How I do it: underwater endoscopic ear surgery

Underwater endoscopic ear surgery does not require suction and so protects the inner ear from unexpected aeration that may damage its function in the treatment of labyrinthine fistula | The Journal of Laryngology & Otology

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A method of underwater endoscopic ear surgery is proposed for the treatment of superior canal dehiscence

Underwater endoscopic ear surgery was performed for plugging of the superior semicircular canal through the transmastoid approach. Saline solution was infused into the mastoid cavity through an Endo-Scrub Lens Cleaning Sheath. The tip of the inserted endoscope was filled completely with saline water.

Using this underwater endoscopic view, the canal was clearly dissected to expose the semicircular canal membranous labyrinth and dehiscence area. No particular complication occurred during the surgical procedure.

The underwater endoscopic ear surgery technique for plugging in superior canal dehiscence secures an excellent visual field and protects the inner ear from unexpected aeration.

Full reference: Yamauchi, D. et al. (2017) How I do it: underwater endoscopic ear surgery for plugging in superior canal dehiscence syndrome. The Journal of Laryngology & Otology. Vol. 131 (Issue 8) pp. 745-748

Dizziness: Approach to Evaluation and Management

Dizziness is a common yet imprecise symptom. It was traditionally divided into four categories based on the patient’s history: vertigo, presyncope, disequilibrium, and light-headedness. However, the distinction between these symptoms is of limited clinical usefulness | American family Physician

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Patients have difficulty describing the quality of their symptoms but can more consistently identify the timing and triggers. Episodic vertigo triggered by head motion may be due to benign paroxysmal positional vertigo. Vertigo with unilateral hearing loss suggests Meniere disease. Episodic vertigo not associated with any trigger may be a symptom of vestibular neuritis. Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment. The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies. The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver. Laboratory testing and imaging are not required and are usually not helpful. Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver). Treatment of Meniere disease includes salt restriction and diuretics. Symptoms of vestibular neuritis are relieved with vestibular suppressant medications and vestibular rehabilitation.

Full reference: Muncie, H. et al. (2017) Dizziness: Approach to Evaluation and Management. American Family Physician. Vol. 95 (no. 3) pp. 154-162.

Evaluation of a Web-Based Module and an Otoscopy Simulator in Teaching Ear Disease.

To determine which teaching method-otoscopy simulation (OS), web-based module (WM), or standard classroom instruction (SI)-produced the best improvement in the diagnosis of middle/external ear pathologies and the development of otoscopy clinical skills | Otolaryngology–Head and Neck Surgery

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Fifty-four medical students (first year, 26; second year, 28) were randomized to receive 1 of the 3 interventions: OS, WM, or SI. All students underwent baseline testing of diagnostic accuracy (25 ear pathologies) and otoscopy skills. Immediately following each intervention and 3 months later, testing was repeated.

Baseline scores for diagnostic accuracy and otoscopy skills did not differ across intervention groups. Immediately postintervention, all groups showed an improvement in diagnostic accuracy (P < .001). OS scored significantly higher than SI (P < .001), as did WM (P = .003). At 3-month follow-up, all groups continued to demonstrate improved diagnostic accuracy as compared with baseline. Again, OS showed improvement over SI (P = .031). For otoscopy clinical skills, only OS improved immediately postintervention (P < .001). OS had significantly higher scores than WM and SI (P < .001). At 3-month follow-up, OS again showed improvement over WM (P < .001) and SI (P = .009).

All groups showed an improvement in diagnostic accuracy immediately postintervention, with the largest increases coming from OS and WM. Otoscopy clinical skills increased and were retained only in OS. Preclerkship medical student acquisition and retention of otolaryngology diagnostic skills can be greatly improved through web-based teaching modules and otoscopy simulation.

Full reference: Wu, V. & Beyea, J.A. (2017) Evaluation of a Web-Based Module and an Otoscopy Simulator in Teaching Ear Disease. Otolaryngology-Head and Neck Surgery. Vol. 156 (Issue 2) pp. 272 – 277

A New Theory for Ménière’s Disease

Ménière’s disease is an inner ear disorder characterized by vertigo attacks, fluctuating and progressive hearing loss, tinnitus, and aural fullness in the affected ear | Otolaryngology–Head and Neck Surgery

The pathophysiology of Ménière’s disease remains elusive. Theories so far are anatomical variation in the size or position of the endolymphatic sac and duct, viral inflammation or autoimmune involvement of the sac, or a genetically determined abnormality of endolymph control. Animal studies on blocking the ductus reuniens and endolymphatic duct have produced hydrops in the cochlea, saccule, and utricle. Cone beam computed tomography images show a similar pattern with apparent obstruction of the ductus reuniens, saccular duct, and endolymphatic sinus. New studies documenting the age of onset of Ménière’s disease show a pattern similar to benign paroxysmal positional vertigo, raising the possibility that the fundamental cause of Ménière’s disease might be detached saccular otoconia.

Full reference: Hornibrook, J. & Bird, P. (2017) A New Theory for Ménière’s Disease: Detached Saccular Otoconia. Otolaryngology-Head and Neck Surgery. Vol. 156 (Issue 2) pp. 350 – 352

 

Novel antimicrobial shows promise for children with AOM

Investigators examined the efficacy and safety of a new formulation of amoxicillin-clavulanate to treat acute otitis media (AOM) in children | Contemporary Pediatrics

Children with acute otitis media (AOM) are routinely and successfully treated with antimicrobials, with data showing that the combination of amoxicillin-clavulanate (A/C) to treat AOM in children aged younger than 3 years is associated with more favorable outcomes than placebo.

Although effective, antimicrobial treatment is associated with the unwanted adverse effect of diarrhea that studies show can affect between 25% to 48% of children. Children who experience this common adverse effect may have to wait to return to daycare until it resolves, which in turn may delay parents’ return to work.

Finding a way to maintain the efficacy of antimicrobial treatment while reducing this unwanted adverse effect was the objective of recent study by Hoberman and colleagues. Based on evidence showing that the clavulanate component of the routinely administered antimicrobial treatment is responsible for diarrhea, the investigators examined the efficacy and safety of a novel formulation of the antimicrobial in which the total effective dose of clavulanate is reduced.

The open-label study found that reducing the total dose of clavulanate was associated with the desired reduction in diarrhea and diaper dermatitis without appearing to compromise efficacy; however, the lead author of the study, Alejandro Hoberman, MD, chief, Division of General Academic Pediatrics, professor of Pediatrics and Clinical and Translational Science, Children’s Hospital of Pittsburgh of UPMC, Pennsylvania, emphasized that these findings will have to be properly studied in a larger clinical trial.

Association of Hearing Impairment and Subsequent Driving Mobility in Older Adults

Hearing impairment (HI) is associated with driving safety (e.g., increased crashes and poor on-road driving performance). However, little is known about HI and driving mobility | The Gerontologist

Image source: Nicolas Alejandro - Flickr // CC BY 2.0

Image source: Nicolas Alejandro – Flickr // CC BY 2.0

Purpose of the Study: This study examined the longitudinal association of audiometric hearing with older adults’ driving mobility over 3 years.

Results: Individuals with moderate or greater HI performed poorly on the UFOV, indicating increased risk for adverse driving events (p < .001). No significant differences were found among older adults with varying levels of HI for driving mobility (p values > .05), including driving cessation rates (p = .38), across time.

Implications: Although prior research indicates older adults with HI may be at higher risk for crashes, they may not modify driving over time. Further exploration of this issue is required to optimize efforts to improve driving safety and mobility among older adults.

Full reference: Edwards, J.D. et al. (2017) Association of Hearing Impairment and Subsequent Driving Mobility in Older Adults. The Gerontologist. 57 (4)pp. 767-775. 

Diagnosing, Treating Benign Paroxysmal Positional Vertigo

Updated guidelines on the diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) suggest a series of in-office maneuvers, rather than expensive imaging tests or medications, offer a faster route to diagnosis and cure | ED Management

  • Typically, patients with BPPV present with symptoms of intense dizziness that may be accompanied by nausea, vomiting, or an intense feeling of disorientation or instability.
  • A very specific diagnostic step called the Dix-Hallpike maneuver can enable physicians to quickly spot the signs of BPPV.
  • When the diagnosis is positive for BPPV, canalith repositioning maneuvers typically can resolve the symptoms.
  • When BPPV is suspected, guideline authors urged providers to stay away from vestibular suppressive medications, which produce a host of side effects and can contribute to a delay in diagnosis.

Full reference: Bhattacharyya, N. et al. (2017) Diagnosing, Treating Benign Paroxysmal Positional Vertigo. ED Management. Online issue: 1st August 2017