Experience with pharmacologic leeching with bivalirudin for adjunct treatment of venous congestion of head and neck reconstructive flaps.

OBJECTIVES: The goal of this study was to review the feasibility of local bivalirudin injection for adjunct treatment of venous congestion of head and neck reconstructive flaps. METHODS: A retrospective chart review of patients who underwent bivalirudin treatment for venous congestion of head and neck reconstructive flaps in a single institution from September 1, 2012 to September 1, 2015 was undertaken. Individuals were treated with variable number of intradermal injections directly into the flap followed by a small skin incision to allow extended passive bleeding. The main outcome measure was improvement of flap congestion. RESULTS: Ten patients with free flap reconstruction (4 anterolateral thigh flaps, 2 pectoralis major flaps, 2 fibula osseocutaneous flaps, 1 supraclavicular flap, and 1 radial forearm free flap) of various head and neck defects underwent treatment with bivalirudin. Bivalirudin injections were utilized as adjunct therapy in 6 patients. Two individuals underwent alternate therapy for venous congestion immediately following injection and therefore the efficacy could not be assessed. Of the 8 remaining flaps, 4 developed partial necrosis, and 1 developed complete necrosis requiring additional reconstruction. Two individuals required blood transfusions during bivalirudin treatment. CONCLUSIONS: Bivalirudin is a safe and feasible adjunct therapy for treatment of flap congestion. It may serve as a useful alternative to traditional leech therapy, as bivalirudin negates the need for antibiotic prophylaxis, eliminates the psychological aversion associated with leech therapy, and avoids the potential for leech migration. Further work to determine the efficacy of bivalirudin to standard leech therapy is warranted.

Saccular Impairment in Alzheimer's Disease Is Associated with Driving Difficulty.

BACKGROUND/AIMS: Patients with Alzheimer's disease (AD) experience increased rates of vestibular loss. Recent studies suggest that saccular impairment in mild cognitive impairment (MCI) and AD patients is associated with impaired spatial cognitive function. However, the impact of saccular impairment on everyday behaviors that rely on spatial cognitive function is unknown. METHODS: We recruited 60 patients (21 MCI and 39 AD) from an interdisciplinary Memory Clinic. Saccular function was measured, and a visuospatial questionnaire was administered to assess whether participants experienced impairments in terms of driving difficulty, losing objects, falls, and fear of falling. RESULTS: In multiple logistic regression analyses, MCI and AD patients with bilateral saccular impairment had a significant, greater than 12-fold odds of driving difficulty (OR 12.1, 95% CI 1.2, 117.7) compared to MCI and AD patients with normal saccular function, and the association appears to be mediated by spatial cognition as measured by the Money Road Map Test. CONCLUSION: This study suggests a novel link between saccular impairment and driving difficulty in MCI and AD patients and demonstrates that driving difficulty may be a real-world manifestation of impaired spatial cognition associated with saccular impairment.

Characterization of Geriatric Dysphagia Diagnoses in Age-Based Cohorts.

OBJECTIVE: An aging population requires increased focus on geriatric otolaryngology. Patients aged ≥65 years are not a homogenous population, and important physiologic differences have been documented among the young-old (65-74 years), middle-old (75-84), and old-old (≥85). We aim to analyze differences in dysphagia diagnoses and swallowing-related quality-of-life among these age subgroups. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care laryngology clinic. SUBJECTS AND METHODS: We identified chief complaint, diagnosis, and self-reported swallowing handicap (Eating Assessment Tool [EAT-10] score) of all new patients aged ≥65 years presenting to the Johns Hopkins Voice Center between April 2015 and March 2017. Dysphagia diagnoses were classified by physiologic etiology and anatomic source. Diagnostic categories and EAT-10 score were evaluated as functions of patient age and sex. RESULTS: Of 839 new patients aged ≥65 years, 109 (13.0%) reported a chief complaint of dysphagia and were included in this study. The most common dysphagia etiologies were neurologic and esophageal. Most common diagnoses were diverticula (15.6%), reflux (13.8%), and radiation induced (8.3%). Diverticula, cricopharyngeal hypertonicity, and radiation-induced changes were associated with higher EAT-10 score (P < .001). Significant differences by sex were found in anatomic source of dysphagia, as men and women were more likely to present with oropharyngeal and esophageal disease, respectively (P = .023). Dysphagia etiology and EAT-10 score were similar across age subgroups. CONCLUSION: Important differences among dysphagia diagnosis and EAT-10 score exist among patients aged ≥65 years. Knowledge of these differences may inform diagnostic workup, management, and further investigations in geriatric otolaryngology.

Geriatric Dysphonia: Characteristics of Diagnoses in Age-Based Cohorts in a Tertiary Voice Clinic.

OBJECTIVE: An aging population has increased focus on geriatric otolaryngology. Those ≥65 years old are not a uniform population, however, and recent gerontology literature recognizes important physiologic differences between the young-old (ages 65-74 years), middle-old (75-84), and old-old (≥85). This study evaluates differences within these groups among dysphonia patients ≥65 years relative to diagnosis and voice-related quality of life (V-RQOL). METHODS: Chart review of all new patients ≥65 years presenting to the Johns Hopkins Voice Center between April 2015 and March 2017 identified chief complaint, diagnosis, and self-reported voice handicap. Etiology of dysphonia diagnoses were classified. Diagnostic categories and V-RQOL were evaluated as functions of patient age and gender. RESULTS: Of 839 new patients ≥65 years, 463 (55.2%) reported chief complaint of dysphonia, with the most common etiologies being vocal fold immobility (28.3%) and atrophy (21.6%). Younger cohorts were more likely to present with benign vocal fold lesion and vocal fold immobility, while older cohorts were more likely to present with atrophy ( P = .016). The odds of having a diagnosis of vocal fold atrophy increased 7% with each year of life (odds ratio = 1.07; 95% CI, 1.03-1.11). V-RQOL scores were similar across gender and age categorization. CONCLUSION: Dysphonia patients ≥65 years are not a uniform group, and important differences exist in terms of diagnosis as a function of age. Knowledge of these differences may inform further investigations in the growing field of geriatric otolaryngology.

Increased Prevalence of Vestibular Loss in Mild Cognitive Impairment and Alzheimer's Disease.

BACKGROUND/AIMS: Recent evidence has shown that Alzheimer's Disease (AD) patients have reduced vestibular function relative to healthy controls. In this study, we evaluated whether patients with Mild Cognitive Impairment (MCI) also have reduced vestibular function relative to controls, and compared the level of vestibular impairment between MCI and AD patients. METHODS: Vestibular physiologic function was assessed in 77 patients (26 MCI, 51 AD) and 295 matched controls using 3 clinical vestibular tests. The association between vestibular loss and cognitive impairment was evaluated using conditional logistic regression models. RESULTS: Individuals with vestibular impairment had a 3 to 4-fold increased odds of being in the MCI vs. control group (p-values < 0.05). MCI patients had a level of vestibular impairment that was intermediate between controls and AD. CONCLUSION: These findings suggest a dose-response relationship between vestibular loss and cognitive status, and support the hypothesis that vestibular loss contributes to cognitive decline.

Vestibular Loss Predicts Poorer Spatial Cognition in Patients with Alzheimer's Disease.

The vestibular system is an important contributor to balance control, spatial orientation, and falls risk. Recent evidence has shown that Alzheimer's disease (AD) patients have a higher prevalence of vestibular impairment relative to healthy controls. We sought to evaluate whether vestibular loss is specifically associated with poor spatial cognitive skills among patients with mild cognitive impairment (MCI) and AD. We enrolled 50 patients (22 MCI and 28 AD) from an interdisciplinary Memory Clinic and measured vestibular physiologic function in all patients. Spatial cognitive function was assessed using the Money Road Map Test (MRMT) and the Trail Making Test Part B (TMT-B). General cognitive function was assessed with the Mini-Mental Status Examination (MMSE). In multivariable linear regression analyses adjusted for age, gender, education level, and MMSE, MCI and AD patients with vestibular loss made significantly more errors on the MRMT relative to patients with normal vestibular function (ß= 7.3, 95% CI 2.4, 12.1 for unilateral vestibular loss and ß= 6.4, 95% CI 1.9, 10.9 for bilateral vestibular loss). We further stratified AD patients into "spatially normal" and "spatially impaired" groups based on MRMT performance, and found that the prevalence of vestibular loss was significantly higher in the spatially impaired AD group relative to the spatially normal AD group. These findings support the hypothesis that vestibular loss contributes specifically to a decline in spatial cognitive ability in MCI and AD patients, independently of general cognitive decline, and may predict a "spatially impaired" subtype of AD.

Understanding the Experience of Age-Related Vestibular Loss in Older Individuals: A Qualitative Study.

BACKGROUND: Inner ear balance (or vestibular) function declines with age and is associated with decreased mobility and an increased risk of falls in older individuals. We sought to understand the lived experience of older adults with vestibular loss in order to improve care in this population. METHODS: Qualitative data were derived from semi-structured interviews of individuals aged 65 years or older presenting to the Balance and Falls Prevention Clinic from February 1, 2014 to March 30, 2015 for evaluation of age-related vestibular loss. Transcripts were analyzed using interpretive phenomenological analysis. We created a taxonomy of overarching superordinate themes based on the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) Framework, and classified key dimensions within each of these themes. RESULTS: Sixteen interviews were conducted with individuals (mean age 76.0 years, 75 % female) with age-related vestibular loss. The three superordinate themes and associated key dimensions were (1) body impairment (including depression, fatigue, fear/anxiety, and problems with concentrating and memory); (2) activity limitation and participation restriction (isolation, needing to stop in the middle of activities, reduced participation relative to expectations, reduced ability to drive or travel, and problems with bending/looking up, standing, and walking); and (3) environmental influences (needing help with daily activities). All participants reported difficulty walking. CONCLUSIONS: Older adults report that vestibular loss impacts their body functioning and restricts their participation in activities. The specific key dimensions uncovered by this qualitative study can be used to evaluate care from the patient's perspective.

Secondary Acquired Cholesteatoma: Presentation and Tympanoplasty Outcomes.

OBJECTIVE: Comparing the clinical features and surgical outcomes of patients undergoing tympanoplasty for secondary acquired cholesteatoma (SAC) versus non-complicated tympanic membrane perforation (TMP). STUDY DESIGN: Retrospective patient review. SETTING: Tertiary-care, academic center. PATIENTS: All 41 patients with diagnosis of SAC confirmed at surgery between January 1, 2007 and June 30, 2014, and an age-matched cohort consisting of patients with TMP. INTERVENTION(S): Tympanoplasty using either medial or lateral graft techniques. MAIN OUTCOME MEASURE(S): Resolution of perforation, SAC, and symptoms. RESULTS: Comparison between the two cohorts failed to reveal significant differences in otologic symptomology, or presentation. There was no significant difference in the resolution of SAC (p = 0.7) between the medial and lateral tympanoplasty techniques. Both techniques also had similar rates of success in the TMP cohort. The medial graft technique was significantly (p = 0.008) more likely to result in a successfully repaired tympanic membrane in the TMP cohort compared with the SAC cohort. The Lateral graft technique demonstrated no significant difference in the likelihood of TMP and SAC resolution. CONCLUSION: The presentation of SAC is similar to that of TMP despite being a separate clinical entity. A clinician's ability to distinguish the two is important to mitigate the destructive potential of untreated SAC and correctly council patients on tympanoplasty success rates. This study was unable to demonstrate a significant difference in disease control between the medial and lateral tympanoplasty techniques, although potential advantages of each technique are discussed.

Vestibular Impairment in Dementia.

OBJECTIVE: Recent studies suggest an association between vestibular and cognitive function. The goal of the study was to investigate whether vestibular function was impaired in individuals with mild cognitive impairment (MCI) and Alzheimer's disease (AD) compared with cognitively normal individuals. STUDY DESIGN: Cross-sectional study. SETTING: Outpatient memory clinic and longitudinal observational study unit. PATIENTS: Older individuals ≥55 years with MCI or AD. Age, sex, and education-matched normal controls were drawn from the Baltimore Longitudinal Study of Aging (BLSA). INTERVENTION: Saccular and utricular function was assessed with cervical and ocular vestibular-evoked myogenic potentials (c- and oVEMPs) respectively, and horizontal semicircular canal function was assessed with video head impulse testing. MAIN OUTCOME MEASURES: Presence or absence of VEMP responses, VEMP amplitude, and vestibular ocular reflex (VOR) gain were measured. RESULTS: Forty-seven individuals with cognitive impairment (MCI N = 15 and AD N = 32) underwent testing and were matched with 94 controls. In adjusted analyses, bilaterally absent cVEMPs were associated with an over three-fold odds of AD (OR 3.42, 95% CI 1.33-8.91, p = 0.011). One microvolt increases in both cVEMP and oVEMP amplitudes were associated with decreased odds of AD (OR 0.28, 95% CI 0.09-0.93, p = 0.038 and OR 0.92, 95% CI 0.85-0.99, p = 0.036, respectively). There was no significant difference in VOR gain between the groups. CONCLUSIONS: These findings confirm and extend emerging evidence of an association between vestibular dysfunction and cognitive impairment. Further investigation is needed to determine the causal direction for the link between peripheral vestibular loss and cognitive impairment.

The Use of Fall Risk Increasing Drugs (FRIDs) in Patients With Dizziness Presenting to a Neurotology Clinic.

OBJECTIVE: To characterize the use of fall risk increasing drugs (FRIDs) in patients with dizziness who presented to a Neurotology academic practice and to evaluate for predictors of FRID use in this population. PATIENTS: A total of 292 subjects presented with dizziness between July 1, 2013 and December 31, 2013. INTERVENTION: Demographic information and FRID use were recorded. MAIN OUTCOME MEASURE: The prevalence and type of FRIDs (psychotropics, antihypertensives, and/or narcotics) used among participants. RESULTS: The overall prevalence of any FRID use was 40.8%. Thirty-nine percent of patients were on psychotropic medications, 37% on antihypertensives, and 8.2% on narcotics. The proportion of patients on two or more FRIDs at presentation was 34%. When categorizing by age group, 40% of patients aged 50 years or greater versus 24% of younger patients (p = 0.004) were on two or more FRIDs. With every decade increase in age, the odds of being on two or more FRIDs increased by 7%. CONCLUSIONS: Forty percent of all patients presenting to a Neurotology Clinic for dizziness were on a FRID. Older patients were significantly more likely to be on multiple FRIDs, specifically antihypertensives and narcotic medications. These findings suggest that to fully assess and treat older patients with dizziness, the use of these medications should be evaluated.

Vestibular Function and Activities of Daily Living: Analysis of the 1999 to 2004 National Health and Nutrition Examination Surveys.

OBJECTIVE: Vestibular dysfunction increases with age and is associated with mobility difficulties and fall risk in older individuals. We evaluated whether vestibular function influences the ability to perform activities of daily living (ADLs). METHOD: We analyzed the 1999 to 2004 National Health and Nutrition Examination Survey of adults aged older than 40 years (N = 5,017). Vestibular function was assessed with the Modified Romberg test. We evaluated the association between vestibular function and difficulty level in performing specific basic and instrumental ADLs, and total number of ADL impairments. RESULTS: Vestibular dysfunction was associated with significantly higher odds of difficulty with nine ADLs, most strongly with difficulty managing finances (odds ratio [OR] = 2.64, 95% confidence interval [CI] = [1.18, 5.90]). In addition, vestibular dysfunction was associated with a significantly greater number of ADL impairments (ß = .21, 95% CI = [0.09, 0.33]). This effect size was comparable with the influence of heavy smoking (ß = .21, 95% CI = [0.06, 0.36]) and hypertension (ß = .10, 95% CI = [0.02, 0.18]) on the number of ADL impairments. CONCLUSION: Vestibular dysfunction significantly influences ADL difficulty, most strongly with a cognitive rather than mobility-based task. These findings underscore the importance of vestibular inputs for both cognitive and physical daily activities.

The Role of Obliteration in the Achievement of a Dry Mastoid Bowl.

OBJECTIVE: To evaluate the impact of mastoid obliteration on the achievement of a dry mastoid bowl and frequency of maintenance care. STUDY DESIGN: Retrospective chart review. SETTING: Academic medical center. PATIENTS: There were 63 canal-wall-down mastoidectomies for chronic otitis media with or without cholesteatoma between 2007 and 2014 with follow-up of at least 6 months. Eighteen mastoids were nonobliterated and 45 were obliterated. Thirteen underwent secondary obliteration of existing mastoid bowls with chronic drainage, whereas 32 underwent primary obliteration at the original canal-wall-down procedure. INTERVENTION: Mastoid obliteration. MAIN OUTCOME MEASURES: Achievement of a dry healed mastoid cavity and frequency of outpatient visits. RESULTS: In more than 80% of the cases, a dry ear was achieved, with no significant difference between the obliterated and nonobliterated cases (p = 0.786). Eleven of the 13 secondary cases experienced cessation of otorrhea, achieving dry ears at rates similar to that of the primary and nonobliterated cases. The secondary obliteration population was also significantly younger than the primary group (22.1 versus 43.5 years, p = 0.002). Multivariable-mixed effects analysis demonstrated a reduction in 0.1 visits per 6-month period following surgery overtime (p < 0.001). CONCLUSIONS: Mastoid obliteration may be valuable in the management of the well-developed and chronically wet mastoid cavity, particularly when the drainage emanates from mucosal disease or cell tracts in a deep sinodural angle. Younger patients may require secondary obliteration because of continued craniofacial maturation several years following canal-wall-down surgery.

An Unusual Case of Bony Styloid Processes That Extend to the Hyoid Bone.

The embryological origin of the hyoid bone is a point of uncertainty, with controversy surrounding the relative contribution of the second pharyngeal arch to hyoid development. We encountered a 52-year-old male with bilateral bony styloid extension to the lesser cornu of the hyoid bone during the workup of a patient with laryngeal cancer. This embryological malformation clearly supports the hypothesis that the second pharyngeal arch gives rise to the lesser cornu and demonstrates an unusual clinical finding that may be encountered by otolaryngologists. We demonstrate the imaging findings and surgical management of this unusual anatomical variant and review the embryological basis for this rare malformation.

Interventions to improve patient participation in the treatment process for culturally and linguistically diverse people with cancer: a systematic review.

Disparities in cancer outcomes for people from culturally and linguistically diverse (CALD) groups are well known. Improving CALD patients' active participation in treatment processes holds potential to improve outcomes, but little is known of effective strategies to facilitate this. This systematic review investigated interventions to improve three aspects of participation in cancer care among CALD groups, namely involvement in decision-making, communication with health providers and treatment adherence. A comprehensive search of electronic bibliographic databases was conducted to identify intervention studies that reported outcomes relevant to patient participation for CALD groups. Two reviewers independently critically appraised the studies and abstracted data. Of 10,278 potential articles, seven met the inclusion criteria, including three randomized controlled, three non-randomized and one mixed-method experimental studies. Interventions included the use of patient navigators, videos and decision aids. The impact on patient participation was varied. The effect of a decision aid and patient navigator interventions on communication with health providers was positive. While the use of a decisions aid successfully facilitated shared decision-making and patients' perception of treatment adherence, the use of patient navigators was ineffective. A computer support system was found to improve general patient participation; however little clarification of what this involved was provided. This systematic review identified few rigorous evaluations of interventions to improve treatment participation for CALD people with cancer, highlighting the lack of a robust evidence base to improve this crucial aspect of care. The development and evaluation of interventions for diverse populations remains a priority.

Sex and age associations with vestibular schwannoma size and presenting symptoms.

OBJECTIVE: To assess the association of sex and age with presenting symptoms and size of vestibular schwannoma at clinical presentation to our clinics. STUDY DESIGN: Retrospective chart review. SETTING: Academic medical center. PATIENTS: Approximately 1,269 subjects diagnosed with unilateral vestibular schwannoma between 1997 and 2010. INTERVENTION: Demographic information, tumor characteristics, and treatment strategy were recorded. MAIN OUTCOME MEASURE: Tumor size, patient-reported presence of hearing loss or dizziness at presentation. RESULTS: Male subjects had significantly larger tumors than female subjects at presentation (18.23 versus 16.81 mm, p = 0.031); this difference was particularly pronounced in patients younger than 40 years. Patient-reported symptoms at baseline also differed by sex: the prevalence of hearing loss was 95.1% in male subjects versus 90.3% in female subjects (p = 0.001), and the frequency of dizziness was 74.3% in female subjects versus 59.0% in male subjects (p<0.0001). In multivariate analyses, male subjects continued to have a borderline significant positive association with tumor size (p = 0.066) and were 2-fold more likely to have hearing loss (odds ratio [OR], 2.082; 95% confidence interval [CI], 1.300-3.336) but half as likely to have dizziness (OR, 0.501; 95% CI, 0.387-0.649) than female subjects. Additionally, for every 1-mm increase in tumor size, patients were more likely to report hearing loss by 14.7% (OR, 1.147; 95% CI, 1.106-1.191) and dizziness by 2.8% (OR, 1.028; 95% CI, 1.016-1.041). CONCLUSION: We observed significant sex differences in the presentation and size of unilateral vestibular schwannomas. As management and treatment strategies are predicated on presenting symptoms and patient factors, these observations merit further study to further understand tumor biology, improve risk stratification, and optimize tumor management.