Current view of neurotransmitter changes underlying tinnitus

Tinnitus is the perception of a monotonous sound not present in the environment. Nearly 20% of the U.S. population suffers from tinnitus, and tinnitus has been reported to be the most prevalent service-connected disability of all U.S. veterans （Henry et al., 2005; Eggermont, 2012; Veterans Benefits Administration, 2014）. Many types of peripheral injury have been understood to induce tinnitus, including damage to the cochlea by intense sound or ototoxic medications and destruction of the auditory nerve by cochlear ablation or nerve transection （Lee and God- frey, 2014）. The pathophysiological mechanisms by which tin- nitus develops are only poorly understood. In order to further clarify the pathogenesis, a need has been expressed for a better understanding of the rebalancing of excitatory and inhibitory signaling mechanisms that occur after peripheral injury （Gold and Bajo, 2014）. One of the current, prominent hypotheses of tinnitus development is that, after being triggered by peripheral injury, tinnitus may result from a maladaptation of the central auditory system to this peripheral dysfunction （Auerbach et al., 2014）, and that one of the mechanisms by which this occurs is a decrease in inhibitory neurotransmission. The major struc- tures that play a role in transmitting neural activity through the ascending central auditory system include the cochlear nucleus and superior olivary complex of the pons-medulla region, the inferior colliculus of the midbrain, the medial geniculate nude- us of the thalamus, and the auditory cortex.

Successful Treatment of Thyroid Carcinoma Invading the Trachea as a Single-Stage Procedure: A Case Report

Objective: Locally advanced thyroid carcinoma is relatively rare;extrathyroid extension, such as to the trachea, is one of the most important prognostic factors. Surgical resection is the mainstay of treatment, and appropriate surgical planning is crucial for obtaining a reasonable prognosis and quality of life of the patients. Case Report: Herein, we report a case of advanced thyroid carcinoma involving the trachea. Total thyroidectomy and window resection of the trachea were performed. The tracheal defect was approximately 2.5 × 3.0 cm in size, extending from the first to the third tracheal cartilage, and was reconstructed with auricular cartilage and covered with the sternohyoid muscles of both sides in a single-stage surgical procedure. The tracheal stoma was closed 2 weeks after the surgery. There were no postoperative complications. Conclusion: This reconstruction of the relatively small defect of the trachea provided excellent functional and cosmetic results.

Audit of Outcomes of Endoscopic Cholesteatoma Ear Surgery

Background: The objective of cholesteatoma surgery is not only to eradicate disease, but also reduce the risk of recurrence. While the use of the endoscope has been shown to reduce the rate of residual disease, there is currently insufficient data on recidivism and hearing outcomes following exclusive endoscopic use in cholesteatoma ear surgery. Objectives: Auditing outcomes of exclusive endoscopic surgery (EES) for the surgical management of cholesteatoma, with a secondary aim of comparing recidivism and hearing outcomes of 4 different surgical techniques, namely, EES, microscopic canal wall down (CWD), microscopic canal wall up (CWU) and combined endoscopic-microscopic techniques (CEM). Methods: A retrospective chart review was conducted at two tertiary academic hospitals in Cape Town, namely, Red Cross War Memorial Children’s Hospital (RCWMH) for patients below13 years and Groote Schuur Hospital (GSH) for patients above 13 years, over a 5 year period, between January 2012 and December 2016. Results: 128 cholesteatoma surgeries overall;110 patients were from GSH and 18 from RCWMH. Eight RCWMH patients underwent EES, 7 had CWU, 2 had CWD and 1 underwent CEM. Overall recidivism in the RCWMH population was 33% (6/18), 2 underwent EES, 2 underwent a microscopic CWU, 1 had a CWD and 1 underwent CEM. The mean postoperative hearing in this group was 40 dB from 50.3 decibels (dB) preoperatively. In the GSH group, 23 underwent an EES, 42 had a CWU, 40 underwent CWD and 5 underwent CEM. Overall recidivism for the GSH group was 17% (19/110). Of those, 7 underwent EES, 8 underwent microscopic CWU, 1 underwent CWD and 3 underwent CEM. Mean postoperative hearing was 47.4 dB from 48.4 dB preoperatively. Conclusions: The CWD technique demonstrated superior outcomes. In the GSH group, the EES approach had the same recurrence rate as CWU. Much higher recidivism was observed in the RCWMH group. Management of cholesteatoma requires a highly individualized approach to determine the most appropriate surgical treatment paradigm.

Synovial osteochondromatosis of the temporomandibular joint: A case report

BACKGROUND Synovial osteochondromatosis is a rare but benign condition that can result in significant impairment of joint functionality.This case report documents an uncommon presentation of this disorder occurring within the temporomandibular joint,causing the patient significant pain,trismus,and difficulty with daily activities such as eating and speaking.A review of the literature including disease mechanisms and previously documented cases is included to provide comprehensive background for clinical decision-making.CASE SUMMARY A 48-year-old male patient presented with a 3-mo history of trismus,crepitus with jaw movement and significant pain while chewing.Physical examination revealed a firm mass and tenderness to palpation at the right temporomandibular joint.Further workup revealed a bilobed mass extending into the joint space as well as significant bony erosion of the glenoid fossa.The patient underwent mass excision with joint reconstruction and pathology revealed synovial osteochondromatosis.The patient reported significant improvement in his symptoms postoperatively.CONCLUSION This report outlines the investigative approach and treatment course of synovial osteochondromatosis.The positive outcome following surgical intervention in this case emphasizes the importance of interdisciplinary collaboration and the potential for improvement in quality of life of this patient population.

接触点头痛的外科治疗

Introduction.Contact point headaches are caused by contact between the nasal s eptum and the lateral nasal wall by a mechanism of referred pain involving the t rigeminal nerve. Our goal was to investigate headaches caused by the contact bet ween the septum and the superior turbinate or medial wall of the ethmoid sinuses and not the middle turbinate. Materials and Methods.A retrospective chart revie w was performed on patients who underwent septoplasty and sinus surgery for head ache. The total number of patients who opted for surgery was 23. Only 12 patient s met the criteria of having a contact point between the septum and medial wall of the ethmoid sinus, or septumand superior turbinate, which were demonstrated v ia CT scan of the sinuses. These patients underwent surgical intervention in ord er to relieve the contact points. Results.According to the same pain questionnai re given pre-and postoperatively, 83%no longer complained of headaches, while 8%had significant relief. Forty-one percent of our patients were previously di agnosed with migraines; 80%of these patients were successfully treated by surge ry. Discussions.Contact point headaches and migraine without aura (MWOA) have si milar symptoms (eg,photophobia, phonophobia, nausea and vomiting, pulsating natu re).We believe contact point headaches should be considered in the patient with a diagnosis of MWOA headaches.

Low Cost Osseointegrated Implant System for Developing Countries

Objective: Osseointegrated hearing implants have been readily available and extensively used in developed countries for over twenty years. Despite a great need for this technology, use of these implants in developing countries has been limited due to the prohibitive cost of the surgical implant system as well as the implant devices themselves. To address this problem we have developed a drill and implant system that mimics the currently available instrumentation using materials that are readily available at a fraction of the cost. Study Design: Proof of Concept. Methods: The construction of the drill and implant system will be described. Testing of the system so that it adhered to Cochlear’sTM Bone anchored hearing aid system specifications including the drill speed and torque settings were measured. Temperature readings were also recorded during procedures performed on human cadaveric temporal bones. Results: The speed of the drill with the guide drill and countersink drill bits ranged from 1400 revolutions per minute (rpm) to 2300 rpm’s. The temperature change of the room temperature temporal bones varied from 0 degrees to +0.2 degrees Fahrenheit during the drilling process with both drill bits. All five implants were stable in the cadaver bone after being checked for initial stability. Conclusion: This low cost implant system may make the BAHA technology more easily available to developing countries pending future studies with animal models.

Postoperative mometasone irrigations improve quality of life in skull base tumor patients

Objectives:The use of topical corticosteroids to manage postoperative sinonasal symptoms after endoscopic skull base surgery (ESBS) has not been well studied.We quantified long‐term impact of postoperative steroid irrigations (SIs) on quality of life of patients after ESBS.Methods:Retrospective review of patients at the University of Pennsylvania undergoing ESBS from 2010 to 2019.Data on patient demographics and postoperative treatment with nasal saline irrigation twice daily with and without dissolved steroids (mometasone or budesonide) was collected.Preoperative,and 1‐,3‐,6‐,12‐,18‐,and 24‐month postoperative Sino‐Nasal Outcome Test (SNOT‐22) scores were assessed.Results:A total of 727 patients were assessed (53.4% males),with 479 patients in the no SI group and 248 patients in the SI group.Preoperative SNOT‐22 scores did not differ significantly (P = 0.19).1‐,3‐,6‐,12‐,18‐,and 24‐month post‐op SNOT‐22 scores did not significantly differ between groups.However,mometasone irrigations resulted in significantly lower postoperative 2‐year SNOT‐22 scores compared to budesonide (P < 0.01) and saline (P = 0.03).Conclusions:Though corticosteroid irrigations are routine in managing inflammatory sinus disease,their role in postoperative management after ESBS for tumors is unclear.Our findings suggest that mometasone irrigation may be effective at improving postoperative quality of life in patients after ESBS.

Pediatric drug-induced sleep endoscopy: An updated review of the literature

The field of drug-induced sleep endoscopy(DISE)has grown considerably over the last 10~15 years,to now include its use in pediatric patients.In this review article,we outline our approach to the use of this technology in Children with Airway Obstruction,most specifically in the management of children with airway obstruction and known or suspected adenotonsillar enlargement.

Pharmacologic management of post-tonsillectomy pain in children

Tonsillectomy is a very common procedure in children,often performed on an outpatient basis.Severe postoperative pain is common,and can be prolonged.Despite a large number of available analgesic medications,often employed in combination,achieving adequate pain control remains a persistent challenge.Research suggests a tendency among caregivers to undertreat pain,and a need for detailed care instructions and education to ensure adequate pain management.Furthermore,ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results.This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.

The impact of endoscopic sinus surgery and aspirin desensitization on psychological burden in aspirin-exacerbated respiratory disease

Background:Aspirin-exacerbated respiratory disease(AERD)is an aggressive inflammatory disorder of the upper and lower respiratory tract.Corticosteroids,leukotriene modifiers,endoscopic sinus surgery(ESS),aspirin(ASA)desensitization,and biological immu-nomodulators are currently used to treat the disorder.Objective:The objective of this study was to determine the psychosocial impact of ESS and ASA desensitization on AERD patients.Methods:All AERD patients who underwent complete ESS were divided into two cohorts based on ASA desensitization status.The psychosocial metrics of the SNOT-22 were collected and analyzed at the following time points:pre-operative,1-month,3-month,6-month,and 12-month after ESS.Results:One hundred and eighty-four AERD patients underwent ESS from November 2009 to November 2018.From this group,130 patients underwent ASA desensitization(AD cohort)and 54 patients remained non-desensitized(ND cohort).AD patients showed a significantly greater reduction in total SNOT-22 scores over the study period compared to ND patients(p=0.0446).Analysis of SNOT-22 psychosocial metrics showed a significantly greater improvement in patient productivity in the AD cohort when compared to the ND cohort(p=0.0214).Further,a sub-group analysis accounting for subject attrition showed a significantly greater improvement in both productivity and concentration in AD patients when compared to the ND cohort(productivity:p=0.0068;concentration:p=0.0428).Conclusions:ESS followed by ASA desensitization decreases the overall psychosocial burden in AERD patients with a significant improvement in perceived productivity and concentration.This has significant implications given the psychosocial impact of chronic diseases.

Neurofibromatosis type 2 and auditory brainstem implantation

Neurofibromatosis type 2 （NF-2） is one of the most common single gene disorders in the nervous system.For approximately 96% of patients with NF-2 present with bilateral Schwannomas involving the eighth cranial nerves, which may be accompanied by Schwannomas involving other cranial, spinal or peripheral nerves, NF-2 is also referred to as ＂bilateral acoustic neuromas＂. Due to progression of tumors, surgery or radiotherapy, patients with bilateral acoustic neuromas will eventually suffer profound or total hearing loss, resulting in decrease of quality of life （QOL）.

Radiofrequency ablation of the lateral palatal space for snoring

Objective:Pilot study to examine the effect of radiofrequency ablation (RFA) of the lateral palatal fat pad in patients with socially-disruptive snoring.Method:Snoring outcomes and complications were compared between a group of patients with treated with RFA ablation of the lateral soft palate fat pad with or without inferior turbinate reduction (8 patients) and another group undergoing inferior turbinate reduction alone (12 patients).Results:Snoring loudness and bothersomeness improved in the palate but not inferior turbinate group.Pain was mild and no major complications were observed.Conclusion:The study supports RFA ablation of the lateral palatal space as a potential low morbidity procedure for snoring.

A pilot prospective prevalence study of chronic rhinosinusitis associated with inflammatory bowel disease

Background:Inflammatory bowel disease(IBD)is characterized by chronic inflammation of the gastrointestinal tract.Extra-intestinal manifestations such as pulmonary diseases have been reported.Chronic rhinosinusitis(CRS),an inflammatory condition of the sinonasal mucosa,has been associated with several lung diseases.Given the relationship between lung and intestinal pathologies,and lung and sinus pathologies,we aimed to determine the prevalence of IBD among CRS patients.Methods:Pilot prevalence study.Ninety-two CRS patients were screened for IBD symptoms from October 2018 to January 2020.Patient-reported disease symptoms and overall quality of life were evaluated using the Sino-Nasal Outcome Test 22(SNOT-22),Short Inflammatory Bowel Disease Questionnaire(SIBDQ),and EuroQol 5 Dimension 5 Level(EQ-5D-5L)questionnaires.The Modified Lund-Kennedy(MLK)endoscopic and Lund-Mackay(LM)grading systems were used to confirm CRS diagnoses.Individuals who reported subjective symptoms of IBD were referred to a gastroenterologist clinic for further diagnostics.Results:Twenty of the 92(20.2%,95%CI:12.6%-29.8%)CRS patients reported symptoms of IBD and four individuals(4.26%,95%CI:1.17%-10.50%)were sub-sequently diagnosed with IBD.Compared to patients without IBD symptoms(n=72),those with symptoms(n=20)reported significantly worse SNOT-22(P=0.002),SIBDQ(P<0.05),and EQ-5D-3L(P=0.0063)scores.However,these patients did not exhibit significantly different MLK(P=0.81)or LM(P=0.04)scores.Conclusion:The prevalence of IBD may be elevated among individuals with CRS relative to the general Canadian population.This pilot study suggests that CRS with IBD is associated with lower quality of life.Further cross-sectional studies with larger sample sizes are required.

The association of Leptospermum honey with cytokine expression in the sinonasal epithelium of chronic rhinosinusitis patients

Objective:To identify the differences in cytokine expression between sinonasal tissue from patients treated with Leptospermum (Manuka) honey (LH) irrigation versus normal saline irrigation twice-daily for twelve weeks following sinus surgery (FESS).Methods:Forty-six CRS patients were recruited.Sinus tissue biopsies were collected during FESS and then at 5 and 12 weeks postoperatively during the course of treatment.A multiplex cytokine assay quantified the abundance of 17 cytokines in biopsied tissue.Cytokine expression fold-change was analyzed between each time point using a robust linear regression model and compared between the two treatment groups.Results:Compared to the saline irrigation group,five cytokines were differently expressed (CI =95%) in sinonasal tissue obtained from subjects in the LH irrigation group during the 12-week treatment period.Cytokines IL-6 (P =0.0400),IL-8 (P =0.0398),MCP-1 (P =0.0284),and MIP-1β (P =0.016) were significantly increased in the LH irrigation group compared to the saline irrigation group.IL-13 was significantly increased in the saline irrigation group compared to the LH group (P =0.0086).Conclusion:LH may potentially act to modulate the expression of IL-6,IL-8,IL-13,MCP-1 and MIP-1β in sinonasal tissue.

Nasopharyngeal carcinoma-Improving cure with technology and clinical trials

Nasopharyngeal carcinoma is a unique cancer in the head and neck region.It has a very distinct geographic variation of incidence with more than ten times difference in incidence in high risk population compared with low-risk population.No other head and neck cancer has this large worldwide variation of incidence.It remained commonest cancer in young male adults below the age of 50 in southern China.

Leveraging real-time data to drive quality improvement in a pediatric health system

We are inundated by data;healthcare is no different.The electronic medical record,the numerous patient care monitors,and the thousands of medications to be reconciled with specific dosing parameters are a few examples of the omnipresent and intimidating nature of data in healthcare.Across the world,healthcare without data does not exist.The data represent many forms but are quickly moving towards electronic formats.As ubiquitous as data are the near universal finding that such data are lagging.There is an urgent need for real-time data in improving processes and ultimately outcomes in healthcare.If data lag by four to eight weeks,if not longer,then true change cannot occur and harm continues in that interval.This review article discusses the urgent need for real-time data and demonstrates examples of how Children's National Medical Center in Washington,DC uses real-time data to drive outcomes.

Cautery-assisted palatal stiffening operation for obstructive sleep apnea: A systematic review and meta-analysis

Objective:To systematically review outcomes for cautery-assisted palatal stiffening operation (CAPSO) as a treatment for adult obstructive sleep apnea (OSA).Methods:Five databases (including PubMed/MEDLINE) were searched through July 12,2017.Results:Eight studies (307 patients) met criteria.Overall,CAPSO alone (80 patients) improved AHI from a mean ± standard deviation (M±SD) of (16.8±11.9) to (9.9±10.9) events/h (41.1% decrease).Mixed CAPSO with/without tonsillectomy (92 patients) improved AHI from a M] SD of (24.8 ± 12.6) to (10.6 ± 9.5) events/h (61.7% decrease).CAPSO with expansion pharyngoplasty (EP),(78 patients) improved AHI from a M ± SD of (26.3 ± 17.7) to (12.6 ± 5.8) events/h (52.1% decrease).CAPSO alone (90 patients) improved lowest oxygen saturation (LSAT) by 5.4 points.Mixed CAPSO with/without tonsillectomy (77 patients) improved LSAT by 10.6 points,and CAPSO with EP (78 patients) improved LSAT by 5.2 points.Sleepiness improved (182 patients) from an Epworth Sleepiness Scale score of 11.8 to 5.1,P < 0.001.Snoring reduced (120 patients) from 7.9 to 2.5 on visual analog scales (0-10 scale),P < 0.001.Conclusions:Apnea-hypopnea index has improved by 41.0% for CAPSO alone,61.7% for CAPSO with tonsillectomy and 52.1% for CAPSO with expansion pharyngoplasty.Additionally,lowest oxygen saturation,sleepiness and snoring have also improved after CAPSO.

Anxiety and depression in spasmodic dysphonia patients

Objective/Hypothesis: Experts used to believe that spasmodic dysphonia (SD) was a psychogenic disorder. Although SD is now established as a neurological disorder, the rates of co-morbid anxiety and depression range from 7.1％ to 62％. Our objective was to study the prev-alence and risk factors associated with these mood disorders in SD patients. Study design: Retrospective. Methods: SD patients who presented for botulinum toxin injections were recruited. Demo-graphic data, Hospital Anxiety and Depression Scale (HADS), Voice Handicap Index-10 (VHI-10), General Self-Efficacy scale (GSES), Disease Specific Self-Efficacy in Spasmodic Dysphonia scale (DSSE), and Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) were collected. Results: One hundred and forty two patients (age (59.2 ± 13.6) years, 25.4％ male) had VHI-10 of 26.3 ± 6.9 (mean ± standard deviation), GSES 33.2 ± 5.8, CAPE-V 43.9 ± 20.9, HADS anxiety 6.7 ± 3.7, and HADS depression 3.6 ± 2.8. About 19 (13.4％) and 4 (2.8％) had symptoms of anx-iety and depression respectively. Final linear regression model for HADS anxiety (R2 = 32.90％) showed that patients who were less likely to have anxiety symptoms were older age (p < 0.001), male (p = 0.002), have higher GSES (p < 0.001) and lower VHI-10 (p = 0.004). Final linear regression model for HADS depression score (R2 = 34.42％) showed that patients who were less likely to have depressive symptoms had high DSSES (p < 0.001). Conclusions: Prevalence of anxiety (13.4％) and depression (2.8％) in SD were lower than previ-ously reported in the literature. Risk factors for anxiety were: younger age, female gender,lower general self-efficacy, and higher perceived vocal handicap. The main risk factor for depression was lower disease specific self-efficacy.

Tracheostomy manipulations: Impact on tracheostomy safety

Importance: Tracheotomy is one of the riskiest procedures for composite morbidity within pediatric otolaryngology. During the postoperative period, each time the tracheostomy tube is manipulated, there is opportunity for morbidity (e.g. a patient is vulnerable to accidental decannulation and airway loss). Objective: To identify areas of improvement in caring for 'fresh tracheostomy' patients by determining the number of times a tracheostomy tube is manipulated from placement until discharge. The hypothesis is that the more a tracheostomy is manipulated, the higher probability of morbidity. Methods: A quality improvement initiative was conducted to map the care of patients who underwent tracheostomy placement over 12 months. Tracheostomy care and manipulation by all providers were reviewed. Complications, wound care, and respiratory treatments were also evaluated. Results: Patients were hospitalized for an average of 39 days (7–140) following tracheostomy. The first tracheostomy tube change occurred on average 6 days (5–10) following placement. Tracheostomy tubes were manipulated an average of 6 (2.5–11.9) times a day to amount to 216 (51–1091) times between placement and discharge. Bedside nurses and respiratory therapists were responsible for 95% of these actions;physicians accounted for 4%. There were 6 tracheostomy related complications. Three were accidental decannulations resulting in cardiopulmonary arrest. One of these caused long term patient morbidity. Patients with more than 4 manipulations per day during the 2 weeks following tracheostomy tube placement, were more likely to have a tracheostomy related complication than those with less than 4 (OR: 12.5;95% CI: 1.2–130.6;P = 0.0349). Interpretation: While uncommon, complications related to tracheostomy can have serious long term effects and at best prolongs length of stay for patients. Reducing the number of tracheostomy manipulations may provide safer postoperative care ultimately reducing morbidity and potentially mortality;children on average have 6 tracheotomy manipulations/day with only 2% being by the physician.