Vincent Van Rompaey

Skin reactions following BAHA surgery using the skin flap dermatome technique

The objectives of the study were to determine the incidence of skin reactions and complications associated with bone-anchored hearing aid (BAHA) implantation. The study is a retrospective case review done in a tertiary referral center. One hundred thirty-eight consecutive patients between 1998 and 2008 underwent implantation of a BAHA and were regularly seen for follow-up. Indications included conductive or mixed hearing loss where a hearing aid cannot be used and since 2000 also had contralateral single-sided perceptive hearing loss. BAHA implantation was done by creating a pedicled flap using the skin flap dermatome technique. Postoperative incidence of skin reactions and complications were measured. Significant postoperative complications requiring revision surgery occurred 37 times in 30 patients. Normal skin healing was seen in 52 patients (63.4%), while abnormal skin healing occurred in 30 patients (36.6%). This study showed that skin problems occur more often than expected. Because of the skin problems with the skin flap technique, the authors have switched to the linear incision technique, hoping to decrease the incidence of skin problems.

Systematic review of the literature on Nitinol prostheses in surgery for otosclerosis : assessment of the adequacy of statistical power

Objective: To perform a systematic review of observational studies reporting hearing outcome in primary stapes surgery where a heat-crimping prosthesis was used. Data Sources: Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, TRIP database, Clinical Trials Registry, ISI Web of Knowledge, and Web of Science. The search was performed on January 1, 2010, including articles published ahead of print. No language restrictions. Study Selection: Inclusion criteria for qualitative synthesis were a population of otosclerosis patients, intervention being primary stapes surgery with a nickel titanium alloy (Nitinol) heat-crimping prosthesis, and hearing outcome. Inclusion criteria for quantitative analysis: application of audiometry guidelines of the American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium for evaluation of conductive hearing loss. Data Extraction: Strategy and reporting based on Cochrane, Quality of Reporting of Meta-analyses, and Meta-analysis of Observational Studies in Epidemiology statements. A bias assessment tool was developed according to Cochrane guidelines. Data Synthesis: A quantitative synthesis was performed, but because of the heterogeneity in postoperative follow-up periods and outcome measures reported, we were not able to pool these data. A sample size analysis was performed to indicate the sample needed to demonstrate a statistically significant difference in hearing outcome between both interventions. Hearing outcome superiority of the Nitinol heat-crimping prosthesis over manually crimping prosthesis types was not demonstrated. Conclusion: Superiority could probably not be demonstrated because of insufficient sample size. Research addressing technical improvements in stapes surgery should agree on a base sample size able to detect the smallest difference that is clinically important or accept the null hypothesis. With data gathered in the Common Otology Database as basis, a sample size of at least 413 patients is needed in both the intervention and the control group. Other clinical outcome measures also should be explored.

Prospective effectiveness of stapes surgery for otosclerosis in a multicenter audit setting: feasibility of the Common Otology Database as a benchmark database.

Introduction: The Common Otology Database (COD) is a joint effort by an international group of otologists to organize audit with a standardized reporting method in middle ear surgery. The first results on hearing outcome of the COD are presented in this article. Objective: The primary objective was to confirm the validity of the benchmark group by comparing hearing outcome results with previously reported results. The secondary objective was to describe the population, technical aspects, and hearing outcomes of stapes surgery. Study Design: Nonrandomized prospective multicenter audit. Setting: Twenty tertiary-referral otologic centers. Patients and Intervention: Primary and revision stapes operations in patients with otosclerosis. Main Outcome Measures: Air-bone gap (ABG), bone-conduction (BC) thresholds, and air-conduction (AC) thresholds were evaluated at 3 and 12 months according to the guidelines of the Committee on Hearing and Equilibrium for the evaluation of conductive hearing loss. Raw data were displayed in an Amsterdam Hearing Evaluation Plot. Results: In primary stapes surgeries, the postoperative ABG was closed to 10 dB or less in 63.6% and to 20 dB or less in 92.6% (median, 8.75 dB). In revision stapes surgeries, the postoperative ABG was closed to 10 dB in 41.2% and to 20 dB in 76.5% of cases (median, 11.25 dB). The overall mean postoperative ABG at 12 months was 10.38 dB compared with 28.75 dB preoperatively. Using laser to perform the fenestration results in a less pronounced BC improvement when compared with procedures without laser assistance. No statistically significant difference in ABG pure-tone average at 3 months could be demonstrated between the different prosthesis types. Conclusion: Results of hearing outcome are similar to previous, primarily retrospective, single-center studies. Our data confirm the effectiveness of stapes surgery in patients with otosclerosis.

Value and discriminative power of the seven-item eustachian tube dysfunction questionnaire

Obstructive eustachian tube (ET) dysfunction is a common condition associated with various otologic symptoms. The current lack of a diagnostic gold standard makes diagnosis and evaluation at follow‐up difficult. The aim of the study was to determine the value and discriminative power of the seven‐item Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) in patients with obstructive ET dysfunction and patulous ET.

Vestibular migraine in an otolaryngology clinic: prevalence, associated symptoms, and prophylactic medication effectiveness.

Objective To assess the prevalence of vestibular migraine (VM) in patients consulting to an otolaryngology clinic, the neuro-otological associated symptoms, and the effect of prophylactic antimigrainous medication on VM symptom improvement. Study Design Retrospective chart review. Setting Tertiary referral otolaryngology clinic. Subjects and Methods We used the diagnostic criteria from the Bárány Society and the International Headache Society to allocate patients to a subgroup: VM, possible VM, and atypical VM. Main Outcome Measure The prevalence of VM, percentages of associated neurotological symptoms, and percentages of effectiveness of prophylactic medication. Results Sixty-five (16%) patients were selected from the total patient population (n = 407) from which 4.2% were assigned to the definite VM group, 5.7% to the probable VM group, and 6.1% to the atypical VM group. We found a significantly different distribution between the groups for photophobia (p = 0.035), ear pressure (p = 0.023), and scotoma (p = 0.015). Thirty patients were administered with flunarizine and 68% responded with an improvement in VM symptoms (p < 0.001). For propranolol, 31 patients were treated and there was an improvement of symptoms in 73% (p < 0.001). Remarkable was the fact that these percentages were not significantly different between the subgroups. Conclusion VM is a common disorder presenting in a dizziness clinic, and detailed history taking is important to assess VM-associated symptoms and thus to prevent underdiagnosis. The latter is very important because our study shows that the majority of patients, regardless of VM subtype, can benefit from a prophylactic treatment, but further prospective studies are necessary.

Mal de debarquement syndrome: a systematic review

Mal de debarquement (MdD) is a subjective perception of self-motion after exposure to passive motion, in most cases sea travel, hence the name. Mal de debarquement occurs quite frequently in otherwise healthy individuals for a short period of time (several hours). However, in some people symptoms remain for a longer period of time or even persist and this is then called mal de debarquement syndrome (MdDS). The underlying pathogenesis is poorly understood and therefore, treatment options are limited. In general, limited studies have focused on the topic, but the past few years more and more interest has been attributed to MdDS and its facets, which is reflected by an increasing number of papers. Till date, some interesting reviews on the topic have been published, but a systematic review of the literature is lacking and could help to address the shortcomings and flaws of the current literature. We here present a systematic review of MdD(S) based on a systematic search of medical databases employing predefined criteria, using the terms “mal de debarquement” and “sea legs”. Based on this, we suggest a list of criteria that could aid healthcare professionals in the diagnosis of MdDS. Further research needs to address the blank gaps by addressing how prevalent MdD(S) really is, by digging deeper into the underlying pathophysiology and setting up prospective, randomized placebo-controlled studies to evaluate the effectiveness of possible treatment strategies.

Erosion of the Long Process of the Incus in Revision Stapes Surgery: Malleovestibular Prosthesis or Incus Reconstruction With Hydroxyapatite Bone Cement?

Objective To study hearing outcome in revision stapedotomy cases where extensive erosion of the long process of the incus was observed in a consecutive series where a malleovestibular prosthesis was used versus a consecutive series where hydroxyapatite (HA) bone cement was used to rebuild the eroded long process of the incus and integrate the prosthesis. Patients Twenty revision cases of surgically treated otosclerosis where extensive incus erosion was observed during revision surgery. Intervention In the earlier consecutive series, 10 cases were treated with malleovestibular prostheses. In the later consecutive series, 10 cases were treated with HA bone cement to rebuild the incus-prosthesis interface. Main Outcome Measures Air-bone gap, bone-conduction thresholds, and air-conduction thresholds were evaluated preoperatively and at 1 to 3 months. Last audiometry available also was reported (median, 12 mo). Pure-tone averages were calculated according to the guidelines of the Committee on Hearing and Equilibrium for the evaluation of conductive hearing loss. Raw data were displayed in an Amsterdam Hearing Evaluation Plot. Results Six male patients and 14 female patients were included. Age varied from 34 to 75 years (median, 53 yr). The median postoperative air-bone gap at last follow-up audiometry was 15.6 in the malleovestibular prosthesis group and 13.1 dB in the HA bone cement group. No short-term or intermediate-term adverse reactions or unsuspected bone conduction deteriorations were seen. Conclusion HA bone cement can be successfully used to reconstruct the long process of the incus in case of extensive erosion of the long process. Intermediate-term hearing outcome is comparable to the outcome of a series of similar cases treated with malleovestibular prostheses. Because the placement of a malleovestibular prosthesis is technically more difficult and presents a high risk to the inner ear, we think HA bone cement can be a useful alternative in these difficult cases.

Responsiveness of the 7-item Eustachian Tube Dysfunction Questionnaire.

OBJECTIVE Baro-challenge-induced Eustachian tube (ET) dysfunction is defined as the presence of aural discomfort, popping, or pain, which only arises in case of ambient pressure changes, without abnormalities on otoscopy or tympanometry. Our primary aim was to determine the discriminative power of the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) in patients with baro-challenge-induced ET dysfunction in comparison with that in healthy controls. The secondary aim was to determine the responsiveness of ETDQ-7 in patients with baro-challenge-induced obstructive ET dysfunction who underwent balloon dilation tuboplasty (BDET). MATERIALS AND METHODS The accuracy of the diagnostic test was determined on the basis of the area under the curve in receiver-operating curve (ROC) analysis. Responsiveness to change of ETDQ-7 was assessed by exploring preoperative and postoperative ETDQ-7 scores using Cohens kappa coefficient. Patients were asked whether their complaints improved, remained stable, or deteriorated after BDET. The findings of subjective evaluation were then compared with the difference in the ETDQ-7 score after BDET. RESULTS In the baro-challenge-induced ET dysfunction group, the median preoperative total ETDQ-7 score was 26, decreasing to 16 after BDET. ROC analysis demonstrated excellent discriminative power for the baro-challenge-induced ET dysfunction group. Cohens kappa coefficient was 0.633, indicating that there was substantial agreement between the ETDQ-7 values before and after BDET. CONCLUSION ETDQ-7 can discriminate between patients with baro-challenge-induced ET dysfunction and healthy controls and can therefore be useful in its diagnosis. Furthermore the ETDQ-7 is responsive to change in patients with baro-challenge-induced ET dysfunction who have undergone BDET, although a larger sample size is required to confirm these preliminary findings.

Altered functional brain connectivity in patients with visually induced dizziness

Background Vestibular patients occasionally report aggravation or triggering of their symptoms by visual stimuli, which is called visually induced dizziness (VID). These patients therefore experience dizziness, discomfort, disorientation and postural unsteadiness. The underlying pathophysiology of VID is still poorly understood. Objective The aim of the current explorative study was to gain a first insight in the underlying neural aspects of VID. Methods We included 10 VID patients and 10 healthy matched controls, all of which underwent a resting state fMRI scan session. Changes in functional connectivity were explored by means of the intrinsic connectivity contrast (ICC). Seed-based analysis was subsequently performed in visual and vestibular seeds. Results We found a decreased functional connectivity in the right central operculum (superior temporal gyrus), as well as increased functional connectivity in the occipital pole in VID patients as compared to controls in a hypothesis-free analysis. A weaker functional connectivity between the thalamus and most of the right putamen was measured in VID patients in comparison to controls in a seed-based analysis. Furthermore, also by means of a seed-based analysis, a decreased functional connectivity between the visual associative area and the left parahippocampal gyrus was found in VID patients. Additionally, we found increased functional connectivity between thalamus and occipital and cerebellar areas in the VID patients, as well as between the associative visual cortex and both middle frontal gyrus and precuneus. Conclusions We found alterations in the visual and vestibular cortical network in VID patients that could underlie the typical VID symptoms such as a worsening of their vestibular symptoms when being exposed to challenging visual stimuli. These preliminary findings provide the first insights into the underlying functional brain connectivity in VID patients. Future studies should extend these findings by employing larger sample sizes, by investigating specific task-based paradigms in these patients and by exploring the implications for treatment.

The Effect of Optokinetic Stimulation on Perceptual and Postural Symptoms in Visual Vestibular Mismatch Patients

Background Vestibular patients occasionally report aggravation or triggering of their symptoms by visual stimuli, which is called visual vestibular mismatch (VVM). These patients therefore experience discomfort, disorientation, dizziness and postural unsteadiness. Objective Firstly, we aimed to get a better insight in the underlying mechanism of VVM by examining perceptual and postural symptoms. Secondly, we wanted to investigate whether roll-motion is a necessary trait to evoke these symptoms or whether a complex but stationary visual pattern equally provokes them. Methods Nine VVM patients and healthy matched control group were examined by exposing both groups to a stationary stimulus as well as an optokinetic stimulus rotating around the naso-occipital axis for a prolonged period of time. Subjective visual vertical (SVV) measurements, posturography and relevant questionnaires were assessed. Results No significant differences between both groups were found for SVV measurements. Patients always swayed more and reported more symptoms than healthy controls. Prolonged exposure to roll-motion caused in patients and controls an increase in postural sway and symptoms. However, only VVM patients reported significantly more symptoms after prolonged exposure to the optokinetic stimulus compared to scores after exposure to a stationary stimulus. Conclusions VVM patients differ from healthy controls in postural and subjective symptoms and motion is a crucial factor in provoking these symptoms. A possible explanation could be a central visual-vestibular integration deficit, which has implications for diagnostics and clinical rehabilitation purposes. Future research should focus on the underlying central mechanism of VVM and the effectiveness of optokinetic stimulation in resolving it.