A New Theory for Menieres Disease: Detached Saccular Otoconia

Ménière's disease is an inner ear disorder characterized by vertigo attacks, fluctuating and progressive hearing loss, tinnitus, and aural fullness in the affected ear. The pathophysiology of Ménière's disease remains elusive. Theories so far are anatomical variation in the size or position of the endolymphatic sac and duct, viral inflammation or autoimmune involvement of the sac, or a genetically determined abnormality of endolymph control. Animal studies on blocking the ductus reuniens and endolymphatic duct have produced hydrops in the cochlea, saccule, and utricle. Cone beam computed tomography images show a similar pattern with apparent obstruction of the ductus reuniens, saccular duct, and endolymphatic sinus. New studies documenting the age of onset of Ménière's disease show a pattern similar to benign paroxysmal positional vertigo, raising the possibility that the fundamental cause of Ménière's disease might be detached saccular otoconia.

http://oto.sagepub.com/cgi/content/abstract/0194599816675843v1?rss=1

The Effect of Vestibular Rehabilitation in Patients with Menieres Disease: A Systematic Review

Objective

To systematically review the evidence on the effect of vestibular rehabilitation in patients with Ménière's disease (MD) on balance and dizziness-related quality of life.

Data Sources

A literature search was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Web of Science, and CINAHL databases.

Review Methods

Articles were reviewed by 2 independent authors and data were compiled in tables for analysis regarding balance (ie, posturography) and dizziness-specific quality of life in patients with MD. A comprehensive search was performed up to November 2015. Studies on relevance and methodological quality were assessed by means of the Cochrane risk of bias tool. For outcome on balance and quality of life, we calculated mean differences and their 95% confidence intervals.

Results

A total of 986 unique studies were retrieved. Five studies, including a total of 498 patients, fulfilled the eligibility criteria, including 2 randomized controlled trials and 3 prospective cohort studies. There was no study with a low risk of bias. We found inconsistent evidence for the effect of vestibular rehabilitation on balance and dizziness-related quality of life.

Conclusion

Based on the low quality of the selected studies, it is inconclusive whether there is a positive effect of vestibular rehabilitation in patients with MD on balance and dizziness-related quality of life.

http://oto.sagepub.com/cgi/content/abstract/0194599816678386v1?rss=1

Evaluation of a Web-Based Module and an Otoscopy Simulator in Teaching Ear Disease

Objective

To determine which teaching method—otoscopy simulation (OS), web-based module (WM), or standard classroom instruction (SI)—produced the best improvement in the diagnosis of middle/external ear pathologies and the development of otoscopy clinical skills.

Study Design

Prospective randomized controlled nonclinical trial.

Setting

Preclerkship undergraduate medical education.

Subjects and Methods

Fifty-four medical students (first year, 26; second year, 28) were randomized to receive 1 of the 3 interventions: OS, WM, or SI. All students underwent baseline testing of diagnostic accuracy (25 ear pathologies) and otoscopy skills. Immediately following each intervention and 3 months later, testing was repeated.

Results

Baseline scores for diagnostic accuracy and otoscopy skills did not differ across intervention groups. Immediately postintervention, all groups showed an improvement in diagnostic accuracy (P < .001). OS scored significantly higher than SI (P < .001), as did WM (P = .003). At 3-month follow-up, all groups continued to demonstrate improved diagnostic accuracy as compared with baseline. Again, OS showed improvement over SI (P = .031). For otoscopy clinical skills, only OS improved immediately postintervention (P < .001). OS had significantly higher scores than WM and SI (P < .001). At 3-month follow-up, OS again showed improvement over WM (P < .001) and SI (P = .009).

Conclusion

All groups showed an improvement in diagnostic accuracy immediately postintervention, with the largest increases coming from OS and WM. Otoscopy clinical skills increased and were retained only in OS. Preclerkship medical student acquisition and retention of otolaryngology diagnostic skills can be greatly improved through web-based teaching modules and otoscopy simulation.

http://oto.sagepub.com/cgi/content/abstract/0194599816677697v1?rss=1

Association between Laryngeal Pepsin Levels and the Presence of Vocal Fold Polyps

Objective

To determine whether pepsin, the main component of refluxed gastric contents, is significantly associated with vocal fold polyps and to evaluate the diagnostic value of pepsin in vocal fold polyps' tissues.

Study Design

Cross-sectional study.

Setting

Nanfang Hospital of Southern Medical University.

Subjects and Methods

The study included 32 patients with vocal fold polyps and 16 healthy controls between 2011 and 2012. Reflux symptom index and reflux finding score assessments, 24-hour combined multichannel intraluminal impedance and pH monitoring, and biopsy of the vocal fold polyp tissues or posterior laryngeal mucosa (healthy controls) for immunohistochemical pepsin staining were performed.

Results

The expression of pepsin was significantly higher in patients with vocal fold polyps than in controls (28/32, 75% vs 5/16, 31.25%; P < .001). The pepsin levels were significantly positively correlated with upright position pharyngeal acid reflux and esophageal reflux parameters adjusted by age. Based on pepsin staining data, the sensitivity and negative predictive values of 24-hour pH monitoring, the reflux symptom index, and the reflux finding score were 70% to 84.62%, whereas their specificity and positive predictive values were relatively low (20%-31.58%).

Conclusion

Pepsin reflux may be a risk factor for vocal fold polyps formation. In addition, pepsin immunohistochemical analysis of polyp biopsy samples appears to be a more sensitive and effective test for diagnosing laryngopharyngeal reflux than the reflux symptom index, the reflux finding score, and 24-hour pH monitoring in a clinical setting.

http://oto.sagepub.com/cgi/content/abstract/0194599816676471v1?rss=1

Head and Neck Cancer: Underfunded and Understudied?

Despite a considerable expansion in our therapeutic repertoire for management of other malignancies, mortality from head and neck cancer (HNC) has not significantly improved in recent decades. Upon normalizing National Institutes of Health–awarded R01 and R01-equivalent grants by incidence, thyroid cancer ($214) and HNC ($1329) received the fewest funding dollars. Upon adjusting funding totals by mortality, HNC was 7th out of 9 cancers evaluated ($6138). These findings highlight HNC as an underfunded disease versus other cancers. As data detailing grant applications (including unsuccessful grants) are not publicly available, it is not clear if these disparities stem from fewer applications or fewer opportunities. Our hope is that this commentary will spur further investigation into strategies to increase HNC inquiry and funding for trainees as well as early-stage and established investigators.

http://oto.sagepub.com/cgi/content/abstract/0194599816674672v1?rss=1

Corrigendum

http://oto.sagepub.com/cgi/reprint/0194599816679126v1?rss=1

Geographic Variation in Use of Vestibular Testing among Medicare Beneficiaries

Objective

There is a lack of consensus regarding the indications for vestibular testing in the evaluation of dizziness and balance disorders. Geographic variation in health services utilization is associated with lack of consensus. To understand the variation in current practice, we investigated the patterns of use of vestibular testing and diagnosis codes for dizziness and balance disorders among individuals ≥65 years of age across different regions of the United States.

Study Design

Cross-sectional study.

Setting

Medicare administrative claims data.

Subjects and Methods

Using the Summarized Denominator file, a sample of the US population linked to the Surveillance, Epidemiology, and End Results (SEER)–Medicare files (years 2000-2010), we identified persons who were ≥65 years of age. We used multivariable analyses to determine the factors associated with vestibular testing and diagnoses.

Results

Of the 231,984 eligible Medicare beneficiaries, 27% were diagnosed with dizziness and balance disorders. Patterns of use of vestibular tests (eye movement recording for spontaneous nystagmus, caloric testing, and rotary chair testing) varied significantly by geographic region. Rotary chair test utilization varied most. We found significant geographic variation in vestibular testing and diagnoses after controlling for age, sex, race, Medicaid participation, and rurality.

Conclusions

There may be opportunities to improve the consistency and efficiency of care for dizziness and balance disorders. It will be important to define appropriate levels of vestibular diagnostic testing and which tests add sufficient value to justify the costs. Further work is needed to better characterize the causes and consequences of variation in vestibular test utilization.

http://oto.sagepub.com/cgi/content/abstract/0194599816676450v1?rss=1