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To describe our experience of a new multidisciplinary balance clinic for the management of patients with vestibular disorders, run as a pilot project for 12 months.
Retrospective review of the outcomes of 194 patients.
All patients were first evaluated at the balance assessment clinic. Subsequently, each case was discussed at the multidisciplinary balance clinic weekly review meeting, and management decisions made.
The mean waiting time for the balance assessment clinic was 12 weeks (standard deviation six weeks). In total, 74 per cent of patients underwent rehabilitation, 26 per cent were seen in the balance specialist clinic, 15 per cent underwent additional testing, 6 per cent were followed up in adult otology clinics and one patient was listed for surgery. The waiting time for vestibular rehabilitation was reduced from 21 to 15 weeks. Patient satisfaction with the service was encouraging, and no adverse outcomes were recorded.
This multidisciplinary balance clinic, run by allied health professionals, represents an alternative model for the management of patients with balance disorders.
Tinnitus is a disturbing symptom and is often the main reason for otology referral. It is usually associated with hearing loss of varying aetiology, and is thought to begin in the cochlea, with later abnormal central activity. We hypothesise that tinnitus without hearing loss may be caused by central and subcortical abnormalities and altered outer hair cell function.
To compare the auditory brainstem responses, middle latency responses and otoacoustic emissions in normal-hearing individuals with and without tinnitus.
The audiological test results of 25 normal hearing subjects with tinnitus (age 18–45 years) were determined, and compared with those of a control group.
A statistically significant difference was found between study group tinnitus ears vs control group ears, as regards wave I latency prolongation, shortening of wave V and absolute I–III and I–V interpeak latency, enlargement of wave Na and Pa amplitude, and distortion product and transient evoked otoacoustic emission signal-to-noise ratios. There was no statistically significant difference between unilateral vs bilateral tinnitus ears.
The pathogenesis and optimum management of tinnitus are still unclear. It often occurs with primary ear disease, usually associated with hearing loss, but may occur in patients with normal hearing. Observed changes in auditory brainstem and middle latency responses indicate central auditory alterations. Tinnitus involves both peripheral and central activity, and complete audiological and neurophysiological investigation is required. Management should be based on both audiological and neurophysiological findings.
To assess the therapeutic efficacy of dexamethasone administered topically to the round window niche, following acoustic trauma induced by intensive impulse noise, in guinea pigs.
Adult, male, albino guinea pigs with a normal Preyer's reflex were exposed to 80 impulse noises (peak value 167 dB, duration 0.5 ms, interval 2 s). Dexamethasone (40 mg/ml) or saline was then topically applied to the round window niche. Each animal's auditory brainstem response was measured before and one day after exposure, and three weeks after topical treatment. Cochlear morphology was examined to assess hair cell loss and spiral ganglion cell damage. To assess oxidative activity, cochlear malondialdehyde and superoxide dismutase concentrations were determined three weeks post-treatment. Following topical application, the pharmacokinetic characteristics of dexamethasone in cochlear perilymph were analysed using high-performance liquid chromatography.
Animals receiving dexamethasone showed reduced noise-induced outer hair cell loss (three weeks post-treatment), and significant attenuation of noise-induced auditory brainstem response threshold shifts (one day post-exposure and three weeks post-treatment), compared with controls. There was no difference in spiral ganglion morphology. Animals receiving dexamethasone also showed a significantly lower malondialdehyde concentration and a higher superoxide dismutase concentration, post-exposure. Following topical application, the perilymph dexamethasone level peaked at 5330.522 µg/ml (15 minutes post-treatment), and was 299.797 µg/ml 360 minutes later.
Topical application of dexamethasone to the round window niche has protective effects against intensive impulse noise induced trauma in the guinea pig cochlea. This drug can diffuse into the inner ear through the round window membrane and persist in the perilymph for a relatively long period. The mechanism of protection may involve an anti-oxidant effect.
To investigate whether hair cell immunophenotypes can be derived from the central nervous system.
We established in vitro cell cultures from embryonic day 14.5 fetal rat brain tissue, and analysed changes in the immunohistochemical features of these cell cultures following differentiation.
The immature neural progenitors obtained from the fetal mouse central nervous system generated cell immunophenotypes which expressed epitopes of the hair cell marker proteins myosin VIIa and Brn-3c and the supporting cell marker pan-cytokeratin.
Neural progenitors have the potential to differentiate into inner ear hair cell and supporting cell phenotypes, and thus may be a useful material for cell transplantation therapy aiming to replace damaged inner ear hair cells.
This study aimed to evaluate the sensitivity of transient evoked otoacoustic emission testing as a screening tool for hearing loss in children, after grommet insertion.
A prospective study was conducted of 48 children (91 ears) aged three to 16 years who had undergone grommet insertion for glue ear. At post-operative review, pure tone audiometry was performed followed by transient evoked otoacoustic emission testing. Outcomes for both tests, in each ear, were compared.
The pure tone audiometry threshold was ≤20 dB in 85 ears (93.4 per cent), 25 dB in two ears (2.2 per cent) and ≥30 dB in four ears (4.4 per cent). Transient evoked otoacoustic emissions were detected in 69 ears (75.8 per cent). The sensitivity of transient evoked otoacoustic emission testing for detecting hearing loss was 100 per cent for ≥30 dB loss but only 66.7 per cent for ≥25 dB loss.
Transient evoked otoacoustic emission testing offers a sensitive means of detecting hearing loss of ≥30 dB following grommet insertion in children. However, the use of such testing as a screening tool may miss some cases of mild hearing loss.
Structured training in endoscopic sinus surgery is essential, considering the serious potential complications. We have developed a detailed endoscopic endonasal surgery training programme, using a lamb's head model. This study aimed to assess the possibilities of using such a model for endoscopic dacryocystorhinostomy training.
Materials and methods:
Dacryocystography was performed on lamb's head models, which were then meticulously dissected, both macroscopically and endoscopically, to assess the nasolacrimal system.
Dacryocystography showed the absence of a lacrimal sac in all the lamb's heads dissected. This result was confirmed by dissection.
Lamb's heads are excellent models with which to teach endoscopic sinus surgery techniques. However, this study clearly demonstrated the absence of a lacrimal sac in all such models dissected. Thus, this animal model is inappropriate for endoscopic dacryocystorhinostomy training.
Surgical approaches to the pterygopalatine and infratemporal fossae are complex and cause significant morbidity. The commonest benign tumour to extend to the pterygopalatine and infratemporal fossae is angiofibroma.
Patients and methods:
This prospective study included 15 male patients aged 12–27 years with recurrent, severe epistaxis. After computed tomography and magnetic resonance imaging, a modified Wormald and Robinson's two-surgeon approach was used. Follow up, with endoscopy and magnetic resonance imaging, ranged from two to five years.
Twelve patients were cured (endoscopically and radiologically). Three patients suffered recurrence, one each in the lateral sphenoid wall, pterygoid canal and infratemporal fossa. Revision surgery was performed, but one patient suffered another recurrence (lateral sphenoid wall with cavernous sinus infiltration) and was referred for gamma knife surgery.
This endoscopic two-surgeon technique is an excellent approach for managing angiofibroma extending to the pterygopalatine and infratemporal fossae. Our modification markedly decreased morbidity by avoiding septum opening and sublabial incision, and by enabling better haemostasis (via maxillary artery control). Recurrence may be minimised by careful examination of the lateral sphenoid wall, pterygoid canal and infratemporal fossa pterygoid muscles.
This study aimed to evaluate voice and quality of life after transoral laser resection of early glottic carcinoma.
We studied 19 patients undergoing transoral laser resection of tumour stage (T) one or T2 glottic carcinoma. Laryngeal function was evaluated by video-stroboscopy, vocal function by the Voice Symptom Scale, the grade-roughness-breathiness-asthenia-strain scale and objective phoniatric assessment, and quality of life by the University of Washington Quality of Life questionnaire.
Patients’ glottic carcinoma tumour-node-metastasis (TNM) staging was T1 N0 M0 in 14 patients and T2 N0 M0 in five. Overall voice grade, roughness and breathiness were mild to moderate in 84 per cent; asthenia and voice strain were more uniformly distributed, with 15 per cent of patients having normal voice quality. Eight patients developed a glottic web post-operatively; anterior commissure web was significantly associated with worse voice grade (p = 0.05). Seven patients (47 per cent) had a ‘mucosal wave’ on the operated vocal fold; this was significantly associated with less strain on phonation (p = 0.05). Voice Symptom Scale score was low overall (15 patients (78.9 per cent) scored less than 30). The fundamental frequency and frequency irregularity were normal in nine patients (47.3 per cent); the closed quotient was normal in six (31.5 per cent). The averaged quality of life score was ≥90 in 14 patients (73.7 per cent); 18 (94.7 per cent) felt their health-related quality of life was either the same or better post-operatively; and overall quality of life was positive in all.
Transoral laser resection of T1 and T2 glottic carcinoma enables adequate tumour tissue excision with preservation of acceptable vocal function. Most patients’ post-operative quality of life is very good. Anterior commissure web formation is associated with poorer vocal function.
Botulinum toxin injection under electromyographic guidance is the ‘gold standard’ for adductor spasmodic dysphonia treatment. The point-touch technique, an alternative injection method which relies on anatomical landmarks, is cheaper, quicker and more accessible, but has not yet gained widespread acceptance due to concerns about patient satisfaction.
To assess swallowing and voice-related quality of life following point-touch botulinum toxin injection in adductor spasmodic dysphonia patients.
Stanford University Voice and Swallowing Center.
Prospective case series (evidence level four).
Consecutive adductor spasmodic dysphonia patients with a stable botulinum toxin dose–response relationship were recruited prospectively. The Eating Assessment Tool and Voice-Related Quality of Life questionnaires were completed pre-treatment and at 10 and 30 per cent completion of the injection cycle, respectively.
Thirty-seven patients completed follow up. The mean total botulinum toxin dose was 0.88 units. Pre-treatment Voice-Related Quality of Life questionnaire results reflected the burden of disease. Post-treatment Eating Assessment Tool and Voice-Related Quality of Life questionnaire results were collected at 2.53 and 7.84 weeks, respectively; the former showed an increase in dysphagia, albeit statistically insignificant, while the latter showed significantly improved scores (both domain and total).
The point-touch technique is a viable alternative for botulinum toxin injection in the treatment of adductor spasmodic dysphonia.
To review foreign body aspiration cases encountered over a 10-year period in a tertiary paediatric hospital, and to assess correlation between foreign body type and language spoken at home.
Study design and method:
Retrospective chart review of all children undergoing direct laryngobronchoscopy for foreign body aspiration over a 10-year period. Age, sex, foreign body type, complications, hospital stay and home language were analysed.
At direct laryngobronchoscopy, 132 children had foreign body aspiration (male:female ratio 1.31:1; mean age 32 months (2.67 years)). Mean hospital stay was 2.0 days. Foreign bodies most commonly comprised food matter (53/132; 40.1 per cent), followed by non-food matter (44/132; 33.33 per cent), a negative endoscopy (11/132; 8.33 per cent) and unknown composition (24/132; 18.2 per cent). Most parents spoke English (92/132, 69.7 per cent; vs non-English-speaking 40/132, 30.3 per cent), but non-English-speaking patients had disproportionately more food foreign bodies, and significantly more nut aspirations (p = 0.0065). Results constitute level 2b evidence.
Patients from non-English speaking backgrounds had a significantly higher incidence of food (particularly nut) aspiration. Awareness-raising and public education is needed in relevant communities to prevent certain foods, particularly nuts, being given to children too young to chew and swallow them adequately.
In an emergency, the non-availability of a conventional paediatric tracheostomy tube is a therapeutic challenge for the attending surgeon.
To describe a simple alternative to a paediatric tracheostomy tube for use in an emergency situation.
Case report of a 14-year-old boy who developed tracheomalacia following partial cricotracheal resection for subglottic stenosis. As a suitably sized tracheostomy tube (with a long narrow segment) was not available, an endotracheal tube was modified and used successfully. Details of the modification, and a relevant literature review, are also discussed.
In the paediatric age group, when an appropriately sized tracheostomy tube is not available, a modified endotracheal tube is a simple temporary alternative; this may be especially useful in an emergency.
Following the onset of facial palsy, physiotherapists routinely inspect the inside of the patient's mouth and cheek for complications such as ulceration or trauma. In several patients with complete facial nerve palsy, it was noticed that when the cheek was stretched there was subsequent spasm of the muscles of facial expression. This also occurred in patients whose facial nerve had been transected.
We present four patients in whom this response was demonstrated. We consider the mechanism of this response and its relevance in the management of patients with facial paralysis.
Following severe or complete denervation, contraction of the facial muscles following mechanical stretch provides evidence of preservation of activity in the facial muscle's excitation–contraction apparatus. Further research will investigate the clinical significance of this sign and whether it can be used as an early predicator of the development of synkinesis, as well as its relevance to facial nerve grafting and repair.
To report a rare case of tuberculous otitis media, and to highlight barriers to clinical and microbiological diagnosis.
Case report and literature review.
Tuberculous otitis media is a rare cause of chronic ear infection in the UK. Its symptoms may mimic a range of other otological conditions, including otitis media, chronic suppurative otitis media, cholesteatoma and necrotising otitis media.
This case report highlights the challenges of obtaining a clinical diagnosis of tuberculous otitis media, and emphasises the fact that screening for acid-fast bacilli is not sufficient, in isolation, to rule out mycobacterial infection.
We report a patient who underwent cochlear implantation in an ear with long-term deafness, after an acoustic neuroma had been removed surgically from the other, hitherto good ear and the cochlear nerve had subsequently been resected to relieve severe tinnitus.
The patient could not tolerate the cochlear implant, because of a moderate headache due to the stimulation level necessary for environmental sound discrimination.
Cochlear implantation in patients with long-term deafness should be considered carefully, even if deafness is monaural.
We report a case of an Oestrus ovis larva which developed into the second larval stage within a healthy, immunocompetent human, and we review the relevant literature.
Clinical case report and Pubmed search of reports of human nasal myiasis due to Oestrus ovis, especially those describing the larval stage.
Humans are not normally hosts of the sheep nasal bot fly, but infestations by its larvae have been described. The eye is the most common site, but larvae have occasionally been found in the human nose. Transformation of larvae into the second and third stages, within the human nose, is even more uncommon.
To the best of our knowledge, we report the first Swedish case, and the third case world-wide, of Oestrus ovis larval development beyond the first larval stage, within an immunocompetent, healthy human.
Nasopharyngeal tuberculosis is a rare condition, even in endemic tuberculosis areas. We report a case of primary nasopharyngeal tuberculosis from a non-endemic area, which presented with symptoms resembling exacerbation of previously diagnosed chronic rhinosinusitis.
A 48-year-old man presented with extreme postnasal drip and an unpleasant nasal odour. Endoscopic examination revealed irregular thickening of the left lateral and posterior wall of the nasopharynx, partially covered with crusts and necrotic tissue. Histopathological study showed typical giant cell epithelioid granulomas with caseous necrosis. Direct examination after Ziehl–Neelsen staining was positive for tuberculosis. After six months of antituberculous triple therapy, endoscopic examination revealed a completely normal nasopharynx.
To our best knowledge, this is the first published report of primary nasopharyngeal tuberculosis in a patient previously diagnosed with chronic rhinosinusitis. The difficulties in obtaining a proper diagnosis in such a case are discussed.
We present the first reported case of sebaceous adenoma of the palate, to our knowledge.
Case report and review of the English language literature, with a focus on the pathological spectrum of sebaceous glands.
A woman presented with a growth on the hard palate, which was excised and examined. Histopathological analysis showed features of sebaceous adenoma. Further evaluation with Sudan Black B special stains and Ki 67 immunohistochemistry was performed.
Sebaceous adenomas in the oral cavity are very rare, with only 10 cases previously reported in the English language literature. Sebaceous adenoma of the palate has not previously been reported, to our knowledge. We discuss the role of special stains and immunohistochemistry in the diagnosis of this tumour.
To present a case of a child with a desmoplastic fibroma of the vidian canal, compressing the vidian nerve.
A 12-year-old girl with several years' history of right-sided facial pain was referred to our institution. Magnetic resonance imaging and computed tomography scans showed an expansile mass involving the right vidian canal. The patient underwent a complete endoscopic surgical resection aided by the FusionTM ENT navigation system. This was performed through a transnasal, trans-septal, trans-sphenoidal route via the right nostril, and achieved macroscopic clearance with minimal peri-operative morbidity. A biopsy of the lesion showed a fibro-osseous lesion consistent with desmoplastic fibroma.
Diagnosis and resection of this rare lesion at an earlier stage would have avoided delays in resolving the child's disabling pain. This emphasises the importance of early referral of unusual cases to tertiary centres.
We report a rare case of successful surgical management of tubercular tracheal stenosis. There was no history of tracheostomy except for trauma management.
A 24-year-old man presented with breathing difficulty. He had previously sustained blunt chest injury, a fractured mandible and minor head injury in a traffic accident. Despite successful mandibular fracture fixation, he subsequently developed progressive breathing difficulty with stridor. The patient was treated successfully with surgical resection and bronchoplastic reconstruction. Post-operatively, endotracheal tuberculosis was diagnosed.
Endotracheal tuberculosis is rare despite the high incidence of pulmonary tuberculosis in India. Early diagnosis and prompt treatment are necessary to prevent tuberculous tracheobronchial stenosis, an extremely rare but serious clinical problem which can cause obstructive pneumonia and exertional dyspnoea. Surgical resection and bronchoplastic reconstruction is the established treatment for such stenosis. Patients with active tuberculosis usually respond to conventional antitubercular treatment.