Annals of Otology,Rhinology & Laryngology

To evaluate volume changes within the tongue post chemoradiation therapy (CRT)

Retrospective review

Academic Medical Center

Subjects included 19 patients that received CRT as the primary treatment for tonsillar or hypopharynx squamous cell carcinoma. Tongue volumes were calculated by three raters from thin slice computed tomography images collected before treatment and up to 29 months post-CRT. Body mass index (BMI) was also collected at each time point.

Inter-rater reliability was high with an ICC of 0.849 (95% CI = 0.773, 0.905). Linear mixed effects modeling showed a mean decrease of 0.45 cm³ (standard error of the mean [SEM] = 0.11) in tongue volume per month post-CRT (P < .001). However, the addition of BMI to the model was significant (χ² (4) = 25.0, P < .001), indicating that BMI was a strong predictor of tongue volume, with a mean decrease of 1.75 cm³ (SEM = 0.49) in tongue volume per unit decrease in BMI (P < .001) and reducing the post-CRT effect on tongue volume decrease per month to 0.23 cm³ (P = .02). BMI significantly (P < .001) decreased by 0.11 units (SEM = 0.02) per month post radiation.

Tongue dysfunction and decreased tongue strength are significant contributors to the dysphagia that patients experience after receiving CRT. In this study, both tongue volume and BMI decreased post-CRT; therefore, BMI could potentially be used as a predictor of tongue volume post-CRT.

To develop a Decision Quality (DQ) tool to measure parents’ DQ concerning ventilation tube (VT) insertion in their children.

Parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic comparing a validated Decisional Conflict (DC) scale with a DQ instrument including Shared Decision-Making (SDM) scale, parental treatment goals, and knowledge about VT.

Of 100 parent participants, 83% were mothers and 14% were fathers. 94% elected VT insertion, 6% elected monitoring or deferred the decision. 44% of the patients were <18 months, 42% were 19 months to 3 years, and the rest were older. The mean DC score was 8.26 out of 100 (95% CI 4.82-11.69), indicating low DC. Mean DQ score was 82.45 out of 100 (95% CI 80.18-84.72), including mean SDM of 87.71 (95% CI 83.53-91.88,), mean knowledge score of 87.5% (95% CI 84.56-91.59) and mean values score of 7.16 (95% CI 6.90-7.41). Comparisons between those who elected VT and those who did not showed that electors had lower DC scores (7.15 vs 24.74, P < .001), higher DQ scores (83.00 vs 72.61, P = .028) with higher SDM scores (88.70 vs 70.22, P = .044) and higher values score (7.20 vs 6.36, P = .034). Cronbach alpha for the DQ scale was 0.76. Spearman’s rho for DQ score versus DC score was −0.458, P < .001.

DQ, as measured with this tool, was higher when parents chose to place tubes. Our DQ instrument has potential use for study of why parents may decline VT when their child meets criteria for them.

This study examined the association between pure tone hearing sensitivity and music listening behaviors among traditional college-aged students and sought to determine factors that mediate hearing sensitivity, including health and fitness levels, gender, and personal listening device (PLD) use.

A convenience sample of college students (N = 182; 133 females, 49 males, mean age = 19.8 ± 1.4 year, average PLD use = 1.52 ± 7.1 hours•day⁻¹) completed hearing assessments, music listening behavior questionnaires, and health and fitness tests.

Most students listened to music at safe intensity levels (<80 dBA), though 18% had higher hearing levels (≥25 dB HL at one of the measured frequencies). Longer listening duration behavior approached but did not reach a statistical association with compromised hearing sensitivity. Of all variables measured, including cardiovascular health, fitness, and music listening, two variables: total cholesterol: triglycerides (TC:TG) and total cholesterol: high-density lipoproteins (TC:HDL) significantly associated with hearing sensitivity at 2 kHz. The odds hearing loss occurring at 4 kHz was 59% lower in females compared with males.

The majority of college students had healthy music listening behavior and fitness, contributing to normal hearing sensitivity in most. In cases where greater hearing threshold levels at one or more frequencies was detected, TC:HDL and TC:TG were statistically related and at 2 kHz, males were more likely to demonstrate higher listening levels compared with females of similar health and fitness level.

To introduce an inexpensive method for objectively evaluating otoscopic visualization of the tympanic membrane wherein learners match what they visualize in standardized patients to tympanic membrane photographs.

Two standardized patients had photographs taken of their tympanic membranes using a commercially-available digital otoscope. First- and third-year medical students were asked to perform an otoscopic examination on each patient using a conventional handheld otoscope and to match what they saw with the correct tympanic membrane image among distractor photographs belonging to other patients. The ability of students to match the standardized patients’ tympanic membrane to the correct photographs was assessed before and after a didactic training session. These measurements were compared between the two cohort groups for construct validity.

Fifty-one first-year medical students (with no previous otoscopy experience) and 44 third-year medical students (with otoscopy experience from completing pediatric and family medicine clinical clerkships) were recruited to voluntarily participate in this study. At baseline, a larger percentage of third-year students correctly matched both tympanic membranes compared to first-year students (27% vs 8%, P < .01). After otoscopy training, correct matching of both tympanic membranes significantly improved among both first-year students (8-31%, P < .01) and third-year students (27-54%, P < .01).

The use of tympanic membrane photographs from standardized patients provides a novel technique for objectively assessing proficiency in otoscopic visualization of the middle ear. The concept is low cost, uses live patients, and can be easily implemented in pre-clinical instruction and beyond.

To evaluate treatment outcomes of upper airway stimulation (UAS) in obstructive sleep apnea (OSA) patients based on patient age, gender, and preoperative disease severity.

Retrospective chart review of patients undergoing UAS from 2014 to 2018 at a tertiary care center. Data collected included demographic information, implantation records, and pre- and postoperative polysomnography (PSG) results. Profound OSA was defined as AHI >65 and age ≥65 was considered advanced age. The primary outcome measured was initial treatment response, defined as a post-operative AHI <20 with a >50% reduction from baseline.

145 patients underwent UAS at our institution including 98 males and 47 females with a mean age of 61.7 ± 11.5 years, mean BMI of 29.1 ± 3.9 kg/m², and mean preoperative AHI of 34.1 ± 18.2 events/hour. After surgery, patients had a significantly lower mean AHI of 8.6 ± 15.0 events/hour (<0.001). Older patients had a lower initial treatment response rate (78%) when compared to their younger counterparts (94%) (P = 0.005). Male gender and profound disease status did not significantly impact treatment response rates; young age was the only variable found to predict early treatment response on multivariate analysis (P = 0.003).

Although the overall OSA population showed significant postoperative AHI reduction with UAS, patients age ≥65 years were less likely to have an initial response to treatment, when compared to their younger counterparts. A larger proportion of elderly patients and patients with profound OSA had residual moderate disease (AHI > 15) after UAS.

4

To identify whether combination therapy with mucolytics and proton pump inhibitors (PPIs) leads to faster and more effective symptomatic relief in patients with laryngopharyngeal reflux (LPR).

Patients diagnosed as LPR with a reflux symptom index (RSI) ≥ 13 and a reflux finding score (RFS) ≥ 7 were enrolled in this prospective study. Patients were randomly allocated to control (PPI only) or experimental (PPI + mucolytics) groups and changes in RSI and RFS values were assessed at 1- and 3-month follow-up.

One hundred sixteen patients were randomly allocated into either the control group (n = 59) or the experimental group (n = 57). The RSI and RFS scores significantly decreased in both groups (all P < .001) after 1 month of treatment; however, there was no significant difference in RSI change between groups (P = .223). After 3 months of treatment, there remained no significant difference in RSI change between groups (P = .592).

Combination therapy with mucolytics and PPI compared to PPI alone did not lead to faster or more effective symptomatic relief in LPR patients.

There is a paucity of research devoted to understanding the communication restrictions encountered by facial paralysis patients. We aim to explore the relationship between patient-reported restrictions in communicative participation and objective facial paralysis severity using validated scales of facial movement.

We performed a pilot retrospective study using a consecutive series of adult patients with a diagnosis of unilateral facial paralysis. In addition to baseline demographics, subjects were evaluated using the Communicative Item Participation Bank Short Form (CPIB), Electronic Facial Assessment by Computer Evaluation (eFACE), and Sunnybrook Facial Grading System (SFGS).

Twenty patients were included, 10 (50%) of whom were female with a mean age of 61 ± 13 years and mean duration of facial paralysis of 53 ± 82 months. The mean CPIB score was 14.6 ± 10.0 (range 0-29) and was comparable to scores of patients with conditions known to cause significant communicative disability. The mean eFACE scores were 67.4 ± 29.2, 44.2 ± 30.1, and 73.8 ± 30.0 for the static, dynamic, and synkinesis domains, respectively, with a composite smile score of 58.5 ± 16.9. After adjusting for age, gender, and duration of facial paralysis, significant moderate correlations were observed between the CPIB and the static eFACE domain (r = –0.51, P = .03) and smile composite score (r = 0.48, P = 0.0049), in addition to between the CPIB and SFGS synkinesis domain (r = 0.48, P = 0.04).

Patients with unilateral facial paralysis experience significant limitations in communicative participation. These restrictions demonstrate moderate to strong correlations with objective assessments of facial paralysis and quality of life measures. Communicative participation may be a helpful means of tracking response to treatment.

IV

We evaluated the graft take rate and hearing gain of endoscopic cartilage myringoplasty with inside out elevation of a tympanomeatal flap for repairing an anterior tympanic membrane perforation.

A retrospective case series

Tertiary university hospital

The study population consisted of patients with an anterior perforation undergoing endoscopic cartilage myringoplasty with inside out elevation of a tympanomeatal flap. The primary outcome was the graft take rate at 6 months. The secondary outcomes were the air–bone gap (ABG) gain at 3 months and complications.

A total of 51 patients with a unilateral anterior marginal perforation were included in this study. The mean operation time was 62.2 ± 8.3 minutes. The graft success rate was 92.2% (47/51) at 6 months. The mean preoperative ABG was 28.07 ± 5.13 dB, while the mean postoperative ABG was 12.24 ± 4.89 dB (P < .05). No patients reported sensorineural hearing loss, altered taste, facial nerve palsy, vertigo, or tinnitus. Two patients with a middle perforation developed postoperative purulent otorrhea that resulted in residual perforations. The cartilage graft was extruded into the anterior annulus in two patients with large perforations that resulted in graft lateralization in one patient and residual perforation in the other.

Endoscopic cartilage myringoplasty with inside out elevation of a tympanomeatal flap is a useful procedure with a low reperforation rate for repairing anterior perforation.

The objective of this study was to examine referral patterns between otolaryngology and gastroenterology in order to delineate areas of clinical overlap, as well as to identify areas that might benefit from improved inter-specialty communication and collaboration.

Montefiore’s Clinical Looking Glass tool was used to define parameters for electronic medical record data extraction from 2015 to 2018. Two cohorts were generated, one representing referrals placed by gastroenterology to otolaryngology and a second representing referrals placed by otolaryngology to gastroenterology. The ICD-10 codes in both cohorts were reviewed and 13 distinct “reason for referral” categories were defined. The rates of referral for each category were then calculated for each of the referral cohorts.

Otolaryngology referred to gastroenterology at a greater rate than gastroenterology referred to otolaryngology, despite seeing fewer total patients than gastroenterology. For referrals from gastroenterology to otolaryngology, the three most frequent referral reasons were oral cavity/oropharyngeal pathology (28.3%), dysphagia (28.3%), and gastroesophageal reflux disease/laryngopharyngeal reflux disease (GERD/LPRD) (11.3%). For referrals from otolaryngology to gastroenterology, the three most frequent referral reasons were GERD/LPRD (61.7%), dysphagia (18.6%), and esophageal pathology (5.3%).

GERD/LPRD was more frequently referred out by otolaryngology than it was by gastroenterology, suggesting the need for further characterization of the discrepancy in management of a disease commonly treated by both specialties. The discrepant rates of referral for dysphagia also suggest a need to better understand what factors contribute to the differences in management of another clinical condition commonly assessed by both specialties.

4

The aim of this study was to investigate the serum renin levels of patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

Twenty-four patients with ISSNHL and 24 asymptomatic healthy volunteers were included in the study. Subjects underwent pure-tone audiometry and serum renin levels were measured.

There were 14 women (mean age:42.35 ± 9.53) and 10 men (mean age:43.8 ± 6.87) in the patient group. There were 14 women (mean age:42.4 ± 4.7) and 10 men (mean age:41.4 ± 4.59) in the control group. ISSNHL was detected on the right side in 13 patients and on the left side in 11 patients. Serum renin levels of the patients and controls were 788.01 ± 327.8 and 282.37 ± 107.73 pg/mL, respectively. The serum renin levels were found to be significantly higher in the patient group compared to the control group (P ≤ .001). There was a statistically significant strong positive correlation between serum renin level and the severity of hearing loss (r = 0.77; P = .001).

Serum renin levels of patients with ISSNHL were higher than controls. There was a statistically significant strong positive correlation between serum renin level and the severity of hearing loss.

Tests for gustatory function have become increasingly important in diagnosis and treatment of patients with taste disorders. While caffeine and quinine hydrochloride solutions have been used for global testing of bitter perception, only quinine has been used to test regional bitter perception by means of taste strips. The aim of the present study was to validate caffeine impregnated taste strips as an alternative to quinine taste strips for assessment of regional bitter perception.

A total of 46 healthy volunteers (mean age/range, 23/19-27 years) were included in this study. Quinine and caffeine impregnated taste strips were pairwise presented at different parts of the tongue. Perceived intensity and hedonic dislike were evaluated using labeled magnitude scales. Additionally, gustatory function was assessed using the taste strips test and overall sense of taste was rated using visual analog scales.

Assessment of gustatory function demonstrated scores within the normogeusic range in most included subjects (mean/SD, 13.1/2.5). Notably, equally concentrated quinine and caffeine impregnated taste strips placed on different regions of the tongue did not lead to significant differences in perceived intensity or hedonic dislike, whereas quinine and caffeine impregnated taste strips of different concentrations placed on the same region on the tongue led to significant differences of perceived intensity and hedonic dislike. Furthermore, no correlation was found between self-assessment of gustatory function and taste strips scores.

Caffeine seems to be a valid bitter compound for regional testing using taste strips and may be used alternatively to quinine.

Middle ear pathologies have been linked with HIV. The onset and development of these pathologies in individuals with HIV have not been categorized; and clarity has not been gained regarding whether their presentation is any different in this population when compared to HIV negative control group.

The aim of this study was to explore and document published evidence reflecting trends in middle ear pathologies in adults living with HIV.

A systematic review of literature from January 1982 to December 2018 was conducted using Medline, CINAHL, PubMed, and Psych Info. Studies that reported the occurrence rate of middle ear pathologies in adults with HIV and published in English were included.

Twelve articles met the inclusion criteria. Evidence suggests that the reported occurrence rates of middle ear pathologies ranges from 2.5% to 58% in this population. The variability in assessment measures as well as the different cut-off criteria used in studies seem to have an influence in the findings, with pure tone audiometry identifying more middle ear pathologies in the current review than tympanometry with 226 Hz probe tone and clinical examination. Otitis media, conductive hearing loss, and type B tympanogram were common findings reported in this study. No evidence of an association between the use of antiretroviral therapy (ART) and the rates of middle ear pathologies was found.

Although there are very few studies that have reported on middle ear pathologies in adults living with HIV, the available studies have sufficiently established a link between HIV and middle ear disease in this population, and have revealed that the rate of occurrence is influenced by a number of factors. Key amongst these is the type of assessment measure used. Careful analysis of middle ear pathologies in this population through well controlled research designs that include different assessment measures. The use of case-control and longitudinal designs to determine differences between groups and to establish the time of onset and development of middle ear pathologies is required.

To report a rare case of idiopathic intracranial hypertension (IIH) presenting with hemifacial spasm (HFS) and review the current literature.

Case report and literature review. The patient’s medical record was reviewed for demographic and clinical data. For literature review, all case reports or other publications published in English literature were identified using PUBMED.

A 43-year-old obese female presented with a 2-year history of left HFS.

Electroencephalography and head computed tomography were unremarkable. Magnetic resonance imaging demonstrated bilateral anterior inferior cerebellar artery vascular loops involving the internal auditory canals as well as IIH-associated findings. A lumbar puncture was performed and revealed an elevated opening pressure of 26 cm H₂0 cerebrospinal fluid. Acetazolamide treatment was then initiated, resulting in complete resolution of the HFS.

HFS may be a rare presenting manifestation of IIH, and treatment of IIH may result in improvement of HFS symptoms. This is the first report of IIH presenting with HFS in the absence of headache or visual change. As a result, this is the first report of HFS as a presenting manifestation of IIH in Otolaryngology literature.

Too little is known about hearing loss rehabilitation in patients with Alström syndrome (AS). Benefits of hearing aids (HA) have not been fully documented and only one case treated with a Cochlear Implant (CI) has been described in the proceedings of a conference. Furthermore, comorbidities and risk of complications following surgical intervention may contraindicate Cochlear Implant procedures in these patients.

The present case report concerns the first AS patient with CI in the literature.

After reporting a concise description of the audiological profile of patients with AS described in the literature, the case of a 22-year-old woman with genetically confirmed Alström syndrome who underwent a sequential bilateral CI (Bi-CI) rehabilitation is reported. Audiological results before and after cochlear implantation are described.

The patient showed an excellent functional outcome with CIs, which enabled her to achieve communicative, social and academic results comparable with her peers, and no complications occurred.

AS is not necessarily an absolute contraindication to CI. For many AS patients, a good cognitive function and adequate life expectancy represent a clear indication to prompt and adequate hearing rehabilitation with CIs. The description of this type of clinical cases could in the future also generate indications for a tailored audiological treatment of patients with very specific needs, such as patients with Alström Syndrome.