Rachel Humphriss

Convergent validity of the tinnitus handicap inventory and the tinnitus questionnaire

For research into tinnitus to be robust and credible, the use of well-validated instruments of self-perceived tinnitus handicap as outcome measures is essential. The tinnitus handicap inventory (THI) and the tinnitus questionnaire (TQ) are two such instruments which are in widespread use. Both questionnaires were administered by mail to 100 consecutive new patients of the Cambridge Tinnitus Clinic, and completed in randomized order. These patients had been referred by the otolaryngology team and had not undergone any tinnitus therapy. The response rate was 78 per cent, neither questionnaire being more acceptable to patients than the other. The convergent validity of the instruments was high, with total and subscale scores all being significantly correlated at the five per cent level (Spearman correlation coefficients). A number of subscale scores were not significantly correlated at the one per cent level however. In particular, the sleep disturbance element of the TQ was demonstrated to have some discriminant validity from the THI and from other elements of the TQ at the one per cent significance level. The THI and TQ have been demonstrated to have high convergent validity and are both suitable for tinnitus outcome studies involving the quantification of self-perceived tinnitus handicap. For research that aims to determine the specific effect of an intervention on tinnitus-related sleep disturbance, the TQ sleep subscale has potential utility. The hypothetical constructs of tinnitus handicap underlying the psychologist-developed TQ and the audiologist-developed THI have been shown to be convergent.

The evidence base for the application of contralateral bone anchored hearing aids in acquired unilateral sensorineural hearing loss in adults

• Acquired unilateral sensorineural hearing loss reduces the ability to localize sounds and to discriminate in background noise.

Change in dizziness handicap after vestibular schwannoma excision.

Objective To evaluate the change in dizziness handicap after translabyrinthine vestibular schwannoma excision. Study Design Prospective administration of the Dizziness Handicap Inventory preoperatively and at 3 and 12 months postoperatively; retrospective review of case notes. Setting A tertiary referral neuro-otology clinic. Patients A total of 100 consecutive patients who had vestibular schwannomas excised between June 1998 and November 2001 and who had completed Dizziness Handicap Inventories preoperatively and at 3 and 12 months postoperatively. Interventions Translabyrinthine excision of a unilateral sporadic vestibular schwannoma; preoperative and postoperative generic vestibular rehabilitation exercises. Main Outcome Measures Dizziness Handicap Inventory scores. Results For most patients, dizziness handicap does not worsen postoperatively. However, for those in whom it does, dizziness handicap becomes significantly worse between preoperative and 3-month postoperative time points but then does not continue to decline. Tumor size, sex, and magnitude of preoperative canal paresis significantly affect the degree of change in handicap. Age, the presence of central vestibular system abnormalities, and the nature of the patients principal presenting symptom have no effect on this handicap change. Conclusions These findings help the clinician in counseling the patient preoperatively about dizziness handicap to be expected postoperatively. In particular, the clinician is now able to take an informed and positive stance in the event of a severe canal paresis preoperatively.

Change in tinnitus handicap after translabyrinthine vestibular schwannoma excision.

Objective: To evaluate the change in tinnitus handicap after translabyrinthine vestibular schwannoma excision. Study Design: Prospective administration of the Tinnitus Handicap Inventory (THI) preoperatively and at 3 and 12 months postoperatively. Setting: A tertiary referral neuro-otology clinic. Patients: A total of 149 patients from a series of 170 consecutive patients who had vestibular schwannomas excised between May 1998 and July 2002 and who had completed THIs preoperatively and at 3 and 12 months postoperatively. Interventions: Translabyrinthine excision of a unilateral sporadic vestibular schwannoma. Main Outcome Measures: THI scores. Results: The number of patients with moderate or severe handicap was 21 (14%) in the preoperative group and 21 (14%) in the 12-month postoperative group. No significant differences in group data were found comparing (by Wilcoxon signed rank test) preoperative data with 3 months postoperative data (p = 0.09), preoperative data with 12 months postoperative data (p = 0.09), and 3 months postoperative data with 12 months postoperative data (p = 0.33). Considering group data, tinnitus handicap is neither alleviated nor exacerbated by translabyrinthine surgery. The application of the validated 20-point criteria for significant change in the status of an individual patient indicates that tinnitus handicap was worse in 10 (6.5%), unchanged in 129 (87%), and better in 10 (6.5%). Conclusions: The findings of the current study can be used during preoperative patient counseling. In particular, the clinician is now able to take an informed and positive stance about the tinnitus handicap to be expected postoperatively.

Contraindications to the Dix-Hallpike manoeuvre: A multidisciplinary review: Contraindicaciones de la maniobra de Dix-Hallpike: Una revisión multidisciplinaria

The Dix-Hallpike manoeuvre is widely used in the diagnosis of positional vertigo and is regarded as safe. The manoeuvre involves a degree of neck rotation and extension, and consequently one might expect there to be some patients, particularly those with neck problems, in whom the manoeuvre is contraindicated. The term ‘neck problem’, however, encompasses a whole range of conditions, including soft tissue disorders, cervical spondylosis, prolapsed intervertebral disk, and severe rheumatoid arthritis with cervical instability. These in turn will give rise to a variety of symptoms, which will vary from minimal pain or stiffness to severe pain or complete immobility, and, in some cases, neurological deficit. Clarification is therefore needed to establish the point at which any neck pain or stiffness ceases to be a minor problem and becomes a contraindication to performing the Dix-Hallpike manoeuvre. This paper clarifies this issue by discussing the issue of absolute contraindications and proposing a simple functional assessment of neck mobility which can be performed prior to performing the Dix-Hallpike manoeuvre. Relative contraindications such as back pathology, vertebrobasilar ischaemia (posterior circulation ischaemic disease), nerve root compression and medical fitness are also discussed. La maniobra de Dix-Hallpike cs ampliamente utilizada en el diagnóstico del vértigo posicional y ha sido considerada como segura. La maniobra involucra un cierto grado de rotación y extensión del cuello, y consecuentemente uno podría esperar que existan algunos pacientes, particularmente aquellos con problemas en el cuello, para quienes dicha maniobra estariá contraindicada. El concepto de “problemas de cuello”, sin embargo, comprende un amplio rango de condiciones, incluyendo trastornos de los tejidos blandos, espondilosis cervical, discos intervertebrales prolapsados, y artritis reumatoide severa con inestabilidad cervical. Estas condiciones dan lugar a una variedad de síntomas que van desde el dolor mínimo o la rigidez, hasta el dolor sevcro o la inmovilidad total, y en algunos casos, el déficit neurológico. Se requiere, por lo tanto, una aclaración para establecer el punto en el que cualquier rigidez o dolor cervical deja dc ser un problcma menor y se convierte en una contraindicación para realizar la maniobra de Dix-Hallpike. Este trabajo aclara el asunto discutìendo las contraindicaciones absolutas y proponiendo una evaluación funcional simple de la movilidad cervical, que puede realizarse antes de ejecutar la maniobra de Dix-Hallpike. Se discuten también las contraindicaciones relativas, tales como la patología de la cspalda, la isquemia vertebrobasilar (enfermedad isquémica circulatoria posterior), la compresión de raíces nerviosas y la condición de salud.

Dizziness in 10 year old children: An epidemiological study

OBJECTIVE Current data about the prevalence and characteristics of dizziness in the paediatric population is very limited and the generalisability of extant studies to the UK population has not been explored. Our study aims to provide a robust estimate of the prevalence of dizziness in 10 year old children in the UK, to describe the characteristics of this dizziness and to explore whether this dizziness is socially patterned. METHODS Data from the Avon Longitudinal Study of Parents and Children (ALSPAC) was analysed (N=13,988). A total of 6965 of these children attended for a balance assessment session at age 10. Those who reported rotary vertigo were interviewed about their symptoms. Logistic regression was used to explore whether dizziness at age 10 is socially patterned. RESULTS A total of 400 children reported rotary vertigo, giving a prevalence estimate of 5.7% [CI 5.2, 6.3%]. 13.1-20.6% of children reported experiencing their dizziness between 1 and 4 times a week (depending on the symptom). 51.5% of children had to stop what they were doing because of the dizziness making them feel unwell. A total of 60% of children reported headache as an accompanying symptom, tentatively suggesting a diagnosis of migraine, although there was no association between reports of headache and a maternal family history of migraine. 20.3% of children with dizziness also reported tinnitus and 17.3% reported that their hearing changed when they were dizzy. CONCLUSIONS Dizziness in 10 year old children is not uncommon and in about half limits current activities. Rotary vertigo is commonly accompanied by dizziness of another description and also by headache. There is no evidence that dizziness at this age is socially patterned.

The Prevalence and Onset of Gaze Modulation of Tinnitus and Increased Sensitivity to Noise After Translabyrinthine Vestibular Schwannoma Excision

Objective: To determine the prevalence and timing of onset of gaze-modulated tinnitus and increased sensitivity to noise in patients who had undergone translabyrinthine excision of a vestibular schwannoma. Study Design: Retrospective questionnaire study. Setting: University hospital departments of audiology and neurotology. Patients: A cohort of 359 patients who had undergone translabyrinthine excision of a vestibular schwannoma in the period 1997 to 2003. Intervention: Translabyrinthine excision of a unilateral sporadic vestibular schwannoma. Main Outcome Measures: Patient reports and visual analogue scale measures of the timing of onset of gaze-modulated tinnitus and the presence, timing of onset, and persistence of increased sensitivity to noise after surgery. Results: Completed questionnaires were returned by 275 patients (77%), of whom 132 (48%) were men and 143 (52%) were women. Preoperative tinnitus was reported in 150 patients (55%). In 124 of these 150 (83%) the tinnitus persisted, and in 26 of 150 (17%) it abated. Of the 125 patients without preoperative tinnitus, 43 (34%) developed it postoperatively. In 167 (61%) patients of the total group of 275, postoperative tinnitus was reported. Gaze-modulated tinnitus was reported in 53 patients (19%). Somatic-evoked or -modulated tinnitus was reported in 38 patients (14%). In response to the question, “Did you notice being extra sensitive to noise after your operation?,” 138 patients (50%) replied that they did. In 111 patients, this persisted. The onset of the modulation of tinnitus was distributed throughout the postoperative period, whereas the onset of increased sensitivity to noise was overwhelmingly in the first 2 months after surgery. Conclusion: Gaze modulation of tinnitus after vestibular schwannoma removal was identified in 19% of patients in this series. The onset data did not convincingly argue for any specific mechanism. The prevalence of increased sensitivity to noise is surprising and may represent central hyperacusis in response to unilateral deafferentation of the auditory system.

Balance ability of 7 and 10 year old children in the population: Results from a large UK birth cohort study §

OBJECTIVE The literature contains many reports of balance function in children, but these are often on atypical samples taken from hospital-based clinics and may not be generalisable to the population as a whole. The purpose of the present study is to describe balance test results from a large UK-based birth cohort study. METHODS Data from the Avon Longitudinal Study of Parents and Children (ALSPAC) were analysed. A total of 5402 children completed the heel-to-toe walking test at age 7 years. At age 10 years, 6915 children underwent clinical tests of balance including beam-walking, standing heel-to-toe on a beam and standing on one leg. A proportion of the children returned to the clinic for retesting within 3 months allowing test-retest agreement to be measured. RESULTS Frequency distributions for each of the balance tests are given. Correlations between measures of dynamic balance at ages 7 and 10 years were weak. The static balance of 10 year old children was found to be poorer with eyes closed than with eyes open, and poorer in boys than in girls for all measures. Balance on one leg was poorer than heel-to-toe balance on a beam. A significant learning effect was found when first and second attempts of the tests were compared. Measures of static and dynamic balance appeared independent. Consistent with previous reports in the literature, test-retest reliability was found to be low. CONCLUSIONS This study provides information about the balance ability of children aged 7 and 10 years and provides clinicians with reference data for balance tests commonly used in the paediatric clinic.

Does cochlear implantation improve speech recognition in children with auditory neuropathy spectrum disorder? A systematic review.

Abstract Objective: Cochlear implantation (CI) is a standard treatment for severe-profound sensorineural hearing loss (SNHL). However, consensus has yet to be reached on its effectiveness for hearing loss caused by auditory neuropathy spectrum disorder (ANSD). This review aims to summarize and synthesize current evidence of the effectiveness of CI in improving speech recognition in children with ANSD. Design: Systematic review. Study sample: A total of 27 studies from an initial selection of 237. Results: All selected studies were observational in design, including case studies, cohort studies, and comparisons between children with ANSD and SNHL. Most children with ANSD achieved open-set speech recognition with their CI. Speech recognition ability was found to be equivalent in CI users (who previously performed poorly with hearing aids) and hearing-aid users. Outcomes following CI generally appeared similar in children with ANSD and SNHL. Assessment of study quality, however, suggested substantial methodological concerns, particularly in relation to issues of bias and confounding, limiting the robustness of any conclusions around effectiveness. Conclusions: Currently available evidence is compatible with favourable outcomes from CI in children with ANSD. However, this evidence is weak. Stronger evidence is needed to support cost-effective clinical policy and practice in this area.

Prenatal alcohol exposure and childhood balance ability: findings from a UK birth cohort study

Objective To investigate the association of prenatal alcohol exposure with balance in10-year-old children. Design Population-based prospective longitudinal study. Setting Former Avon region of UK (Southwest England). Participants 6915 children from the Avon Longitudinal Study of Parents and Children who had a balance assessment at age 10 and had data on maternal alcohol consumption. Outcome measures 3 composite balance scores: dynamic balance (beam-walking), static balance eyes open, static balance eyes closed (heel-to-toe balance on a beam and standing on one leg, eyes open or closed). Results Most mothers (95.5%) consumed no-to-moderate amounts (3–7 glasses/week) of alcohol during pregnancy. Higher total-alcohol consumption was associated with maternal-social advantage, whereas binge drinking (≥4 units/day) and abstinence were associated with maternal social disadvantage. No evidence was found of an adverse effect of maternal-alcohol consumption on childhood balance. Higher maternal-alcohol use during pregnancy was generally associated with better offspring outcomes, with some specific effects appearing strong (static balance eyes open and moderate total alcohol exposure at 18 weeks, adjusted OR 1.23 (95% CI 1.01 to 1.49); static balance eyes closed and moderate total alcohol exposure at 18 weeks, adjusted OR 1.25 (95% CI 1.06 to 1.48). Similar results were found for both paternal and postnatal maternal alcohol exposure. A Mendelian-randomization approach was used to estimate the association between maternal genotype and offspring balance using the non-synonymous variant rs1229984*A (ADH1B) to proxy for lower maternal alcohol consumption; no strong associations were found between this genotype/proxy and offspring balance. Conclusions No evidence was found to indicate that moderate maternal alcohol consumption in this population sample had an adverse effect on offspring balance at age 10. An apparent beneficial effect of higher total maternal alcohol consumption on offspring balance appeared likely to reflect residual confounding.