Laura J. Orvidas

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.

Pediatric dermoid cysts of the head and neck

OBJECTIVE: To review the characteristics and determine treatment outcomes of pediatric dermoid cysts. STUDY DESIGN AND SETTING: Retrospective review of the presentation, diagnosis, treatment, and outcomes of all pediatric dermoid cysts of the head and neck examined between 1980 and 2002 at Mayo Clinic. RESULTS: Forty-nine patients (59% girls) had a dermoid cyst of the head and neck. The median age at diagnosis was 22 months. The most common presenting sign was a palpable mass, noted in 100% of patients. During evaluation, approximately 25 patients (51%) had imaging studies. The most common location of the cysts was periorbital (61%), followed by the neck (18%; including 1 submental cyst). Various surgical approaches were chosen. In 2 patients (4%), the dermoid cyst had an intracranial extension. Only 1 patient experienced recurrence. The median pathologic diameter of the cysts was 1.2 cm. CONCLUSIONS: Dermoid cysts are unusual neoplasms that often present in childhood, with the orbit being the area most commonly affected in the head and neck region. Imaging studies help rule out an intracranial or intraorbital extension. With complete excision, recurrence is unusual. SIGNIFICANCE: Our review will assist both primary care physicians and subspecialists in diagnosing and treating dermoid cysts.

Changes in incidence and indications of tonsillectomy and adenotonsillectomy, 1970-2005

Objective: To investigate 35-year epidemiological trends in tonsillectomy and adenotonsillectomy. Study Design/Subjects: Cross-sectional survey. Subjects included all patients from birth to age 29 years who had tonsillectomy or adenotonsillectomy from 1970 to 2005. Results: Study included 8106 patients (median age 8.0 years; range, 6 months to 29 years; male 3646 patients [45%]). Overall tonsillectomy incidence increased from 126 (95% confidence interval [CI], 111-140) per 100,000 person-years in 1970 through 1974 to 153 (95% CI, 139-166) in 2000 through 2005. A dominant factor, adenotonsillectomy incidence rose sharply from 243 (95% CI, 223-261) per 100,000 person-years in 1970 through 1974 to 485 (95% CI, 462-509) in 2000 through 2005. The indication of upper airway obstruction increased from 12 percent of patients in 1970 to 77 percent in 2005. Conclusions: Epidemiological trends in tonsillectomy and adenotonsillectomy have shifted substantially. Overall numbers have increased, and surgical indications have shifted from infection to upper airway obstruction.

Pediatric Lymphangiomas of the Head and Neck

To better define the cause, presentation, diagnosis, and staging of lymphangiomas, we reviewed all cases of lymphangiomas of the head and neck region in children seen at our institution between 1986 and 1996. Sixty-seven children were identified (31 male and 36 female). Age at presentation ranged from birth to 18 years. All but 8 patients presented with an obvious mass, and 5 required tracheotomy because of airway obstruction. The most common location was the submandibular region (37%), followed by the parotid gland (31%). Treatment ranged from observation to extensive and multiple resections. Thirty-one patients underwent only 1 resection, and 2 patients received interferon as part of their treatment. Lesions involving the lip, hypopharynx and/or larynx, the tongue, and the floor of the mouth had high rates of recurrent or persistent disease. We review our experience with these difficult lesions and propose a staging system based on functional deficit, cosmetic changes, sites of involvement, and age at diagnosis.

Pseudotumor of Infancy and Congenital Muscular Torticollis: 170 Cases†

Objectives To review pseudotumor of infancy (POI) and congenital muscular torticollis (CMT) and to suggest an algorithm for treatment.

Late-Onset Laryngomalacia: A Variant of Disease

OBJECTIVE To identify and describe the features of laryngomalacia (LM) in a cohort of older children, with the goal of providing an approach to diagnosis and management of these patients. Laryngomalacia is a common congenital disorder characterized by decreased laryngeal tone, supraglottic collapse, and stridor during inspiration and is rarely seen in older children. However, the presence of LM in this population may be obscured by related but uncommon clinical features. DESIGN Prospective collection and retrospective evaluation of older children with evidence of LM from 1998 to 2005. SETTING Two tertiary pediatric institutions. PATIENTS Prospective data collection of 239 patients with LM, including 222 with congenital LM and 17 diagnosed as having LM when they were older than 2 years and without a medical history of prior disease or symptoms-late-onset LM (mean age at onset, 6.6 years). INTERVENTION Supraglottoplasty. MAIN OUTCOME MEASURE Symptom improvement. RESULTS Patients with late-onset LM were classified into 3 categories according to their symptom complex; those presenting with feeding-disordered LM (n = 7; mean age at onset, 3.3 years), sleep-disordered LM (n = 7; mean age at onset, 6.3 years), and exercise-induced LM (n = 3; mean age at onset, 15 years). Stridor was rarely present except in patients with exercise-induced LM during strenuous activity. Profound arytenoid redundancy and prolapse was discovered in all patients during nasolaryngeal endoscopy. Typical anatomic features of congenital LM (shortened aryepiglottic folds or retroflexed epiglottis) were not discovered. No patient had a history of neuromuscular disease. Supra-arytenoid reduction (supraglottoplasty) led to clinical cure in all patients (mean duration of follow-up, 7.4 months). Prior adenotonsillectomies were performed in 5 patients with sleep-disordered LM. This did not improve symptoms, and these patients displayed evidence of LM as the source of obstruction. CONCLUSIONS Physicians should consider late-onset LM as a potential cause of feeding difficulties in toddlers, sleep apnea in children, and exercise intolerance in teenagers. As in infants with LM, supraglottoplasty improves late-onset disease.

Verrucous carcinoma of the larynx : A review of 53 patients

Verrucous carcinoma of the larynx is a rare laryngeal neoplasm that can be confused with a benign process. Although usually curable at an early stage, it can be locally aggressive if left untreated. We describe our experience with this tumor and make recommendations for diagnosis and treatment.

Management of Eustachian Tube Dysfunction With Nasal Steroid Spray: A Prospective, Randomized, Placebo-Controlled Trial

OBJECTIVE To determine the efficacy of intranasal aqueous triamcinolone acetonide in treating the tympanometric signs and symptoms of eustachian tube dysfunction, such as otitis media with effusion and negative middle ear pressure. DESIGN Randomized, placebo-controlled, double-blind prospective clinical trial. SETTING Tertiary referral clinic. PATIENTS Adults (≥18 years) and children (6-17 years) presenting with otitis media with effusion, negative middle ear pressure, or both. INTERVENTIONS The 2 treatment arms consisted of aqueous triamcinolone or matching placebo administered once daily intranasally for 6 weeks. All subjects underwent tympanometry, otologic examination, and completion of a symptom questionnaire before and after treatment. MAIN OUTCOME MEASURES Resolution of abnormal tympanometry and change in symptom scores (severity and frequency). RESULTS Ninety-one patients presenting from September 1, 2005, through December 31, 2008, with otitis media with effusion or with negative middle ear pressure were enrolled and randomly assigned to treatment or placebo in a double-blind manner. No statistically significant difference in normalization of abnormal tympanometric signs was demonstrated with the active treatment arm compared with placebo on either a per-patient basis (19% vs 32%; P = .18) or a per-ear basis (22% vs 35%; P = .15). There was also no significant difference in the overall poststudy symptom score between the 2 treatment arms, after adjusting for the prestudy overall symptom score in an analysis of covariance model (P = .27). CONCLUSION These findings do not support the use of intranasal steroid sprays to treat the manifestations of eustachian tube dysfunction. Trial Registration clinicaltrials.gov Identifier: NCT00279916.

Quality of life after tonsillectomy in children with recurrent tonsillitis

OBJECTIVE To describe changes in disease-specific and global quality of life (QOL) for children with recurrent or chronic tonsillitis at 6 months and 1 year after tonsillectomy using two validated instruments, the Tonsil and Adenoid Health Status Instrument (TAHSI) and the Child Health Questionaire-PF28 (CHQ-PF28). STUDY DESIGN AND SETTING A multicenter, prospective observational outcomes study. RESULTS Ninety-two children, mean age (SD) 10.6 (3.4) years, enrolled with follow-up available for 58 children at 6 months and 38 children at 1 year. The children showed significant improvements in all subscales of the TAHSI including airway and breathing, infection, health care utilization, cost of care, eating and swallowing (all P < 0.001), and behavior (P = 0.01). Significant improvements were also found on several subscales of the CHQ-PF28, such as general health perceptions, physical functioning, parental impact, and family activities (all P < 0.001). CONCLUSION/SIGNIFICANCE This uncontrolled study provides prospective evidence of improved disease-specific and global QOL in children after tonsillectomy.

ADENOCARCINOMA OF THE NOSE AND PARANASAL SINUSES: A RETROSPECTIVE STUDY OF DIAGNOSIS, HISTOLOGIC CHARACTERISTICS, AND OUTCOMES IN 24 PATIENTS

Adenocarcinomas of the sinonasal cavity are unusual tumors with variable clinical courses.