Daniel Hajioff

MEDICAL STUDENTS IN ENT OUTPATIENT CLINICS : APPOINTMENT TIMES, PATIENT SATISFACTION AND STUDENT SATISFACTION

Outpatient clinics are increasingly important in medical education. The effect of students on clinic times and patient satisfaction, as well as their own satisfaction, were studied.

Pre-operative imaging for cochlear implantation: magnetic resonance imaging, computed tomography, or both?

Abstract Objective Previous studies of computed tomography (CT) and magnetic resonance imaging (MRI) before cochlear implantation have been of limited sample size, lacked statistical analysis, and been inconsistent in their conclusions. We aim to quantify the utility of CT, MRI, and their combination in order to rationalize their selection. Methods Clinical records and radiological findings were correlated retrospectively in 158 adults and children. All underwent both CT and MRI. Results A total of 27.9% (95% confidence interval (CI): 21.0–35.5) of patients had a significant radiological abnormality, but these were considered critical to subsequent management in only 12.7% (7.9–18.9). All these were detected by MRI. They were missed by CT in 6.3% (3.1–11.3). In all, 6.3% also had non-critical abnormalities that were reported only on CT. Cochlear dysmorphisms were more common in children but the overall frequency of abnormalities and their detection rates did not depend on age. Omitting CT and using MRI alone are estimated to miss no critical abnormalities (95% CI: 0–2.3 %). Conclusions While CT may be better at defining some abnormalities, MRI appears to be able to detect all abnormalities that are critical to patient management. Most candidates for cochlear implantation can therefore be assessed by MRI initially. CT is most likely to be helpful in those with a history of severe middle ear disease, meningitis, or dysmorphic syndromes, who should undergo both CT and MRI.

The Role of Vestibular Caloric Tests in Cochlear Implantation

Objective Vestibular function tests are often undertaken before cochlear implantation, in part to help select the side of surgery. The authors aim to determine whether implantation on the side of better vestibular function leads to greater perception of dizziness by patients than implantation on the side of worse or similar function. Study Design Historical cohort study. Setting Tertiary cochlear implantation center. Subjects and Methods The records of 177 adult recipients of a unilateral cochlear implant were reviewed retrospectively in 2 groups. Group A included patients with an implant in the ear with worse or similar caloric responses. Group B included patients with an implant in the ear with the stronger caloric response. All patients underwent preoperative bithermal caloric testing: a clinically significant difference was defined by a 20% lateral canal paresis. They were assessed postoperatively by the Dizziness Handicap Inventory and supplementary questions. Results Fifty-seven percent of both groups reported dizziness in the first 7 days postoperatively. At 2 months, 20% of group A and 34% of group B experienced some dizziness. Fourteen percent of group A and 10% of group B felt that cochlear implantation had resulted in impaired balance. The Dizziness Handicap Inventory scores of 86% of group A (median score 0) and 76% of group B (median score 10) corresponded with low handicap. None of these results differed significantly between groups A and B. Conclusion Although cochlear implantation may result in dizziness, it is almost always short-lived and mild, even when the ear with the stronger caloric response is implanted.

Smartphone speech-to-text applications for communication with profoundly deaf patients

OBJECTIVE Visual communication aids, such as handwriting or typing, are often used to communicate with deaf patients in the clinic. This study aimed to establish the feasibility of communicating through smartphone speech recognition software compared with writing or typing. METHOD Thirty doctors and medical students were timed writing, typing and dictating a standard set of six sentences appropriate for a post-operative consultation, and the results were assessed for accuracy and legibility. RESULTS The mean time for smartphone dictation (17.8 seconds, 95 per cent confidence interval = 17.0-18.7) was significantly faster than writing (59.2 seconds, 95 per cent confidence interval = 56.6-61.7) or typing (44 seconds, 95 per cent confidence interval = 41.0-47.1) (p < 0.001). Speech recognition was slightly less accurate, but accuracy increased with time spent dictating. CONCLUSION Smartphone dictation is a feasible alternative to typing and handwriting. Slow speech may improve accuracy. Early clinical experience has been promising.

The clinical utility of search coil horizontal vestibulo-ocular reflex testing

Conclusion. Testing of the horizontal vestibulo-ocular reflex (VOR) with head rotations (including head impulses) using the magnetic scleral search coil technique (SCT HHI) provides valuable additional diagnostic information in patients with persistent dizziness, oscillopsia or imbalance. It identifies high and low frequency/acceleration vestibular abnormalities that are frequently missed using other methods. Objectives. To evaluate the diagnostic utility of SCT measurement of the horizontal VOR in the multidisciplinary neurotology clinic of a tertiary referral centre. Patients and methods. The records of 127 consecutive patients referred for persistent dizziness, oscillopsia, imbalance, or with clinical findings suggestive of high frequency/acceleration vestibular dysfunction were reviewed. All had been tested with clinical head impulses, bithermal calorics and vestibular-evoked myogenic potentials. VOR gain (peak eye velocity/peak head velocity) had been measured both in response to sinusoidal oscillations in a rotating chair (0.1–11Hz) and to manually delivered horizontal head rotations (peak head velocities 50–500°/s) using SCT. Results. Agreement between the different test modalities of horizontal semicircular canal function was moderate. Relative to SCT HHI, clinical HHI showed the highest sensitivity and the lowest specificity (both 70%). SCT HHI appeared to have the greatest diagnostic yield, when compared with calorics and SCT ROT (23% of all abnormalities shown were detected only by SCT HHI) and also allowed detection of significant asymmetries in patients with bilateral vestibular dysfunction.

The role of post-operative imaging in cochlear implant surgery: A review of 220 adult cases

Abstract Objectives To determine the incidence of abnormal radiological findings after cochlear implantation and their effect on clinical outcomes. Methods Retrospective review of 220 adult cochlear implants. Clinical records and post-operative plain X-rays were reviewed and compared with pre-operative and 6-month post-operative City University of New York (CUNY) speech scores. Results There were no cases of extra-cochlear array misplacement. Imaging showed 20 cases of incomplete array insertion (9.2%), 3 cases of kinking of the array (1.4%), 2 cases of tip rollover (0.9%), and 1 case of apparent array fracture (0.5%). Patient management was not altered by abnormal imaging. Patients with abnormal radiological findings had slightly minor improvements (median 39 vs. 56%) in City University of New York (CUNY) speech discrimination scores at 6 months (Mann–Whitney U test, P = 0.043). Conclusion All abnormalities on post-operative imaging were minor and did not alter patient management. The future role of post-operative imaging is discussed.

Ear pain and facial palsy

An 84 year old woman presented to our ear, nose, and throat emergency clinic with a seven week history of right sided earache and hearing loss. She had received treatment in the community, including aural microsuction, oral penicillin, and metronidazole. Despite this treatment her symptoms were worsening and the pain was now severe. During the previous day she had developed a right sided facial weakness. Her medical history included well controlled hypertension, glaucoma, and hypercholesterolaemia. On clinical examination, she had a partial right facial nerve palsy with incomplete eye closure; her forehead muscles were also affected. Neurological examination was otherwise normal. She was afebrile and systemically well. The right ear canal was inflamed with granulation tissue and debris along its floor. After microsuction of debris, the tympanic membrane appeared normal. Blood tests showed a raised C reactive protein and a white blood cell count at the upper end of the normal range. Computed tomography of the temporal bones showed opacification of the right mastoid air cells but no bony erosion or evidence of intracranial infection. ### 1 What is the diagnosis? #### Short answer Necrotising (malignant) otitis externa. #### Long answer Necrotising otitis externa is erosive infection of the external ear canal and temporal bone, as shown in this patient by opacification of the right mastoid air cells (figure⇓). It is also referred to as malignant otitis externa because of its aggressive and potentially fatal course, although this term is misleading because the condition is not cancerous.1 Deaths are caused by osteomyelitis and periostitis of the external auditory meatus, which can spread along the …

Pack or No Pack after Ear Surgery: A Randomized Controlled Trial

Objective: 1) To see if there is a difference in patient and clinician reported outcomes between patients randomized to postoperative ear packing, compared to those who did not have the ear packed after middle ear surgery. 2) To see if there is a also a difference in hearing outcome between both groups. Method: Randomized controlled trial of adult patients to have either Bismuth Iodoform Paraffin Paste pack or no ear pack postoperatively after primary canal wall up middle ear surgery. Setting: tertiary teaching hospital, UK (2011). Outcome measures: clinicians/patients recorded visual analogue scale scores at 3 weeks and 3 months postoperatively. Audiometry was recorded at 3 months. Results: Thirty-two patients of similar sex and age were randomized to the 2 treatment arms. There was no statistically significant inter-group difference in 3-week composite clinician and patients mean visual analogue scores (146 mm versus 184 mm [P = .3]). The graft take rates and the appearance of the ear canals at 3 months were similar in both groups (P = 1.0 for both outcomes). There was also no significant inter-group difference in the change in mean air conduction thresholds in response to surgery (11.3 dB and 3.5 dB) in the ear pack and no pack groups, respectively (P = .08). Conclusion: No differences in total patient symptoms and clinician findings or hearing were demonstrated between patients with a postoperative pack compared to those without a postoperative pack following middle ear surgery. This pilot study provides justification for a larger clinical trial to investigate the need for postoperative ear canal packing.

A Comparison of the Clinical Value of Computerised Tomography Versus Magnetic Resonance Imaging in Cochlear Implantation Candidates

METHODS: Three-dimensional (3-D) images of membranous labyrinth were reconstructed from 31 normal temporal bones, 6 temporal bones from 3 patients with bilateral Ménière’s, 16 temporal bones from 8 patients with unilateral Ménière’s. Volumes of each part of membranous labyrinth were measured in each temporal bone group after 3-D reconstruction. RESULTS: The mean volumes and normal volume-limits of the cochlear duct, saccule, and utricle were 7.67 and 9.77, 2.42 and 3.68, and 10.65 and 16.45 mm3, respectively. All 3 patients with bilateral Ménière’s disease showed endolymphatic hydrops in both sides of ear. Of 8 patients with unilateral Ménière’s disease, 5 had no symptom in the contralateral ear, whereas 3 had histories of progression from unilateral to bilateral Ménière’s disease. All diseased (8 ears) and all symptomatic contralateral sides (3 ears) showed endolymphatic hydrops. In contrast, no hydrops was observed in any part of membranous labyrinth in the contralateral ears (5 ears). CONCLUSIONS: Our findings suggest that endolymphatic hydrops contribute to the onset of symptoms in the patients with Ménière’s disease. In addition, the volume data obtained from this study could be useful for the assessment of hydrops in the diagnostic imaging of the inner ear of Ménière’s disease.

Otological Trauma Resulting from the Soho Nail Bomb in London, April 1999

We report the otological effects of the April 1999 Soho Nail Bomb on 17 patients. Twenty-one (62%) tympanic membranes were perforated (pars tensa only); 78% closed spontaneously within 6 months. The mean size of the perforation in the tympanic membrane nearer to the blast was significantly larger than the opposite side [33% +/- 8.3 (mean +/- SD) and 13% +/- 4.1 respectively; P = 0.02]. All patients reported hearing losses that were mixed conductive and sensorineural but mainly high-frequency sensorineural (4, 6 and 8 kHz, pure tone average 42.3 dB +/- 20.5). The sensorineural hearing loss correlated inversely with the distance from the explosion but not with the size of perforation. There was no significant difference in the hearing loss between the ear facing the blast and the opposite ear. Fifteen patients (88%) had temporary tinnitus. No patient complained of any vestibular symptoms. The otological effects of a nail bomb in an enclosed space have not been previously reported. Furthermore, an inverse correlation between hearing loss and distance from the explosion and a significant difference in perforation size facing the blast, compared with the opposite side, are also presented for the first time. The high spontaneous closure rate of perforations and minimal ongoing disability from sensorineural losses favour conservative management in most cases.