Nandini Govil

Hearing Impairment and Incident Dementia and Cognitive Decline in Older Adults: The Health ABC Study

Background Age-related peripheral hearing impairment (HI) is prevalent, treatable, and may be a risk factor for dementia in older adults. In prospective analysis, we quantified the association of HI with incident dementia and with domain-specific cognitive decline in memory, perceptual speed, and processing speed. Methods Data were from the Health, Aging and Body Composition (Health ABC) study, a biracial cohort of well-functioning adults aged 70-79 years. Dementia was defined using a prespecified algorithm incorporating medication use, hospital records, and neurocognitive test scores. A pure-tone average in decibels hearing level (dBHL) was calculated in the better hearing ear using thresholds from 0.5 to 4kHz, and HI was defined as normal hearing (≤25 dBHL), mild (26-40 dBHL), and moderate/severe (>40 dBHL). Associations between HI and incident dementia and between HI and cognitive change were modeled using Cox proportional hazards models and linear mixed models, respectively. Results Three-hundred eighty seven (20%) participants had moderate/severe HI, and 716 (38%) had mild HI. After adjustment for demographic and cardiovascular factors, moderate/severe audiometric HI (vs. normal hearing) was associated with increased risk of incident dementia over 9 years (hazard ratio: 1.55, 95% confidence interval [CI]: 1.10, 2.19). Other than poorer baseline memory performance (difference of -0.24 SDs, 95% CI: -0.44, -0.04), no associations were observed between HI and rates of domain-specific cognitive change during 7 years of follow-up. Conclusions HI is associated with increased risk of developing dementia in older adults. Randomized trials are needed to determine whether treatment of hearing loss could postpone dementia onset in older adults.

Glucocorticoids in laryngology: a review.

To provide the otolaryngologist an evidence‐based sound review of glucocorticoid use for laryngeal pathology.

Novel Application of Steroid Eluting Stents in Choanal Atresia Repair A Case Series

Purpose: To describe the application of mometasone furoate eluting sinus stent technology in the treatment of choanal atresia (CA) in the hopes of preventing postsurgical stenosis. Methods: We analyzed 3 consecutive patients aged 4 days to 16 years undergoing repair of CA at a tertiary pediatric hospital. Mometasone furoate eluting sinus stents were placed intraoperatively. Postoperative need for revision surgery as well as routine surveillance endoscopy were used to determine success of surgery. Results: Three patients of varying age and etiology underwent successful repair of choanal atresia/stenosis. The steroid eluting sinus stent was deployed successfully in all 3 cases. There was no identifiable restenosis in any of the 3 patients with 12-month follow-up. There were no complications noted throughout the follow-up period. Conclusions: Choanal atresia is a rare disorder that can prove difficult in postsurgical management. In our case series, mometasone furoate eluting stents were effective and safe for the management of this disease process. Further prospective studies are needed to determine the exact safety profile, long-term consequences, and efficacy of steroid eluting sinus stents in the pediatric population.

Glucocorticoids for Vocal Fold Disease: A Survey of Otolaryngologists

OBJECTIVE/HYPOTHESIS Glucocorticoids (GCs) are commonly used in the treatment of laryngeal disorders despite the absence of clear guidelines regarding their use. We sought to assess clinical practice patterns regarding GC use for various vocal fold diseases and to ascertain factors underlying the selection of particular GCs for different vocal fold pathology. STUDY DESIGN Prospective, survey. METHODS A web-based 20-question survey querying clinical indications for GC use and other factors influencing decision making in GC administration was distributed to 5280 otolaryngologists via e-mail using a commercially available database. RESULTS The overall response rate for the survey was 4% (212/5280). Of the respondents, 99% reported GCs to be valuable in their practice. Previous experience/results, familiarity, and use in practice (68%, 54%, and 37%, respectively) were the most commonly cited reasons for choosing a particular GC; pharmacokinetic profile and academic literature were infrequently cited reasons. Fifty-four percent of respondents were more likely to prescribe GCs for vocal performers compared with other patients. Additionally, most respondents stated that the potential for side effects only occasionally prevented GC utilization. CONCLUSIONS GC prescription practices vary greatly among otolaryngologists. Drug choice appears to be driven primarily by clinician preference and personal experience rather than by specific pharmacologic or physiologic rationale. These findings likely reflect the current lack of well-constructed studies in the laryngology literature to guide GC selection and administration for benign disorders of the larynx and highlight an important potential area for future studies.

Optimizing Positioning for In-Office Otology Procedures

Objective Surgeons often report musculoskeletal discomfort in relation to their practice, but few understand optimal ergonomic positioning. This study aims to determine which patient position—sitting versus supine—is ergonomically optimal for performing otologic procedures. Study Design Observational study. Setting Outpatient otolaryngology clinic setting in a tertiary care facility. Subjects and Methods We observed 3 neurotologists performing a standardized simulated cerumen debridement procedure on volunteers in 2 positions: sitting and supine. The Rapid Upper Limb Assessment (RULA)—a validated tool that calculates stress placed on the upper limb during a task—was used to evaluate ergonomic positioning. Scores on this instrument range from 1 to 7, with a score of 1 to 2 indicating negligible risk of developing posture-related injury. The risk of musculoskeletal disorders increases as the RULA score increases. Results In nearly every trial, RULA scores were lower when the simulated patient was placed in the supine position. When examined as a group, the median RULA scores were 5 with the patient sitting and 3 with the patient in the supine position (P < .0001). When the RULA scores of the 3 neurotologists were examined individually, each had a statistically significant decrease in score with the patient in the supine position. Conclusion This study indicates that patient position may contribute to ergonomic stress placed on the otolaryngologist’s upper limb during in-office otologic procedures. Otolaryngologists should consider performing otologic procedures with the patient in the supine position to decrease their own risk of developing upper-limb musculoskeletal disorders.

Pediatric Atypical Mycobacterium Infection Presenting as Wheezing and Concern for Foreign Body Aspiration.

Atypical mycobacterium infection most commonly presents as asymptomatic cervical lymphadenitis in immunocompetent children. Over the last several decades, rates of Mycobacterium avium complex (MAC) infection have been increasing in both number and severity, with more cases of pulmonary infection reported in healthy children. However, guidelines on how to treat children with these infections remain unclear. The presentation of this disease is variable and often presents with an indolent course of wheezing that is misdiagnosed as foreign body aspiration. Several case reports have described successful treatment of these children with surgical excision without the need for additional treatment with antimycobacterial agents. We present the case of a healthy 20-month old male with wheezing and concern for foreign body ingestion. Rigid bronchoscopy demonstrated a left bronchus mass. The patient underwent video-assisted thoracoscopic surgery (VATS) with improvement in respiratory symptoms. Final pathology showed necrotizing granulomatous infection consistent with MAC. This report demonstrates the importance of keeping intrathoracic MAC infection in the differential when evaluating an immunocompetent child with wheezing or shortness of breath.

The role of tympanostomy tubes in surgery for acquired retraction pocket cholesteatoma

OBJECTIVE 1. To determine whether intraoperative tympanostomy tubes (TT) during surgery for acquired retraction pocket cholesteatoma (ARPC) can decrease recurrence of ARPC and retraction pockets (RP). 2. To determine the need for subsequent TT in children that did not initially receive TT. STUDY DESIGN Retrospective review of children who underwent primary surgery for ARPC. SETTING Tertiary care childrens hospital. SUBJECTS AND METHODS Audiometry, operative reports, office findings, and recurrence of ARPC and RP were analyzed. Univariate analysis with Fishers exact test, Wilcoxon rank-sum and t test, as well as multivariate analysis with logistical regression, were used for statistical analyses. RESULTS 21 patients had TT at initial surgery and 34 patients did not. The recurrence of ARPC was 24% for the TT Group versus 44% for the no TT group (p=0.09). The incidence of RP was 33% in the TT group versus 41% in the no TT groups (p=0.35). 35% of the no TT group subsequently required TT. Audiometric outcomes were not different between groups. TT placement did not significantly affect the odds of recurrent ARPC and RP (95% CI 0.12-1.83, p=0.28 for ARPC and 95% CI 0.30-4.60, p=0.82 for RP). However, the odds of recurrent ARPC and RP were significantly increased in children with stapes and malleus erosion by cholesteatoma. Children with stapes and malleus involvement had 5.28 and 11.8 times higher odds of recurrent ARPC compared to those without ossicular erosion (95% CI 1.09-25.6, p=0.04 stapes and 95% CI 1.58-88.3, p=0.02 malleus). Similarly, children with malleus involvement had an 18.6 times higher odds of recurrent RP (95% CI 1.62-214, p=0.02) compared to those who did not. Incus erosion was not a significant predictor for recurrent ARPC and RP. CONCLUSION There was no statistical difference in recurrence or audiometric outcomes between patients who underwent TT versus those who did not during initial surgery for ARPC. However malleus and stapes erosion were significantly associated with recurrent ARPC and RP. These findings suggest that TT at initial ARPC surgery did not play a role in preventing recurrence, but malleus and incus erosion, was predictive of recurrent disease. A larger, prospective study of TT at initial surgery for ARPC is needed.

Response to: “Regarding ‘Optimizing Positioning for In-Office Otology Procedures’”

We wish to thank Dr Hetzler for his favorable comments regarding our manuscript promoting ergonomic posturing during otologic procedures and for the additional insights that he provided for time spent in the operating room. We enjoyed reading his recommendations for a periodic “seventh-inning stretch” and encouraging all personnel to partake in such activities. There are other factors that influence the position of the surgeon’s head, neck, arms, and torso during otologic surgery, such as the focal length of the objective lens, body habitus of the patient, ability to rotate the neck, and angle of the ear canal. Optimizing positioning of the patient’s head and having the surgeon’s elbows and arms close to the body should provide better access, enhance dexterity, and lessen fatigue. These additional issues could be the focus of future studies addressing ergonomic dynamics. Thank you again for sharing your experience in optimizing positioning in performing otologic procedures.

Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (OSA)

The prevalence of obstructive sleep apnea (OSA), its complex pathophysiology, and the suboptimal adherence rates with positive pressure therapy, necessitate alternative treatment strategies in many OSA patients. Hypoglossal nerve stimulation (HNS) represents a novel and unique therapeutic approach that combines a surgical implant procedure with a titratable medical device to provide multilevel upper airway improvement via neuromodulation of the hypoglossal nerve. A recent multicenter prospective trial reported significant reduction in polysomnographic measures of disease severity and significant improvement in patient-reported quality of life measures that were maintained at 3-year follow-up, with overall low morbidity and good patient acceptance and adherence. HNS therapy has established itself as a key component of the OSA treatment armamentarium, although further work is needed to advance the technology, determine the most appropriate patient phenotypes, refine the implant procedure, and optimize stimulation parameters and titration protocols.

The Role of Tympanostomy Tubes in Surgery for Acquired Retraction Pocket Cholesteatoma

Objectives: (1) Determine whether intraoperative tympanostomy tubes (TT) during surgery for acquired retraction pocket cholesteatoma (ARPC) results in improved hearing outcomes or decreased recurrence of ARPC. (2) Determine the need for subsequent TT in children that did not receive TT at initial surgery. Methods: Institutional review board–approved retrospective review of children 4 to 18 years, who underwent primary surgery (tympanoplasty or tympanomastoidectomy) for ARPC at a tertiary care children’s hospital from January 1, 2000, to December 31, 2012. Audiometry, operative reports, office findings, TT, and recurrence data for ARPC were analyzed. The chi-square test was used for statistical analysis. Results: Preoperative Mills staging for extent of cholesteatoma was similar for both groups. A total of 24 patients had TT at initial surgery (TT Group) and 34 patients did not (no TT Group). The average preoperative and postoperative SRT were 23dB and 25dB, respectively, for the TT Group, and 31 dB and 31 dB for the no TT Group. The recurrence rate for ARPC was 29% for the TT Group versus 41% for the no TT Group (P = .35). Thirty-five percent of patients in the no TT Group required TT at a subsequent surgery. Conclusions: There was no statistical difference in recurrence or audiometric outcomes between patients who underwent TT insertion versus those who did not during initial surgery for ARPC. However, since the incidence of recurrent ARPC was 12% lower when TT were placed, and since the rate of subsequent TT was 35% in the no TT Group, a larger, prospective study of TT at initial surgery for ARPC is needed.