M. Jennifer Derebery

Techniques of intranasal steroid use.

OBJECTIVE: The effectiveness of topical intranasal steroids (INS) sprays for the treatment of allergic and nonallergic rhinitis may be limited by lack of instruction in the optimal spray technique. To determine whether the technique used affects the efficacy and safety of the product, this review of evidence had the goal of identifying and establishing a preferred method of applying INS sprays. STUDY DESIGN: A MEDLINE search of pertinent literature on 7 INS and 1 intranasal antihistamine spray preparations conducted with the use of appropriate search terms, yielded an initial 121 articles, 29 of which were identified as appropriate for review and grading for quality of evidence. RESULTS: The analysis provided no definitive evidence regarding how best to instruct patients to use INS or antihistamine spray devices. CONCLUSIONS: On the basis of a lack of clear evidence regarding instructions to maximize efficacy and safety of these drugs, the panel recommended a 7-step standard technique. (Otolaryngol Head Neck Surg 2004;130:5–24.)

Psychometric validation of the rhinitis control assessment test: a brief patient-completed instrument for evaluating rhinitis symptom control.

BACKGROUND Allergic rhinitis is common, but a validated tool for comprehensive assessment of disease control is not available. OBJECTIVE To develop a simple patient-completed instrument (the Rhinitis Control Assessment Test [RCAT]) to help detect problems with control of rhinitis symptoms. METHODS During a visit to an allergy specialist, 410 patients with allergic rhinitis completed a Total Nasal Symptom Score (TNSS) assessment and the 26-item developmental RCAT. Physicians also completed a global assessment of rhinitis symptom control for each patient. RESULTS Stepwise regression methods identified 6 items from the developmental RCAT (frequency of nasal congestion, sneezing, and watery eyes; sleep interference; activity avoidance; and self-assessed control) that were most predictive of the allergists global rating of rhinitis symptom control. A summated rating scale from these 6 items showed good convergent validity (r > 0.70) with scale scores from the TNSS. The discriminant validity of the 6-item scale was demonstrated as mean RCAT scale scores differed significantly across groups of patients differing in physician-rated disease severity (F = 54.4), TNSS severity (F = 193.8), and physician-recommended change in therapy (F = 50.6) (P < .001 for all). CONCLUSIONS The RCAT, a 6-item patient-completed instrument, has satisfactory psychometric properties and seems to be a valid tool for assessing control of allergic rhinitis. Further validation studies will provide confirmation.

Allergic management of Meniere's disease: An outcome study

The effect of allergy immunotherapy and elimination of suspected food allergens was evaluated in patients with Menieres disease. A total of 137 patients with Menieres disease for whom allergy treatment had been recommended were identified and were mailed and returned a symptoms questionnaire. One hundred thirteen had received allergy treatment; 24 did not have treatment and served as a control group. Information regarding history, signs and symptoms, allergy test results, and audiologic data were obtained by chart review. The 113 patients treated with desensitization and diet showed a significant improvement from pretreatment to posttreatment in both allergy and Menieres symptoms. Ratings of frequency, severity, and interference with everyday activities of their Menieres symptoms also appeared better after allergy treatment than ratings from the control group of untreated patients. Vertigo control results, by use of the American Academy of Otolaryngology–Head and Neck Surgery classification, categorized 47.9% as class A or B. Hearing was stable or improved in 61.4%. Patients with Menieres disease can show improvement in their symptoms of tinnitus and vertigo when receiving specific allergy therapy. The inner ear may be the target, directly or indirectly, of an allergic reaction.

Prevalence of allergy in Meniere’s disease

OBJECTIVES: The goal of this study was to determine the prevalence of allergy in a population of patients with Menieres disease. METHODS: A survey was mailed to all patients with Menieres disease seen at our institution from 1994 to July 1998 (n = 1490). As a control group, 172 patients with otologic problems other than Menieres disease completed the same survey. RESULTS: Of 734 respondents with Menieres disease, 59.2% reported possible airborne allergy, 40.3% had or suspected food allergies, and 37% had had confirmatory skin or in vitro tests for allergy. These prevalence rates were significantly higher than those found in the control group, of which 42.7% reported having or suspecting airborne allergies and 25% had or suspected food allergies (differences all significant at P ≤ 0.005). CONCLUSION: The prevalence of allergy appears to be much higher in patients with Menieres disease than in the general population or the population of patients visiting an otologic clinic for other symptoms. (Otolaryngol Head Neck Surg 2000;123: 69-75.)

Allergy and health-related quality of life

OBJECTIVE: We asked patients with allergies to complete the SF-36 Health Survey, a health-related quality-of-life (QOL) measure, to determine the impact of allergy on QOL. STUDY DESIGN AND SETTING: In total, 377 adults—140 men (37%) and 237 women (63%)—seen in a tertiary care private neurotologic practice allergy clinic completed the questionnaire before beginning immunotherapy and dietary management. One hundred patients completed both initial and 1-year follow-up questionnaires. The SF-36 measures 8 health concepts ranging from physical to mental health, and scale scores range from 0 to 100. RESULTS: Initial mean scores ranged from a high of 79.1 for the physical functioning scale to a low of 47.2 for the vitality scale, lower (poorer) on all scales than norms for the general US population. Significant improvement occurred from initial to follow-up on all scales. The largest improvements were in role functioning-physical, role functioning-emotional, and social functioning. CONCLUSION: Findings suggest that allergy symptoms can affect QOL and that treatment with specific immunotherapy and/or dietary management may lead to measurable improvements. SIGNIFICANCE: The significant impact of allergy must be recognized, and treatment should be offered. The SF-36 can be used to evaluate treatment outcome. (Otolaryngol Head Neck Surg 2000; 123:393-9.)

Allergic and Immunologic Features of Ménière's Disease

Ménières disease (MD), which by definition is idiopathic, has been ascribed to various causes, including both inhalant and food allergies. Patients with MD report higher rates of allergy history and positive skin or in vitro tests compared with a control group of patients with other otologic diseases and to the general public. Recent immunologic studies have shown higher rates of circulating immune complexes, CD4, and other immunologic components in patients with MD compared with healthy controls. Published treatment results have shown benefit from immunotherapy and/or dietary restriction for symptoms of MD in those patients who present with both allergy and MD.

ALLERGY FOR THE OTOLOGIST: External Canal to Inner Ear

Allergy may affect the outer, the middle, or the inner ear. Although the otologic manifestations of allergy are not by themselves diagnostic, the history, including family history and associated symptoms in other target organs, will often help lead to the correct diagnosis and institution of therapy. Patients with significant and chronic symptoms, including those with labyrinthine symptoms of allergy, will respond well to specific immunotherapy and/or dietary elimination.

Foot and Ear Disease-The Dermatophytid Reaction in Otology†

Chronic otitis externa (COE) is occasionally refractory to treatment and may persist for years. In such cases, a dermatophytid (id) reaction from a fungal infection in a remote location should be suspected. Immunotherapy with dermatophyte (Trichophyton, Oidiomycetes, and Epidermophyton [T.O.E.]) extracts and dust mite, based on serial endpoint titration skin test results, as well as a yeast elimination diet is the treatment of choice.

Facing the music: pre- and postconcert assessment of hearing in teenagers.

Objective Determine the effect of exposure to a single rock/pop concert on pure-tone hearing thresholds and outer hair cell function in teenagers. Study Design Repeated measures pre- and postconcert assessment of hearing. Setting Mobile hearing conservation test vehicle and large indoor concert venue. Subjects Twenty-nine normal-hearing teenagers and young adults ages 13 to 20 years. Intervention Attendance at a public rock/pop concert. Main Outcome Measures Pre- and postconcert pure-tone thresholds in both ears from 500 Hz to 8 kHz, pure-tone average (PTA) for 2, 3, and 4 kHz, distortion product otoacoustic emissions (DPOAEs), proportion of subjects experiencing a PTA change of 10 dB or greater. Results Concert sound levels at the subjects’ position averaged 98.5 dBA. Only 3 subjects used the hearing protection provided. Thresholds for 2 to 6 kHz increased significantly from pre- to postconcert (p ⩽ 0.001). The increase in PTA (2, 3, and 4 kHz) between test intervals averaged 6.3 and 6.5 dB for the right and left ears, respectively, and 33.3% of subjects had a threshold shift of 10 dB or greater in the PTA in at least 1 ear (p ⩽ 0.001). The number of subjects experiencing a reduction in DPOAE amplitude (17/25) and the change in mean amplitude were statistically significant (p ⩽ 0.001 and p ⩽ 0.004, respectively). Conclusion Exposure to a single live-music rock/pop concert can produce a threshold shift and decrease in otoacoustic emissions amplitude indicating impact on outer hair cell function. Results clearly indicate a need for research on this public health issue regarding “safe” listening levels, especially in younger people with more years for accrual of damage.

Outcomes of endolymphatic shunt surgery for Ménière's disease: comparison with intratympanic gentamicin on vertigo control and hearing loss.

Objective: To compare proportions of the combined outcome of vertigo control and hearing preservation between intratympanic gentamicin injections and endolymphatic sac shunt surgery for intractable vertigo in Ménières disease patients. Study Design: Analysis of published data and retrospective review. Setting: Tertiary otologic referral center. Patients: Patients with Ménières disease who had failed medical management: 183 surgical patients (shunt group) and 203 patients obtained from 6 published gentamicin treatment studies (gentamicin group). Cases were included if hearing and vertigo data were available before and after treatment with no previous surgical or injection treatment. Average patient age ranged from 45 to 59 years across studies. Gentamicin studies had nearly equal female to male subjects, whereas the shunt group was 60% female. Interventions: Endolymphatic sac shunt surgery or intratympanic gentamicin treatment of differing doses and injection schedules. Main Outcome Measure: Proportion of patients with best combined vertigo control/hearing preservation. Hearing preservation is 10 dB or less increase in pure-tone average. Outcomes were categorized as follows: complete vertigo control/hearing preservation (best), complete vertigo control/hearing loss, incomplete vertigo control/hearing preservation, and incomplete vertigo control/hearing loss (worst). Results: The shunt group showed a significantly higher percentage of the best outcome (62%) than the gentamicin group (56%, p ≤ 0.003), as well as a higher rate of complete vertigo control (86% versus 71%; p ≤ 0.001). Conclusion: A higher percentage of patients undergoing shunt surgery attained complete vertigo control/hearing preservation relative to intratympanic gentamicin. There continues to be significant variability in gentamicin outcomes, suggesting that the technique requires additional refinement before consistently producing good outcomes.