Tinnitus update: what can be done for the ringing?

Physicians will frequently encounter patients who report tinnitus. Tinnitus is a symptom whereby there is the perception of sound or sounds in the ear or head in the absence of an external source of sound. Most individuals experiencing tinnitus will have a neutral reaction to the percept, but in a small proportion of patients, tinnitus can be a debilitating symptom. When it causes burden, patients can be affected in multiple different facets of life, including impairment in sleep, hearing cognition and psychological and psychiatric well-being, often resulting in high healthcare utilisation and societal costs. Hence, chronic, disabling tinnitus is a complex condition with multifactorial causes and multiple perpetuating biopsychosocial factors. Despite efforts to increase knowledge about its pathophysiology and research into treatments, little impact on real-world clinical practice has been seen. There are no proven effective pharmacological treatments or complementary medicines specifically for chronic, disabling tinnitus. Despite this, there is a role for treating this condition through a multidisciplinary approach specifically targeting comorbid active psychiatric conditions, using hearing aids in appropriate clinical settings such as in those with a coassociated confirmed hearing loss, and specialised cognitive behavioural therapy for patients reporting bothersome tinnitus. Cognitive behavioural therapy remains the most valuable evidence-based intervention in this regard. This narrative review attempts to summarise the current understanding in terms of pathophysiology, assessment and treatment of tinnitus for the internal physician who may encounter patients with disabling, chronic tinnitus.

In silico prediction of ARB resistance: A first step in creating personalized ARB therapy.

Angiotensin II type 1 receptor (AT1R) blockers (ARBs) are among the most prescribed drugs. However, ARB effectiveness varies widely, which may be due to non-synonymous single nucleotide polymorphisms (nsSNPs) within the AT1R gene. The AT1R coding sequence contains over 100 nsSNPs; therefore, this study embarked on determining which nsSNPs may abrogate the binding of selective ARBs. The crystal structure of olmesartan-bound human AT1R (PDB:4ZUD) served as a template to create an inactive apo-AT1R via molecular dynamics simulation (n = 3). All simulations resulted in a water accessible ligand-binding pocket that lacked sodium ions. The model remained inactive displaying little movement in the receptor core; however, helix 8 showed considerable flexibility. A single frame representing the average stable AT1R was used as a template to dock Olmesartan via AutoDock 4.2, MOE, and AutoDock Vina to obtain predicted binding poses and mean Boltzmann weighted average affinity. The docking results did not match the known pose and affinity of Olmesartan. Thus, an optimization protocol was initiated using AutoDock 4.2 that provided more accurate poses and affinity for Olmesartan (n = 6). Atomic models of 103 of the known human AT1R polymorphisms were constructed using the molecular dynamics equilibrated apo-AT1R. Each of the eight ARBs was then docked, using ARB-optimized parameters, to each polymorphic AT1R (n = 6). Although each nsSNP has a negligible effect on the global AT1R structure, most nsSNPs drastically alter a sub-set of ARBs affinity to the AT1R. Alterations within N298 -L314 strongly effected predicted ARB affinity, which aligns with early mutagenesis studies. The current study demonstrates the potential of utilizing in silico approaches towards personalized ARB therapy. The results presented here will guide further biochemical studies and refinement of the model to increase the accuracy of the prediction of ARB resistance in order to increase overall ARB effectiveness.

Review of 18F-Fluciclovine PET for Detection of Recurrent Prostate Cancer.

Fluorine 18 (18F) fluciclovine (anti-1-amino-3-18F-fluorocyclobutane-1-carboxylic acid [FACBC]) is a radiolabeled amino acid analog that takes advantage of the amino acid transport upregulation in several types of cancer cells. FACBC is taken up to a greater extent in prostate cancer cells than in surrounding normal tissue, providing an opportunity for its use in cases of this common cancer. In 2016, the U.S. Food and Drug Administration found the accuracy of FACBC PET to be superior to that of other molecular imaging techniques and subsequently granted approval for its use in PET of recurrent prostate cancer. As FACBC is an 18F radiotracer, an on-site cyclotron is not required for its production. This feature enables the widespread clinical availability of this agent and, in turn, an opportunity for improved patient care. The clinical pharmacology and imaging features of FACBC are reviewed, and the role of this agent in the imaging of recurrent prostate cancer, within the context of research that supports its effectiveness, is discussed. The administration of and image acquisition facilitated by using FACBC, as compared with 18F fluorodeoxyglucose, which is more widely used, are described. In addition, the criteria for interpreting FACBC imaging findings are outlined, with emphasis on common causes of false-positive and false-negative findings. ©RSNA, 2019.

The NSAID dilemma: managing osteoarthritis in high-risk patients.

For decades, evidence-based data and reported experience have warned that the common chronic oral nonsteroidal anti-inflammatory drug (NSAID) therapy for osteoarthritis (OA) in elderly patients is ultimately dangerous. Elderly patients with OA are at heightened risk for developing serious gastrointestional and cardiovascular adverse events, including gastrointestinal bleeding, myocardial infarction, and stroke. Prescribing NSAIDs, especially in an elderly population, continues to be discouraged because of these significant risks. A dilemma exists for individuals who need the established efficacy associated with oral NSAIDs but who are at increased risk for serious adverse events associated with these agents. The goal of this clinical review was to evaluate the risks versus benefits of current options in the treatment of OA. This review found that topical NSAIDs seem to be the safest choice among all options to mitigate gastrointestinal and cardiovascular risks and should be considered prior to the initiation of oral nonselective or cyclooxygenase (COX)-2-selective NSAIDs for individuals presenting with a localized expression of OA. Further research is needed to evaluate and compare these therapies in treating both pain and inflammation effectively while mitigating safety risks in high-risk populations.

Wideband Absorbance in Ears with Retraction Pockets and Cholesteatomas: A Preliminary Study.

OBJECTIVES: The objective of this study was to describe wideband absorbance (WBA) findings in patients with cholesteatomas and retraction pockets (RPs). DESIGN: In this prospective study, tympanometry, audiometry, and wideband tympanometry (WBT) were performed on 27 ears with an RP (eight with epitympanic RP and 19 ears with mesotympanic RP), 39 ears with a cholesteatoma (23 ears with epitympanic and 16 ears with mesotympanic cholesteatomas [MCs]), and 49 healthy ears serving as controls. RESULTS: Mean WBA at ambient pressure (WBAamb) of both experimental groups was reduced significantly between 0.8 and 5 kHz relative to the control group. The difference between mean WBAamb and mean WBA at tympanometric peak pressure (WBATPP) was greater for the RP (0.12-0.16 between 0.5 and 1.5 kHz) than for the cholesteatoma group (0.03-0.11 between 0.6 and 3 kHz). Mean WBAamb of both epitympanic RP (ERP) and epitympanic cholesteatoma (EC) subgroups was significantly lower than that of the control group. Mean WBATPP of the ERP subgroup attained normal levels as per the control group, while mean WBATPP of EC subgroup was significantly lower than that of the control group at 0.8 to 1.5 kHz and 4 to 5 kHz. In contrast, both mesotympanic RP and MC subgroups demonstrated similar mean WBAamb and WBATPP values. No significant differences in WBAamb and WBATPP results between the RP and cholesteatomas groups were observed. Receiver operating characteristic (ROC) analyses indicated that the area under the ROC curve for distinguishing between the RP and cholesteatomas groups ranged from 0.44 to 0.60, indicating low accuracy in separating the two groups. CONCLUSION: While it is not possible to distinguish between the RP and cholesteatomas groups based on the WBAamb and WBATPP results, it is potentially feasible to differentiate between the EC and ERP conditions. Further study using a large clinical sample is recommended to determine the sensitivity and specificity of the WBA test to identify the EC and ERP conditions.

Predictive Accuracy of Wideband Absorbance at Ambient and Tympanometric Peak Pressure Conditions in Identifying Children with Surgically Confirmed Otitis Media with Effusion.

BACKGROUND: Wideband absorbance (WBA) measured at ambient pressure (WBAA) does not directly account for middle ear pressure effects. On the other hand, WBA measured at tympanometric peak pressure (TPP) (WBATPP) may compensate for the middle ear pressure effects. To date, there are no studies that have compared WBAA and WBATPP in ears with surgically confirmed otitis media with effusion (OME). PURPOSE: The purpose of this study was to compare the predictive accuracy of WBAA and WBATPP in ears with OME. RESEARCH DESIGN: Prospective cross-sectional study. STUDY SAMPLE: A total of 60 ears from 38 healthy children (mean age = 6.5 years, SD = 1.84 years) and 60 ears from 38 children (mean age = 5.5 years, SD = 3.3 years) with confirmed OME during myringotomy were included in this study. DATA COLLECTION AND ANALYSIS: Results were analyzed using descriptive statistics and analysis of variance. The predictive accuracy of WBAA and WBATPP was determined using receiver operating characteristics (ROC) analyses. RESULTS: Both WBAA and WBATPP were reduced in ears with OME compared with that in healthy ears. The area under the ROC (AROC) curve was 0.92 for WBAA at 1.5 kHz, whereas that for WBATPP at 1.25 kHz was 0.91. In comparison, the AROC for 226-Hz tympanometry based on the static acoustic admittance (Ytm) measure was 0.93. CONCLUSIONS: Both WBAA and WBATPP showed high and similar test performance, but neither test performed significantly better than 226-Hz tympanometry for detection of surgically confirmed OME.

Arthroscopic Repair of Rare Transtendinous Rotator Cuff Tear: Utilizing Established Portals and a Posterior Superior Accessory Portal.

There is a high incidence of rotator cuff injuries in the adult population, and there are well-described techniques for the most common types. Full-thickness transtendon rotator cuff tears are an uncommon injury, and there is limited literature on the appropriate treatment. These rare injuries are important to recognize due to the risk of repair failure using traditional techniques. Simply anchoring the medial portion of the tendon to the anatomic footprint after debriding the lateral tendon risks overtensioning the tendon. Previous techniques share the problem of poor visualization and difficulty passing sutures from standard portals. This technique uses 2 portals, the well-described Neviaser portal and a posterior superior accessory portal. Through these 2 portals, the goal is to increase visualization, increase ease of passing sutures, and avoid debridement of intact tendon.

Eustachian Tube Dysfunction and Wideband Absorbance Measurements at Tympanometric Peak Pressure and 0 daPa.

BACKGROUND: Although wideband absorbance (WBA) provides important information about middle ear function, there is limited research on the use of WBA to evaluate eustachian tube dysfunction (ETD). To date, WBA obtained under pressurized condition has not been used to evaluate ETD. PURPOSE: The objective of the study was to compare WBA at 0 daPa and tympanometric peak pressure (TPP) conditions in healthy ears and ears with ETD. Research Design: A cross-sectional study design was used. Study Sample: A total of 102 healthy ears from 79 participants (mean age = 10.0 yr) and 43 ears from 32 patients with ETD (mean age = 16.0 yr) were included in this cross-sectional study. WBA was measured at 0 daPa (WBA0) and TPP WBA at TPP (WBATPP). DATA COLLECTION AND ANALYSIS: WBA results were analyzed using descriptive statistics and t-tests with the Bonferroni correction. An analysis of variance with repeated measures was applied to the data. RESULTS: WBA0 was significantly lower in the ETD group than in the control group. The WBA0 of the control group demonstrated a broad peak between 1.25 and 4 kHz, whereas the WBA0 of the ETD group had a peak between 2.5 and 4 kHz. WBATPP of the ETD group approached values close to that of the control group. In the control group, WBATPP was only 0.06 to 0.09 higher than WBA0, whereas in the ETD group, WBATPP was 0.29 to 0.42 higher than WBA0 between 0.6 and 1.5 kHz. A differential pattern of WBA at TPP relative to 0 daPa was observed between ears with ETD and ears with otitis media with effusion (OME) and negative middle ear pressure (NMEP). CONCLUSIONS: Hence, a comparison of WBA0 and WBATPP can provide potentially useful diagnostic information, and hence can be used as an adjunct tool to evaluate ETD. This is important especially in young children or some adults who are unable to perform maneuvers such as Toynbee or Valsalva during ETD assessment. Further research is needed to verify the results using test performance measures to determine whether WBA0 and WBATPP can objectively determine the presence of ETD or OME with NMEP.

All Knot-less Arthroscopic Superior Capsular Reconstruction.

Irreparable rotator cuff tears are a complicated problem, and current treatment options include nonoperative rehabilitation, debridement with or without a biceps tenotomy, tuberoplasty, partial rotator cuff repair, patch augmentation, biodegradable spacers, tendon transfer, and reverse shoulder arthroplasty. Arthroscopic superior capsular reconstruction is a more recent technique that is gaining popularity for use in irreparable rotator cuff tears. However, this surgery can be technically complicated. The purpose of this technique is to increase reproducibility and simplify a complicated procedure by addressing the current challenges of previous techniques.

Squamous cell carcinoma of the floor of the mouth: tumour thickness and the rate of cervical metastasis.

BACKGROUND: Increased thickness of oral cavity squamous cell carcinoma (SCC) has been shown to be associated with higher rates of cervical metastasis. Most of the previous studies have focused on SCC of the oral tongue. There are few studies that have examined solely carcinoma of the floor of the mouth and these studies differ in the thickness of tumour that is associated with significantly increased rates of cervical metastasis. METHODS: Patients with SCC of the floor of the mouth of all stages who were treated with excision and neck dissection were identified. Primary tumour thickness and other pathological features were determined in the pathological specimens and were correlated to the incidence of pathological cervical lymph node metastasis. Fisher's exact test and the unpaired t-test were used for statistical analysis. RESULTS: Fifty-three patients were studied (43 men and 10 women). The median age was 56.5 years (range 43-86 years). The median tumour thickness in patients with lymph node metastases (14.6 mm) differed significantly from those without metastases (8.6 mm) (P = 0.004). When T1 and T2 cases were looked at in isolation, the median tumour thickness of cases with lymph node metastases (11.1 mm) again was significantly greater than those without metastases (4.6 mm) (P = 0.04). Subgrouping tumours into those > or =7.5 mm or < 7.5 mm showed a significantly increased rate of lymph node metastasis (57% compared with 12%, P = 0.001). There was no statistically significant association between perineural invasion or tumour differentiation and the presence of lymph node metastases. CONCLUSION: Tumour thickness has been shown to be directly related to rates of cervical lymph node metastasis in floor of mouth SCC. The primary tumour thickness associated with significantly increased rates of metastasis is similar to that shown in previous studies examining SCC of the oral tongue.

The Impact of Smoking on Ossiculoplasty Outcomes.

OBJECTIVES: To assess the impact of tobacco smoking on outcomes after ossiculoplasty. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care center. PATIENTS: Adult patients (16-88 yr of age) undergoing ossiculoplasty with cartilage tympanoplasty. OUTCOME MEASURES: Patients were classified as smokers (TOB) or nonsmokers (TOB). Comparisons were then made between these two groups with regard to early and late audiometric outcomes, rate of cure of conductive hearing loss, rate of successful graft healing, and incidence of complications after surgery. RESULTS: There was no significant difference between the two groups with regard to postoperative ΔPTA-ABG (change in pure-tone average air-bone gap) (-14.4 dB vs. -14.6 dB for TOB vs. TOB, respectively, p = 0.946) or final audiometric outcome (ΔPTA-ABGfinal) (-13.6 dB vs. -11.7 dB for TOB vs. TOB, respectively, p = 0.315), cure of conductive hearing loss, defined as closure of the PTA-ABG to ≤20 dB HL, at postoperative audiometry (75.0% [129/172] for the TOB group vs. 69.3% [52/75] for the TOB group, p = 0.355), late audiometry (71.4% [105/147] for the TOB group vs. 66.7% [44/66] for the TOB group, p = 0.483), or successful graft healing (99.4% in the TOB group vs. 98.7% in the TOB group, p = 0.544). However, complications were observed significantly (p = 0.0003) more often in the TOB group (34.7% [26/75]) than the TOB group (14.5% [25/172]). CONCLUSION: Smoking is not a significant risk factor for anatomic failure of cartilage tympanic membrane graft or worsened audiometric outcome after ossiculoplasty. However, complications were significantly more common in smokers, supporting the practice of primary tympanostomy tube placement at the time of ossiculoplasty.

Morel-LAvallee lesion initially diagnosed as quadriceps contusion: ultrasound, MRI, and importance of early intervention.

Morel-Lavallee lesions (MLL) are rare, closed degloving injuries caused by trauma that delivers a shearing force to the soft tissue most commonly of the hip. If not treated in the acute and subacute setting these lesions are often complicated by re-accumulation of fluid, infection, or chronic pain. We present a unique case of a recurrent, massive medial knee/thigh MLL in which proper treatment was delayed due to initial diagnosis of a quadriceps contusion. We describe the ultrasound and magnetic resonance imaging findings of this patient and based on a review of recent literature propose that the initial management should have included early drainage/debridement, which likely could have prevented recurrence and significantly shortened the clinical course.

Smartphone-based system to improve transportation access for the cognitively impaired.

This project developed and evaluated a smartphone-based system to improve mobility and transportation access for the cognitively impaired. The proposed system is intended to allow the cognitively impaired to use public transportation systems, community transportation and dedicated transportation services for the disabled with greater ease and safety. Individuals with cognitive disabilities are often unable to operate an automobile, or may require a prolonged recovery period before resuming driving. Public transportation systems represent a significant means to allow these individuals to maintain independence. Yet public transportation systems can pose significant challenges to individuals with cognitive impairment. The goal of this project is to develop a system to reduce these barriers via a technological solution consisting of components developed both for the cognitively impaired user and their caregiver or family member. The first component consists of a cognitive prosthetic device featuring traditional memory cueing and reminders as well as custom location-based transportation specific functions. This cognitive mobility assistant will leverage the computing power and GPS location determination capabilities of inexpensive, powerful smart phones. The second component consists of a management application which offers caregivers the ability to configure and program the reminder and transit functions remotely via the Internet. Following completion of the prototype system a pilot human test was performed with cognitively disabled individuals and family members or caregivers to assess the usability and acceptability of both system components.

Pediatric cartilage tympanoplasty with primary intubation.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to analyze the anatomical and audiologic results in pediatric Type I cartilage tympanoplasties with primary intubation. Our hypothesis was that the outcome of patients with tubes placed would be similar to those without tubes, even though the ears that received tubes were in worse condition. STUDY DESIGN: Retrospective chart review of patients undergoing cartilage tympanoplasty with intubation between 2007 and 2012. METHODS: All surgeries were performed or supervised by the senior author as the surgeon, using a modification of the perichondrium/cartilage island flap. All patients had a tube placed through the cartilage to allow for middle ear aeration. Hearing results were reported using a four-frequency (500, 1,000, 2,000, 3,000 Hz) pure-tone average and a pure-tone average air-bone gap (PTA-ABG). Postoperative complications were recorded. RESULTS: During the study period, cartilage with intubation was used for tympanic membrane reconstruction in 20 patients. Of these, 10 (50.0%) had craniofacial abnormalities, and the remainder had documented Eustachian tube dysfunction with mucoid effusion present at the time of surgery. The average patient age was 8 years, and the average follow-up was 39 months. The average pre- and postoperative PTA-ABGs were 25.1 ± 11.2 dB (standard deviation, SD) and 15.1 ± 10.2 dB (p < 0.05), respectively, and the average pre- and postoperative PTAs were 36.6 ± 12.4 and 24.9 ± 12.0 dB (p < 0.05), respectively. Only one case had to undergo revision, which was a result of a cholesteatoma. Of the 20 patients, 15 still had patent tubes at last follow-up, three had their tubes removed, and two had tube extrusion. CONCLUSIONS: Cartilage tympanoplasty with intubation achieves good anatomical and audiologic results when Eustachian tube dysfunction or craniofacial abnormalities are present. Significant hearing improvement was realized in a patient population that is characteristically more prone to problems.

Indoor inertial waypoint navigation for the blind.

Indoor navigation technology is needed to support seamless mobility for the visually impaired. This paper describes the construction and evaluation of an inertial dead reckoning navigation system that provides real-time auditory guidance along mapped routes. Inertial dead reckoning is a navigation technique coupling step counting together with heading estimation to compute changes in position at each step. The research described here outlines the development and evaluation of a novel navigation system that utilizes information from the mapped route to limit the problematic error accumulation inherent in traditional dead reckoning approaches. The prototype system consists of a wireless inertial sensor unit, placed at the users' hip, which streams readings to a smartphone processing a navigation algorithm. Pilot human trials were conducted assessing system efficacy by studying route-following performance with blind and sighted subjects using the navigation system with real-time guidance, versus offline verbal directions.

Indoor magnetic navigation for the blind.

Indoor navigation technology is needed to support seamless mobility for the visually impaired. This paper describes the construction of and evaluation of a navigation system that infers the users' location using only magnetic sensing. It is well known that the environments within steel frame structures are subject to significant magnetic distortions. Many of these distortions are persistent and have sufficient strength and spatial characteristics to allow their use as the basis for a location technology. This paper describes the development and evaluation of a prototype magnetic navigation system consisting of a wireless magnetometer placed at the users' hip streaming magnetic readings to a smartphone processing location algorithms. Human trials were conducted to assess the efficacy of the system by studying route-following performance with blind and sighted subjects using the navigation system for real-time guidance.

Public transportation assistant for the cognitively impaired.

This project developed and evaluated the utility of a mobility assistant cognitive prosthetic that leverages the computing power and GPS location determination capabilities of smart phones to provide location-sensitive mobility assistance. New relatively inexpensive smart phones offer powerful computing and location sensing capabilities. A prototype cognitive prosthetic was developed to assist users in their use of transportation systems. User Interface design included remote caregiver programming features, and automated SMS status generation. Location specific memory cues are triggered by comparing current GPS coordinate location with expected route coordinates obtained from stored route databases based on the GTFS feeds from transit systems. Additional development focused on developing algorithms to identify potential user errors, such as wrong-bus. These reminders and instructions will allow cognitively disabled persons to utilize public transportation systems with greater confidence leading to greater mobility and independence.

Indoor waypoint navigation via magnetic anomalies.

A wide assortment of technologies have been proposed to construct indoor navigation services for the blind and vision impaired. Proximity-based systems and multilateration systems have been successfully demonstrated and employed. Despite the technical success of these technologies, broad adoption has been limited due to their significant infrastructure and maintenance costs. An alternative approach utilizing the indoor magnetic signatures inherent to steel-frame buildings solves the infrastructure cost problem; in effect the existing building is the location system infrastructure. Although magnetic indoor navigation does not require the installation of dedicated hardware, the dedication of resources to produce precise survey maps of magnetic anomalies represents a further barrier to adoption. In the present work an alternative leader-follower form of waypoint-navigation system has been developed that works without surveyed magnetic maps of a site. Instead the wayfarer's magnetometer readings are compared to a pre-recorded magnetic "leader" trace containing magnetic data collected along a route and annotated with waypoint information. The goal of the navigation system is to correlate the follower's magnetometer data with the leader's to trigger audio cues at precise points along the route, thus providing location-based guidance to the user. The system should also provide early indications of off-route conditions. As part of the research effort a smartphone based application was created to record and annotate leader traces with audio and numeric data at waypoints of interest, and algorithms were developed to determine (1) when the follower reaches a waypoint and (2) when the follower goes off-route. A navigation system utilizing this technology would enable a low-cost indoor navigation system capable of replaying audio annotations at precise locations along pre-recorded routes.

Are cell salvage and autologous blood transfusion safe in endonasal surgery?

OBJECTIVE: Endoscopic transnasal approaches to the skull base and intracranial disease are an emerging subspecialty. The limits of this approach are often dictated by exposure and blood loss. Cell salvage techniques are widely used in other surgical fields. However, in otolaryngology, questions remain regarding its safety because work is performed in a contaminated field. In this literature review, we present the evidence for perioperative cell saver blood transfusion in potentially contaminated fields and the need for further investigation of its use in endonasal surgery. DATA SOURCES: MEDLINE and Evidence Based Medicine Reviews databases were searched for relevant articles. REVIEW METHODS: All English articles discussing autologous blood transfusion in endonasal surgery were reviewed. RESULTS: Despite a wide search pattern, no articles that discuss this topic were found in the English literature. Therefore, we went on to present data on the general use of cell saver blood in contaminated fields. CONCLUSION: Cell saver blood is widely accepted in surgery. It offers many advantages in elective operations in which blood loss is expected to be significant. Cell saver blood has been transfused from contaminated fields in other forms of surgery without an associated increase in morbidity. There is good evidence that antibiotic prophylaxis is mandatory in this setting. There is no direct evidence that cell salvage blood is safe in endonasal surgery. Cell salvage is part of a multimodality approach, including the use of hypotensive anesthesia, topical procoagulants, a dedicated team with appropriate equipment, and a good surgical technique with a focus on hemostasis.