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Traditional Versus Laser Stapedotomy: A Comparative Study
Oral Presentations
The Guy’s Hospital Balance Clinic: An MDT Approach Jeremy Corcoran, MSc (presenter); Gareth Jones, MSc; Rachel Ritchie, MSc OBJECTIVE: Patients complaining of dizziness or vertigo may present to a variety of specialties before a diagnosis is made. The Guy’s multidisciplinary balance one-stop clinic consists of two ear nose and throat consultants, three audiologists, and three vestibular physiotherapists. Patients are assessed by a vestibular physiotherapist and a full audiovestibular assessment performed. Patients are then discussed at a multidisciplinary team meeting. A diagnosis is made and treatment arranged. We report the diagnostic spread of patients attending this service in 2009. METHOD: The records of all patients seen in the Guy’s balance clinic were reviewed and their diagnoses recorded. RESULTS: 308 new patients were assessed by this service during 2009. Diagnoses include unilateral peripheral vestibular deficit (101), benign paroxysmal positional vertigo (50), multilevel vestibulopathy (38), vertiginous migraine (34), central (17), Me´nie`re’s disease (12), other otological pathology (11), psychogenic (10), drug induced (6), systemic (5), post-operative (3), cervicogenic (2), cardiac (2), other (17). CONCLUSION: This one-stop service provides an efficient, thorough vestibular assessment and management pathway. The relative spread of diagnoses is similar to those found in other units and we would recommend this model to other units. The Skull High Frequency Vibration-Induced Nystagmus Test Georges Dumas, MD (presenter); Alexandre Karkas, MD; Sebastien Schmerber, MD, PhD OBJECTIVE: Establish the effectiveness of skull vibration induced nystagmus test as a rapid bed side high frequency stimulation test, in the evaluation of peripheral unilateral vestibular lesions. METHOD: A series of 16,000 patients were studied in a prospective series for 13 years in a tertiary center under videonystagmoscopy with the skull vibration-induced nystagmus test. 240 patients were randomly chosen for numerical and statistical data analysis: 93 patients had a partial unilateral vestibular lesion, 131 patients had a total unilateral vestibular lesion, and 36 patients had a brain stem lesion.
RESULTS: Total unilateral vestibular lesion revealed always a skull vibratory nystagmus beating toward the safe side at all frequencies of stimulations in total correlation with the headshaking test and caloric test. In partial unilateral vestibular lesion, a skull vibration nystagmus was found in 76% of cases and the direction at 30Hz was opposite to that recorded at 100Hz in 10% of cases. CONCLUSION: Skull vibration-induced nystagmus test is a useful complementary test to the caloric and head-shaking tests. It is a global vestibular test that can be used to detect vestibular asymmetric responses as part of a bedside examination. The skull vibration nystagmus direction is always beating toward the safe side in total unilateral vestibular lesions, whatever the stimulus location or frequency but can be frequencydependent in partial unilateral vestibular lesions. The caloric test should no longer be considered as an absolute reference test in the diagnosis of peripheral vestibular lesions, since a normal caloric test cannot exclude a vestibular pathology. The vestibule should be explored at multiple frequencies. Therefore, a skull vibration nystagmus test is required among other vestibular tests in order to improve the clinical assessment in vestibular diseases. Totally Endoscopic Stapedotomy: Technique and Results Joao-Flavio Nogueira, MD (presenter); Daniel Cruz, MD OBJECTIVE: To describe the endoscopic technique for stapes surgery, discussing the preliminary results and also showing the potential advantages and disadvantages. METHOD: Review of 5 consecutive patients, submitted to totally endoscopic stapes surgery from May to December 2009. All patients were women with age ranging from 22 to 47 years old. All presented bilateral conductive hearing loss (audiogram). All patients were operated under general hypotensive anesthesia and by the same surgeon. RESULTS: No complications were observed during surgery and after the procedures. The follow-up period ranged from 2 to 8 months. All patients referred improvement at their hearing at the operated side. The air-bone gap was completely closed in all patients at the side which the surgery was performed (postoperative audiogram). Also, no residual tympanic membrane perforations were observed. CONCLUSION: In this small series, endoscopic stapedotomy was technically feasible, safe and promising. There were both advantages and disadvantages. However, a larger series is mandatory to assess the role of endoscopes in otosclerosis surgery. Traditional Versus Laser Stapedotomy: A Comparative Study Sanjeev Mohanty, MBBS, MS, FICS (presenter)
ORALS
BPPV. Treatment of BPPV using CRM results in improved postural stability in dynamic posturography. The vestibular rehabilitation exercise using dynamic posturography is helpful for those patients whose balance ability were still abnormal after CRM.
P107
P108
Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
OBJECTIVE: The objective of this study was to compare hearing outcomes, post operative vertigo and tinnitus for patients undergoing laser stapedotomy versus conventional fenestration stapedotomy. METHOD: Study Design: Prospective Study Year(s)/ Month(s) Study Conducted: 2006-2009. Disease/Condition Studied: Clinical Otosclerosis. Subjects Studied: Otosclerotic patients without previous otological surgery. Setting in Which Subjects Studied: Tertiary care University Hospital. Intervention(s): Randomized. Outcome Measurement(s): Pure-tone audiometry was performed before surgery, postoperatively, and on routine follow-up examination. Independent Variables: Tinnitus and vertigo were subjectively assessed via a questionnaire before surgery, postoperatively, and on routine follow-up examination. Preliminary Analyses (Analysis of Ongoing Study): None. Statistical Methods: 2 test. RESULTS: Of the 35 patients, 15 (42.8%) underwent laser stapedotomy and 20 (57.2%) underwent conventional stapedotomy. The conventional stapedotomy mean air-bone gap (ABG) closed from a preoperative value of 26 dB (standard deviation [SD], 10dB) to 8 dB (SD, 7 dB) on average follow up of 365 days. In 15 laser stapedotomy patients with an average follow up of 365 days, the preoperative mean ABG closed from 31 dB (SD, 10 dB) to 6 dB (SD, 7 dB). There was a trend toward improvement in low-frequency air conduction thresholds after conventional stapedotomy versus worsening of highfrequency thresholds in the Laser group. There was a statistically significant improvement in most recent postoperative high-frequency (6000-8000 Hz) air conduction thresholds in the Laser stapedotomy patients compared with patients who underwent conventional laser stapedotomy. Tinnitus and Vertigo also were present in equal proportions in both the series. CONCLUSION: Laser Stapedotomy when used for otosclerosis, provides excellent hearing in both high and low frequencies as compared to hearing improvement in lower frequencies in conventional stapedotomy. Transtympanic Dexamethasone for Cisplatin Ototoxicity Denise Murphy (presenter); Sam Daniel, MSc, MD, FRCSC OBJECTIVE: Cisplatin chemotherapy causes ototoxicity manifested as hearing loss and/or tinnitus. Ototoxicity is induced via damage to the inner ear by reactive oxygen species. Dexamethasone reduces reactive species and has a well-documented history of transtympanic (TT) clinical use for various cochlear disorders. Objectives in the guinea pig model are: 1) To determine the safety of transtympanic dexamethasone; 2) To determine the effect of transtympanic dexamethasone on cisplatin ototoxicity. METHOD: A prospective, randomized, controlled trial was conducted in a well-established guinea pig model. During the course of one year, pre- and post-treatment Auditory Brain-
stem Responses (ABRs) were compared to measure threshold changes in 58 guinea pigs. The safety of TT dexamethasone and the effect of TT dexamethasone on cisplatin ototoxicity were examined. Comparisons of the mean ABR thresholds using a 2-tailed Student t-test were calculated to determine statistical significance. RESULTS: Ears treated with transtympanic dexamethasone alone showed a slight improvement in hearing thresholds (p ⫽ 0.04). Transtympanic dexamethasone in cisplatin-treated guinea pigs showed signs of otoprotection, particularly in the lower frequencies (8 kHz). CONCLUSION: Transtympanic dexamethasone presents as a simple, safe, and potentially effective treatment modality against cisplatin ototoxicity. Validation of a Virtual Reality Temporal Bone Simulator Sameer Khemani, MBBS, MEd, DOHNS, FRCS (presenter); Catherine Rennie, MBBS; Arvind Singh, MBBS, DLO, FRCS; Neil Tolley, MD, FRCS, DLO OBJECTIVE: To establish face and content validity of the VOXEL-MAN temporal bone simulator. METHOD: Five virtual reality (VR) temporal bone study days were conducted over 8 months (June 2009-Jan 2010) at Imperial College NHS Trust, London, UK. Fifty otolaryngology trainees and 15 consultants were recruited. A familiarization session was followed by a 45-minute VR cortical mastoidectomy session. Subjects used a 5-point Likert scale to assess realism, training capacity, assessment capability, trainee confidence, and global rating. RESULTS: The mean familiarization time was 12.5 minutes. No difference existed between trainer and trainees’ mean scores in each domain. Realism: Appearance of anatomy, drill and overall graphics scored favorably (mean scores 4.0, 4.1, 4.1). Drill performance and tissue reaction were rated as undecided (mean scores 3.7, 3.6). Training capacity: Ability to teach anatomy, surgical planning and hand-eye coordination scored highly (mean scores 4.9, 4.7, 4.7). Drilling technique and hand-eye co-ordination scored favorably (mean scores 4.2, 4.1, 4.4). Assessment capability was rated as undecided (mean score 3.9). Trainee Confidence: There was a significant improvement re surgical anatomy (p⬍0.05). Although confidence to perform the procedure in the O.R improved, this was not significant. Global rating: Both groups felt VR-integrated study days should be included in training (mean scores 4.5, 4.8 respectively). CONCLUSION: Face and content validity of the VOXELMAN temporal bone simulator was established for training. Improvements in drill haptics, tissue reaction, the incorporation of auditory cues, and additional visual cues will improve its capacity as an assessment tool.
The Guy’s Hospital Balance Clinic: An MDT Approach Jeremy Corcoran, MSc (presenter); Gareth Jones, MSc; Rachel Ritchie, MSc OBJECTIVE: Patients complaining of dizziness or vertigo may present to a variety of specialties before a diagnosis is made. The Guy’s multidisciplinary balance one-stop clinic consists of two ear nose and throat consultants, three audiologists, and three vestibular physiotherapists. Patients are assessed by a vestibular physiotherapist and a full audiovestibular assessment performed. Patients are then discussed at a multidisciplinary team meeting. A diagnosis is made and treatment arranged. We report the diagnostic spread of patients attending this service in 2009. METHOD: The records of all patients seen in the Guy’s balance clinic were reviewed and their diagnoses recorded. RESULTS: 308 new patients were assessed by this service during 2009. Diagnoses include unilateral peripheral vestibular deficit (101), benign paroxysmal positional vertigo (50), multilevel vestibulopathy (38), vertiginous migraine (34), central (17), Me´nie`re’s disease (12), other otological pathology (11), psychogenic (10), drug induced (6), systemic (5), post-operative (3), cervicogenic (2), cardiac (2), other (17). CONCLUSION: This one-stop service provides an efficient, thorough vestibular assessment and management pathway. The relative spread of diagnoses is similar to those found in other units and we would recommend this model to other units. The Skull High Frequency Vibration-Induced Nystagmus Test Georges Dumas, MD (presenter); Alexandre Karkas, MD; Sebastien Schmerber, MD, PhD OBJECTIVE: Establish the effectiveness of skull vibration induced nystagmus test as a rapid bed side high frequency stimulation test, in the evaluation of peripheral unilateral vestibular lesions. METHOD: A series of 16,000 patients were studied in a prospective series for 13 years in a tertiary center under videonystagmoscopy with the skull vibration-induced nystagmus test. 240 patients were randomly chosen for numerical and statistical data analysis: 93 patients had a partial unilateral vestibular lesion, 131 patients had a total unilateral vestibular lesion, and 36 patients had a brain stem lesion.
RESULTS: Total unilateral vestibular lesion revealed always a skull vibratory nystagmus beating toward the safe side at all frequencies of stimulations in total correlation with the headshaking test and caloric test. In partial unilateral vestibular lesion, a skull vibration nystagmus was found in 76% of cases and the direction at 30Hz was opposite to that recorded at 100Hz in 10% of cases. CONCLUSION: Skull vibration-induced nystagmus test is a useful complementary test to the caloric and head-shaking tests. It is a global vestibular test that can be used to detect vestibular asymmetric responses as part of a bedside examination. The skull vibration nystagmus direction is always beating toward the safe side in total unilateral vestibular lesions, whatever the stimulus location or frequency but can be frequencydependent in partial unilateral vestibular lesions. The caloric test should no longer be considered as an absolute reference test in the diagnosis of peripheral vestibular lesions, since a normal caloric test cannot exclude a vestibular pathology. The vestibule should be explored at multiple frequencies. Therefore, a skull vibration nystagmus test is required among other vestibular tests in order to improve the clinical assessment in vestibular diseases. Totally Endoscopic Stapedotomy: Technique and Results Joao-Flavio Nogueira, MD (presenter); Daniel Cruz, MD OBJECTIVE: To describe the endoscopic technique for stapes surgery, discussing the preliminary results and also showing the potential advantages and disadvantages. METHOD: Review of 5 consecutive patients, submitted to totally endoscopic stapes surgery from May to December 2009. All patients were women with age ranging from 22 to 47 years old. All presented bilateral conductive hearing loss (audiogram). All patients were operated under general hypotensive anesthesia and by the same surgeon. RESULTS: No complications were observed during surgery and after the procedures. The follow-up period ranged from 2 to 8 months. All patients referred improvement at their hearing at the operated side. The air-bone gap was completely closed in all patients at the side which the surgery was performed (postoperative audiogram). Also, no residual tympanic membrane perforations were observed. CONCLUSION: In this small series, endoscopic stapedotomy was technically feasible, safe and promising. There were both advantages and disadvantages. However, a larger series is mandatory to assess the role of endoscopes in otosclerosis surgery. Traditional Versus Laser Stapedotomy: A Comparative Study Sanjeev Mohanty, MBBS, MS, FICS (presenter)
ORALS
BPPV. Treatment of BPPV using CRM results in improved postural stability in dynamic posturography. The vestibular rehabilitation exercise using dynamic posturography is helpful for those patients whose balance ability were still abnormal after CRM.
P107
P108
Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
OBJECTIVE: The objective of this study was to compare hearing outcomes, post operative vertigo and tinnitus for patients undergoing laser stapedotomy versus conventional fenestration stapedotomy. METHOD: Study Design: Prospective Study Year(s)/ Month(s) Study Conducted: 2006-2009. Disease/Condition Studied: Clinical Otosclerosis. Subjects Studied: Otosclerotic patients without previous otological surgery. Setting in Which Subjects Studied: Tertiary care University Hospital. Intervention(s): Randomized. Outcome Measurement(s): Pure-tone audiometry was performed before surgery, postoperatively, and on routine follow-up examination. Independent Variables: Tinnitus and vertigo were subjectively assessed via a questionnaire before surgery, postoperatively, and on routine follow-up examination. Preliminary Analyses (Analysis of Ongoing Study): None. Statistical Methods: 2 test. RESULTS: Of the 35 patients, 15 (42.8%) underwent laser stapedotomy and 20 (57.2%) underwent conventional stapedotomy. The conventional stapedotomy mean air-bone gap (ABG) closed from a preoperative value of 26 dB (standard deviation [SD], 10dB) to 8 dB (SD, 7 dB) on average follow up of 365 days. In 15 laser stapedotomy patients with an average follow up of 365 days, the preoperative mean ABG closed from 31 dB (SD, 10 dB) to 6 dB (SD, 7 dB). There was a trend toward improvement in low-frequency air conduction thresholds after conventional stapedotomy versus worsening of highfrequency thresholds in the Laser group. There was a statistically significant improvement in most recent postoperative high-frequency (6000-8000 Hz) air conduction thresholds in the Laser stapedotomy patients compared with patients who underwent conventional laser stapedotomy. Tinnitus and Vertigo also were present in equal proportions in both the series. CONCLUSION: Laser Stapedotomy when used for otosclerosis, provides excellent hearing in both high and low frequencies as compared to hearing improvement in lower frequencies in conventional stapedotomy. Transtympanic Dexamethasone for Cisplatin Ototoxicity Denise Murphy (presenter); Sam Daniel, MSc, MD, FRCSC OBJECTIVE: Cisplatin chemotherapy causes ototoxicity manifested as hearing loss and/or tinnitus. Ototoxicity is induced via damage to the inner ear by reactive oxygen species. Dexamethasone reduces reactive species and has a well-documented history of transtympanic (TT) clinical use for various cochlear disorders. Objectives in the guinea pig model are: 1) To determine the safety of transtympanic dexamethasone; 2) To determine the effect of transtympanic dexamethasone on cisplatin ototoxicity. METHOD: A prospective, randomized, controlled trial was conducted in a well-established guinea pig model. During the course of one year, pre- and post-treatment Auditory Brain-
stem Responses (ABRs) were compared to measure threshold changes in 58 guinea pigs. The safety of TT dexamethasone and the effect of TT dexamethasone on cisplatin ototoxicity were examined. Comparisons of the mean ABR thresholds using a 2-tailed Student t-test were calculated to determine statistical significance. RESULTS: Ears treated with transtympanic dexamethasone alone showed a slight improvement in hearing thresholds (p ⫽ 0.04). Transtympanic dexamethasone in cisplatin-treated guinea pigs showed signs of otoprotection, particularly in the lower frequencies (8 kHz). CONCLUSION: Transtympanic dexamethasone presents as a simple, safe, and potentially effective treatment modality against cisplatin ototoxicity. Validation of a Virtual Reality Temporal Bone Simulator Sameer Khemani, MBBS, MEd, DOHNS, FRCS (presenter); Catherine Rennie, MBBS; Arvind Singh, MBBS, DLO, FRCS; Neil Tolley, MD, FRCS, DLO OBJECTIVE: To establish face and content validity of the VOXEL-MAN temporal bone simulator. METHOD: Five virtual reality (VR) temporal bone study days were conducted over 8 months (June 2009-Jan 2010) at Imperial College NHS Trust, London, UK. Fifty otolaryngology trainees and 15 consultants were recruited. A familiarization session was followed by a 45-minute VR cortical mastoidectomy session. Subjects used a 5-point Likert scale to assess realism, training capacity, assessment capability, trainee confidence, and global rating. RESULTS: The mean familiarization time was 12.5 minutes. No difference existed between trainer and trainees’ mean scores in each domain. Realism: Appearance of anatomy, drill and overall graphics scored favorably (mean scores 4.0, 4.1, 4.1). Drill performance and tissue reaction were rated as undecided (mean scores 3.7, 3.6). Training capacity: Ability to teach anatomy, surgical planning and hand-eye coordination scored highly (mean scores 4.9, 4.7, 4.7). Drilling technique and hand-eye co-ordination scored favorably (mean scores 4.2, 4.1, 4.4). Assessment capability was rated as undecided (mean score 3.9). Trainee Confidence: There was a significant improvement re surgical anatomy (p⬍0.05). Although confidence to perform the procedure in the O.R improved, this was not significant. Global rating: Both groups felt VR-integrated study days should be included in training (mean scores 4.5, 4.8 respectively). CONCLUSION: Face and content validity of the VOXELMAN temporal bone simulator was established for training. Improvements in drill haptics, tissue reaction, the incorporation of auditory cues, and additional visual cues will improve its capacity as an assessment tool.