Objective This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV. Purpose The primary purposes of this guideline are to improve the 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 testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV. Action Statements The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

/pdf/clinical-practice-guideline-benign-paroxysmal-positional-4c8374bric.pdf

Clinical practice guideline: Benign paroxysmal positional vertigo

Objective A great deal of variability exists in the speech-recognition abilities of postlingually deaf adult cochlear implant (CI) recipients. A number of previous studies have shown that duration of deafness is a primary factor affecting CI outcomes; however, there is little agreement regarding other factors that may affect performance. The objective of the present study was to determine the source of variability in CI outcomes by examining three main factors, biographic/audiologic information, electrode position within the cochlea, and cognitive abilities in a group of newly implanted CI recipients. Design Participants were 114 postlingually deaf adults with either the Cochlear or Advanced Bionics CI systems. Biographic/audiologic information, aided sentence-recognition scores, a high resolution temporal bone CT scan and cognitive measures were obtained before implantation. Monosyllabic word recognition scores were obtained during numerous test intervals from 2 weeks to 2 years after initial activation of the CI. Electrode position within the cochlea was determined by three-dimensional reconstruction of pre- and postimplant CT scans. Participants' word scores over 2 years were fit with a logistic curve to predict word score as a function of time and to highlight 4-word recognition metrics (CNC initial score, CNC final score, rise time to 90% of CNC final score, and CNC difference score). Results Participants were divided into six outcome groups based on the percentile ranking of their CNC final score, that is, participants in the bottom 10% were in group 1; those in the top 10% were in group 6. Across outcome groups, significant relationships from low to high performance were identified. Biographic/audiologic factors of age at implantation, duration of hearing loss, duration of hearing aid use, and duration of severe-to-profound hearing loss were significantly and inversely related to performance as were frequency modulated tone, sound-field threshold levels obtained with the CI. That is, the higher-performing outcome groups were younger in age at the time of implantation, had shorter duration of severe-to-profound hearing loss, and had lower CI sound-field threshold levels. Significant inverse relationships across outcome groups were also observed for electrode position, specifically the percentage of electrodes in scala vestibuli as opposed to scala tympani and depth of insertion of the electrode array. In addition, positioning of electrode arrays closer to the modiolar wall was positively correlated with outcome. Cognitive ability was significantly and positively related to outcome; however, age at implantation and cognition were highly correlated. After controlling for age, cognition was no longer a factor affecting outcomes. Conclusion There are a number of factors that limit CI outcomes. They can act singularly or collectively to restrict an individual's performance and to varying degrees. The highest performing CI recipients are those with the least number of limiting factors. Knowledge of when and how these factors affect performance can favorably influence counseling, device fitting, and rehabilitation for individual patients and can contribute to improved device design and application.

Factors affecting open-set word recognition in adults with cochlear implants.

http://web.mit.edu/hst.723/www/ThemePapers/Implants/WilsonDormanReview2008.pdf

Cochlear implants: a remarkable past and a brilliant future

Neurological involvement in Wegener's granulomatosis was studied by reviewing the charts of 324 consecutive patients in whom the diagnosis was made at the Mayo Clinic. One hundred nine patients (33.6%) had neurological involvement. Peripheral neuropathy occured in 53; cranial neuropathy, in 21; external ophthalmoplegia, in 16; cerebrovascular events, in 13; seizures, in 10; cerebritis, in 5; and miscellaneous involvement, in 25. The mean age and sex ratio were similar in the patients with and those without neurological involvement. Among the patients with peripheral neuropathy, 42 had mononeuropathy multiplex; 6, distal symmetrical polyneuropathy; and 5, unclassified peripheral neuropathy. Multiple mononeuropathy was a major presenting symptom in 8 patients. A significantly higher percentage of patients with peripheral neuropathy, compared to those without peripheral neuropathy, had kidney involvement (p < 0.001). The second, sixth, and seventh cranial nerves were most frequently affected. Multiple cranial nerves were affected in 8 patients. Unusual neurological manifestations in the miscellaneous group were spastic paraparesis, temporal arteritis, Horner's syndrome, and papilledema.

Neurological involvement in Wegener's granulomatosis : an analysis of 324 consecutive patients at the Mayo clinic

Objective: To update a 15-year-old study of 800 postlinguistically deaf adult patients showing how duration of severe to profound hearing loss, age at cochlear implantation (CI), age at onset of severe to profound hearing loss, etiology and CI experience affected CI outcome. Study Design: Retrospective multicenter study. Methods: Data from 2251 adult patients implanted since 2003 in 15 international centers were collected and speech scores in quiet were converted to percentile ranks to remove differences between centers. Results: The negative effect of long duration of severe to profound hearing loss was less important in the new data than in 1996; the effects of age at CI and age at onset of severe to profound hearing loss were delayed until older ages; etiology had a smaller effect, and the effect of CI experience was greater with a steeper learning curve. Patients with longer durations of severe to profound hearing loss were less likely to improve with CI experience than patients with shorter duration of severe to profound hearing loss. Conclusions: The factors that were relevant in 1996 were still relevant in 2011, although their relative importance had changed. Relaxed patient selection criteria, improved clinical management of hearing loss, modifications of surgical practice, and improved devices may explain the differences.

/pdf/factors-affecting-auditory-performance-of-postlinguistically-39eiz61pbt.pdf

Factors Affecting Auditory Performance of Postlinguistically Deaf Adults Using Cochlear Implants: An Update with 2251 Patients

A model of auditory performance and a model of ganglion cell survival in postlinguistically deafened adult cochlear implant users are suggested to describe the effects of aetiology, duration of deafness, age at implantation, age at onset of deafness, and duration of implant use. The models were compared with published data and a composite data set including 808 implant users. Qualitative agreement with the model of auditory performance was found. Duration of deafness had a strong negative effect on performance. Age at implantation had a slight negative effect on performance, increasing after age 60 years. Age at onset of deafness had little effect on performance up to age 60. Duration of implant use had a positive effect on performance. Aetiology had a relatively weak effect on performance.

Factors Affecting Auditory Performance of Postlinguistically Deaf Adults Using Cochlear Implants

Between 1944 and 1987, 112 patients with inverting papilloma of the nasal cavity were treated. The average duration of follow-up for this population was 6.2 years. The most common symptoms were nasal obstruction and history of previous surgery for nasal "polyps". Recurrence rates were lower when treatment consisted of lateral rhinotomy with medial maxillectomy (14%) vs. transnasal operation with a sinus procedure (35%) or transnasal operation alone (58%). Recurrence rates between men and women were not significantly different when treatment methods were analyzed; however, a higher-than-expected association with tobacco usage was noted. Eight (7%) of the 112 patients had associated nasal carcinoma. Current treatment is lateral rhinotomy with medial maxillectomy to prevent troublesome and potentially malignant recurrent disease.

The clinical behavior of inverting papilloma of the nose and paranasal sinuses: report of 112 cases and review of the literature.

One hundred eighty cases of Meniere's disease were identified in the Rochester, MN population during the 30-year period, 1951 through 1980. The annual age-adjusted incidence rate per 100,000 population was 15.3; the preponderance for females (16.3) over males (13.3) was not statistically significant. There was no change in annual incidence rate from 1951 through 1970, and a slight decrease in the period, 1971 through 1980. The prevalence rate on January 1, 1980, was 218.2 per 100,000 population. Clinical aspects of Meniere's disease noted during the course of this study are reported.

Meniere's disease: A 30‐Year epidemiologic and clinical study in rochester, mn, 1951‐1980.

Objectives To review our experiences with some of the preoperative and postoperative findings in five children who were diagnosed with auditory neuropathy and were provided with cochlear implants. We describe changes in auditory function, which enabled these children to have significant improvement in their hearing and communication skills.

Study Design Pre- and postoperatively, these children received complete medical examinations at Mayo Clinic, including related consultations in audiology, pediatrics, neurology, medical genetics, otolaryngology, psychology, speech pathology, and radiology.

Methods These children typically had additional medical and audiological examinations at more than one medical center. The hearing assessments of these children included appropriate behavioral audiometric techniques, objective measures of middle ear function, acoustic reflex studies, transient (TOAE) or distortion product (DPOAE) otoacoustic emissions, auditory brainstem responses (ABR), and, in some cases, transtympanic electrocochleography (ECoG). After placement of the internal cochlear implant devices (Nucleus CI24), intraoperatively we measured electrode impedances, visually detected electrical stapedius reflexes (VESR) and neural response telemetry (NRT). These intraoperative objective measures were used to help program the speech processor for each child. Postoperatively, each child has had regular follow-up to assure complete healing of the surgical incision, to assess their general medical conditions, and for speech processor programming. Their hearing and communication skills have been assessed on a regular basis. Postoperatively, we have also repeated electrode impedance measurements, NRT measurements, otoacoustic emissions, and electrical auditory brainstem responses (EABR). We now have 1 year or more follow-up information on the five children.

Results The five children implanted at Mayo Clinic Rochester have not had any postoperative medical or cochlear implant device complications. All of the children have shown significant improvements in their sound detection, speech perception abilities and communication skills. All of the children have shown evidence of good NRT results. All but case D (who was not tested) showed evidence of good postoperative EABR results. Otoacoustic emissions typically remained in the non-operated ear but, as expected, they are now absent in the operated ear.

Conclusion Our experiences with cochlear implantation for children diagnosed with auditory neuropathy have been very positive. The five children we have implanted have not had any complications postoperatively, and each child has shown improved listening and communication skills that have enabled each child to take advantage of different communication and educational options.

Cochlear Implants in Five Cases of Auditory Neuropathy: Postoperative Findings and Progress†

A series of 30 patients with inverted papillomas of the nose and/or the paranasal sinuses is presented. The inverted papilloma is a rare tumor with an overall incidence varying from 0.5% to 4% of all primary nasal tumors. The incidence of inverted papilloma is much more common in the fifth to seventh decades. An association between inverted papilloma and carcinoma is well established. In the large series of patients, the incidence of malignancy associated with inverted papilloma ranges from 1% to 13%, and in our series 10%. Treatment of inverted papilloma is always surgical. The incidence of recurrence is directly related to the method of surgical treatment. Among our 20 patients who were treated by limited surgery, there was recurrence in 14 cases (70%). By contrast, medial maxillectomy and ethmoidectomy via lateral rhinotomy reduced the recurrence rate dramatically. In our opinion this approach is the surgery of choice in the treatment of inverted papilloma.

https://onlinelibrary.wiley.com/doi/pdf/10.1288/00005537-197701000-00005

George W. Facer

Papers

Factors Affecting Auditory Performance of Postlinguistically Deaf Adults Using Cochlear Implants

The clinical behavior of inverting papilloma of the nose and paranasal sinuses: report of 112 cases and review of the literature.

Meniere's disease: A 30‐Year epidemiologic and clinical study in rochester, mn, 1951‐1980.

Cochlear Implants in Five Cases of Auditory Neuropathy: Postoperative Findings and Progress†

Inverting papilloma of the nose and paranasal sinuses.