Neuromonics Tinnitus Treatment: Third Clinical Trial

Ear & Hearing: April 2007 - Volume 28 - Issue 2 - pp 242-259

doi: 10.1097/AUD.0b013e3180312619

Davis, Paul B.; Paki, Bardia; Hanley, Peter J.

Objectives: The Neuromonics Tinnitus Treatment combines the use of a novel approach to acoustic stimulation with a structured program of counseling and support by a clinician specifically trained in tinnitus rehabilitation. The distinctive acoustic component has been designed to provide stimulation to auditory pathways deprived by hearing loss, engage positively with the limbic system, and allow intermittent, momentary tinnitus perception within a pleasant and relaxing stimulus, thereby facilitating desensitization to the tinnitus signal. The purposes of this study were (1) to demonstrate the efficacy of the treatment, when enhanced with various modifications since previously reported trials and (2) to test the relative clinical effectiveness of two variations of the approach. In the first, intermittent tinnitus perception was facilitated throughout treatment through the use of a stimulus in which intensity peaks allowed the patients' tinnitus perception to be completely covered up, whereas in the intensity troughs their tinnitus was briefly discernible. In the second, subjects experienced little tinnitus perception while listening to the treatment for the first 2 mo, then experienced intermittent perception.

Design: Thirty-five subjects with a predominantly moderate to severe level of tinnitus-related distress before treatment were randomly allocated into one of two treatment groups, corresponding to the two stage-based variations of the Neuromonics Tinnitus Treatment. Participants were provided with a high-fidelity personal sound player with earphones and an acoustic stimulus that had been spectrally modified according to their individual audiometric profile. They were instructed to use the acoustic stimulus for at least 2 hr per day, particularly at those times when their tinnitus was usually disturbing. Each group had equal amounts of clinician time for education, monitoring, and support.

Results: At 2, 4, 6, and 12 mo after commencing treatment, both groups displayed clinically and statistically significant improvements in tinnitus distress, awareness, and minimum masking levels as well as loudness discomfort levels. Improvements increased with time over the first 6 mo of therapy, at which time 91% of all subjects across the two groups reported an improvement in tinnitus disturbance (as measured by the Tinnitus Reaction Questionnaire) of at least 40%, with a mean improvement of 65%. Also, 80% of subjects at 6 mo reported a level of tinnitus disturbance that was no longer clinically significant. There was some indication of a more consistent benefit over 12 mo for the group that was provided initially with a high level of tinnitus interaction; however, inter-group differences were not statistically significant. A relation between reported treatment usage (hours per day) and clinical outcomes was observed, suggesting that a dosage effect may apply with the stimulus provided.

Conclusions: This study found that the Neuromonics Tinnitus Treatment provides rapid and profound improvements to the severity of tinnitus symptoms and their effect on the subject's quality of life. This was a consistent effect, provided by a treatment that subjects reported as being pleasant to use. Both of the stage-based variations of the treatment that were tested in this study were shown to be successful in achieving these outcomes

Chronic cough and irritable larynx

Journal of Allergy and Clinical Immunology (JACI) (Dec 2010) 

Bucca CB, Bugiani M, Culla B, Guida G, Heffler E, Mietta S, Moretto A, Rolla G, Brussino L

BACKGROUND: Perennial rhinitis (PR), chronic rhinosinusitis (CRS), or both, asthma, and gastroesophageal reflux disease (GERD) are the most frequent triggers of chronic cough (CC). Extrathoracic airway receptors might be involved in all 3 conditions because asthma is often associated with PR/CRS and gastroesophageal refluxate might reach the upper airway. We previously found that most patients with rhinosinusitis, postnasal drip, and pharyngolaryngitis show laryngeal hyperresponsiveness (LHR; ie, vocal cord adduction on histamine challenge) that is consistent with an irritable larynx. 

OBJECTIVE: We sought to evaluate the role of LHR in patients with CC. 

METHODS: LHR and bronchial hyperresponsiveness (BHR) to histamine were assessed in 372 patients with CC and in 52 asthmatic control subjects without cough (asthma/CC-). In 172 patients the challenge was repeated after treatment for the underlying cause of cough. RESULTS: The primary trigger of CC was PR/CRS in 208 (56%) patients, asthma in 41 (11%) patients (asthma/CC+), GERD in 62 (17%) patients, and unexplained chronic cough (UNEX) in 61 (16%) patients. LHR prevalence was 76% in patients with PR/CRS, 77% in patients with GERD, 66% in patients with UNEX, 93% in asthma/CC+ patients, and 11% in asthma/CC- patients. Upper airway disease was found in most (95%) asthma/CC+ patients and in 6% of asthma/CC- patients. BHR discriminated asthmatic patients and atopy discriminated patients with PR/CRS from patients with GERD and UNEX. Absence of LHR discriminated asthmatic patients without cough. After treatment, LHR resolved in 63% of the patients and improved in 11%, and BHR resolved in 57% and improved in 18%. 

CONCLUSIONS: An irritable larynx is common in patients with CC and indicates upper airway involvement, whether from rhinitis/sinusitis, gastric reflux, or idiopathic sensory neuropathy.

The effects on cardiac functions and arterial blood gases of totally occluding nasal packs and nasal packs with airway

The Laryngoscope

Volume 120, Issue 11, pages 2325–2330, November 2010

1. Ehab Zeyyan MD¹, 
2. Münir Demir Bajin MD^2,*,
3. Kudret Aytemir MD², 
4. Taner Yılmaz MD¹

Article first published online: 22 OCT 2010

DOI: 10.1002/lary.21064

Abstract

Objective:

To evaluate the effects on cardiac functions and blood arterial gases of totally occluding nasal packs and nasal packs with airway.

Study Design:

Prospective, randomized trial.

Methods:

Thirty-nine adults without any comorbidities underwent septoplasty or septorhinoplasty and had nasal packs placed postoperatively; 19 nasal packs with airways and 20 totally occluding nasal packs. Twenty-four-hour Holter monitorization was done pre- and postoperatively. Arterial blood gas analysis was performed both before the operation and after application of nasal packs.

Results:

Application of packs with airway did not cause any significant changes in blood gas parameters. Packing with totally occluding nasal packs caused a significant decrease in HCO₃ and pCO₂, and insignificant changes in pO₂, O₂ saturation, and pH. No serious arrhythmias were observed in any patient. In both groups, nasal packing resulted in a significant increase in minimum heart rates, a significant decrease in maximum heart rates, and insignificant changes in the mean heart rates. Heart rate variability obtained from 24-hour Holter electrocardiography was analyzed by power spectral analysis. An increase in the high-frequency (HF) domain, a decrease in the low-frequency (LF) domain, and a decrease in the LF/HF ratio were observed after packing in both groups.

Conclusions:

Nasal pack-induced cardiac complications may occur due to increased vagal stimuli secondary to nasal mucosa compression rather than obstruction-related hypoxia. The use of nasal packs in the elderly patients with cardiopulmonary disease warrants close observation. Nasals packs with airways should be preferred in patients susceptible to hypoxia. Laryngoscope, 2010

The effects of uncinectomy and natural ostial dilatation on maxillary sinus ventilation: a clinical experimental study

European Archives of Oto-Rhino-Laryngology (Nov 2010)

Kutluhan A, Salviz M, Bozdemir K, Kanbak O, Ulu M, Yalçiner G, Bilgen AS 

The purpose of this study was to determine the effect of uncinectomy without sinusotomy and natural ostial dilatation on maxillary sinus ventilation in chronic rhinosinusitis. 

Twenty patients with chronic rhinosinusitis were included in this study. The patients were randomly divided into two groups. Group 1 consisted of patients with uncinectomy (n = 10), while group 2 was made up of patients treated with natural ostial dilatation (n = 10). The CO(2) tension and pressure levels of the maxillary sinus during inspiration and expiration phases were obtained and compared before and after the procedures within and between the groups. 

The mean CO(2) tension levels in both groups were significantly decreased after the procedures. The mean maxillary sinus pressure during inspiration was significantly decreased to a negative value after uncinectomy; however, no significant change was observed during expiration. There were no significant changes in maxillary sinus pressures after natural ostial dilatation procedure. Both uncinectomy and natural ostial dilatation seem to be equally effective in decreasing maxillary sinus pCO(2) levels. 

The effects of decreased maxillary sinus pressure during inspiration after uncinectomy on mucociliary clearance and development mechanisms of chronic rhinosinusitis seem to be worth investigating.

Bacterial communication encourages chronic, resistant ear infections

Bacterial communication encourages chronic, resistant ear infections

Complications of adenotonsillectomy

Current Opinion in Otolaryngology & Head & Neck Surgery:

December 2010 - Volume 18 - Issue 6 - p 539–543

doi: 10.1097/MOO.0b013e3283404dcc

Pediatric otolaryngology: Edited by Lisa Buckmiller

Statham, Melissa M

Abstract

Purpose of review: Tonsillectomy and adenoidectomy are two of the most commonly performed pediatric surgical procedures. As with all surgical intervention, tonsillectomy and adenoidectomy are associated with a host of potential complications. Fortunately, for most children undergoing adenotonsillectomy (T&A), complications are rare. This review is intended to summarize recent reports, which may lead to prevention and treatment of T&A complications.

Recent findings: The presented reports of complications and risk factors for complications in children undergoing T&A highlight perioperative medical management as a means to decrease perioperative complications. Certain tonsillectomy techniques, such as microdebrider intracapsular tonsillectomy, may lead to decreased posttonsillectomy hemorrhage and dehydration. Despite published recommendations, preoperative assessments for bleeding diatheses vary among practitioners. Conversely, guidelines for evaluation of posttonsillectomy hemorrhage are lacking. Some pediatric populations, such as children with coagulopathy, neurologic disease, and obesity, have increased risk of perioperative complications, and recent reports regarding their care are presented.

Summary: We present recent data pertinent to the contemporary management of medical and surgical complications of T&A, with particular focus on specific at-risk pediatric populations. In the patient groups illustrated in this review, anticipation of complications may decrease complications or lead to improved management of complications when they occur.

Acute epiglottitis: epidemiology and Streptococcus pneumoniae serotype distribution in adults

The Journal of Laryngology & Otology 

25 Nov 2010

M Isakson^a1 and S Hugosson^a1 c1

^a1 Department of Otolaryngology, Örebro University Hospital, Sweden

Abstract

Objectives: We studied the incidence and bacterial epidemiology of acute epiglottitis presenting in the first 16 years following the introduction of general childhood vaccination against Haemophilus influenzae type b. Our main objectives were to analyse (1) the incidence of Streptococcus pneumoniae epiglottitis in adults and (2) the distribution of pneumococcal serotypes involved.

Materials and methods: The medical records of patients with acute epiglottitis (International Classification of Disease code J05.1) were investigated. Streptococcus pneumoniae serotyping was performed using gel precipitation.

Results: The overall incidence of acute epiglottitis was 0.98 cases/100 000/year, compared with 4.5 cases/100 000/year before the vaccination programme. The incidence was reduced both in children and adults, compared with pre-vaccination values. However, the incidence of Streptococcus pneumoniae epiglottitis in adults increased from 0.1 to 0.28 cases/100 000/year over the same time period. The causative agent was Streptococcus pneumoniae in 10 adults. Nine of 10 pneumococcal strains could be serotyped. All but one serotype is represented in the 23-valent pneumococcal polysaccharide vaccine (PPV23) used in adults.

Conclusion: In acute epiglottitis, now a disease of adults, the most important bacterial aetiology is Streptococcus pneumoniae. The serotype distribution found in this study indicates that the infection is preventable by PPV-23 vaccination with the 23-valent polysaccharide vaccine.

(Accepted July 07 2010)

Key words

• Epiglottitis; 
• Epidemiology; 
• Streptococcus Pneumoniae; 
• Vaccination

Correspondence:

^c1 Address for correspondence: Dr Svante Hugosson, Dept of Otolaryngology, Örebro University Hospital, SE-701 85 Örebro, Sweden Fax: +46 19 10 33 01 E-mail: svante.hugosson@orebroll.se

Footnotes

Dr S Hugosson takes responsibility for the integrity of the content of the paper

Competing interests: None declared

Postoperative bleeding in paediatric ENT surgery. First results of the German ESPED trial

Hämostaseologie 30 (41), S108-11 (Nov 2010)

Bidlingmaier C, Olivieri M, Stelter K, Eberl W, von Kries R, Kurnik K; 

Bleeding after ear-nose-and throat surgery in children is a serious complication. With the help of the German Surveillance Unit for Rare Paediatric Disorders (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland; ESPED) a two year survey was performed to record the incidence, severity, reasons and treatment of haemorrhages. During the study period, 1069 bleeds were reported from 720 paediatric hospitals and departments of otorhinolaryngology after adenoidectomy and tonsillectomy. 713 reports could be analyzed. Two deaths occurred after adenoidectomy.

Although laboratory screening was performed in more than 70% of all cases, bleeding complications were neither foreseeable nor preventable. Inherited coagulopathies were rare and in most cases not detected, neither by laboratory screening nor by taking a history.

Since preoperative measures cannot help much to improve the situation, all efforts have to be taken to improve the postoperative period, especially since more than 20% of the hemorrhages occurred during weekends. Guidelines on postoperative care and behaviour should therefore be implemented and parents and patients must be informed on bleeding risks and on what to do in case of emergency. If bleeding occurs, extensive coagulation testing is mandatory.

Safety of intranasal Bevacizumab (avastin) treatment in patients with hereditary hemorrhagic telangiectasia-associated epistaxis

The Laryngoscope (Nov 2010)

Chen S, Karnezis T, Davidson TM; 

OBJECTIVES/HYPOTHESIS:: Assess for complications of intranasal Bevacizumab application in patients with hereditary hemorrhagic telangiectasia (HHT)-associated epistaxis. 

STUDY DESIGN:: Retrospective chart review. 

METHODS:: In 58 patients presenting with recurrent HHT epistaxis, Bevacizumab was applied intranasally either as a submucosal injection or as a topical spray between October 2006 and June 2010. In many of the injected patients, the potassium titanyl phosphate (KTP) laser was used adjunctively for vessel photocoagulation. A phone interview was performed in July 2010 to assess for treatment complications. 

RESULTS:: Of the 58 treated patients 52 were contacted. Patient surveys were performed 1.5 to 46 months following their initial Bevacizumab treatment. Within the treatment population, five patients had sustained a septal perforation. Notably, these patients were treated early in the study period at which time the cartilaginous septum was often both injected and lasered. Subsequently, the treatment protocol was changed and the cartilaginous septum was neither lasered nor injected. After these changes were made no additional septal perforations were identified. No other adverse events were associated with intranasal Bevacizumab treatment. 

CONCLUSIONS:: Bevacizumab applied as either a submucosal injection or as a topical nasal spray, with or without application of the KTP laser, is a safe treatment regimen. Still, when Bevacizumab injections are performed, the cartilaginous nasal septum should be avoided as patients may develop septal perforations. Laryngoscope, 2010.

ENT morbidity at high altitude

The Journal of Laryngology & Otology

• FirstView Article
• doi: 10.1017/S0022215110002331 (About doi)
• Published online by Cambridge University Press 17 Nov 2010

B K Prasad

Department of ENT and Head and Neck Surgery, Command Hospital (Eastern Command (EC)), Kolkata, West Bengal, India

Abstract

Background: People suffer unique health problems in high altitude areas, due to such factors as elevation, aircraft ascent and descent, extreme cold, hypoxia, hypobaria, and low relative humidity. This study was conducted to evaluate ENT morbidity at high altitude.

Methods: Serving soldiers introduced to a high altitude environment who presented with various ENT symptoms were examined to identify ENT disease. In addition, patients undergoing hyperbaric chamber therapy, tracheostomy and treatment of cold injuries were also examined for ENT problems.

Results: The following were detected: 13 cases of otic barotrauma, 11 cases of sinus barotrauma, three cases of vertigo, six cases of pinna frostbite, three cases of barotrauma caused by hyperbaric chamber therapy, an unusually high incidence of epistaxis, and innumerable patients with high altitude pharyngitis.

Conclusion: Diseases of the ear, nose and throat contribute significantly to high altitude morbidity. In a military context, health education of troops is necessary to avoid such problems.

(Accepted June 28 2010)

Correspondence:

^c1 Address for correspondence: Lt Col (Dr) B K Prasad, Department of ENT and Head and Neck Surgery, Command Hospital (EC), Alipore Road, Kolkata 700027, West Bengal, India Email: bipin_rupa@rediffmail.com

Footnotes

Presented at the 62nd Annual Conference of the Association of Otolaryngologists of India, 8 January 2010, Mumbai, India