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OBJECTIVE To review insights gained from a 21-year experience with gentamicin-induced vestibulotoxicity including differences in vestibulotoxicity between single daily dosing (SDD) and multiple daily dosing (MDD) regimens. STUDY DESIGN Retrospective case series. SETTING Tertiary care center. PATIENTS Patients with gentamicin vestibulotoxicity referred to the Hertz Multidisciplinary Neurotology Clinic between January 1993 and September 2014. INTERVENTION None. MAIN OUTCOME MEASURES Spectrum of vestibular dysfunction measured using videonystagmography, vestibular evoked myogenic potentials, video head impulse testing, and magnetic scleral search coil testing. RESULTS Of 53 patients with gentamicin-induced vestibulotoxicity, 24 received SDD and 29 received MDD treatment. The most common indications for treatment were sepsis, endocarditis, and osteomyelitis. Angular acceleration receptor function (semicircular canals) was more commonly affected than linear acceleration receptor function (otolithic organ of the saccule; 100% vs. 62%). A significant proportion of patients (53%) developed vestibulotoxicity in the absence of nephrotoxicity and 40% experienced vestibulotoxicity in a delayed fashion up to 10 days posttreatment cessation (mean 3.9 ± 0.7). Therapeutic monitoring did not necessarily prevent delayed vestibulotoxicity. Nephrotoxicity was less common for SDD compared with MDD (60% vs. 35%, p = 0.01). However, the SDD group experienced vestibulotoxicity at a lower cumulative dose (6.3 vs. 7.0 g, p = 0.04) and shorter duration of therapy (20.7 vs 29.4 d, p = 0.02). CONCLUSIONS Our study further highlights important insights regarding gentamicin-induced vestibulotoxicity. While SDD is associated with decreased risk for nephrotoxicity compared with MDD, it confers a higher risk for vestibulotoxicity.

OBJECTIVES/HYPOTHESIS The traditional medical care model of "assess and refer" in a sequential fashion fails to recognize the complexities that arise due to overlapping physical and psychiatric comorbidities experienced by patients with chronic dizziness or imbalance, thus resulting in inadequate treatment outcomes. We aimed to evaluate the impact of a novel interdisciplinary approach to care that integrates nursing and psychiatry (INaP) on dizziness-related disability. STUDY DESIGN Retrospective cohort study. METHODS We compared the change in clinical assessment scores (i.e., Dizziness Handicap Inventory [DHI], Dizziness Catastrophizing Scale) at approximately 8 months follow-up between those who did (INaP+) and did not receive INaP (INaP-). Data from 229 patients with dizziness or imbalance referred to an interdisciplinary neurotology clinic in Toronto, Ontario, Canada were acquired from August 2012 to December 2016 and January 2011 to December 2013 for the INaP+ and INaP- groups, respectively. RESULTS A mean group difference in the percentage change in DHI scores was found, with greater reductions in dizziness-related disability in the INaP+ group (n = 121) versus the INaP- group (n = 108). This remained significant after controlling for age, gender, baseline illness severity, and duration between baseline and follow-up visits. CONCLUSIONS The novel interdisciplinary approach of incorporating INaP appears to be more effective than interdisciplinary care without INaP in reducing dizziness-related disability in patients with chronic dizziness or imbalance. Clinical settings should consider the addition of INaP to achieve better patient outcomes. Future studies are required to test the hypothesis that INaP is more efficient and cost-effective than the traditional model of care. LEVEL OF EVIDENCE 3 Laryngoscope, 130:1800-1804, 2020.

Impaired insight into illness (IMP-INS) is common among individuals with schizophrenia spectrum disorders (SSD), contributing to medication nonadherence and poor clinical outcomes. Caloric vestibular simulation (CVS) is typically used to assess peripheral vestibular system function. Left cold CVS is also a transiently effective treatment for IMP-INS and hemineglect secondary to right brain hemisphere stroke, and possibly for IMP-INS and mood stabilization in patients with SSD. Participants with SSD and moderate-to-severe IMP-INS participated in an exploratory double blind, crossover, randomized controlled study of the effects of CVS on IMP-INS. Participants sequentially received all experimental conditions—left cold (4°C), right cold, and body temperature/sham CVS—in a random order. Repeated measures ANOVA were performed to compare changes in IMP-INS, mood and positive symptom severity pre and 30 min post CVS. A significant interaction was found between CVS condition, time, and body temperature nystagmus peak slow phase velocity (PSPV) for IMP-INS, indicating that single session left cold CVS transiently improved IMP-INS while right cold CVS may have worsened IMP-INS, particularly in participants with greater vestibular reactivity (i.e. higher PSPV) to body temperature CVS. The procedure’s effectiveness is attributed to stimulation of underactive right hemisphere circuits via vestibular nuclei projections to the contralateral hemisphere.

Introduction: To determine the impact of a head-referenced cochlear implant (CI) stimulation system, BalanCI, on balance and postural control in children with bilateral cochleovestibular loss (BCVL) who use bilateral CI. Methods: Prospective, blinded case-control study. Balance and postural control testing occurred in two settings: (1) quiet clinical setting and (2) immersive realistic virtual environment (Challenging Environment Assessment Laboratory [CEAL], Toronto Rehabilitation Institute). Postural control was assessed in 16 and balance in 10 children with BCVL who use bilateral CI, along with 10 typically developing children. Children with neuromotor, cognitive, or visual deficits that would prevent them from performing the tests were excluded. Children wore the BalanCI, which is a head-mounted device that couples with their CIs through the audio port and provides head-referenced spatial information delivered via the intracochlear electrode array. Postural control was measured by center of pressure (COP) and time to fall using the WiiTM (Nintendo, WA, USA) Balance Board for feet and the BalanCI for head, during the administration of the Modified Clinical Test of Sensory Interaction in Balance (CTSIB-M). The COP of the head and feet were assessed for change by deviation, measured as root mean square around the COP (COP-RMS), rate of deviation (COP-RMS/duration), and rate of path length change from center (COP-velocity). Balance was assessed by the Bruininks-Oseretsky Test of Motor Proficiency 2, balance subtest (BOT-2), specifically, BOT-2 score as well as time to fall/fault. Results: In the virtual environment, children demonstrated more stable balance when using BalanCI as measured by an improvement in BOT-2 scores. In a quiet clinical setting, the use of BalanCI led to improved postural control as demonstrated by significant reductions in COP-RMS and COP-velocity. With the use of BalanCI, the number of falls/faults was significantly reduced and time to fall increased. Conclusions: BalanCI is a simple and effective means of improving postural control and balance in children with BCVL who use bilateral CI. BalanCI could potentially improve the safety of these children, reduce the effort they expend maintaining balance and allow them to take part in more complex balance tasks where sensory information may be limited and/or noisy.

Objectives The traditional medical care model of "assess and refer" requires revamping to address the multifaceted needs of patients with chronic dizziness and imbalance by adopting an interdisciplinary approach to care that integrates nursing and psychiatry (INaP). We aim to present a novel interdisciplinary approach that incorporates INaP in the care of patients with chronic dizziness and imbalance. Methods Presentation of an interdisciplinary model of care that incorporates INaP provided at the Toronto General Hospital in Toronto, Canada. Results Interdisciplinary care incorporating INaP, which includes the provision of support from an interdisciplinary health care team (ie, neurotologist, neurologist, psychiatrist, physiotherapist, and nurse clinician), psychoeducation about the interaction between chronic dizziness and psychiatric comorbidities, and ongoing access to medical and psychosocial assessment and intervention, addresses the physical and emotional aspects of patients' experience with chronic dizziness. Conclusions The novel comprehensive interdisciplinary approach incorporating INaP may be more effective than interdisciplinary care without INaP in improving clinical outcomes in patients with chronic dizziness. In the subsequent study, we present data comparing patients treated for chronic dizziness and imbalance with and without the integration of INaP in an interdisciplinary setting. Level of evidence 5 Laryngoscope, 130:1792-1799, 2020.

Objectives To evaluate the biological behaviour of tumour remnants intentionally left in the surgical bed following the incomplete excision of vestibular schwannomas (VS) and to review the relation between extent of resection and preservation of facial nerve function. Methods A retrospective chart review of 450 patients who underwent surgery for resection of VS over 23 years (1992–2014). Of these, 50 (11%) patients had residual tumour intentionally left on/around the facial nerve (near-total or subtotal excision) to preserve facial nerve function intra-operatively. The growth of residual tumour was evaluated using serial magnetic resonance imaging scanning; pre- and postoperative facial nerve function was assessed using the House-Brackmann grading scale. Setting Tertiary referral neurotology unit. Results Of the 42 non-NF2 cases where the tumour was intentionally incompletely excised, 28 (67%) patients underwent subtotal resection (mean follow-up 68.5 ± 39.0 months) and 14 (33%) underwent near-total resection (mean follow-up 72.9 ± 48.3 months). Three patients (all in subtotal resection group) showed regrowth. This was not statistically different from the near-total resection group (χ2 = 0.92, P = 0.31). The mean overall growth for these cases was 0.68 mm ± 0.32 mm/year. 5 (one near total, four subtotal) of the eight NF2 patients (62.5%) were excluded from our analysis. In the non-NF2 group, poor facial nerve outcomes (House-Brackmann scores of III-IV) were seen in 2/14 and V-VI in 3/14 of the near total compared with 7/25 and 4/25 respectively in the subtotal group. Conclusions Given that the primary surgery for the VS was only for tumours that were relatively large or grew during conservative treatment, the low rate of tumour remnant growth (7%) is reassuring. It may be appropriate to have a lower threshold for leaving tumour on the facial nerve in non-NF2 patients where complete resection may jeopardise facial nerve function.

The objective of this study was to determine the incidence of olfactory dysfunction in workers following head injury in the work place, to define its relationship to the site, severity of injury and direction of force. The demographics of head injured workers were also assessed to determine whether those with olfactory loss were more likely to have sustained a cochleovestibular injury.Retrospective case analysis.Tertiary referral university hospital in Toronto, Ontario.A total of 3438 consecutive patients referred from the Workplace Safety and Insurance Board (WSIB) in the province of Ontario who sustained a work-related head injury were assessed between 1987 and 2014.Olfactory and cochleovestibular dysfunction assessed by history, clinical examination and subjective and objective tests.Olfactory dysfunction (OD) was identified in 413 of 3438 patients (12.0%) of which 321 were diagnosed with anosmia and 92 with hyposmia. In our series, injuries from a fall were the commonest cause for OD and a frontal or mid-face impact was more likely to result in OD than other regions (P = 0.0002). A loss of consciousness (LOC) of any duration correlated with OD. In those with olfactory dysfunction, an associated skull fracture occurred in 37.1% of patients and a CSF leak in 4.1%, which was significantly higher compared with those without OD(0.0001). Patients with OD had a higher incidence of cochlear and vestibular loss (19.9% and 20.6%, respectively) compared with those without OD (14.3% and 17.1%, respectively).Post-traumatic olfactory dysfunction is more likely to occur in patients who experienced a moderate to severe head injury, LOC and more likely to result from a frontal or mid-face blow to the skull. Cochleovestibular dysfunction is likely to occur concurrently with olfactory dysfunction.

Background An analysis of the scope of practice of recent Otolaryngology – Head and Neck Surgery (OHNS) graduates working as general otolaryngologists has not been previously performed. As Canadian OHNS residency programs implement competency-based training strategies, this data may be used to align residency curricula with the clinical and surgical practice of recent graduates. Methods Ontario billing data were used to identify the most common diagnostic and procedure codes used by general otolaryngologists issued a billing number between 2006 and 2012. The codes were categorized by OHNS subspecialty. Practitioners with a narrow range of procedure codes or a high rate of complex procedure codes, were deemed subspecialists and therefore excluded. Results There were 108 recent graduates in a general practice identified. The most common diagnostic codes assigned to consultation billings were categorized as ‘otology’ (42%), ‘general otolaryngology’ (35%), ‘rhinology’ (17%) and ‘head and neck’ (4%). The most common procedure codes were categorized as ‘general otolaryngology’ (45%), ‘otology’ (23%), ‘head and neck’ (13%) and ‘rhinology’ (9%). The top 5 procedures were nasolaryngoscopy, ear microdebridement, myringotomy with insertion of ventilation tube, tonsillectomy, and turbinate reduction. Although otology encompassed a large proportion of procedures billed, tympanoplasty and mastoidectomy were surprisingly uncommon. Conclusion This is the first study to analyze the nature of the clinical and surgical cases managed by recent OHNS graduates. The findings demonstrated a prominent representation of ‘otology’, ‘general’ and ‘rhinology’ based consultation diagnoses and procedures. The data derived from the study needs to be considered as residency curricula are modified to satisfy competency-based requirements.

Purpose To report long-term (>4 years) toxicity and quality of life (QoL) among patients with nasopharyngeal carcinoma (NPC) treated with intensity modulated radiation therapy (IMRT) in a nonendemic center. Methods and Materials A cross-sectional cohort study enrolled patients with NPC who were disease-free and ≥4 years after IMRT ± chemotherapy. Physician-reported adverse events (Common Terminology Criteria for Adverse Events, version 4.03) and patient-reported QoL (Functional Assessment of Cancer Therapy-Head and Neck, Functional Assessment of Chronic Illness Therapy-Fatigue), utilities (EuroQOL-5D), head and neck symptoms (MD Anderson Symptom Inventory-Head and Neck), and emotional distress (Hospital Anxiety and Depression Scale) were collected. Consenting patients also underwent endocrine screening and audiometry. Results Among 107 patients enrolled, median age at enrollment and time since treatment were 57 (32-81) and 7.5 years (4.2-11.1), respectively. Most patients (99%) received 70 Gy in 35 fractions; the majority (93%) received concurrent chemotherapy. Mean scores for the Functional Assessment of Cancer Therapy-Head and Neck, Functional Assessment of Chronic Illness Therapy-Fatigue, and EuroQOL-5D were 105.0 (46-148), 116.6 (44-160), and 0.85 (0.29-1.00), respectively. Dry mouth, mucus, swallowing/chewing, memory, and teeth/gum problems were scored highest on the MD Anderson Symptom Inventory-Head and Neck; mean symptom severity and symptom interference scores were 2.3 and 2.4, respectively. Grade 3 or higher physician-reported adverse events were noted in 50 patients (47%), most frequently hearing problems (46, 43%). Audiometry revealed significant bilateral hearing loss (grade ≥3) in 68 patients (72%). Depression (25%), anxiety (37%), and fatigue (28%) were common and strongly correlated with QoL. Most patients (69%) developed hypothyroidism; 1 patient (1%) developed pituitary dysfunction requiring hormone replacement. V50 >90 and V45 >99 to the thyroid correlated with significantly higher rates of hypothyroidism. Conclusions Despite the implementation of IMRT, survivors of NPC still experience many physical symptoms that affect long-term QoL many years after treatment. Depression, anxiety, and fatigue remain common in long-term survivors and are highly correlated with QoL.

Conventional computed tomography (CT) imaging is the standard imaging technique for temporal bone diseases, whereas cone-beam CT (CBCT) imaging is a very fast imaging tool with a significant less radiation dose compared with conventional CT. We hypothesize that a system for intraoperative cone-beam CT provides comparable image quality to diagnostic CT for identifying temporal bone anatomical landmarks in cadaveric specimens.Cross-sectional study.University tertiary care facility.Twenty cadaveric temporal bones were affixed into a head phantom and scanned with both a prototype cone-beam CT C-arm and multislice helical CT. Imaging performance was evaluated by 3 otologic surgeons and 1 head and neck radiologist. Participants were presented images in a randomized order and completed landmark identification questionnaires covering 21 structures.CBCT and multislice CT have comparable performance in identifying temporal structures. Three otologic surgeons indicated that CBCT provided statistically equivalent performance for 19 of 21 landmarks, with CBCT superior to CT for the chorda tympani and inferior for the crura of the stapes. Subgroup analysis showed that CBCT performed superiorly for temporal bone structures compared with CT. The radiologist rated CBCT and CT as statistically equivalent for 18 of 21 landmarks, with CT superior to CBCT for the crura of stapes, chorda tympani, and sigmoid sinus.CBCT provides comparable image quality to conventional CT for temporal bone anatomical sites in cadaveric specimens. Clinical applications of low-dose CBCT imaging in surgical planning, intraoperative guidance, and postoperative assessment are promising but require further investigation.

The otolaryngologist will find in this article a direct and frank discussion and useful advice for how to get started performing solely endoscopic ear surgery for abnormalities of the middle ear. The author provides discussion and photos based on his experience with this procedure. Presented herein are selection of the endoscope, how to approach the first fully endoscopic procedure, patient selection, preoperative planning, setting up the operating room, pitfalls typically encountered, and how to gain skills to perform this procedure successfully.

Aim:(1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content).Materials and methods:All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed.Results:Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent.Conclusion:Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.

Assault and violence at the workplace although uncommon are occupational health and safety hazards. Although there is no paucity of literature on cochleovestibular dysfunction after head injuries, there is little published on cochleovestibular dysfunction as a consequence of assault at the workplace. This article is protected by copyright. All rights reserved.

There has been a reduction in the number of modified radical mastoidectomy and revision mastoidectomy surgeries per head of population in Ontario between 1987 and 2007, we believe that this represents a true reduction in prevalence of cholesteatoma. The increase of cases performed at the University Hospital Network, Toronto (UHN) may represent a shift to subspecialization in the treatment of chronic ear disease.To analyze the trends in mastoid operations for chronic middle ear disease in the Canadian province of Ontario between 1987 and 2007 and to determine whether an increasing proportion of these procedures are being performed in tertiary referral centres.The year on year population and number of mastoid procedures performed per year in Ontario and at the UHN between 1987 and 2007 were obtained from Statistics Canada and the Ministry of Health and Long-Term Care, Ontario, respectively. Population-adjusted rates of mastoid surgery for Ontario and the UHN. These data were collated and graphically represented for trend analysis.The population-adjusted number of mastoid procedures for Ontario declined from 7.1 cases per 100,000 in 1986 to 4.1 cases per 100,000 in 2006. During this time the number of both modified radical mastoidectomies and revision mastoid surgeries at UHN increased.

IMPORTANCE: Catastrophizing is a maladaptive thought process that involves irrational fear and worry about anticipated or actual symptoms. Although clinically relevant, the role of catastrophizing in patients with chronic dizziness or imbalance has not yet been explored to our knowledge. OBJECTIVES: To validate a measure of dizziness catastrophizing and to assess its association with dizziness-related disability compared with other negative affect constructs (eg, anxiety and depression). DESIGN, SETTING, AND PARTICIPANTS: For this retrospective medical record review, the Dizziness Catastrophizing Scale (DCS), a dizziness-specific catastrophizing assessment tool, was adapted from the previously validated Pain Catastrophizing Scale. Psychometric evaluation of the DCS was performed. In addition, the associations of dizziness catastrophizing and positive and negative affectivity with dizziness-related disability were assessed using structural equation modeling and regression analyses. Data were collected using a retrospective medical record review from April 27, 2010, to June 25, 2014. The dates of analysis were June 3 to August 15, 2017. The setting was the Multidisciplinary Neurotology Clinic at the Toronto General Hospital (Toronto, Ontario, Canada). Participants were 457 adult outpatients with dizziness or imbalance who were referred to the clinic. MAIN OUTCOMES AND MEASURES: Psychometric properties of the DCS and its association with dizziness-related disability, as measured with the Dizziness Handicap Inventory. RESULTS: Among 457 patients (mean [SD] age, 53.4 [15.4] years; 154 [33.7%] male), the DCS demonstrated good convergent (r = 0.78, P

Objectives: To measure morbidity and mortality rates following insertion of gastrostomy tubes in head and neck cancer patients. To determine evidence for any relationship between gastrostomy insertion technique and complication rates. Design: A prospective cohort study and qualitative systematic review. Setting: Multi-cancer networks in the South West of England, Hampshire and the Isle of White. Participants: One hundred and seventy-two patients with head and neck cancer undergoing gastrostomy tube insertion between 2004 and 2005. Percutaneous endoscopic gastrostomy (PEG) was performed in 121 patients. Fifty-one patients had radiologically inserted gastrostomy (RIG). Twenty-seven studies reporting outcomes following 2353 gastrostomy procedures for head and neck cancer. Main outcome measures: Post-procedure mortality, major and minor complications. Results: In the present series, mortality rates were 1.0% (1/121) for PEG and 3.9% (2/51) for RIG. Overall major complication rates following PEG and RIG were 3.3% (4/121) and 15.6% (9/51) respectively. In our systematic review and meta-analysis of 2379 head and neck cancer patients, we observed fatality rates of 2.2% (95% CI 0.014–0.034) following PEG and 1.8% (95% CI 0.010–0.032) following RIG. Furthermore, major complication rates following PEG were 7.4% (95% CI 5.9–9.3%) and 8.9% (95% CI 7.0–11.2%) after RIG. Conclusions: Procedure related mortality rates following gastrostomy in head and neck cancer patients are higher than those in mixed patient populations. Major complication rates following RIG in head and neck cancer patients are greater than those following PEG. Major complications following PEG in patients with head and neck cancer appear no worse than in mixed pathology groups. We have identified that RIG is associated with increased morbidity and mortality in patients who are ineligible for PEG. The serious nature of the complications associated with gastrostomy particularly in patients with head and neck cancer requires careful consideration by the referring physician.

Background:Examination of the upper aerodigestive tract is an important part of ENT practice. The use of both flexible and rigid nasendoscopes is the most common way of achieving this in the out-patient setting. However, these procedures can cause pain or discomfort for the patient, and topical preparations have been used in an attempt to reduce this.Objectives:The variability in current practice amongst those performing nasendoscopy may suggest an uncertainty as to what constitutes best practice for this procedure. A systematic review of the literature was undertaken in an attempt to clarify this.Methods:A literature search of the Cochrane ENT group trials register, the Cochrane central register of controlled trials (CENTRAL), CINAHL (1982–2007), MEDLINE (1950–2007) and EMBASE (1974–2007) was performed. Reference lists of selected studies were scanned for additional research material.Results:Eighteen studies relevant to this review were identified. The evidence suggests that local anaesthetic is not beneficial when performing flexible nasendoscopy, neither alone nor in combination with a vasoconstrictor. Water is better than lubricant for flexible endoscope passage and gives a superior optical outcome. Further research is required on the use of endosheaths for flexible and rigid nasendoscopy.

Summary Objective General Practitioners (GPs) are required to diagnose a number of common ear pathologies on a regular basis. In particular, otitis media with effusion (OME) can be well managed in primary care if a reliable diagnosis can be made. We set out to assess the confidence and ability of GPs to diagnose otopathology, as well as the access that they had to tympanometry and pneumatic otoscopy to assist in making their diagnoses. Methods Twenty GPs were shown a series of forty slides, half with OME and half with normal tympanic membranes; they were then asked to state whether each image represented an ear with OME or not. The same GPs were then shown 20 slides, half of which were ears with a common pathology and half were normal; the participants were asked to state whether the slide was of a normal ear or make a diagnosis of the pathology. Access to equipment and previous training were assessed via a short questionnaire. Results The median score for the correct diagnosis of OME was 53% (range 30–67.5%), only slightly higher than chance. The participants correctly identified that an ear was abnormal for a mean of 80% of the time (range 65–95%), but were only able to make a correct diagnosis of the pathology for a mean of 41% of the ears (range 20–80%). No participant had access to pneumatic otoscopy or tympanometry in their practices. Conclusions GPs have difficulty in correctly diagnosing OME from otoscopy alone, but are able to determine the presence of other otopathology. They were less able to diagnose specific abnormalities.

Objectives:To measure the thermal properties of operative endoscopes used in otorhinolaryngological practice.Methods:A series of endoscopes of varying diameters and angulations were attached to a light source and temperature measurements taken of their shaft and tip; a measurement was also taken 5 mm in front of the endoscope tip.Results:Temperature changes took place rapidly. The amount of heat produced by the endoscopes was maximal at the tip, with larger diameter endoscopes attaining a higher temperature. Temperatures on the shaft and in front of the tip reached relatively constant temperatures independent of the type of endoscope. The maximum temperature achieved was 104.6°C for the 4 mm, 0° endoscope. Cooling occurred rapidly after the light source was switched off.Conclusion:The heat produced by some endoscopes is sufficiently great to cause thermal injury to tissues. Awareness of the temperatures produced by these endoscopes should prompt clinicians to actively cool their endoscopes during a procedure, before any thermal injury is caused.

INTRODUCTION Sending patients a copy of the letters that are produced for their referring general practitioners (GPs) from an out-patient consultation is a policy of the UK Department of Health. Little research has been done to establish how patients attending out-patient departments feel about this practice and the effect this may have on the department itself. PATIENTS AND METHOD We asked 500 patients attending our out-patient department to complete a questionnaire. Patients were only included if they had previously been offered a copy letter by our department. RESULTS Of patients, 95% were in favour of the practice and 93.4% understood all or most of the contents of the letter. Dictation in front of the patients made them less likely to request a copy of the letter (P < 0.001). Impact of queries related to the letters was minimal with only three patients making contact with the department during the 3 months that the study was being conducted. CONCLUSIONS Our experience has shown that copying patients into their GP letters is a useful and popular practice for patients and has little impact on the running of the department. Patients also are in favour of having their letter dictated in their presence and this reduces their need to have a copy sent to them.

To evaluate the evidence and trends in published literature on the treatment of Ménière's syndrome or disease (MS/D) by comparing studies published in the last two decades.A literature search was performed on AMED, EMBASE, HMIC, MEDLINE, PsycINFO, BNI, CINAHL, HEALTH BUSINESS ELITE, CENTRAL and Cochrane Ear, Nose and Throat disorders groups trials register using a combination of MeSH. The date of last search was October 2014.Two hundred five studies (104 in decade I and 101 in decade II) were evaluated to report trends in the management of this condition, the differing levels of evidence published for each treatment modality, evaluate whether the guidelines published by the AAOHNS-Committee on Hearing and Equilibrium had been correctly employed, and whether the randomized controlled trials (RCTs) were compliant with the CONSORT guidelines.The number of published RCTs almost tripled from decade I (1994-2003) to decade II (2004-2103). There was a significant decline in the use of surgical intervention (p = 0.013); however, the number of studies involving the use of intratympanic injection remained largely unchanged. There was a shift in the level of evidence in published studies; studies with level 1 evidence tripled from decade I to II (4.8 to 17.8%, respectively) (p = 0.03); however, compliance with the AAOHNS-CHE criteria for reporting treatment outcomes and the CONSORT checklist was still poor.Although the evidence base on published literature on MS/D has improved over the last decade with an increase in emphasis on RCTs and quality of life (QoL) studies, a significant number of studies failed to follow AAOHNS-CHE criteria for reporting treatment outcome and the CONSORT criteria for reporting RCTs.

The NHS Connecting for Health agency continues to implement the national programme for information technology within the National Health Service (NHS). In preparation, NHS employees are being encouraged to develop their information technology skills via the European computer driving licence training course.A postal survey of British Association of Otorhinolaryngologists members was undertaken to evaluate their levels of information technology training, competency and knowledge. Three hundred and thirty-six surgeons responded.Most respondents had received no formal information technology training. Only 3.9 per cent had taken the European computer driving licence course.Most surgeons felt comfortable using word processing and presentation software but were less comfortable with other applications. Junior surgeons were more confident in all areas of information technology application than senior surgeons.Seventy-two per cent of surgeons wanted more information technology training. Most felt that such training should be routine at undergraduate and postgraduate level.With the national programme committed to improving information technology infrastructure within the NHS, more formal training should be provided to ensure a basic standard of information technology competency amongst ENT surgeons.

INTRODUCTION Time spent waiting to see a doctor in the out-patient department is a significant source of dissatisfaction for patients. Out-patient staff are often repeatedly questioned about the running of the clinic and why a delay has developed. These complaints and requests often result in further delays to the clinic. PATIENTS AND METHODS An information sheet was written to answer these questions. We set out to determine if the distribution of these sheets increased patient satisfaction with waiting times in the outpatient setting. Twelve sequential ENT clinics at the Lister Hospital, Stevenage were randomised into two groups. Patients attending clinics in Group A (n = 103) received an information sheet while those attending clinics in Group B (n = 124) received no information sheet. At the end of their clinic visit, all patients completed a questionnaire in which they were asked to provide a rating of their levels of satisfaction with various experiences in the out-patient department on a rating score from 1 to 5. RESULTS We found levels of satisfaction regarding waiting times to be significantly higher in the group who received information sheets (P < 0.001). No verbal complaints were received by the nursing staff at clinics where the information sheet was distributed. Four verbal complaints were received at the clinics where no sheets were distributed. CONCLUSIONS We believe that the use of information sheets is a cost-effective method of improving patient satisfaction and that this is a useful tool both in the primary care setting and in hospital out-patient departments.

Objectives: Using a microscope to achieve a view of the canal during dewaxing is the most commonly performed method of dewaxing in secondary care, but an endoscope can also be used. We set out to compare endoscopic and microscopic dewaxing. Design: Randomised clinical trial. Setting: Otolaryngology Outpatient Department. Participants: One hundred participants selected sequentially from patients requiring dewaxing of their ears to allow examination of the tympanic membrane. Patients with external or middle ear pathology were excluded. Methods: Patients were randomly assigned to have dewaxing performed using microinstruments aided by vision with a microscope or an endoscope. All participants who were entered the study completed the study. Main outcome measures: Levels of pain and discomfort experienced by the participants were assessed by a visual analogue scale (VAS). Difficulty of performing the dewaxing indicated by the endoscopist using a VAS. The length of time taken to perform the dewaxing was also recorded. Results: Endoscopic dewaxing was less uncomfortable than microscopic dewaxing for patients (VAS median values 5 and 25 respectively; P

The introduction of Choose and Book may have a significant effect on the proportion of urgent referrals seen by ENT surgeons. Much of the responsibility for prioritisation will be transferred to the GP. Patients who are considered urgent by the ENT surgeon will be added to those considered urgent by the GP. Our results show that there was little agreement between GPs and ENT surgeon on what constitutes an urgent referral. The combined effect of joint prioritisation and the removal of the 'soon' category resulted in a 270% increase in 'urgent' referrals in our sample. This potentially unforeseen consequence of the Choose and Book system should be taken into consideration by ENT departments to allow for an expansion of the 'urgent' category.

Background: Routine aspiration of middle-ear effusions prior to ventilation tube (grommet) insertion is practised by many surgeons. It has been suggested that removing the fluid from the middle ear improves immediate post-operative hearing levels and reduces the chance of the ventilation tube becoming obstructed. The potential adverse effects of applying suction to the middle ear include acoustic trauma and an increased risk of tympanosclerosis and otorrhoea. We undertook a review of the literature in order to determine the benefits or side effects associated with middle-ear aspiration prior to ventilation tube insertion.Objectives: To compare clinical outcomes associated with aspirating versus not aspirating the middle ear prior to ventilation tube insertion.Methods: The Cochrane ENT group trials register, DARE, the Cochrane central register of controlled trials (CENTRAL), MEDLINE (1960–2005) and EMBASE (1960–2005) were searched using relevant terms. Reference lists of selected studies were scanned for additional research material.Results: Seven studies were identified, of which three fitted the inclusion criteria of our review. Current evidence suggests that aspiration of middle-ear effusions prior to insertion of ventilation tubes is not associated with any improvement in clinical outcome, in terms of post-operative hearing levels, otorrhoea or rates of blockage of ventilation tubes. Significantly increased rates of tympanosclerosis were observed in one study and the development of acoustic trauma was observed; however, no significant association was confirmed. Although more research is needed, there is no evidence that aspiration of middle-ear effusion prior to grommet insertion confers any advantage.

Objectives: Previous studies have shown that nasendoscopy is made easier with the use of lubrication at the expense of the quality of the view obtained, but had no effect on the discomfort or pain experienced by the patient. We set out to determine whether the advantages of lubrication with a standard lubricant (KY Jelly) could be achieved by using water, without incurring the same disadvantages. Design: Single blind randomized controlled trial. Setting: Outpatient Departments at two District General Hospitals. Participants: One hundred and fifty participants selected sequentially from patients requiring a nasendoscopy where the endoscope would be passed far enough to view the larynx. Patients requiring topical anaesthetic were excluded. Methods: Patients were randomly assigned to have either water or standard lubricant applied to the nasendosope prior to nasendoscopy. Levels of pain experienced by the patient were recorded on a visual analogue score as well as visual analogue scores from the clinician for the levels of difficulty in passing the endoscope. All participants who were entered the study completed the study. Endoscopy was performed by all grades of medical staff. Main outcome measures: Levels of pain experienced by the participants were assessed by a visual analogue scale. Difficulty of passing the scope was indicated by the endoscopist using a visual analogue scale, as was the quality of image obtained. Results: Endoscopists found the insertion of the endoscope was easier and the image better when water was used rather than KY Jelly. There was no significant difference in reported in levels of pain experienced by the patient. Conclusion: Although the use of water as a lubricant during nasendoscopy confers no additional benefit in term of the levels of pain suffered by patients during the procedure, it makes the insertion of the endoscope easier and provides a better quality image than standard lubrication.

The round window region is a critical area of the middle ear; the aim of this paper is to describe its anatomy from an endoscopic perspective, emphasizing some structures, the knowledge of which could have important implications during surgery, as well as to evaluate what involvement cholesteatoma may have with these structures. Retrospective review of video recordings of endoscopic ear surgeries and retrospective database review were conducted in Tertiary university referral center. Videos from endoscopic middle ear procedures carried out between June 2010 and September 2012 and stored in a shared database were reviewed retrospectively. Surgeries in which an endoscopic magnification of the round window region and the inferior retrotympanum area was performed intraoperatively were included in the study. Involvement by cholesteatoma of those regions was also documented based on information obtained from the surgical database. Conformation of the tegmen of the round window niche may influence the surgical view of round window membrane. A structure connecting the round window area to the petrous apex, named the subcochlear canaliculus, is described. Cholesteatoma can invade the round window areas in some patients. Endoscopic approaches can guarantee a very detailed view and allow the exploration of the round window region. Exact anatomical knowledge of this region can have important advantages during surgery, since some pathology can invade inside cavities or tunnels otherwise not seen by instrumentation that produces a straight-line view (e.g. microscope).

Program Description:The goals of cholesteatoma surgery are the complete removal of disease while minimizing the risk of recurrence. A secondary goal is to optimize postoperative hearing. This miniseminar features distinguished experts in the field who will present well-established methods of cholesteatoma surgery. Important topics, such as intact-canal-wall versus canal-wall-down surgery, recurrence prevention, use of cartilage, and management of labyrinthine fistula will then be discussed in a case-based format. The role of endoscopes and use of magnetic resonance imaging for detection of recurrence will be discussed. Finally, ossiculoplasty techniques will be presented.Educational Objectives:(1) Perform cholesteatoma surgery as practiced by experts in the field. (2) Examine advantages and disadvantages of endoscopic techniques. (3) Incorporate various methods for preventing recurrence.

Background Idiopathic sudden sensorineural hearing loss (ISSHL) is characterised by sudden loss of hearing of cochlear or retro-cochlear origin without an identifiable cause. Antivirals are commonly prescribed, but there is no consensus on the treatment regimen or their effectiveness. Objectives To determine the effectiveness and side effect profile of antivirals in the treatment of ISSHL. Search methods We systematically searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5), PubMed, EMBASE, CINAHL and other databases to 12 June 2012. We also scanned the reference lists of identified studies for further trials. Selection criteria Randomised controlled trials comparing different antivirals versus placebo (both with or without other treatment). Data collection and analysis Two authors independently extracted data, met to resolve disagreements and contacted study authors for further information. We assessed study risk of bias independently. We considered meta-analysis inappropriate and ultimately not possible due to differing treatment protocols of varying dose and duration, together with differing inclusion criteria and outcome measures between studies. The results of each study are reported individually. Main results We included four randomised trials (257 participants). The overall risk of bias in the included studies was low. Two trials compared the addition of intravenous acyclovir to a steroid (prednisolone). One included 43 participants, the other 70 patients. Neither demonstrated any hearing improvement with ISSHL. Another (84 patients) did not show any statistically significant difference between groups with the addition of valacyclovir to prednisolone (compared to steroid plus placebo) with respect to change in pure-tone audiogram. Comparing the addition of intravenous acyclovir to hydrocortisone with hydrocortisone alone, the final trial did not show any statistically significant difference between groups (60 patients). No trial documented any serious adverse effects related to the use of antiviral treatment. One study reported slight to moderate nausea equally in the acyclovir and placebo groups (one patient in each). Another reported insomnia, nervousness and weight gain with valacyclovir (number not specified). Even though no meta-analysis was possible, evidence from the four RCTs has demonstrated no statistically significant advantage in the use of antivirals in the treatment of ISSHL. Authors' conclusions There is currently no evidence to support the use of antiviral drugs in the treatment of ISSHL. The four trials included in this review were, however, small and with a low risk of bias. Further randomised controlled trials with larger patient populations, using standardised inclusion criteria, antiviral regimes and outcome measures, are needed in order for adequate meta-analysis to be performed to reach definitive conclusions. A uniform definition of ISSHL should also be established, together with what constitutes adequate recovery.

Rigid nasendoscopy is a commonly used method of examining the nasal cavity and postnasal space. Co-phenylcaine is useful for its vasoconstrictive and anaesthetic properties, but the length of time allowed for it to take effect is variable. We performed a single-blind, randomized, controlled trial to determine whether it was better to allow one or 10 minutes for co-phenylcaine to take effect. Fifty patients were randomized into two groups, 25 in each. Patients in the 10 minute group experienced less discomfort (p=0.02) and less pain (p=0.018) than those in the one minute group. Ease of examination was also greater in the 10 minute group, as was the quality of the image obtained (p

Keypoints • Syringing of ears to remove cerumen is losing favour in primary care owing to the fact that it is carried out ‘blind’ and that the potential exists for serious complications. • Dewaxing under direct vision is difficult without a microscope. • A technique is described where wax is removed under direct vision using a rigid endoscope in conjunction with a Jobson–Horne probe and St Bartholomew's wax hook. • This is a relatively inexpensive technique that could be introduced to primary care practitioners or to ENT surgeons who do not have easy access to an operating microscope in the outpatient department.

Introduction: Once fitted with hearing aids, much reliance is placed on patients' own ability to manage their devices effectively. There has, however, been little research to assess how patients' own confidence compares with their actual ability to manage their hearing aids. This study compares patients' perceptions of their ability to insert their hearing aids with their observed ability to insert the devices satisfactorily.Method: Eighty-five patients provided a rating of their level of confidence in fitting their hearing aid, using a visual analogue score (VAS). This was then compared with their observed level of ability, assessed by an audiologist, also using a VAS (both scores 0–100 mm).Results: We found a weak to moderate correlation between the subjective and objective scores (Pearson r = 0.4912).Conclusions: From these results, we would advise caution when accepting a patient's perceived level of ability as the only indicator of their true ability to insert their hearing aid. This also has important implications for follow-up services that rely only on telephone conversations with patients after a first fitting.

Program Description:Endoscopic ear surgery (EES) is a current hot topic in our specialty, but it is not entirely correct to introduce EES as “new.” Although not new, it is clear that during the last few years, endoscopes have proven to be safe and effective instruments to manage ear diseases in a minimally invasive way, preserving important anatomical structures, allowing functional approaches to well-known conditions. Moreover, endoscopes have provided a better view and understanding of traditional middle ear anatomy and physiology, allowing new landmarks, novel concepts of tissue preservation, ventilation routes, and management of other conditions within the middle ear and beyond.Educational Objectives:1) Describe the endoscopic anatomy of the middle and inner ears, discussing the concepts of related physiology. 2) Discuss the main totally endoscopic and combined surgical approaches to middle ear conditions, discussing the possible advantages and disadvantages. 3) Present the instruments needed, system ...

Objectives/Hypothesis An analysis of the frequency and intensity of postoperative aftercare required for modified radical mastoidectomy (MRM) and patterns of healing in the postoperative period. Study Design A retrospective review of all primary modified radical mastoidectomies carried out for cholesteatoma under the care of the senior author between the years of 2004 and 2009 with minimum follow-up of 2 years. Methods The time and number of interventions required to achieve a stable and dry mastoid cavity were collected. Cross-sectional and longitudinal analysis of the behavior of the cavities was carried out. Results Overall, 73 cases (71 patients) were identified. Patients were followed up for a median of 45.7 months (interquartile range, 31.8–70.5). After initial debridement, most cavities settled rapidly, but this was not always predictable, with a large proportion requiring further clinical intervention after the cavity was stable, sometimes for prolonged periods of time. At the time of analysis, 73% had achieved a stable cavity, 17 (23%) still required attention (nine for wax removal and eight for debridement); two were lost to follow-up. No revision surgeries were required. At 6 months, 36% of cavities were settled, 42% at 1 year, 53% at 18 months, and 62% at 2 years. After two standard postoperative visits, a total of 632 visits were made by these patients. Conclusions Following MRM, the majority of patients achieve a dry, self-cleaning mastoid cavity. This might require periods of intense care interspersed with periods of quiescence. These results allow the benefits of this procedure to be put in the context of the entire patient journey. Level of Evidence 4. Laryngoscope 124:2380–2385, 2014

Objectives/Hypothesis A prototype system for intraoperative cone beam computed tomography (CBCT) imaging has been developed and augmented with real time optical tracking of a surgical drill. We hypothesize that this system provides sufficient accuracy for guidance of temporal bone surgery. Study Design Basic research. Methods Measurements of drill localization accuracy using CBCT imaging were obtained with a custom three-dimensional calibration object. Integrated CBCT imaging and drill tracking were prospectively evaluated on 12 cadaver temporal bones. Six inexperienced and six experienced surgeons conducted four surgical tasks: cortical mastoidectomy, posterior tympanotomy, cochleostomy, and a translabyrinthine approach to the internal auditory canal. Questionnaires provided expert feedback on tracking accuracy and system usability. Results Target registration error measurements of drill tracking accuracy and precision yielded a mean of 0.76 mm, a maximum of 1.30 mm, and a standard deviation of 0.21 mm. Anatomical landmark identification tasks (e.g., facial nerve, incus, semicircular canals, cochlea) provided additional validation of system accuracy. The usability and utility of the guidance system were positively rated by both groups of surgeons, with further modifications underway to improve tracking line of sight and registration workflow. Experienced but in particular inexperienced surgeons indicated significant benefits in cases involving extensive disease, abnormal anatomy, and loss of anatomical landmarks. Conclusions The integration of intraoperative CBCT imaging with optical tracking provides sufficient accuracy to localize anatomical structures within the temporal bone using an otological drill. Future studies will explore the role of this technology in complex oncological resections, in surgery for congenital anomalies, and as a tool for teaching. Level of Evidence 4. Laryngoscope, 123:2823–2828, 2013

OBJECTIVE: To record with video-otoscopy the appearance of the tympanic membranes of a cross section of children aged 9 to 10 years. STUDY DESIGN: Cross-sectional study nested within an established longitudinal study of childhood development, the Avon Longitudinal Study of Parents and Children. SETTING: South West England, U.K. PARTICIPANTS: Approximately 6908 of 7261 children with ages ranging from 105 to 140 months born between April 1, 1991, and December 31, 1992, were examined by trained technicians with video-otoscopy. MAIN OUTCOME MEASURES: Two photographs were taken of each child's tympanic membranes to show the features of the pars tensa and the pars flaccida. RESULTS: In just less than three quarters of the children, both ears were normal. Retraction of the pars flaccida was present in 9.6% of children, and that of the pars tensa was present in 7.9%. Most of these changes were mild with few severe retractions. There were 15 cases of overt or suspected cholesteatoma. CONCLUSION: The tympanic membrane changes reflect most of the middle ear disease seen in 9- to 10-year-old children. The prevalence is low, and few children have serious disease at this stage.

Objective: 1) Develop an auditory biofeedback device based on the Apple iPod Touch. 2) Investigate the efficacy of auditory biofeedback for patients with bilateral vestibular loss (BVL) using postu...

Objective: 1) Report the largest series to date of patients with cerebellar ataxia with bilateral vestibulopathy (CABV). 2) Understand the unique balance problems in this disorder; we studied the eye movements crucial for gaze stabilization.Method: From over 16 years at a multidisciplinary neuro-otology clinic, 32 patients (mean age, 51.7 (SD = 19.3)) with symptoms of CABV syndrome over a median of 5 (IQR = 2-10) years were selected for both clinical and oculographic analysis of their central and peripheral vestibular function.Results: Vestibulo-ocular reflex (VOR) function was impaired on Halmagyi head thrust testing in 74% of patients; patients studied by oculography revealed a subnormal mean VOR gain of 0.67. Impaired dynamic visual acuity was abnormal in 88%. Importantly, this impairment would have been underestimated by bithermal caloric testing, in which only 22% were subnormal. Gaze-evoked nystagmus (70%), impaired smooth pursuit (88%), and impaired cancellation of the VOR (93%) revealed the associ...

Thyroidectomy has few complications, as a result, many patients are concerned about the prominence of their scar. Performing thyroid surgery through excessively small incisions in order to maximise cosmesis may increase the likelihood of complications. This study investigates the relationship between conventional approach thyroidectomy scar length and patient satisfaction. A validation of self-measurement of neck circumference and thyroidectomy scar was carried out with the measurements taken by patients compared with those taken by an investigator. One hundred consecutive patients who had undergone conventional thyroidectomy and total thyroidectomy within 24 months were invited to measure their scars and neck circumference, and to score their satisfaction on a Likert scale of 1–10. Spearman’s correlation was calculated for the relationship between absolute and relative scar length, and patient satisfaction. Thirty-four patients entered the preliminary study and 80 patients entered the main study (80% response rate). Measurements by patients and investigators were closely associated: Spearman’s Rank correlation coefficient for neck circumference and for scar length were ρ = 0.9, p