David D. Pothier

Introducing Endoscopic Ear Surgery into Practice

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.

Endoscopic Management of Chronic Otitis Media and Tympanoplasty

The endoscope allows for better inspection for cholesteatoma in cases with chronic otitis media, better access to selective epitympanic poor ventilation and secondary selective chronic otitis media, better visualization of anterior poor ventilation of the mesotympanum (reestablishing adequate ventilation to the mesotympanum), better visualization and reconstruction of anterior tympanic membrane perforations, allows use of Sheehys lateral graft tympanoplasty through a transcanal approach, and increases the odds of preoperative detection of ossicular chain disruption associated with perforations.

Intraoperative Cone-Beam Computed Tomography and Multi-Slice Computed Tomography in Temporal Bone Imaging for Surgical Treatment

Objective 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. Study Design Cross-sectional study. Setting University tertiary care facility. Subjects and Methods 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. Results 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. Conclusion 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.

Double impairment: clinical identification of 33 cases of cerebellar ataxia with bilateral vestibulopathy.

Objective. Following recently described small series of patients with the syndrome of cerebellar ataxia with bilateral vestibulopathy (CABV), the authors undertook a careful clinical and laboratory assessment of patients who presented to their unit with characteristics of this syndrome. Study Design. Case note review. Setting. Tertiary, university-based, multidisciplinary neurootology clinic. Subjects. Thirty-three patients whose characteristics fit this syndrome. Methods. Patients presenting to the Multidisciplinary Neurotology Clinic with characteristics of CABV were entered into a bespoke database. This was analyzed to identify the clinical findings and results of vestibular investigations for this group. Results. Patients presented at a mean age of 54 years (SD, 17.6) with symptoms having been present for a median of 3 years (interquartile ratio, 2.0-9.5). Caloric testing greatly underestimated the disorder, being subnormal in only 18% of patients; the head-thrust test was abnormal and dynamic visual acuity testing was abnormal 88% and 91% of the time, respectively. Of the patients, 76% demonstrated gaze-evoked nystagmus. Impaired smooth pursuit (97% of patients showed low gain with saccadic corrections) and impaired cancellation of the vestibulo-ocular reflex (in 97% of patients) were found. Impaired saccular otolithic function was abnormal in 33%, adding to patient imbalance. Conclusion. The unique double-pathway balance impairment in CABV patients causes a high prevalence of subnormal function of both central and peripheral vestibular function. This is an easily missed clinical entity that is often associated with normal caloric investigations. As many patients with this syndrome are poor candidates for vestibular rehabilitation therapy, resources are better devoted to the early implementation of assistance with their safe ambulation and activities of daily living.

Ménière's Syndrome or Disease: Time Trends in Management and Quality of Evidence Over the Last Two Decades.

Objective 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. Data Sources 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. Study Selection and Data Extraction 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. Results 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. Conclusion 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 Use of Real-Time Image Stabilization and Augmented Reality Eyewear in the Treatment of Oscillopsia

Objectives/Hypothesis. The symptom of oscillopsia in patients with bilateral vestibular loss (BVL) can be reduced as dynamic visual acuity (DVA), the reduction in visual acuity during head movement, is improved by using real-time image stabilization, delivered by augmented reality eyewear. Setting. Tertiary multidisciplinary neurotology clinic. Study Design. Prospective experimental study. Methods. Immersive virtual reality glasses used in combination with a compact digital video camera were used. A software algorithm was developed that used a center-weighted Lucas-Kanade optical flow method to stabilize video in real time. Six patients with BVL were tested for changes in DVA using the eyewear. The ability to read a Snellen chart during a 2-Hz oscillating head rotation DVA test was measured. Results. For combined scores of vertical and horizontal head rotations, the mean number of lines readable at rest was 7.86, which dropped to 2.77 with head movement (a combination of vertical and horizontal perturbations). This increased to a mean of 6.14 lines with the image stabilization software being activated. This difference was statistically significant (P < .001). Conclusion. This is the first successful attempt to improve dynamic visual acuity in patients with bilateral vestibular loss. Recent hardware upgrades are promising in improving these results even further.

Time trend analysis of mastoidectomy procedures performed in Ontario, 1987-2007.

Abstract Conclusions: 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. Objective: 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. Methods: 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. Results: 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.

The Sadé and Tos staging systems: not adequately reliable methods of staging retraction of the tympanic membrane?

have an impact on SNOT22 scores. Racial differences have been studied extensively in quality of life surveys and many other disease groups. A recent publication comparing health-related quality of life amongst the minority populations in the United States found that after adjusting for confounders, certain races ⁄ ethnic groups were more or less likely to report physical distress and mental distress than Whites. Such racial differences are likely to be present in patients with chronic rhinosinusitis and nasal polyposis as well. To date, there has been no publication on this. Further analysis of data from the National Audit may therefore reveal interesting differences between racial groups, smokers and non-smokers, and alcoholic drinkers, in SNOT22 scores. It may show that some races do indeed have more SNOT than others.

The behaviour of residual tumour after the intentional incomplete excision of a vestibular schwannoma: is it such a bad thing to leave some behind?

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.

The behavior of mastoidectomy cavities following modified radical mastoidectomy

An analysis of the frequency and intensity of postoperative aftercare required for modified radical mastoidectomy (MRM) and patterns of healing in the postoperative period.