David M. Barrs

Clinical practice guideline: benign paroxysmal positional vertigo.

Objectives: This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV. Purpose: The primary purposes of this guideline are to improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology–head and neck surgery, physical therapy, and physical medicine and rehabilitation. Results The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV. Disclaimer: This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. ® 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Clinical Practice Guideline: Sudden Hearing Loss

Objective. Sudden hearing loss (SHL) is a frightening symptom that often prompts an urgent or emergent visit to a physician. This guideline provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with SHL. The guideline primarily focuses on sudden sensorineural hearing loss (SSNHL) in adult patients (aged 18 and older). Prompt recognition and management of SSNHL may improve hearing recovery and patient quality of life (QOL). Sudden sensorineural hearing loss affects 5 to 20 per 100,000 population, with about 4000 new cases per year in the United States. This guideline is intended for all clinicians who diagnose or manage adult patients who present with SHL. Purpose. The purpose of this guideline is to provide clinicians with evidence-based recommendations in evaluating patients with SHL, with particular emphasis on managing SSNHL. The panel recognized that patients enter the health care system with SHL as a nonspecific, primary complaint. Therefore, the initial recommendations of the guideline deal with efficiently distinguishing SSNHL from other causes of SHL at the time of presentation. By focusing on opportunities for quality improvement, the guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients. Results. The panel made strong recommendations that clinicians should (1) distinguish sensorineural hearing loss from conductive hearing loss in a patient presenting with SHL; (2) educate patients with idiopathic sudden sensorineural hearing loss (ISSNHL) about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy; and (3) counsel patients with incomplete recovery of hearing about the possible benefits of amplification and hearing-assistive technology and other supportive measures. The panel made recommendations that clinicians should (1) assess patients with presumptive SSNHL for bilateral SHL, recurrent episodes of SHL, or focal neurologic findings; (2) diagnose presumptive ISSNHL if audiometry confirms a 30-dB hearing loss at 3 consecutive frequencies and an underlying condition cannot be identified by history and physical examination; (3) evaluate patients with ISSNHL for retrocochlear pathology by obtaining magnetic resonance imaging, auditory brainstem response, or audiometric follow-up; (4) offer intratympanic steroid perfusion when patients have incomplete recovery from ISSNHL after failure of initial management; and (5) obtain follow-up audiometric evaluation within 6 months of diagnosis for patients with ISSNHL. The panel offered as options that clinicians may offer (1) corticosteroids as initial therapy to patients with ISSNHL and (2) hyperbaric oxygen therapy within 3 months of diagnosis of ISSNHL. The panel made a recommendation against clinicians routinely prescribing antivirals, thrombolytics, vasodilators, vasoactive substances, or antioxidants to patients with ISSNHL. The panel made strong recommendations against clinicians (1) ordering computerized tomography of the head/brain in the initial evaluation of a patient with presumptive SSNHL and (2) obtaining routine laboratory tests in patients with ISSNHL.

Intratympanic Steroid Injections for Intractable Ménière's Disease†

Objective To examine whether intratympanic injection of dexamethasone is effective in controlling vertigo in patients with Ménières disease who have persistent vertigo despite standard medical treatment, including a low‐salt/no‐caffeine diet and diuretics.

Facial nerve trauma: Optimal timing for repair†

Due to the uncertainty of optimal timing for facial nerve repair after severe trauma, a study was designed to investigate facial nerve repair in micro‐pigs by grafting at intervals after nerve transection ranging from 0 to 90 days. Following adequate time for regeneration, it was possible to electrically stimulate across the nerve graft in all animals. No significant difference existed between operative groups for electrophysiologic testing. Axon counts demonstrated a trend toward a lower regeneration rate in more delayed grafts. This trend and the ease of grafting with less scar and nerve stump resection suggest that the best results may be obtained with grafting as early as possible. Grafting at 21 days, the peak of neuron cell‐body metabolic activity, did not produce better results. Since statistically significant differences do not exist between individual groups, grafting several months after trauma can be successful, if medically necessary.

Preliminary ossiculoplasty results using the Kurz titanium prostheses

Objective Limitations in biocompatibility and hearing improvement with ossicular chain reconstruction prostheses are addressed with new, lightweight titanium prostheses designed to maximize visualization of the capitulum and footplate regions. The effectiveness of these new prostheses is being tested in a prospective multicenter study. Study Design Prospective case series. Setting Multicenter (8 sites), primarily tertiary private practice or academic otologic clinics. Patients A convenience sample of 31 patients undergoing ossiculoplasty, with 16 partial ossicular chain reconstructions using the Bell prosthesis and 15 total reconstructions using the Aerial prosthesis. Intervention Ossiculoplasty using new Kurz titanium prostheses. Cartilage was interposed between the tympanic membrane and the prosthesis. Main Outcome Measures Air-bone gap for pure tone average and 3,000 and 4,000 Hz, assessed preoperatively and 3 months, 6 months, and 12 months postoperatively; percent of patients obtaining an air-bone gap of ≤20 dB; high-frequency average (1,000, 2,000, and 4,000 Hz) to evaluate sensorineural hearing loss; and extrusion rate. Results A postoperative air-bone gap of ≤20 dB was obtained in 81% of Bell prosthesis patients and 67% of Aerial prosthesis patients at 3 months. The results were stable to improved for later time intervals. High-frequency gaps were similar to the pure tone average gap. To date, there have been no instances of extrusion, and all the surgeons found the prostheses easy to use and thought that the design characteristics facilitated accurate placement. Conclusions Initial evaluation of the Kurz titanium prostheses produced low extrusion rates (none to date) with excellent hearing results, including good high-frequency conduction. Good visualization and accurate placement were easy to achieve. Further studies are needed to confirm long-term efficacy.

Hearing aids : A review of what's new

OBJECTIVE: To review the recent innovations in hearing aid technology. STUDY DESIGN: Review of the literature. SETTING: Private tertiary referral otology/neurotology practice. RESULTS: Recent innovations including digital signal processing (DSP), directional microphone technology, and open mold hearing aid fitting have resulted in improved satisfaction with current hearing aids. CONCLUSION: Current hearing aid technology with its innovations better meet needs of individuals who are hard of hearing. SIGNIFICANCE: The image commonly held of hearing aids by the general public is a negative one that can be improved with greater education.

Intratympanic Injections of Dexamethasone for Long-Term Control of Vertigo†

Objective: To examine whether intratympanic injection of dexamethasone is effective in long‐term control of vertigo for patients with Ménière disease whose dietary and diuretic therapy has proved unsuccessful.

Metastatic tumors to the sphenoid sinus.

Patients with cranial nerve palsies and roentgenographic evidence of sphenoid sinus destruction present diagnostic problems. Although the presence of local primary neoplasms may be considered first, metastatic disease from distant sites also should be considered.

Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic.

Background:Many patients consult neurologists because of vertigo. Benign paroxysmal positional vertigo (BBPV) is one of the most common types of vertigo. Although the clinical presentation of this common condition is straightforward, the diagnosis and diagnostic maneuvers can be challenging. Objectives:How useful is the Dix-Hallpike test in establishing the diagnosis of BPPV? How useful is an alternative positional test, such as the side-lying maneuver, in the diagnosis of BPPV? Methods:We addressed the question through development of a structured critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarian, and clinical content expert in the field of otolaryngology. Participants started with a clinical scenario and structured questions, devised search strategies, located and compiled the best evidence, performed critical appraisals, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. Results:A single study comparing the Dix-Hallpike and side-lying tests was identified. For the Dix-Hallpike test, the estimated sensitivity was 79% [95% confidence interval (CI) 65–94], specificity was 75% (33–100), positive likelihood ratio (LR) was 3.17 (95% CI 0.58–17.50), negative LR was 0.28 (95% CI 0.11–0.69). For the side-lying test, the estimated sensitivity was 90% (95% CI 79–100), specificity was 75% (33–100), positive LR was 3.59 (95% CI 0.65–19.67), negative LR was 0.14 (95% CI 0.04–0.46). The study employed very weak methodology, and therefore the results had limited validity. Conclusions:The Dix-Hallpike test is the standard from which the diagnosis of posterior semicircular canal BPPV is made. Hence evaluations of its diagnostic test properties and utility are challenging. For patients unable to move into the Dix-Hallpike test positions, alternative tests such as the side-lying test can be attempted. These modifications, however, are rarely necessary.

Assessing recovery of facial function following acoustic neuroma surgery.

Assessing preservation of facial nerve function in acoustic neuroma surgery has been difficult because there has been no standard means of reporting. A patient questionnaire and grading system are presented which assess the degree of facial nerve recovery quite accurately. It is proposed that this questionnaire be used as a standard method for reporting facial nerve function postoperatively. This questionnaire was used with a series of patients to assess their recovery following acoustic neuroma surgery. At 1 year, 64% of patients reported normal facial function and another 15% reported good return of facial function. Only 2% reported complete facial paralysis.