Farhoud Faraji

Evaluation of the efficacy of caffeine cessation, nortriptyline, and topiramate therapy in vestibular migraine and complex dizziness of unknown etiology

OBJECTIVE The aim of this study was to evaluate the efficacy of a therapeutic pathway for vestibular migraine (VM) and complex dizziness of undetermined etiology (CDUE) with caffeine cessation and pharmacotherapy. STUDY DESIGN This study is a retrospective chart review. INTERVENTION(S) Patients were recommended to stop intake of caffeine and other putative migraine-triggering agents. Pharmacotherapy was initiated with nortriptyline or topiramate if symptoms persisted despite diet modification. MAIN OUTCOME MEASURE Self-reported dizziness is the main outcome measure. RESULTS Vestibular migraine and CDUE were considered contributing factors to dizziness in 34 and 10, respectively, of 156 patients. Fourteen percent of patients reported improvement in symptoms upon caffeine cessation, whereas 46% of patients reported a reduction in dizziness after nortriptyline therapy (P = .007). Topiramate reduced symptoms in 25% of patients. In total, 75% of VM patients and 56% of patients with CDUE received sufficient benefit from this therapeutic pathway to not progress to other treatments. CONCLUSIONS Vestibular migraine and CDUE can be treated effectively with a therapeutic pathway consisting of caffeine cessation followed by pharmacotherapy.

The comparative usefulness of orthostatic testing and tilt table testing in the evaluation of autonomic-associated dizziness.

Objective: To elucidate the usefulness of clinical orthostatic blood pressure testing (COBP) as a screening tool for autonomic dysfunction. Study Design: In this retrospective case review, the records of 156 consecutive patients with nonotologic dizziness as the primary complaint seen in an academic neurotology clinic between 2005 and 2009 were reviewed. The objective of this study was accomplished by comparing the diagnostic yield of COBP with that of head-upright tilt table testing (HUT) and assessing the sensitivity and specificity of COBP in predicting an abnormal HUT in patients with nonotologic dizziness. Setting: Ambulatory tertiary referral center. Patients: Patients presenting to the clinic with dizziness without otologic cause. Intervention(s): Clinical evaluation, orthostatic blood pressure testing, and HUT. Main Outcome Measure(s): The primary outcome assessed in this study was patient blood pressure. Blood pressures were measured in the clinic in the following order: supine, sitting, and standing. Positive COBP was defined as a reduction in systolic or diastolic blood pressure greater than 20 or 10 mm Hg, respectively, or both, within 3 minutes of sitting from supine or standing from sitting. For comparison, HUT was used as the gold standard. A positive HUT was defined as a reduction in systolic or diastolic blood pressure greater than 20 or 10 mm Hg, respectively, or both, relative to baseline at any point after initiation of HUT. Results: Forty patients were referred for HUT. Twenty-four (61.5%) of these patients were deemed to have a positive response. Thirty-three patients (85%) referred to HUT were initially evaluated with COBP, which revealed orthostatic hypotension (OH) in 8 patients (24%). COBP was calculated to have sensitivity and specificity of 21% and 71%, respectively, when asymptomatic OH was included in the positivity criteria. When asymptomatic OH was excluded from the positivity criteria, the sensitivity and specificity remained similar at 25% and 76%, respectively. However, the exclusion of asymptomatic OH from the positivity criteria resulted in a decrease in the positive predictive value from 50% to 25% and an increase in the negative predictive value from 40% to 76%. Overall, HUT detected 16 patients with an abnormal result that were missed by COBP testing. Conclusion: Evaluation for autonomic dysfunction should be part of the comprehensive evaluation of a dizzy patient, involving, at a minimum, orthostatic testing of blood pressure and heart rate. Patients with nonotologic dizziness and light-headedness with a normal neurotologic evaluation can reasonably be referred for HUT, even in the presence of normal in-office orthostatic testing.

Intratympanic Triamcinolone and Dexamethasone in the Treatment of Ménière's Syndrome.

OBJECTIVE To describe the safety and potential efficacy of intratympanic administration of triamcinolone (40 mg/mL) in the treatment of unilateral Ménières syndrome. STUDY DESIGN Single-institution retrospective analysis. SETTING Tertiary referral neurotology clinic. PATIENTS Eighteen patients diagnosed with unilateral Ménières syndrome with vertigo refractory to medical management. INTERVENTION(S) Intratympanic injection of triamcinolone or dexamethasone. OUTCOME MEASURE(S) Kaplan-Meier analysis was implemented to determine the rate of successful vertigo control. Responders were defined as patients who achieved sufficient vertigo control to decline ablative therapy. Nonresponders were defined as those who did not achieve satisfactory vertigo control and required ablative or surgical therapy. Pre- and posttreatment audiogram data was used to evaluate changes in hearing. Patient follow-up data was assessed for complications potentially resulting from intratympanic therapy. RESULTS No patient experienced profound hearing loss or other serious adverse events as a result of intratympanic triamcinolone therapy. Tympanic membrane perforation occurred in three (18%) patients, all of whom had received three or more previous intratympanic injections. Satisfactory vertigo control with intratympanic triamcinolone therapy was achieved in 14 (78%) of 18 subjects. CONCLUSION Our results suggest that intratympanic triamcinolone therapy on an as-needed basis is a safe and potentially effective procedure for vertigo control in patients with Ménières syndrome. These findings warrant the implementation of prospective, controlled trials to investigate its safety and efficacy further.

Autoimmune-Related Nasal Septum Perforation: A Case Report and Systematic Review

Background Inflammatory injury of nasal respiratory mucosa is a common feature of multisystem autoimmune disease. Certain autoimmune disorders are associated with nasal septum perforation (NSP). We performed a systematic review of the literature to better understand the association of NSP with specific autoimmune disorders. This is a case report of a 29-year-old woman with a history of arthralgia, autoreactive antibody titers, platelet dysfunction, and NSP. The constellation of symptoms and potential familial involvement indicated that the NSP in this patient was an early sign of an autoimmune disorder, an unknown autoimmune disorder, or a known disease with incomplete penetrance. Methods A systematic review of the literature was performed by two independent reviewers. Relevant articles were reviewed, and data that pertained to autoimmune-related NSP were extracted and analyzed. Results Overall, 140 cases of autoimmune-associated NSPs were reported. Granulomatosis with polyangiitis (48%), relapsing polychondritis (26%), and cocaine-induced midline lesions (15%) constituted 89.3% of the reported cases. Conclusion NSP is a potential sign of systemic disease. The identification of an NSP, especially in the context of other unexplained symptoms or workup suggestive of an autoimmune disorder, should prompt clinical evaluation for multisystem autoimmune disease with consideration of granulomatosis with polyangiitis, relapsing polychondritis, or cocaine-induced midline lesions.

Oropharyngeal cancer is no longer a disease of younger patients and the prognostic advantage of Human Papillomavirus is attenuated among older patients: Analysis of the National Cancer Database

OBJECTIVES HPV-positive oropharyngeal cancer (OPC) patients have been observed to be younger than patients with HPV-negative OPC at diagnosis. We evaluated recent trends in age at OPC diagnosis, and whether older age attenuates the survival benefit of HPV-positive tumor status. MATERIALS AND METHODS Patients diagnosed with OPC from 2004 to 2014 represented in the National Cancer Database were included. HPV tumor status was available after 2010. Trends in age by calendar year were compared using linear regression. Overall survival was compared using Cox Proportional Hazards models. RESULTS The mean age of OPC patients (N = 119,611) increased significantly from 2004 to 2014 (ß = 0.21 years of age per calendar year, 95% confidence interval [CI] = 0.19-0.23). The increase in age from 2010 to 2014 was similar for HPV-positive (N = 21,880; ß = 0.63, 95%CI = 0.53-0.72) and HPV-negative (N = 11,504; ß = 0.59, 95%CI = 0.45-0.74) patients. Between 2010 and 2014, the proportion of OPCs that were HPV-positive increased significantly for all age groups, including for patients ≥70 years old (from 45% to 60%, ptrend < 0.001). Although patients ≥70 years with HPV-OPC had improved survival compared to those with HPV-negative OPC (adjusted hazard ratio [aHR] = 0.65, 95%CI = 0.55-0.76), the survival benefit of HPV-positive tumor status was significantly attenuated compared to younger HPV-OPC patients (50-59 years: aHR = 0.45, 95%CI = 0.39-0.51; pinteraction < 0.001). CONCLUSION The age at OPC diagnosis is increasing for both HPV-positive and HPV-negative patients, and a rising proportion of older patients have HPV-positive tumors. These findings dispel the notion that HPV-positive OPC is a disease of younger patients, identify a growing elderly population of HPV-positive OPC patients with reduced survival, and have implications for evolving treatment paradigms.

Human Papillomavirus and Head and Neck Cancer

Human papillomavirus (HPV) is a common sexually transmitted pathogen and the primary infectious cause of HPV-related oropharyngeal carcinoma (HPV-OPC). HPV-OPC is distinct in its pathophysiology, epidemiology, and clinical course from HPV-negative head and neck squamous cell carcinoma (HNSCC). The incidence of HPV-OPC has steadily grown over the past several decades. This rise has been attributed to sexual behaviors that increase exposure to HPV. While intensive investigation is clarifying the risk factors and treatment strategies for HPV-OPC, the natural history of carcinogenic HPV infection in HNSCC remains incompletely understood. This chapter provides an overview of carcinogenic HPV infection and the epidemiology of oral HPV infection.

Stereotactic radiotherapy in three weekly fractions for the management of vestibular schwannomas

PURPOSE This study evaluates the rates of tumor control, hearing preservation and cranial nerve toxicity with the use of CyberKnife stereotactic radiotherapy consisting of 2100 cGy to the 80% isodose line delivered in three weekly fractions to treat vestibular schwannomas. MATERIALS AND METHODS Retrospective chart review of vestibular schwannoma patients treated with CyberKnife stereotactic radiotherapy or undergoing watchful waiting between 2006 and 2017 was performed. For inclusion, patients receiving CyberKnife stereotactic radiotherapy must have had pretreatment magnetic resonance imaging and audiography, and 2 follow-up magnetic resonance imaging and audiograms. Watchful waiting patients must have had a minimum of 2 magnetic resonance imaging and 2 audiograms. RESULTS Forty patients met inclusion criteria. Twenty-two underwent CyberKnife stereotactic radiotherapy. Eighteen remain in watchful waiting. Crude tumor control was 86.4% at mean radiographic follow-up of 52.3 months. Kaplan-Meier progression-free survival was 76.9% at 5 years. Kaplan-Meier survival from radiographic growth was 61.5% at 5 years. Kaplan-Meier hearing preservation was 17.5% at 5 years. All patients undergoing watchful waiting presenting with serviceable hearing maintained serviceable hearing. Serviceable hearing among CyberKnife stereotactic radiotherapy patients was 42.9% prior to treatment and 14.2% through mean follow-up of 53.7 months. One patient experienced trigeminal nerve toxicity 45 months after SRT. 95.5% of CyberKnife stereotactic radiotherapy patients were complication-free. CONCLUSIONS Our fractionation regimen provides tumor control consistent with current literature. Hearing outcomes, however, should be discussed with patients prior to CyberKnife stereotactic radiotherapy.

Diagnostic dilemmas of mechanical restriction of the medial rectus: A case report

Background Due to the proximity of the maxillary sinus and ethmoid sinuses to the orbit, inflammatory processes that originate in the sinonasal region have the potential to extend into the orbit. Objective We presented a case of ptosis and restrictive strabismus of the medial rectus muscle. Methods A case report with a literature review of possible diagnoses. Results Biopsy, imaging, and laboratory evaluation by otolaryngology, ophthalmology, and rheumatology services were unable to identify the cause of the fibrosis after 22 months of follow-up. A response to oral steroids indicated an inflammatory process. Conclusion Unilateral mechanical restriction of the medial rectus muscle is a rare complication of nasal disease. Inflammatory processes and iatrogenic injury are known to cause fibrosis of surrounding tissue. We presented a unique case of medial rectus fibrosis that did not meet the diagnostic criteria of recognized etiologies.

Isolated craniopharyngioma in the nasal cavity

Abstract We describe the occurrence of a papillary squamous infrasellar craniopharyngioma isolated to the nasal cavity and maxillary sinus in a 48-year-old male presenting with epistaxis and nasal obstruction. Diagnosis was made by histological analysis of incisional biopsy in clinic. Computed tomography and magnetic resonance imaging were performed to evaluate the extent of tumor involvement. The tumor was excised by endoscopic surgery in the operating room with intraoperative frozen section analysis to confirm clear margins. The patient had an uncomplicated post-operative course and no evidence of tumor recurrence at eight months follow-up. This represents the third confirmed case of infrasellar craniopharyngioma isolated to the nasal cavity.

Endoscopic orbital exenteration in the treatment of acute invasive fungal sinusitis

Abstract Acute invasive fungal sinusitis is a rare disease with a severe and rapidly devastating course. In this report, we describe a case of Rhizopus spp. mucormycosis invading the paranasal sinuses and causing vision loss and confusion. After being biopsied and diagnosed at an outside hospital, the patient was transferred and emergently treated with antifungal therapy and surgical resection by transnasal endoscopic surgery.