular schwannoma. A screening MRI likely also confers benefits of shorter exam time and no contrast use. Further investigation is needed to confirm the relative performance of screening protocols for vestibular schwannomas.

Preoperative Lumbar Drain Use During Acoustic Neuroma Surgery and Effect on CSF Leak Incidence.

OBJECTIVE: To determine if preoperative lumbar drain (LD) use reduces the incidence of postoperative cerebrospinal fluid (CSF) leak in patients undergoing acoustic neuroma resection. METHODS: Retrospective review of 282 patients presenting for acoustic neuroma resection between 2005 and 2014. RESULTS: Two hundred and eighty-two patients had a mean tumor size of 19.1 mm ± 10.2 mm. Twenty-nine (10.3%) patients developed a postoperative CSF leak. Two hundred and twenty patients (78.0%) received a preoperative LD, and 20 (9.1%) developed a CSF leak. Sixty-two (22.0%) patients did not receive a preoperative LD, and 9 (14.5%) developed a CSF leak. No significant difference in CSF leak frequency was observed with use versus no use of a LD (P = .23). Fifteen (5.3%) patients with an LD placed had a complication related to the LD. No significant difference in CSF leak frequency was observed with patient age, neurofibromatosis type-2 diagnosis, tumor size, or sidedness. CONCLUSIONS: Postoperative CSF leaks are among the most common complications of acoustic neuroma microsurgery. No formal guidelines exist for elective placement of a preoperative LD to lower the incidence of CSF leaks. Our reported CSF leak incidence with preoperative LD placement is not significantly lower than without LD use, and there is a complication rate associated with LD use.

Hospital Anxiety and Depression Scale: Factor Structure, Internal Consistency and Convergent Validity in Patients with Dizziness.

Psychiatric comorbidities, particularly anxiety-related pathologies, are often observed in dizzy patients. The Hospital Anxiety and Depression Scale (HADS) is a widely used self-report instrument used to screen for anxiety and depression in medical outpatient settings. The purpose of this study was to assess the factor structure, internal consistency and convergent validity of the HADS in an unselected group of patients with dizziness. The HADS and the Dizziness Handicap Inventory (DHI) were administered to 205 dizzy patients. An exploratory factor analysis was conducted and indicated a 3-factor structure, inconsistent with the 2-subscale structure (i.e. anxiety and depression) of the HADS. The total scale was found to be internally consistent, and convergent validity, as assessed using the DHI, was acceptable. Overall findings suggest that the HADS should not be used as a tool for psychiatric differential diagnosis, but rather as a helpful screener for general psychiatric distress in the two domains of psychiatric illness most germane in dizzy patients.

Translabyrinthine Craniotomy Is Associated with Higher Risk of Asymptomatic Dural Venous Sinus Thrombosis in Vestibular Schwannoma Resection.

OBJECTIVE: Characterize the incidence, risk factors, and patient outcomes of dural venous sinus thrombosis identified on postoperative imaging after retrosigmoid or translabyrinthine craniotomy for vestibular schwannoma resection. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary academic referral center. PATIENTS: Eighty-one patients 19 to 82 years of age with vestibular schwannomas, 58% female. INTERVENTIONS: Retrosigmoid or translabyrinthine craniotomy with postoperative magnetic resonance imaging/magnetic resonance venography. MAIN OUTCOME MEASURES: Association between operative approach, age, sex, body mass index, tumor size, dominant sinus, operative time, laterality, and perioperative cerebrospinal fluid (CSF) leaks with rate of thrombosis. RESULTS: Translabyrinthine craniotomy was associated with the highest relative risk of thrombosis (odds ratios [OR] = 19.82, 95% confidence interval [CI] = 1.75-224, p = 0.007), followed by male sex (OR = 5.53, 95% CI = 1.63-18.8, p = 0.035). Other patient and demographic risk factors were not associated with increased rates of dural venous thrombosis, nor was there an association with postoperative CSF leak. 81% (25/31) of thrombi had resolved within 3 years of surgery. CONCLUSIONS: Translabyrinthine approach and male sex most strongly predicted postoperative dural venous thrombosis after postauricular craniotomy for vestibular schwannoma resection. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: Better understanding of risk factors and management of dural venous thrombosis after vestibular schwannoma surgery. LEARNING OBJECTIVE: Characterize clinically significant risk factors for dural venous thrombosis in vestibular schwannoma surgery. DESIRED RESULT: Identification of patient and operative risk factors for dural venous thrombosis. LEVEL OF EVIDENCE: III. INDICATE IRB OR IACUC: Exempt.

Systematic Review and Meta-analysis for Surgery Versus Stereotactic Radiosurgery for Jugular Paragangliomas.

OBJECTIVE: Comprehensively analyze tumor control and treatment complications for jugular paraganglioma patients undergoing surgery versus stereotactic radiosurgery (SRS). DATABASES REVIEWED: EMBASE, Medline, and Scopus. METHODS: The databases were searched for English and Spanish articles from January 1, 1995, to January, 1, 2019, for studies reporting tumor control and treatment side effects regarding patients with jugular paraganglioma treated with surgery or SRS. Main outcome measures included short-term and long-term tumor recurrence, as well as postintervention complications. RESULTS: We identified 10,952 original abstracts, 705 eligible studies, and 107 studies for final data extraction. There were 3,498 patients-2,215 surgical patients and 1,283 SRS patients. Bayesian meta-analysis was applied to the extracted data, with tau measurements for study heterogeneity. SRS tumors were larger (3.9 cm 3 versus 8.1 cm 3 ). Meta-analysis results demonstrated low rates of long-term recurrence for both modalities (surgery, 15%; SRS, 7%), with SRS demonstrating lower rates of postintervention cerebrospinal fluid leak, dysphagia, and cranial nerve Vll, lX, X, Xl, or Xll palsies. CONCLUSIONS: This study demonstrates excellent control of jugular paragangiomas with both surgery and SRS, with higher rates of lower cranial neuropathies, dysphagia, and cerebrospinal fluid leaks among surgical patients.

Systematic Review of Otologic and Neurotologic Surgery Using the 3-dimensional Exoscope.

Objective: The 3D exoscope is an emerging technology that has been met with success in neurosurgery and is now increasingly used in otologic and neurotologic surgery. There is currently no consensus on its safety, efficiency, and utility, compared to the traditional microscope for these procedures. This systematic review aims to evaluate the use of the 3-dimensional (3D) exoscope for otologic and neurotologic surgery. Databases Reviewed: MEDLINE/PubMed, Web of Science, Scopus, and EMBASE. Methods: A systematic search of the databases was conducted for otologic and neurotologic surgery using the 3D exoscope. English language papers with no limit on the date of publication were considered. Inclusion criteria: full articles studying otologic or neurotologic/skull base surgery using exoscopes. Exclusion criteria: non-otologic surgery and non-neurotologic/skull base surgery, exclusive use of the traditional microscope, editorials, video reports, and letters. Two authors independently reviewed papers for inclusion; discrepancies were settled by consensus. Extracted variables included: number of patients, types of surgical procedures, operative and postoperative complications, setup and operative time, and visualization and ergonomic rating. Results: Six articles containing 128 surgical cases (103 exoscopic and 25 microscopic) were analyzed. Of the exoscopic cases, 21% were surgeries for chronic ear disease, 5% were cochlear implants, and 74% were lateral skull base procedures encompassing a wide variety of approaches. Conclusion: Based on preliminary studies, the exoscope appears to be comparable in safety, visualization, and efficiency compared to the operating microscope, with the potential for increased comfort and ease of use.

Vestibular Dysfunction and Gross Motor Milestone Acquisition in Children With Hearing Loss: A Systematic Review.

OBJECTIVE: To describe the impact of vestibular dysfunction on gross motor development in children with hearing loss. DATA SOURCES: MEDLINE (PubMed), Embase (Elsevier), Web of Science (Clarivate), and the Cumulative Index of Nursing and Allied Health Literature (EBSCO). REVIEW METHODS: A systematic review was reported in concordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Articles on children with hearing loss who underwent at least 1 instrumented measure of vestibular function and had gross motor milestones assessed were included. The Downs and Black checklist was used to assess risk of bias and methodological quality. RESULTS: Eleven articles were included in the systematic review. Three articles stratified quantitative results of gross motor milestone acquisition by severity of vestibular impairment. Over half of studies were case series published within the last 5 years. This systematic review showed that children with hearing loss and severe, bilateral vestibular dysfunction demonstrate delayed gross motor milestones. However, it was difficult to draw conclusions on whether milder forms of vestibular dysfunction significantly affect gross motor milestone acquisition in children with hearing loss. The reason is that most studies were of low to moderate quality, used different assessment methods, and contained results that were descriptive in nature. CONCLUSIONS: This emerging area would benefit from future research, such as higher-quality studies to assess vestibular function and gross motor milestones. This would allow for better characterization of the impacts of vestibular impairment, especially milder forms, in children with hearing loss.

Vestibular function after cochlear implantation: A test battery and case-by-case approach.

OBJECTIVES: The purpose of this study was to assess the effects of cochlear implantation on the functional integrity of the horizontal semicircular canal using multiple methodologies, and to discuss and highlight the limitations of using isolated vestibular tests to assess vestibular function in surgical ears. METHODS: Ten cochlear implant patients were consented to undergo a preoperative and 3-month postoperative vestibular assessment. The horizontal semicircular canal (SCC) was assessed using three different vestibular test measures that assess function using different stimuli and at different frequencies ranges: caloric testing, sinusoidal harmonic acceleration testing in the rotary chair, and video head impulse testing in the plane of the horizontal SCC. Data was analyzed using different methods: descriptive, statistical, and by an examination of individual case studies. RESULTS: Each analysis method yielded a different interpretation. Statistical analysis showed no significant group mean differences between baseline pre-op vestibular test results and 3-month post-op vestibular test results. Descriptive analysis showed 30% of individuals presented with postoperative abnormal vestibular testing findings. A case study examination showed that only one patient presented with a post-op decrease in vestibular function in the implanted ear. CONCLUSIONS: There are several limitations of conventional vestibular testing in postsurgical cochlear implant patients. A test-battery approach, including case history, and test interpretation made on a case-by-case basis is needed to determine whether the patient has undergone vestibular damage, is at risk for falling, or in need of further management. LEVEL OF EVIDENCE: 2b individual cohort study.

Associations of Vestibular Tests With Penn Acoustic Neuroma Quality of Life Scores After Resection of Vestibular Schwannoma.

OBJECTIVE: Determine associations between preoperative caloric testing and video head impulse testing (vHIT) with baseline and postoperative Penn Acoustic Neuroma Quality of Life (PANQOL) scores following resection of vestibular schwannoma (VS). STUDY DESIGN: Retrospective case series. SETTING: Two tertiary referral hospitals. PATIENTS: Adult patients with unilateral VS, preoperative calorics, vHIT, and dizziness handicap inventory (DHI) score. INTERVENTIONS: Surgical resection of VS and postoperative surveys. MAIN OUTCOME MEASURES: PANQOL scores. RESULTS: Forty-three patients were included (58.1% women) with a median age of 54 years (range, 28-82). Mean tumor size was 14.8 mm (σ=8.6), and 28 (65.1%) were right-sided. Average preoperative vHIT gain was 0.7 (σ = 0.3). Covert and overt saccades were present in 8 (25%) and 14 (42.4%) patients, respectively. Average preoperative unilateral weakness was 47% (σ = 33.2). Translabyrinthine approach was performed in 26 (60.5%) patients. No significant difference of PANQOL scores was noted at baseline or over time between patients with normal (>0.8) or abnormal (<0.8) gain. Patients with more unilateral weakness (>50%) had significantly higher baseline PANQOL scores compared with those with < 25% or 25 to 50% (p = 0.02), but had significant improvement in scores over time (p = 0.01). Higher preoperative DHI preoperatively was significantly associated with worse PANQOL scores at all timepoints (ß=0.57, p = 0.0064). No differences in PANQOL scores amongst surgical approaches were observed. CONCLUSION: Preoperative vestibular testing with vHIT, calorics, DHI, and baseline PANQOL surveys may allow for patient counseling regarding postoperative quality of life over time.

Recurrent and Progressive Facial Baroparesis on Flying Relieved by Eustachian Tube Dilation.

OBJECTIVES: Facial baroparesis is a rare phenomenon of seventh cranial nerve palsy traditionally reported in divers, with only 11 cases reported in aviation so far. It is important to correctly diagnose facial baroparesis given the differential diagnosis of stroke and decompression disease and offer appropriate treatment for recurrent cases. METHODS: The authors present the case of a patient with recurrent and progressive facial baroparesis treated with Eustachian tube balloon dilation. Institutional medical records were reviewed, and analysis of the current literature was performed. RESULTS: A 37-year-old woman experienced recurrent and progressive left facial paralysis on descent from altitude on commercial airline flights, with resolution between flights. The patient flew frequently for work-related trips and for the past 7 years had noted facial paralysis that began with mild asymmetry of the face and progressed to an inability to close her left eye. She denied any otologic symptoms other than ear fullness and pressure causing left otalgia. The right side was not involved. After treatment with Eustachian tube dilation, the patient has been on numerous flights with complete resolution of symptoms. CONCLUSIONS: This study presents a rare case of facial baroparesis on commercial flight descent that resolved after left Eustachian tube dilation. Although unilateral facial palsy can be concerning for stroke, a history of ear fullness and pressure may suggest facial baroparesis instead. For recurrent and progressive cases, Eustachian tube dilation should be considered for treatment.

Associations of Video Head Impulse Test and Caloric Testing among Patients with Vestibular Schwannoma.

OBJECTIVE: To determine relationships between caloric testing (CT) and video head impulse testing (vHIT) among patients with unilateral vestibular schwannoma (VS). To describe the distribution of CT and vHIT measurements and assess associations with tumor size and self-perceived handicapping effects. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral hospital. SUBJECTS AND METHODS: Subjects were adults with presumed unilateral VS between 2014 and 2017. Interventions were CT and vHIT. Primary outcomes were vHIT value (abnormal <0.8) and CT value (abnormal >25%). Secondary outcomes were tumor size and Dizziness Handicap Inventory scores. RESULTS: Fifty-one individuals had complete data for CT and vHIT. The odds of abnormal gain increases by 2.18 for every 10% increase in unilateral weakness on CT (range, 1.44-3.34; P < .001). A significant negative correlation between CT and gain exists (rs = -0.64, P < .001). Odds of observing saccades increased by 2.68 for every 10% increase in unilateral weakness (range, 1.48-4.85; P = .001). This association was larger in magnitude for overt than covert saccades (odds ratios, 2.48 and 1.59, respectively). Tumor size was significantly associated with an increase in caloric weakness (ß = 0.135, P < .001). With every 10-mm increase of tumor size, odds of abnormal gain on vHIT increased 4.13 (range, 1.46-11.66; P = .007). Mean Dizziness Handicap Inventory score was 19.7 (σ = 22), without association to caloric weakness, gain, or tumor size. CONCLUSION: CT and vHIT both effectively assess vestibular function for patients with VS and correlate to tumor size. These findings are important as vHIT has a lower overall cost, improved patient tolerance, and demonstrated reliability.

Bone-anchored hearing aid abutment skin overgrowth reduction with clobetasol.

OBJECTIVES: The bone-anchored hearing aid (BAHA) osseointegrated cochlear stimulator can treat hearing loss in a variety of clinical situations. Occasionally skin/scar overgrowth may cover the abutment. This overgrowth interferes with affixing the BAHA to the abutment. Surgical scar revision/excision has been used to treat this problem. Clobetasol (0.05%), a steroid gel, can reduce skin overgrowth. Experience with skin overgrowth and the efficacy of clobetasol to treat this problem was reviewed. SUBJECTS AND METHODS: The authors conducted a retrospective analysis of patients who underwent BAHA abutment implantation from January 2003 through December 2006. RESULTS: Eighty-eight patients (2 patients received bilateral BAHAs) were reviewed. Twenty (22%) of 90 sites developed overgrowth. Thirteen of 20 sites were treated with clobetasol. The overgrowth resolved in 11 (85%) of 13 sites after treatment. Patients with incomplete skin graft survival were significantly more likely to develop skin overgrowth (P = 0.0017). CONCLUSION: Clobetasol is an effective treatment for abutment skin/scar overgrowth. Clobetasol allows patients to resume BAHA use and obviates the need for scar revision.

Chemical meningitis following cerebellopontine angle tumor surgery.

OBJECTIVE: Postoperative chemical meningitis mimics bacterial meningitis, complicating the diagnosis until results of cerebrospinal fluid (CSF) cultures can be obtained. We analyzed clinical and laboratory data from a series of 1146 patients to identify findings that could exclude bacterial meningitis. SUBJECTS AND METHODS: We reviewed the charts of patients who developed meningitis after cerebellopontine angle surgery. Lumbar puncture data from asymptomatic postoperative patients were our control. STUDY DESIGN: Clinical symptoms, CSF profiles, and serum white blood cell (WBC) counts were compared between patients with chemical meningitis, bacterial meningitis, and asymptomatic patients. RESULTS: The incidence of meningitis in our series of 1146 patients was 4.54 percent; 0.87 percent was culture-proven bacterial meningitis. The patients with bacterial meningitis had significantly higher CSF and serum WBC counts, and lower CSF glucose. The major difference between asymptomatic patients and those with chemical meningitis was the significantly lower ratio of CSF WBCs to red blood cells (RBCs) in asymptomatic patients. CONCLUSION: Patients with mild CSF leukocytosis and normal CSF glucose without high serum WBC counts or focal neurological deficits may be treated for chemical meningitis.

Alexander's law revisited.

BACKGROUND: It is a common occurrence in the balance function laboratory to evaluate patients in the post-acute period following unilateral vestibular system impairment. It is important to be able to differentiate spontaneous nystagmus (SN) emanating from peripheral vestibular system impairments from asymmetric gaze-evoked nystagmus (GEN) that originates from central ocular motility impairment. PURPOSE: To describe the three elements of Alexander's Law (AL) that have been used to define SN from unilateral peripheral impairment. Additionally, a fourth element is described (i.e., augmentation of spontaneous nystagmus from unilateral peripheral vestibular system impairment) that differentiates nystagmus of peripheral vestibular system origin from nystagmus that originates from a central eye movement disorder. RESEARCH DESIGN: Case reports. STUDY SAMPLE: Case data were obtained from two patients both showing a nystagmus that followed AL. INTERVENTION: None DATA COLLECTION AND ANALYSIS: Videonystagmography (VNG), rotational, vestibular evoked myogenic potential (VEMP), and neuro-imaging studies were presented for each patient. RESULTS: The nystagmus in Case 1 occurred as a result of a unilateral, peripheral, vestibular system impairment. The nystagmus was direction-fixed and intensified in the vision-denied condition. The nystagmus in Case 2, by appearance identical to that in Case 1, was an asymmetric gaze-evoked nystagmus originating from a space-occupying lesion in the cerebello-pontine angle. Unlike Case 1, the nystagmus did not augment in the vision-denied condition. CONCLUSIONS: Although nystagmus following AL usually occurs in acute peripheral vestibular system impairment, it can occur in cases of central eye movement impairment. The key element is whether the SN that follows AL is attenuated or augmented in the vision-denied condition. The SN from a unilateral peripheral vestibular system impairment should augment in the vision denied condition. An asymmetric GEN will either not augment, decrease in magnitude, or disappear entirely, in the vision-denied condition.

Preoperative Imaging Findings and Cost in Adults With Postlingual Deafness Prior to Cochlear Implant.

OBJECTIVE: To assess the imaging findings of computed topography (CT) and magnetic resonance imaging (MRI) in adults with postlingual deafness and otherwise normal clinical history and physical exam. Additionally, determine the influence and implications of these findings with respect to surgical outcomes and cost. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral hospital. PATIENTS: Adults with postlingual deafness with no history of prior ear surgery, chronic ear disease, meningitis, otosclerosis, or head trauma. INTERVENTIONS: Cochlear implantation of 1 or both ears, with preoperative CT, MRI, or both. MAIN OUTCOME MEASURES: Imaging results were classified as normal, abnormal affecting surgery, incidental requiring follow-up, or incidental not requiring follow-up. Average cost of each imaging modality was determined. RESULTS: A total of 128 patients met the inclusion criteria. Of these, 82 (64.1%) had both CT and MRI performed, 33 (25.8%) had CT, and 13 (10.2%) had MRI prior to cochlear implant (CI). Scans were normal in 125 (97.7%) of cases. Of the remaining 3 (2.3%) patients, there were incidental findings requiring follow-up. All implants were placed successfully, and in no instance did the results of the scan influence the surgery. The average cost of imaging per patient was $4707. CONCLUSION: In adults with postlingual deafness with an otherwise benign clinical history, CT and MRI are unlikely to affect or preclude surgery. With new MRI safe cochlear implants, imaging can be performed safely postoperatively if needed.

Osseointegrated implants for auricular prostheses: An alternative to autologous repair.

OBJECTIVES/HYPOTHESIS: This study compares the hospital cost of osseointegrated implants for retention of an auricular prosthesis to autologous ear reconstruction. STUDY DESIGN: Retrospective review. METHODS: This study includes patients who underwent reconstruction for either congenital or acquired ear defects at Duke University Medical Center during 2009 to 2015. RESULTS: A total of nine patients had autologous repair representing nine operative ears, and 16 patients had an osseointegrated implant representing 18 operative ears (two bilateral). The average age for the autologous repair was 11.6 years with 56% male versus 40.7 years with 56% male for the osseointegrated implant patients. For autologous patients, indications for surgery were anotia/microtia in 8/9 (89%) and trauma in 1/9 (11%) versus 6/16 (387.5%) anotia/microtia, 8/16 (50%) cancer, and 2/16 (132.5%) trauma in the osseointegrated implant group. The mean number of surgeries was 3.1 for autologous repairs and 1.0 for osseointegrated repairs (mean difference confidence interval [CI]: -2.4 to -1.8, P < .001). The average cost to the hospital for an osseointegrated repair was $6,491.39 versus $10,047.93 for autologous repairs (CI: $6,496.38 to $-616.68, P = .02) CONCLUSIONS: Osseointegrated implants for retaining an auricular prosthesis has a similar cost to autologous repair of ear defects, but patients underwent an average of two more surgeries with autologous repair. Patients should be able to choose the reconstruction option that best suits their condition and preferences. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2153-2156, 2018.

Otorhinolaryngology and Diving-Part 1: Otorhinolaryngological Hazards Related to Compressed Gas Scuba Diving: A Review.

IMPORTANCE: Scuba diving is becoming increasingly popular. However, scuba diving is associated with specific risks; 80% of adults and 85% of juvenile divers (aged 6-17 years) have been reputed to have an ear, nose, or throat complaint related to diving at some point during their diving career. Divers frequently seek advice from primary care physicians, diving physicians, and otorhinolaryngologists, not only in the acute setting, but also related to the long-term effects of diving. OBSERVATIONS: The principles underpinning diving-related injuries that may present to the otorhinolaryngologist rely on gas volume and gas saturation laws, and the prevention of these injuries requires both that the diver is skilled and that their anatomy allows for pressure equalization between the various anatomical compartments. The overlapping symptoms of middle ear barotrauma, inner ear barotrauma, and inner ear decompression sickness can cause a diagnostic conundrum, and a thorough history of both the diver's symptoms and the dive itself are required to elucidate the diagnosis. Correct diagnosis and appropriate treatment result in a more timely return to safe diving. CONCLUSIONS AND RELEVANCE: The aim of this review is to provide a comprehensive overview of otorhinolaryngological complications during diving. With the increasing popularity of diving and the frequency of ear, nose, or throat-related injuries, it could be expected that these injuries will become more common and this review provides a resource for otorhinolaryngologists to diagnose and treat these conditions.

Otorhinolaryngology and Diving-Part 2: Otorhinolaryngological Fitness for Compressed Gas Scuba Diving: A Review.

IMPORTANCE: Self-contained underwater breathing apparatus (scuba) diving has become increasingly popular with millions of people diving each year. Otorhinolaryngologists are often consulted either by patients or diving physicians regarding fitness to dive, and at present, the guidelines do not provide comprehensive information regarding the evaluation of this patient cohort. The aim of this review is to provide a comprehensive overview of existing otorhinolaryngological guidelines for fitness to dive recreationally. OBSERVATIONS: There is a paucity of guidelines for assessing otorhinolaryngological fitness to dive in the recreational diver. Comprehensive guidelines exist from US, European, and UK regulatory bodies regarding fitness for commercial diving; however, not all of these can be directly extrapolated to the recreational diver. There are also a variety of conditions that are not covered either by the existing fitness for recreational diving guidelines or the commercial regulatory bodies. CONCLUSIONS AND RELEVANCE: With the paucity of recreational fitness to dive guidelines we must draw on information from the commercial diving regulatory bodies. We have provided our own recommendations on the conditions that are not covered by either of the above, to provide otorhinolaryngologists with the information they require to assess fitness for recreational diving.

Multicenter US Clinical Trial With an Electric-Acoustic Stimulation (EAS) System in Adults: Final Outcomes.

OBJECTIVE: To demonstrate the safety and effectiveness of the MED-EL Electric-Acoustic Stimulation (EAS) System, for adults with residual low-frequency hearing and severe-to-profound hearing loss in the mid to high frequencies. STUDY DESIGN: Prospective, repeated measures. SETTING: Multicenter, hospital. PATIENTS: Seventy-three subjects implanted with PULSAR or SONATA cochlear implants with FLEX electrode arrays. INTERVENTION: Subjects were fit postoperatively with an audio processor, combining electric stimulation and acoustic amplification. MAIN OUTCOME MEASURES: Unaided thresholds were measured preoperatively and at 3, 6, and 12 months postactivation. Speech perception was assessed at these intervals using City University of New York sentences in noise and consonant-nucleus-consonant words in quiet. Subjective benefit was assessed at these intervals via the Abbreviated Profile of Hearing Aid Benefit and Hearing Device Satisfaction Scale questionnaires. RESULTS: Sixty-seven of 73 subjects (92%) completed outcome measures for all study intervals. Of those 67 subjects, 79% experienced less than a 30 dB HL low-frequency pure-tone average (250-1000 Hz) shift, and 97% were able to use the acoustic unit at 12 months postactivation. In the EAS condition, 94% of subjects performed similarly to or better than their preoperative performance on City University of New York sentences in noise at 12 months postactivation, with 85% demonstrating improvement. Ninety-seven percent of subjects performed similarly or better on consonant-nucleus-consonant words in quiet, with 84% demonstrating improvement. CONCLUSION: The MED-EL EAS System is a safe and effective treatment option for adults with normal hearing to moderate sensorineural hearing loss in the low frequencies and severe-to-profound sensorineural hearing loss in the high frequencies who do not benefit from traditional amplification.