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Background It is generally accepted that headshake nystagmus (HSN) is generated from an asymmetrical peripheral vestibular input and a correlation exists between HSN and canal paresis. There have been limited reports, however, how HSN correlates with the more recently introduced tests of vestibular function. Aims/objectives To evaluate the correlation between HSN and unilateral weakness on caloric testing, high-frequency vestibulo-ocular reflex (VOR) function on video head impulse testing (VHIT) and otolith function determined by vestibular evoked myogenic potentials (VEMPs). Methods A retrospective study of all patients who underwent complete vestibular function testing at our tertiary referral center from 2016 to 2019 was performed. Demographic data, clinical diagnosis (where available), the results of video-nystagmography, vHIT, and VEMPs were evaluated. Results Of the 1499 patients in the study period, 101 (6.7%) had HSN. Vestibular test abnormalities were more common in patients with HSN. The sensitivity of HSN for underlying pathology was low in comparison with vestibular testing. However, HSN demonstrated a high specificity. Conclusions and significance HSN generation is likely more complex than caloric-induced nystagmus, probably due to additional variables within the vestibular system. HSN may provide clinicians with additional information concerning high-frequency VOR function involving lateral semicircular and otolith dysfunction.

Impairment of ipsilesional vestibulo-ocular reflex (VOR) function is well described in vestibular schwannoma (VS) and a correlation between gain of the VOR and tumor size has been suggested. Bilateral VOR impairment may also occur in VS patients, but its mechanisms are poorly understood. We sought to explore the effect of unilateral VS on ipsilesional and contralesional high-acceleration VOR function using video head impulse testing, and evaluate potential factors responsible for contralesional VOR impairment. Materials and methods Chart review in tertiary referral center of patients with unilateral VS, who completed neurotological examination and vestibular function testing. Results One hundred one patients (mean age 57.4 yrs) were included. Maximal tumor diameter ranged from 0.3 to 5.0 cm. Forty one patients had evidence of brainstem compression from VS on magnetic resonance imaging (MRI). Ipsilesional and contralesional VOR impairment was present in 81 (80%) and 44 (43%) patients, respectively. Bilateral VOR impairment was seen in 42 (42%) patients. Bilateral VOR impairment correlated with tumor size. Presence of brainstem compression was associated with reduced ipsilesional VOR gain, but not contralesional VOR gain.

Background Pulsatile tinnitus (PT) can have huge impact on the patients’ quality of life and can be associated with curable vascular anomalies. In the present study, we aim firstly to describe our protocol for venous BTO and secondly to report possible predictors for a positive BTO test. Methods All consecutive PT patients undergoing BTO for the purpose of determining eligibility for venous neuro-intervention were included. We recommend BTO for patients when there is uncertainty in the association of the venous pathology identified on non-invasive cross-sectional imaging (CTV or MRV) and the patient's symptoms. Results Between May 2016 and October 2022, we recorded 29 venous balloon test occlusions fulfilling our inclusions criteria. Over the 29 procedures scheduled, 8 finally did not lead to a successful balloon test occlusion. The main reason was that the patient did not hear the PT on the day the angiogram was performed. Two patients could not have the BTO due to difficulties in venous navigation. After BTO, only four patients of our cohort were scheduled for an endovascular treatment. Conclusion We describe a technique and present a single cohort of venous BTO in severe PT patients with unclear anatomical cause. This angiographic test was useful to exclude patients from endovascular surgery and discuss the most probable cause of the PT. Complexity of vascular PT should support a patient-based approach when discussing interventional treatment.

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.

Purpose: Benign paroxysmal positional vertigo has typically been reported to be the most common cause of post-traumatic dizziness. There is however paucity in the literature about other peripheral vestibular disorders post-head injury. This article provides an overview of other causes of non-positional dizziness post-head trauma from our large institutional experience.Methods: The UHN WSIB Neurotology database (n=4,291) between 1998 and 2018 was retrospectively studied for those head-injured workers presenting with non-positional peripheral vestibular disorders. All subjects had a detailed neurotological history and examination and vestibular testing including video nystagmography, video head impulse testing (or a magnetic scleral search coil study), vestibular-evoked myogenic potentials, and audiometry. Imaging studies included routine brain and high-resolution temporal bone CT scans and/or brain MRI.Results: Based on a database of 4,291 head-injured workers with dizziness, 244 were diagnosed with non-positional peripheral vertigo. Recurrent vestibulopathy (RV) was the most common cause of non-positional post-traumatic vertigo. The incidence of Meniere’s disease in the post-traumatic setting did not appear greater than found in the general population. Conclusion: The clinical spectrum pertaining to recurrent vestibulopathy, Meniere’s disease, delayed endolymphatic hydrops, drop attacks, superior semicircular canal dehiscence syndrome, and uncompensated peripheral vestibular loss are discussed.

OBJECTIVES/HYPOTHESIS Chronic dizziness (CD) and imbalance have multiple etiologies. CD is strongly linked with psychiatric and psychological comorbidities, thus an interdisciplinary approach, including psychopharmacological interventions, is recommended. Despite the use of this comprehensive treatment approach, the recovery of individuals with CD that pursue long-term disability (LTD) insurance or legal claims (LC) appears hampered. As such, we aimed to compare symptom recovery from CD in an interdisciplinary setting between patients receiving LTD/LC versus those who were not, and to explore the factors that may contribute to changes in symptom severity. STUDY DESIGN Retrospective cohort study. METHODS Dizziness-related diagnoses were extracted from the charts of 195 adults in an outpatient interdisciplinary neurotology clinic in Toronto, Canada. Patients with baseline Dizziness Handicap Inventory (DHI) and Dizziness Catastrophizing Scale (DCS) assessments between August 2012 and July 2018 and a mean follow-up visit within approximately 10 months were included. The study participants were categorized as "LTD/LC+" (n = 92) or "LTD/LC-" (n = 103), referring to either receiving or pursuing LTD/LC or not, respectively. RESULTS There were differences in the mean percentage changes in DHI (t[187] = 3.02, P = .003) and DCS (t[179] = 2.63, P = .009) scores between LTD/LC+ and LTD/LC- patients. LTD/LC+ patients showed 8.0% and 7.6% mean increases in DHI and DCS scores, respectively, whereas LTD/LC- patients showed 21.5% and 25.9% reductions in DHI and DCS scores, respectively, controlling for age, sex, and baseline illness severity. CONCLUSIONS Patients receiving or pursuing LTD insurance or a legal claim did not improve from CD and dizziness catastrophizing compared to those who were not. Future studies are required to test these findings prospectively and to determine the factors that may contribute to symptom recovery, including the anxiety-aggravating effects of the LTD/LC process and the deleterious consequences of developing a sick-role while afflicted with a chronic illness. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.

Objectives Several studies have reported an association between benign paroxysmal positional vertigo (BPPV) and bone mineral density or serum vitamin D levels. The aim of this review is to provide further clarification regarding the relationship between BPPV and calcium metabolism. Design PubMed and MEDLINE databases were systematically reviewed to identify all English language papers regarding the relationship between BPPV and the following terms: osteoporosis, osteopenia, bone mineral density, serum vitamin D levels, and bone metabolism. Results Of the 456 identified records, 28 studies were eligible for this review. Most were retrospective studies with inherent limitations and often conflicting results. While the literature is not conclusive, osteoporosis in patients of at least 50 years old appears to have an association with BPPV. Similarly, an association was observed between recurrent BPPV and vitamin D deficiency. Conclusion There is only weak evidence to support the relationship between BPPV and osteoporosis or low serum 25-hydroxyvitamin D levels. Further prospective studies with more robust methodologies are needed to clarify the association between BPPV and disorders of bone metabolism.

Background:Falls are a growing concern in seniors (≥65 yrs). Cognitive impairment (CI) and vestibular impairment (VI) increase fall risk. The aim of this study is to assess the prevalence of CI and VI in seniors experiencing falls.Methods:Participants (≥65 yrs) with falls were recruited from Falls Prevention Programs (FPPs) and a Memory Clinic (MC). CI was assessed using the Montreal Cognitive Assessment at FPPs. VI was assessed at an MC and FFPs using the Head Impulse- (video + bedside), Headshake-, Dix-Hallpike test, and test of sensory interaction in balance. Questionnaires included Dizziness Handicap Inventory (DHI) and Activities-specific Balance Confidence Scale (ABC).Results:Of 41 participants (29 FPPs, 12 MC); mean age was 80.1 ± 7.1 years, and 58.5% were female. Overall, 82.9% had VI. At FPPs, 76.0% had CI, and 72.3% had CI + VI. Bilateral vestibular hypofunction (BVH) was more common than unilateral vestibular hypofunction (UVH) (70.6% vs. 29.4%); p = 0.016. Dizziness Handicap (DHI) was not different between those with a VI (23.5 ± 23.9) versus without VI [PVI + no impairment] (10.0 ± 15.4); p = 0.160. Balance confidence (ABC) was lowest in VI but not significantly different between those with a VI (63.4 ± 27.3) versus without VI [PVI + no impairment] (85.0 ± 16.5); p = 0.053.Conclusions:VI and CI are prevalent in seniors experiencing falls. For seniors with history of falls, both cognitive and vestibular functions should be considered in the assessment and subsequent treatment. Screening enables earlier detection, targeted interventions, and prevention, reducing the clinical and financial impact.

BackgroundPulsatile tinnitus (PT) is a debilitating condition that can be caused by a vascular abnormality, such as an arterial or venous lesion. Although treatment of PT-related venous lesions has been shown to successfully cure patients of the associated ‘tormenting’ rhythmical sound, much controversy still exists regarding their role in the etiology of PT.MethodsA patient presented with a history of worsening, unilateral PT. A partial venous sinus obstruction related to the large arachnoid granulation was detected on the right side, and subsequently stented at the right transverse sinus. High-fidelity computational fluid dynamics (CFD) was performed on a 3D model digitally segmented from the pre-stent venogram, with assumed pulsatile flow rates. A post-stent CFD model was also constructed from this. Data-driven sonification was performed on the CFD velocity data, blinded to the patient’s self-reported sounds.ResultsThe patient reported that the PT was completely resolved after stenting, and has had no recurrence of the symptoms after more than 2 years. CFD simulation revealed highly disturbed, turbulent-like flow at the sigmoid sinus close to auditory structures, producing a sonified audio signal that reproduced the subjective sonance of the patient’s PT. No turbulence or sounds were evident at the stenosis, or anywhere in the post-stent model.ConclusionsFor the first time, turbulence generated distal to a venous stenosis is shown to be a cause of PT. High-fidelity CFD may be useful for identifying patients with such ‘torrents’ of flow, to help guide treatment decision-making.

INTRODUCTION Bilateral posterior semicircular canal (PSCC) occlusion is a successful treatment of bilateral benign positional vertigo (BPV) refractory to particle repositioning manoeuvers. Little about the effects on the vestibular ocular reflex (VOR) postoperatively, which is the intent of this study. METHODS All patients who underwent bilateral posterior canal occlusion for BPV at the University Health Network by the senior author (J.A.R.) between 2001 and 2017 with pre- and postoperative vestibular testing were included in the study.All patients underwent a detailed history and neuro-otological examination including dynamic visual acuity (DVA). Laboratory testing including video head impulse testing or magnetic scleral search coil testing, video nystagmography, cervical and ocular vestibular evoked myogenic potentials and audiological testing before and following their procedure at 1, 6, and 12 months postoperatively. RESULTS Three patients were included in the study, all females, with a mean age of 41 years (range 36-44 yr). All patients had developed bilateral BPV after head trauma. Mean length of follow-up was 26 months (range 6-84 mo). All patients demonstrated a reduction in the vertical VOR of between 0.37 and 0.57/s at 1 month postocclusion. Between 6 and 12 months postoperatively, an improvement in their vertical VOR between 0.45 and 0.75/s was observed. Clinically, all patients reported complete resolution of their positional vertigo with a negative Dix-Hallpike bilaterally at follow-up. None reported oscillopsia, which was confirmed with DVA testing. CONCLUSION Bilateral PSCC occlusion results in a reduction in the vertical VOR of the PSCCs.Over a 6 to 12 month time period improvement in the VOR gain can be demonstrated, most likely due to central compensation. There is clinical correlation with improvement in DVA testing. Bilateral PSCC occlusion is a safe and effective treatment for bilateral BPV proved refractory to particle repositioning manoeuvers.

Purpose of Review The purpose of the study is to evaluate and highlight objective audiologic and vestibular outcomes following “functional” transmastoid surgery on the vestibular labyrinth.

Vestibular disorders result in symptoms that significantly impact an individual’s quality of life. Vestibular rehabilitation therapy (VRT) has, for many years, been used as an effective means of treating patients and their vestibular-related symptoms. For clinicians, it is crucial to stay up to date with the current best evidence in VRT in order to optimize patient management. Current evidence is in support of VRT for treating patients with a variety of vestibular disorders, both central and peripheral. High level evidence studies support the use of treatment techniques of adaptation and substitution for gaze stabilization, habituation, balance and gait training, and canalith repositioning maneuvers. Recent evidence has also examined and found promising results with technological innovations that are targeted at those with bilateral vestibular hypofunction and insufficient gains with a standard exercise-based program. Nevertheless, factors such as anxiety overlay/depression, time when beginning therapy, and adherence may have an impact on how a patient will do with his/her VRT program and should be acknowledged. Quantifiable and evidence-based literature supports the use of VRT for patients with a variety of vestibular disorders and their associated symptoms. The clinician needs to become familiar with each patient’s complaints and goals, as well as any potential barriers to positive outcomes with VRT, and combine this with their knowledge of current evidence-based literature in order to develop the optimal program for each unique patient.

Objectives/Hypothesis Neurotological findings secondary to electrical injuries have rarely been reported in the world literature. We attempt to characterize the neurotological findings following electrical injury and to determine the role head injury and loss of consciousness play in this population's clinical presentation. Study Design Retrospective cohort study. Methods A database containing 3,438 patients with work-related injuries was scanned for individuals who sustained and survived electrical injuries at work. Detailed analysis of the frequencies of presenting features and test results was performed. A comparative analysis was made between the subsets of patients with and without loss of consciousness and/or head injury. Results A cohort of 42 patients was identified. All patients had multiple symptoms. Dizziness was a significant complaint in all workers with electrical injuries. Other common complaints included tinnitus and imbalance. Characterization of these symptoms is provided in detail according to statistical frequency. In this cohort, 25 workers had a concomitant head injury and 17 workers had an associated loss of consciousness. There was no statistically significant difference when clinical presentation, examination, and balance testing results were compared between the subsets. Conclusions Frequency and characterization of symptoms following electrical injury are provided. Dizziness is the most common presenting neurotological feature. Loss of consciousness and/or associated head injury do not affect the clinical presentation in this particular population. Level of Evidence 2b. Laryngoscope, 2017

ObjectiveCarotid artery aneurysm is a potentially fatal complication of skull base osteomyelitis. It is important to know the warning signs for this complication, as early diagnosis is of great importance. This report aimed to determine whether the pattern of cranial nerve involvement may predict the occurrence of aneurysm involving the internal carotid artery in skull base osteomyelitis.MethodsTwo diabetic patients with skull base osteomyelitis were incidentally diagnosed with pseudo-aneurysm of the petrous internal carotid artery on follow-up magnetic resonance imaging. They presented with lower cranial nerve palsy; however, facial nerve function was almost preserved in both cases. Computed tomography angiography confirmed aneurysms at the junction of the horizontal and vertical segments of the petrous carotid artery.ResultsInternal carotid artery trapping was conducted using coil embolisation. Post-coiling magnetic resonance imaging demonstrated no procedure-related complications. Regular follow up has demonstrated that patients’ symptoms are improving.ConclusionOne should be mindful of this potentially fatal complication in skull base osteomyelitis patients with lower cranial nerve palsies, with or without facial nerve involvement, especially in the presence of intracranial thromboembolic events or Horner's syndrome.

Many pharmaceuticals have ototoxicity (both cochlear and/or vestibular) as part of their adverse medication profile. The aminoglycoside class of antimicrobials has been especially well studied in this regard. Many questions remain unanswered as to how to best monitor and prevent this complication. A bilateral vestibular loss profoundly affects an individual's quality of life, physical activities, and overall independence. Paradoxically, the effects of gentamicin ototoxicity have provided further insight into the workings of the vestibular system, especially the vestibulo-ocular reflex. The microbiological activity, therapeutic use, toxicities, and genetics predisposing a person to aminoglycoside ototoxicity are presented. The clinical importance of recognizing ataxia, disequilibrium, and oscillopsia as presenting symptoms for vestibulotoxicity rather than hearing loss or vertigo is stressed. Documented risk factors and new observations regarding the spectrum of vestibular dysfunction and differences in vestibulotoxicity from multiple daily dosing vs. single daily dosing schedules are presented for the first time. While most vestibulotoxicity arises from systemic aminoglycoside administration, intratympanic application has been used therapeutically for intractable Ménière's disease. Commercially available ototopical aminoglycoside preparations for the treatment of external/middle ear disease in the presence of a tympanic membrane defect have also been documented to cause unintentional ototoxicity.

Background Vestibular evoked myogenic potentials (VEMPs) have an accepted role in the diagnosis of the superior semicircular canal dehiscence (SSCD) syndrome. The current impression is that ocular VEMPs (oVEMPs) are more sensitive than cervical VEMPs (cVEMPs) for detecting a SSCD and that oVEMP testing in response to air conducted sound provides an excellent screening test without risk of radiation exposure from computerized tomography (CT). Aims/objectives To report on patients with elevated oVEMP amplitudes but without evidence for a SSCD on multiplanar CT imaging. Material and methods Retrospective chart review of all patients referred for vestibular function testing to our department. Patients with oVEMP peak-to-peak amplitudes ≥17 μν without evidence for a SSCD on imaging were evaluated. Results 26 patients had oVEMP peak-to-peak amplitudes ≥17 μν with no evidence of a SSCD on imaging. The most common diagnosis was Meniere's disease in those identified. Conclusion and significance oVEMPs can provide false positive results for diagnosis of a SSCD and an elevated oVEMP amplitude in itself is insufficient for diagnosis of a SSCD.

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.

Objective The aim of this study was to determine the effectiveness of the canalith repositioning procedure (CRP) in the treatment of benign paroxysmal positional vertigo (BPPV) among patients after mild-to-moderate traumatic brain injury. Methods An unblinded, nonrandomized, case comparison interventional study with repeated measures (1, 5, 9, and 12 weeks postenrollment) of three groups of patients with traumatic brain injury (BPPV, n = 21; nonspecific dizziness, n = 23; no dizziness, n = 12) was conducted. Patients in the BPPV group received the CRP at baseline and repeatedly until a negative Dix-Hallpike Maneuver was observed. Participants in the other two groups did not receive the CRP. Results Symptom resolution at the 12-week follow-up was observed in 75% of patients in the BPPV group versus 8.3% in the nonspecific dizziness group (p = .0006). A significant Group × Time interaction was observed for the Dizziness Handicap Inventory (F = 4.2, p = .003) and 36-item Short Form Health Questionnaire physical component scores (F = 2.16, p = .035) with the BPPV group showing significantly improved scores by the 12-week follow-up. Although there were between-group differences on the 36-item Short Form Health Questionnaire mental health component scores (F = 4.06, p = .022), changes over time were not significant in the groups. Conclusions Treatment with the CRP for posttraumatic BPPV resulted in significant symptom resolution and improvement in perceived physical health status.

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 Meniere's syndrome or disease (MS/D) is typically characterised by episodic vertigo, aural fullness, tinnitus and fluctuating hearing loss. There are multiple options available for treatment with variation in consensus on the best intervention. Objective To evaluate the evidence on the efficacy of intratympanic therapies [steroids, gentamicin, antivirals and other therapies] on the frequency and severity of vertigo and other symptoms of MS/D. Search strategy A literature search was performed on AMED, EMBASE, HMIC, MEDLINE, PsycINFO, BNI, CINAHL, HEALTH BUSINESS ELITE, CENTRAL and Cochrane Ear, Nose and Throat disorders group trials register using various MeSH. The search was restricted to English and human subjects, and the last date of search was December 2014. Selection criteria Randomised controlled trials of intratympanic therapies [steroids, gentamicin antivirals and latanoprost] versus a placebo or another treatment. Results We analysed 8 RCT's comparing intratympanic steroids, gentamicin, ganciclovir (antiviral) and latanoprost versus another form of intratympanic treatment or placebo. Conclusions On the basis of 6 RCT's (n = 242), there is evidence to support the effectiveness of intratympanic steroids and gentamicin to control symptoms of vertigo in MS/D albeit with a risk of hearing loss with gentamicin. However, there was no consensus found on doses or treatment protocols. There was no evidence to support the use of other forms of intratympanic therapy (antivirals and latanoprost) in MS/D.

127 Background: Ototoxicity after cisplatin +/- radiation occurs in 22-58% of patients with head and neck cancers. Routine post-treatment hearing tests are useful in the early detection of hearing loss, allowing for possible early intervention. This study aimed to identify current hearing screening practices for follow-up, barriers to screening, and recommendations for its implementation. Methods: Stakeholders (physicians, nurses, coordinators, audiologists) identified barriers and facilitators to the implementation of a routine hearing screening follow-up program at Princess Margaret Cancer Centre. Themes were identified using an inductive approach and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices. Results: The problem: While all patients received baseline hearing tests, follow-up testing was inconsistently performed in asymptomatic patients. Patients may also lack awareness of subclinical hearing loss. A formalized follow-up hearing test program was identified as the best approach by stakeholders. Barriers: Individual-level barriers included limited knowledge about intervals for hearing testing and lack of time during clinic visits. Institutional-level factors included personnel, financial resources and logistical supports. Patient travel distances and times were barriers, as well as scheduling tests on the same day as other clinic visits. Societal stigma of hearing loss was a possible barrier. Facilitators: These included greater staff and patient education, and designating a local clinic champion. Instructions for follow-up after identifying hearing loss was deemed essential. Adapting to the local context: Automated flagging post-treatment and auto-referrals to the Hearing Clinic through the electronic medical record system could facilitate increased rates of participation. Mail/phone reminders could be useful adjuncts. Conclusions: Participants supported a formal post-treatment hearing test program for patients with head and neck cancers treated with cisplatin +/- radiation. Individual and institutional barriers were identified, but could be mitigated by appropriate facilitators.

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.

Objective To determine which measure of the salivary flow rate, stimulated or unstimulated, is most strongly associated with pathologic changes in minor salivary gland (MSG) biopsy specimens, and to explore the correlation of salivary flow with oral surface damage, disease duration, and symptom severity in patients with primary Sjogren's syndrome (SS). Methods In all patients (n = 32), a biopsy of the MSG was performed, and stimulated salivary flow was assessed. Beginning in 2002, unstimulated salivary flow was also assessed. Scores for the severity of symptoms, according to the decayed/missing/filled teeth (DMF) index, were recorded. Associations between measures of salivary flow and covariates characterizing pathology were examined. Results A definite association between stimulated salivary flow and the MSG focus score, the grade of MSG fibrosis, the duration of dry mouth symptoms, and the DMF score was observed. In contrast, unstimulated salivary flow was not associated with fibrosis, atrophy, the DMF score, or the duration of dry mouth symptoms. In patients with primary SS, the DMF score was associated with pathologic changes in the MSG. Among patients with sicca, 57.9% had an abnormal unstimulated salivary flow rate (versus 82.4% of patients with primary SS), and 15.2% had an abnormal stimulated salivary flow rate (versus 61.8% of patients with primary SS). Among patients with sicca, neither stimulated salivary flow nor unstimulated salivary flow was associated with the degree of fibrosis or atrophy or with the DMF score. Conclusion Compared with unstimulated salivary flow, stimulated salivary flow appeared to be a better measure of inflammation (according to the focus score) and fibrosis. In patients with sicca, the unstimulated salivary flow rate appeared to be abnormal more commonly compared with the stimulated salivary flow rate. In the future, stimulated salivary flow may serve as a noninvasive surrogate biomarker of inflammation and fibrosis as well as a measure of response to treatment in patients with primary SS.

PURPOSE The purpose of this study was to use factor analysis to analyze 90 clinical characteristics of a cohort of 231 patients with primary Sjogren syndrome (pSS). METHODS The records of all patients seen at the University Health Network Sjogren Syndrome Clinic from October 1992 to July 2006 were reviewed and documented. Those diagnosed as pSS by the American European Consensus Criteria of 2002 were included. The 90 clinical variables, including health history, blood analysis, symptoms of dry eye and dry mouth, salivary flow and biopsy, tear flow and staining, were analyzed by factor analysis. RESULTS Two hundred thirty-one patients with pSS charts were reviewed, and 90 variables were recorded. Factor analysis resulted in three factors: factor 1: ocular surface staining, factor 2: antimicrosomal antibodies and antithyroid antibodies, and factor 3: serum anti-Ro and anti-La. CONCLUSIONS Ocular surface staining accounted for the greatest variance in this population of patients with pSS.

Assess vestibular and balance function in meningitis-induced profound sensorineural hearing loss (SNHL).Prospective cohort study.Tertiary pediatric referral center.Nine pediatric participant with profound SNHL after bacterial meningitis with (8) and without (1) unilateral Cochlear implant.Horizontal canal function in response to caloric and high-frequency rotation (0.25-5 Hz). Saccular function assessed by the vestibular evoked myogenic potential. Static and dynamic balance performance on the balance subset of the Bruininsk-Oseretsky Test of Motor Proficiency 2. Labyrinthine ossification on computed tomography preimplant, with follow-up imaging in a subset (n = 7).Horizontal canal function in response to caloric stimulation was abnormal in all children, with 5 of 8 demonstrating bilateral areflexia and 3 of 8 having asymmetric hypofunction with better function on the implanted side. In response to rotation, horizontal canal function was abnormal in all but 1 child (8 of 9). Saccular function, assessed by VEMP, was intact in most of the children (5 of 7). Static and dynamic balance (Bruininsk-Oseretsky Test of Motor Proficiency 2 scores) were significantly poorer in the meningitis group compared with both normal-hearing controls (p0.01) and children with SNHL of variable etiology and Cochlear implant (p0.01). Labyrinthine ossification was present in all cases, with variable extent, location, and progression.Vestibular function and balance are compromised in children with SNHL after meningitis. Whereas vestibular loss seems well compensated at low frequency through an overreliance on visual inputs, deficits surface during high-frequency rotation, particularly in dark. Saccular function seems less susceptible to damage from meningitis. Extent, location, and progression of ossification were variable. Despite profound dysfunction on objective testing, subjective limitations in functional balance were not reported, demonstrating the significant ability of children to compensate for even the most severe vestibular losses.

Objectives/hypothesis Similarities between the peripheral auditory and vestibular systems suggest that children with sensorineural hearing loss (SNHL) may demonstrate vestibular and balance impairments. This hypothesis was studied in 40 children with severe to profound SNHL and unilateral cochlear implants. Study design Prospective cross-sectional study with repeated measures. Methods Vestibular function was assessed with caloric, rotational, and vestibular evoked myogenic potential testing; balance was assessed using the balance subset of the Bruininks-Oseretsky Test of Motor Proficiency-II, a standardized test of static and dynamic balance. Results Horizontal semicircular canal function was abnormal in response to a caloric stimulus in 50% (16/32), with a large proportion of those [6/16 (38%)] reflecting mild to moderate unilateral abnormalities. In comparison, horizontal semicircular canal function in response to rotation was abnormal in 38% (14/37). Saccular function was absent bilaterally in 5/26 (19%) and unilaterally in 5/26 (19%) with vestibular evoked myogenic potential. Age standardized balance abilities were significantly poorer in the study population [micro = 12.9 +/- 5(SD)] compared with normal hearing controls [micro = 17 +/- 5(SD); P = .0006] and correlated best with horizontal canal function in response to a rotational stimulus (P = .004; R = 0.24). SNHL from meningitis was associated with worse balance function than other etiologies. Conclusions Vestibular and balance dysfunction occurred in >1/3 of children with SNHL and cochlear implants, and is highly dependent on etiology. Although compliance with all tests was high, rotational chair testing, which assesses higher frequency motion (0.25-5 Hz) and thus more "real world" vestibular function, correlated best with dynamic balance. For this reason, rotational chair testing may represent the test of choice in this population, particularly given that it is amenable to testing children of all ages.

Seventy-two patients with a unilateral vestibular schwannoma have been treated conservatively for a median of 121 months. They have been followed prospectively by serial clinical examination, MRI scans and audiometry. Twenty-five patients (35%, 95% CI: 24-47) failed conservative management and required active intervention during the study. No factors predictive of tumour growth or failure of conservative management could be identified. Seventy-five per cent of failures occurred in the first half of the 10-year study. The median growth rate for all tumours at 10 years was 1 mm/year (range -0.53-7.84). Cerebellopontine angle tumours grew faster (1.4 mm/year) than intracanalicular tumours (0 mm/year, P < 0.01); 92% had growth rates under 2 mm/year. Hearing deteriorated substantially even in tumours that did not grow, but did so faster in tumours that grew significantly (mean deterioration in pure tone average at 0.5, 1, 2 and 3 kHz was 36 dB; speech discrimination scores deteriorated by 40%). Patients who failed conservative management had clinical outcomes that were not different from those who underwent primary treatment without a period of conservative management.

OBJECTIVE:: To investigate whether transient, high-acceleration interaural head heaves (translational vestibulo-ocular reflex [tVOR]) could aid in the diagnosis of otolith diseases. STUDY DESIGN:: Prospective cohort study. SETTING:: Tertiary referral center. PATIENTS:: Thirteen patients with symptoms suggestive of otolith diseases and 10 age-matched controls. INTERVENTIONS:: Patients underwent a clinical otoneurologic examination and standard laboratory audiovestibular evaluation, including audiometry, electronystagmography with bithermal caloric, Halmagyi-Curthoys head thrust test with search coils, and vestibular-evoked myogenic potential. All subjects underwent subjective visual vertical (SVV) and tVOR testings. MAIN OUTCOME MEASURES:: Sensitivity (ratio of peak eye to peak head velocities) and velocity gain (ratio of actual to ideal peak eye velocities). RESULTS:: Five of 13 patients showed no abnormality in any tests. Of the remaining 8, 3 (38%) had reduced tVOR responses, whereas 1 (13%) had abnormal SVV. Sensitivity and velocity gains were symmetrically reduced in 2 patients, who had symptoms for 8 and 24 months. A third patient, symptomatic for 7 weeks, had asymmetric reduction of tVOR responses and a deviated SVV. CONCLUSION:: Both head heave and SVV tests detect acute, asymmetric otolith diseases. Subjective visual vertical test relies on imbalance of utricular tone and may not detect bilateral symmetric diseases or partial diseases with central compensation. Our preliminary data in a small group of patients show that measuring the tVOR in a higher and more physiologic range of frequencies may serve as useful adjunct to detect acute and chronic otolith dysfunction and seems to be superior to the SVV in detecting bilateral symmetric or asymmetric otolith diseases.

Various topical preparations are widely used for treating external otitis, acute otitis media with perforation, post-tympanostomy tube otorrhea, and chronic suppurative otitis media. Solutions and suspensions that enter the middle ear through a perforated tympanic membrane can reach the inner ear by crossing through the round window membrane. The safety of various components of otic solutions used in this way, particularly aminoglycosides, corticosteroids, solvents, and preservatives, has been questioned in light of their ototoxic potential. The authors' objective is to review the literature discussing the safety of commonly used classes of otic preparations in settings in which the constituents can access the middle and inner ear in high concentrations and discuss their clinical experience with ototoxicity and experience with medical-legal issues.

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.

Objectives: To systematically review the published experience on intratympanic gentamicin treatment for intractable Meniere's disease. Study Design: Meta-analysis using a random effect model. Methods: A comprehensive literature search was performed for articles using intratympanic gentamicin as a sole treatment modality with reporting of results according to the American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) guidelines for Meniere's disease. Two reviewers independently assessed trial quality and extracted data. Results: Fifteen trials with 627 patients met the inclusion criteria. All trials reported “before-after” outcome measures, using patients as their own controls. No double-blind or blinded prospective control trials were identified. Complete (class A) vertigo control was achieved in 74.7% (confidence interval [CI]95% 67.8–81.5%) of patients, and complete or substantial (class B) control was achieved in 92.7% (CI95% 89.5–96.0%). The success rate was not affected by gentamicin treatment regimen (fixed vs. titration). Hearing level and word recognition were not adversely affected, regardless of gentamicin treatment regimen. Analysis of functional level was not performed because of lack of data in the selected articles. Conclusions: Intratympanic gentamicin treatment for intractable Meniere's disease appears to be effective in the relief of vertigo. Cochleotoxicity and ototoxicity is unlikely to be a major side effect. However, the level of evidence reflected from the eligible articles is insufficient, especially because of relatively poor study design. Therefore, it is prudent that patients eligible for this type of treatment should be selected carefully and titrated with low-dose gentamicin. Further investigation with this treatment modality with control subjects is warranted.

Vestibular schwannomas have been traditionally managed with microsurgical removal and in recent years, stereotactic radiotherapy. However, there is a group of patients in whom a conservative management approach might represent a desirable alternative. The aim of this study was to determine the natural history and outcome following the conservative management of 72 patients with unilateral vestibular schwannomas. This is a prospective cohort review of a previously published group of patients [Clin. Otolaryngol. (2000) 25, 28-39] with unilateral vestibular schwannoma that were initially analysed at our institution in 1998 [Walsh R.M., Bath A.P., Bance M.L. et al., Clin. Otolaryngol. (2000) 25, 28]. The mean duration of follow-up was 80 months (range 52-242 months). All the patients in the study underwent serial magnetic resonance imaging (MRI) for assessment of tumour growth. Patients were deemed to have failed conservative management if there was evidence of rapid radiological tumour growth and/or increasing signs and symptoms, which necessitated active intervention. The mean tumour growth rate for the entire group at the second review was 1 mm/year (range -0.84-9.65 mm/year). The mean growth rate for cerebellopontine angle tumours (1.3 mm/year) was significantly greater than that of internal auditory canal (IAC) tumours (0 mm/year) (P = 0.005). The majority of tumours (87.14%) grew

To assess how effectively the American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium (AAO-HNS CHE) guidelines for the diagnosis and evaluation of therapy in Meniere's disease have been applied in the last 11 years of published literature. This was a MedLine-based review. Some 79.7% of papers attempted to use the AAO-HNS CHE guidelines. However, only 50% of these publications managed to use the AAO-HNS CHE criteria in the diagnosis and evaluation of therapy correctly. In order to advance our understanding of this condition, improved application of the AAO-HNS CHE guidelines by authors and editors alike is required in the reporting of results of the therapy of Meniere's disease.