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Whole person (holistic) health deals with the mind-body-spirit connection as a unified domain. Balancing the whole person's health makes it possible for cells, tissues, and fluids that are out of balance in disease to come back into balance as the person heals from illness. The Automatic Pattern Recognition and Interruption system can facilitate rapid change in people, once they are freed up from subconscious mind constraints. The goal of the modern, transformed health-care system should be to combine the best of conventional care and whole person health to produce the best health care on the planet.

The endocannabinoid system is located throughout the central and peripheral nervous systems, endocrine system, gastrointestinal system, and within inflammatory cells. The use of medical cannabinoids has been gaining traction as a viable treatment option for varying illnesses in recent years. Research is ongoing looking at the effect of cannabinoids for treatment of common otolaryngologic pathologies. This article identifies common otolaryngologic pathologies where cannabinoids may have benefit, discusses potential drawbacks to cannabinoid use, and suggests future directions for research in the application of medical cannabinoids.

The use of complementary and integrative medicine has increased . It is estimated that one-third of the population of the United States uses some form of alternative medicine. Physicians should consider integrative medicine therapies . Alternative medical therapies for the common cold and influenza include herbal supplements, dietary supplements, diet, and other adjunct therapies. However, it is important to research and study these therapies. Therefore, communication with patients and other health care providers is important. This will ensure effective and positive patient care experiences. Further randomized clinical trials are necessary to further establish the role of various alternative options.

To evaluate the utility of intracochlear electrocochleography (ECochG) monitoring during cochlear implant (CI) surgery on postoperative hearing preservation.Prospective, randomized clinical trial.Ten high-volume, tertiary care CI centers.Adult patients with sensorineural hearing loss meeting the CI criteria who selected an Advanced Bionics CI.Patients were randomized to CI surgery either with audible ECochG monitoring available to the surgeon during electrode insertion or without ECochG monitoring. Hearing preservation was determined by comparing preoperative unaided low-frequency (125-, 250-, and 500-Hz) pure-tone average (LF-PTA) to postoperative LF-PTA at CI activation. Pre- and post-CI computed tomography was used to determine electrode scalar location and electrode translocation.Eighty-five adult CI candidates were enrolled. The mean (standard deviation [SD]) unaided preoperative LF-PTA across the sample was 54 (17) dB HL. For the whole sample, hearing preservation was "good" (i.e., LF-PTA change 0-15 dB) in 34.5%, "fair" (i.e., LF-PTA change15-29 dB) in 22.5%, and "poor" (i.e., LF-PTA change ≥30 dB) in 43%. For patients randomized to ECochG "on," mean (SD) LF-PTA change was 27 (20) dB compared with 27 (23) dB for patients randomized to ECochG "off" ( p = 0.89). Seven percent of patients, all of whom were randomized to ECochG off, showed electrode translocation from the scala tympani into the scala vestibuli.Although intracochlear ECochG during CI surgery has important prognostic utility, our data did not show significantly better hearing preservation in patients randomized to ECochG "on" compared with ECochG "off."

"Because Western medicine has remained largely unsuccessful at treating tinnitus symptoms, many physicians as well as patients have turned to alternative treatment options to decrease patients' suffering and improve their quality of life. Although research in complementary/integrative medicine continues to be scarce and inconclusive, studies are pointing toward the positive effects of acupuncture, herbal remedies, dietary supplements, antioxidants, melatonin, and hypnosis on tinnitus. Although the efficacies of these treatments are inconsistent and may depend on a patient's unique circumstances, studies acknowledge that each treatment is worth trying in light of the potential benefits while being both noninvasive and well tolerated."

To test the feasibility and impact of a simulation training program for myringotomy and tube (MT) placement.Prospective randomized controlled.Multi-institutional.An MT simulator was used to assess the impact of simulation training vs no simulation training on the rate of achieving competency. Novice trainees were assessed using posttest simulator Objective Structured Assessment of Technical Skills (OSATS) scores, OSATS score for initial intraoperative tube insertion, and number of procedures to obtain competency. The effect of simulation training was analyzed using χA total of 101 residents and 105 raters from 65 institutions were enrolled; however, just 63 residents had sufficient data to be analyzed due to substantial breaches in protocol. There was no difference in simulator pretest scores between intervention and control groups; however, the intervention group had better OSATS global scores on the simulator (17.4 vs 13.7,A multi-institutional simulation study is feasible. Novices trained using the MT simulator achieved higher scores on simulator but not initial intraoperative OSATS, and they did not reach

Objectives: (1) To determine how otologic/neurotologic surgeons counsel patients with superior semicircular canal dehiscence (SSCD). (2) To understand the plethora of presenting symptoms associated with SSCD and appropriate management. (3) To suggest appropriate management; oftentimes avoiding surgery. Methods: This was a survey study of both community and academic physicians. A 23-question survey was distributed to all members of the American Neurotological (ANS) and American Otologic Societies (AOS) via email in the Fall of 2018. A total of 54 responses were received from a possible pool of 279 for a response rate of 19.4%. Inferences were made about the population through sample proportions and confidence intervals. Results: All respondents use computed tomography (CT) in diagnosing SSCD and 11.1% use CT exclusively. Cervical vestibular evoked myogenic potential (VEMP; 77.8%) are used more often than ocular VEMPs (38.9%). Magnetic resonance imaging (7.4%) is used infrequently; 96.3% of surgeons surveyed have seen patients with SSCD on imaging that are asymptomatic. Following surgical treatment, respondents reported balance issues and mild-to-moderate high-frequency sensorineural hearing loss (88.4%); 32.6% reported that the majority (>50%) of their patients needed further intervention after surgery, typically aggressive vestibular rehabilitation. Conclusions: There is a discrepancy in the systematic approach to SSCD between both the surgeons and the published literature. Patients with SSCD on ultra-high-resolution CT may have myriad symptoms while others are asymptomatic, and surgery may lead to additional complications. We will present a methodical recommendation to assist in the management of patients with SSCD depending upon their symptoms. This may improve patient selection, counseling, and outcomes.

OBJECTIVE To evaluate surgical findings and hearing results for patient's undergoing the described surgical approach for congenitally absent or dysplastic oval window (OW). STUDY DESIGN The Institutional Review Board approved retrospective review of patients with conductive hearing loss (CHL) operated on from 1992 to 2016. SETTING Academic tertiary center. PATIENTS Patients with CHL, an intact tympanic membrane (TM), and without history of chronic infection underwent middle ear exploration. Eleven patients and 13 ears underwent an oval window drill-out (OWD) procedure. INTERVENTION Eleven patients presented, all with dysplastic or congenitally absent oval window (CAOW). CHL was identified using audiometry and tuning forks, many patients also had preoperative computed tomography temporal bones. A transcanal approach was used and an OWD was performed with a variety of prostheses placed. MAIN OUTCOME MEASURE Audiometric studies before and after intervention were compared with 12 month and long-term follow-up (1-22 yr). RESULTS Preoperative air-bone gaps ranged from 40 to 60 dB and averaged 55.1 dB. Postoperative air-bone gaps ranged from 0 to 60 dB and averaged 24.1 dB. The preoperative pure-tone average (PTA) ranged from 55 to 99 dB and averaged 71.3 dB. Postoperative PTA ranged from 21 to 108 dB and averaged 49.6 dB. CONCLUSION Dysplastic and CAOW are uncommon congenital major ear anomalies. OWD is a viable treatment option, though careful counseling is critical, as significant complications are possible, especially with facial nerve (FN) abnormalities. This series demonstrates successful closure of the air-bone gap for many patients with this technique.

Objective To evaluate the adherence to oral cavity quality guidelines endorsed by the American Head and Neck Society (AHNS) at a large tertiary care hospital. Methods This retrospective study identified patients treated for early-stage oral tongue squamous cell carcinoma at a tertiary care hospital from 1992 to 2013. Patient charts were reviewed for 26 process quality measures and four key indicator process quality measures as endorsed by the AHNS. Patients were then grouped by diagnosis date either before (historical group, 1992-2007) or after (current treatment group, 2008-2013) the published process quality measures from the AHNS. Descriptive statistics were used to evaluate the rates of adherence for each process quality measure within the 2 groups. Results Of the 57 patients identified, 29 were female (51%). The mean age was 62.3 years. A majority of the oral cavity cancers were stage I (59.6%), followed by stage II (35.1%) and stage III (5.3%). Compliance with the process quality measures was in the acceptable range in both cohorts. However, several areas demonstrated lower adherence in both cohorts. Statistically significant improvements were noted between the two cohorts, which showed a measurable improvement in adherence to process quality measures in several key areas over time. Conclusion Using the process quality measures proposed by the AHNS, adherence to the process quality measures for early-stage oral cavity cancer care at a tertiary care center was successfully evaluated. In general, good compliance with the proposed process quality measures was found and several areas for improvement were identified. Level of evidence 2c Laryngoscope, 129:1816-1821, 2019.

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.The guideline development group made

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the "Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)." To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed emphasize diagnostic accuracy and efficiency, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing, and increasing the appropriate therapeutic repositioning maneuvers. An updated guideline is needed due to new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

The Envoy Esteem and the Carina system are the 2 totally implantable hearing devices. The Esteem is designed for patients with bilateral moderate to severe sensorineural hearing loss who have an unaided speech discrimination score of greater than and equal to 40%. The Carina system is designed for patients with moderate to severe sensorineural hearing loss or those with mixed hearing loss. The Esteem offers a technologically advanced method to provide improvements in hearing and is available in the United States, whereas the Carina system is currently not available in the United States.

The purpose of this review is to describe our experience with management of chronic tinnitus and to review the recent literature on the best treatment options available for treating patients who are troubled by their tinnitus. In addition, we want to highlight our experience and approach to this very common problem.Treatment options for patients are based on the severity of the tinnitus and any associated problems. The use of nutritional supplements has a place in the treatment of mild-to-moderate tinnitus. Ginkgo biloba and B-complex vitamins may have an impact on selected patients. Treatment of underlying or accompanying anxiety disorders especially with cognitive behavior therapy can help to reduce the distress associated with tinnitus. Surgical treatment options, such as cochlear implant, have been shown to be very effective in reducing tinnitus in patients with sudden unilateral hearing loss as the cause of tinnitus. Other surgical approaches, such as repetitive transcranial magnetic stimulation and vagal stimulator, have had some limited benefits.Treatment for subjective tinnitus can range from the conventional to the investigational modalities. Best treatment options take into account the possible cause of the tinnitus and other associated symptoms.

The objective is to perform a systematic review and meta-analysis of the literature on the long-term results of hearing preservation after vestibular schwannoma resection.Ovid/Medline, PubMed, Embase, and the Cochrane library from January 1980 to January 2015.Inclusion criteria: age ≥18 years, minimum 10 patients in the treatment group, hearing preserving microsurgery, no previous radiation treatment, serviceable hearing at immediate postop follow-up, hearing outcomes reported using Gardner Robinson or the American Academy of Otolaryngology-Head and Neck Surgeons hearing grading scales, and average follow-up of 5 years. Preoperative, immediate postoperative, and last follow-up audiograms were required. Exclusion criteria included neurofibromatosis type 2 patients and surgery for salvage therapy or decompression.Quality evaluated using Methodological Index for Non-Randomized Studies.Meta-analysis was performed using R v3.2.2, Metafor package v 1.9-7. Cohen's D was used to determine effect size. Ten reports had at least 5-year follow-up and used standardized hearing grading scales. The systematic review found that if hearing was preserved at Class A or B at early postop visit, the chance of preserving hearing at 5 years was excellent. Those who maintained speech discrimination score ≥ 89% at the early postoperative follow-up had better long-term hearing preservation. The meta-analysis reveals that only preoperative and postoperative pure-tone average was associated with long-term hearing preservation.Long-term (5 yr) hearing durability rates are generally very good. Most studies do not report patient and tumor characteristics, therefore precluding combining studies for meta-analysis. Only preoperative and postoperative postoperative pure-tone average was associated with long-term hearing durability.

Allergic rhinitis has a high prevalence and negatively impacts quality of life. Patients commonly use complementary and integrative modalities to help alleviate their symptoms of allergic rhinitis, with approximately one in five receiving acupuncture. This article reviews the evidence base on the efficacy/effectiveness, safety and cost-effectiveness of acupuncture for allergic rhinitis.Our review of the medical literature from January 2013 through December 2014 revealed that there is research demonstrating efficacy and effectiveness for acupuncture in the treatment of allergic rhinitis, as well as improvement of quality of life and quality-adjusted life-years.There are high-quality randomized controlled trials that demonstrate efficacy and effectiveness for acupuncture in the treatment of both seasonal and perennial allergic rhinitis. Smaller head-to-head studies also show some preliminary benefit of acupuncture when compared with antihistamines, but these had a variety of methodological limitations. Further studies of higher quality are needed, particularly with a focus on comparative effectiveness research.

Purpose of review Complementary and integrative medicine (CIM), formerly known as alternative medicine, is now part of the mainstream management for patients with a host of medical issues. This current opinion focuses on the use of CIM, more specifically, the use of nutritional and herbal therapies and homeopathic medications for patients with allergic symptoms. Recent findings The literature review revealed that naturally occurring substances when compared with placebo more often than not resulted in significant improvement of the allergic rhinitis symptoms. Summary Despite encouraging results, additional studies with greater rigor are needed.

Simulation has become a valuable tool in medical education, and several specialties accept or require simulation as a resource for resident training or assessment as well as for board certification or maintenance of certification. This study investigates current simulation resources and activities in US otolaryngology residency programs and examines interest in advancing simulation training and assessment within the specialty.Web-based survey.US otolaryngology residency training programs.An electronic web-based survey was disseminated to all US otolaryngology program directors to determine their respective institutional and departmental simulation resources, existing simulation activities, and interest in further simulation initiatives. Descriptive results are reported.Responses were received from 43 of 104 (43%) residency programs. Simulation capabilities and resources are available in most respondents' institutions (78.6% report onsite resources; 73.8% report availability of models, manikins, and devices). Most respondents (61%) report limited simulation activity within otolaryngology. Areas of simulation are broad, addressing technical and nontechnical skills related to clinical training (94%). Simulation is infrequently used for research, credentialing, or systems improvement. The majority of respondents (83.8%) expressed interest in participating in multicenter trials of simulation initiatives.Most respondents from otolaryngology residency programs have incorporated some simulation into their curriculum. Interest among program directors to participate in future multicenter trials appears high. Future research efforts in this area should aim to determine optimal simulators and simulation activities for training and assessment as well as how to best incorporate simulation into otolaryngology residency training programs.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.

Objective Determine if the noise levels of wind exposure experienced by cyclists reach levels that could contribute to noise-induced hearing loss. Study Design Industrial lab research. Setting Industrial wind tunnel. Subjects and Methods A commercial-grade electric wind tunnel was used to simulate different speeds encountered by a cyclist. A single cyclist was used during the simulation for audiometric measurements. Microphones attached near the ears of the cyclist were used to measure the sound (dB sound pressure level) experienced by the cyclist. Loudness levels were measured with the head positioned at 15-degree increments from 0 degrees to 180 degrees relative to the oncoming wind at different speeds (10-60 mph). Results Wind noise ranged from 84.9 dB at 10 mph and increased proportionally with speed to a maximum of 120.3 dB at 60 mph. The maximum of 120.3 dB was measured at the downwind ear when the ear was 90 degrees away from the wind. Conclusions Wind noise experienced by a cyclist is proportional to the speed and the directionality of the wind current. Turbulent air flow patterns are observed that contribute to increased sound exposure in the downwind ear. Consideration of ear deflection equipment without compromising sound awareness for cyclists during prolonged rides is advised to avoid potential noise trauma. Future research is warranted and can include long-term studies including dosimetry measures of the sound and yearly pre- and postexposure audiograms of cyclists to detect if any hearing loss occurs with long-term cycling.

Objectives/Hypothesis To determine the usefulness and the costs of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of patients with dizziness in the emergency department (ED). Study Design Retrospective chart review. Methods Charts of patients with a specific health maintenance insurance plan presenting with dizziness and vertigo to a large health system's ED between January 2008 and January 2011 were reviewed. Patient demographics, signs/symptoms, and CT and MRI results were assessed. CT and MRI charges were determined based on positive versus unremarkable findings. Data analysis included stepwise logistic regressions. Results Of 1681 patients identified, 810 (48%) received CT brain/head scan totaling $988,200 in charges. Of these, only 0.74% yielded clinically significant pathology requiring intervention. However, 12.2% of MRI studies yielded discovery of significant abnormalities. Logistic regression analysis revealed that older patients (P = .001) were more likely to receive a CT scan. Conclusions In the 3-year period studied, CT scans for ED patients with dizziness and vertigo yielded a low predictive value for significant pathology. These data reveal a great opportunity for cost savings by developing stricter guidelines for ordering CT scans for this set of ED patients. The use of MRI in all cases of dizziness was found to be neither practical nor useful. However, appropriately directed MRI of the brain is recommended in patients with dizziness and other neurological signs or symptoms. Level of Evidence 4. Laryngoscope, 123:2250–2253, 2013

This article discusses the mechanisms of aging, future areas of exploration, and strategies to achieve successful aging given the current state of medical knowledge. The article begins with mitochondrial function and cell growth and decline, then presents aspects over which humans have control over their health: nutrition, use of nutritional supplementation, body posture, exercise, lifestyle choices, and use of traditional Chinese medicine. The discussion concludes with the role of the physician in offering patient education regarding behaviors for a healthy life.

This article discusses the mechanisms of aging and future areas of exploration, and addresses strategies to achieve successful aging given the current state of medical knowledge. The authors begin at the beginning, with mitochondrial function and cell growth and decline, then continue to present aspects over which humans have control over their health: nutrition, body posture, exercise, lifestyle choices, and Traditional Eastern medicine. The discussion concludes with the role of the physician in offering patient education regarding behaviors for a healthy life.

Objectives/Hypothesis: The purpose of the study was to determine the effect of electrical stimulation of the auditory cortex in patients with tinnitus. Study Design: Nonrandomized clinical trial. Methods: Two patients with debilitating tinnitus refractory to conventional therapies were treated. Patients were evaluated with validated questionnaires and psychoacoustic measures to determine the frequency and pitch of their tinnitus. Tones at these frequencies were then presented to the first patient (RP) under magnetoencephalography (MEG) and functional magnetic resonance imaging (fMRI) to determine the tonotopic map for these frequencies in Heschl's gyrus. These tonotopic sites were targeted for implant with a quadripolar electrode. In the second patient (MV), only the fMRI tonotopic map was performed. These fMRI results detected an area of increased activity, which was selected as the site for the implanted bipolar electrode. Results: Patient RP (bilateral tinnitus for 2 years) has experienced a sustained reduction to near elimination of tinnitus with intracerebral implanted electrodes, whereas patient MV (unilateral tinnitus for 7 years) had an unsustained reduction in her tinnitus. Conclusion: These findings suggest that the perception and annoyance of tinnitus may be modulated or reduced through electrical stimulation of the auditory cortex. These unsustained effects for patient MV may have been influenced by the longstanding nature of her tinnitus or by another reason as yet undetermined.

Importance Asymmetric sensorineural hearing loss (ASNHL) is commonly encountered in an otolaryngologic clinical practice. Determining what factors are associated with abnormal magnetic resonance imaging (MRI) findings will help with diagnostic workup. Objective To evaluate the association between clinical and audiometric factors and abnormal MRI findings in patients with ASNHL. Design, Setting, and Participants Retrospective medical record review from an urban, tertiary referral center of 451 patients with ASNHL who underwent MRI testing between January 2005 and December 2011. Main Outcomes and Measures Medical records were reviewed for audiometric parameters as well as clinical presentation and compared with MRI results, which were categorized as abnormal, normal, or incidental. Data analysis included χ 2 tests, logistic regression analysis, and multivariate analysis. Results A total of 48 patients (10.6%) had abnormal MRI findings. Only 21 patients (4.7%) had a mass of the cerebellopontine angle/internal auditory canal on MRI, making up 40% of all abnormal MRI findings. The next most common MRI finding was labyrinthitis (n = 13; 25%). Vertigo/dizziness (n = 20; P = .01), tinnitus (n = 18; P = .02), sudden hearing loss (n = 15; P = .054), and 15-dB asymmetry at 3 kHz (n = 39; P = .01) were associated with abnormal MRI findings. Loud noise exposure was associated with normal MRI findings. Logistic regression analysis showed that vertigo/dizziness (odds ratio [OR], 2.14; 95% CI, 1.15-3.96; P = .02), unilateral tinnitus (OR, 2.15; 95% CI, 1.14-4.03; P = .02), and 15-dB asymmetry at 3 kHz (OR, 2.62; 95% CI, 1.24-5.57; P = .01) were significantly associated with abnormal MRI findings. Multivariate analysis showed that only 15-dB asymmetry at 3 kHz (OR, 2.42; 95% CI, 1.07-5.50; P = .03) was significantly associated with an abnormal MRI finding. Conclusions and Relevance This study found that asymmetry of 15 dB at 3 kHz on audiometry was associated with higher positive yield on use of MRI in evaluating patients with ASNHL. We recommend that patients who present with ASNHL with this audiometric characteristic undergo MRI as part of their diagnostic workup.

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

A consistent management algorithm for subjective tinnitus remains to be elucidated. Chronic tinnitus yields approximately US$2110 in annual health care costs per patient. However, it is unclear whether spending more in the management of tinnitus equates with greater patient satisfaction. Thus, the aim of this study is to correlate patient satisfaction with patient demographics, provider recommendations, and total health care-related expenditures.A retrospective chart review and a patient satisfaction questionnaire.All data were collected from a large Midwestern hospital.Patients were included who presented to the tinnitus clinic during the year 2011 and were between the ages of 18 and 89 years. They were excluded with diagnoses of Ménière's disease, pulsatile tinnitus, acoustic neuromas, or autoimmune inner ear diseases. The retrospective data and satisfaction surveys were entered by 3 of the authors. Responses were based on Likert scales.Of the 692 patients included, 230 completed and returned the satisfaction questionnaire (33.2% response rate), yielding an overall mean of $662.60 charges. The frequency of intervention recommendations per patients ranged from 0 to 13, with a median of 4. Spearman's correlations did not result in significant correlations between patient satisfaction and number of clinic visits (P=.499) or associated charges (P=.453).Given that the variability among provider recommendations, the high overall mean of tinnitus-related charges, and patient satisfaction was not related to costs, further research is needed examining patient preference in the treatment of tinnitus.

OBJECTIVE The purpose of the study was to analyze changes in neural response telemetry using the Cochlear Nucleus 24 Contour before and after stylet removal in a human model. STUDY DESIGN Prospective study. SETTING Tertiary referral center. PATIENTS Twelve patients (23-72 years old) undergoing cochlear implantation, using the Nucleus 24 Contour implant, secondary to congenital and age-related hearing loss. INTERVENTION Cochlear implantation with Cochlear Nucleus 24 Contour implant. MAIN OUTCOME MEASURE Neural response telemetry thresholds were recorded initially with the stylet in and then with the stylet out during the implant procedure. RESULTS Stimulus levels to obtain neural response telemetry threshold after stylet removal were statistically lower after the stylet was removed. CONCLUSION The Nucleus 24 Contour achieves a perimodiolar position once the stylet is removed, and this leads to reduction in the current required to elicit a threshold neural response telemetry response.

Age-related hearing loss, known as presbyacusis, is characterized by the progressive deterioration of auditory sensitivity associated with the aging process and is the leading cause of adult auditory deficiency in the USA. Presbyacusis is described as a progressive, bilateral, high-frequency hearing loss that is manifested on audiometric assessment by a moderately sloping pure tone audiogram. Approximately 23% of the population between 65 and 75 years of age, and 40% of the population older than 75 years of age are affected by this condition. It was estimated in 1980 that 11% of the population was 76 years or older and this number is expected to almost double by the year 2030. When one considers that the population over 65 years of age is experiencing the most accelerated development of hearing loss, the potential socioeconomic ramifications are staggering. Curiously, the frequency of presbyacusis varies across different societies. This discrepancy has been attributed to many factors including genetics, diet, socioeconomic factors, and environmental variables. The purpose of this article is to review the various molecular mechanisms underlying presbyacusis and to offer insights into potential methods of mitigating the effects of aging on hearing impairment.

The purpose of the study is to test the ability of resveratrol to protect the auditory system from reactive oxygen species (ROS)-mediated noise damage. Oxidative stress is mediated by ROS, which are known to cause cellular and molecular damage. Interfering with this process, using ROS inhibitors/scavengers such as antioxidants has shown promise in protecting specific systems from oxidative damage. Among the antioxidants receiving recent attention is resveratrol, an active component in red wine. Study design and setting Ten Fischer rats were used for this study. The experimental group (n = 5) received 7 weeks of resveratrol treatment (430/microg/kg/day), by gavage, and the control group (n = 5) received normal saline solution by gavage. Baseline auditory brainstem responses (3, 6, 9, 12 and 18 kHz) were determined for both groups. After 21 days, animals were exposed to noise (105 dB, 4500 to 9000 Hz for 24 hours). Postnoise auditory brainstem responses were assessed at 4 recovery time points: immediate, at 3 days, 7 days, and 4 weeks after noise exposure.Results demonstrate that the resveratrol group showed reduced threshold shifts compared with the control group after noise exposure. These shifts were significantly different between groups at 6 and 9 kHz (P0.05), corresponding to the region most represented by the frequency of the traumatic noise.Conclusion/significance Initial studies in our laboratory as well as other investigators have shown the importance of specific antioxidant therapy in the prevention of ischemic, noise, and age related hearing loss. The current study demonstrates a protective effect of resveratrol on noise-induced hearing loss.

We describe the methodology and rationale behind the delivery of therapeutic medicines to the inner ear. The inner ear has long been impervious to pharmacologic manipulation. This is most likely the result of a protective mechanism called the blood-labyrinth barrier, whose function closely resembles that of the blood-brain barrier. This protective barrier impedes the clinician's ability to treat inner ear diseases with systemically administered medications. Since 1935, otolaryngologists have attempted to manipulate the inner ear with transtympanically injected medicines. Success has varied widely, but medicinal ablation of vestibular function can be achieved in this manner. Unfortunately, the auditory system is also at great risk from any medicine that is delivered to the inner ear via the middle ear. Over the past 10 years, significant improvements in drug delivery have allowed for more “titratable” treatment, which has reduced (but not eliminated) the risk of permanent hearing loss. In this article, we discuss both novel and time-tested methods of delivering medicines to the inner ear. We also review the classes of medications that alter inner ear function and the attendant risks of such treatments.

Tinnitus is a significant medical problem affecting approximately 50 million Americans, 12 million of them severely. Once a thorough evaluation has been performed by a qualified otolaryngologist, and no life-threatening pathology has been identified, the opportunity for treatment exists. Treatment options are extensive and range from approved protocols to anecdotal remedies. Although tinnitus may not miraculously disappear, many therapeutic options exist that may help to make the tinnitus more manageable.

Lecithin is a polyunsaturated phosphatidylcholine (PPC), which are high energy functional and structural elements of all biologic membranes. PPC play a rate-limiting role in the activation of numerous membrane-located enzymes, including superoxide dismutase and glutathione, which are important antioxidants protecting cell membranes from damage by reactive oxygen species (ROS). ROS-induced damage to mitochondrial DNA may lead to reduced mitochondrial function in the cochlea and resultant hearing loss.The effects of lecithin on aging and age-associated hearing loss were studied in rats by measuring hearing sensitivities using auditory brainstem responses (ABR). In addition, mitochondrial function as a measure of aging was assessed by determining mitochondrial membrane potentials using flow cytometry and by amplifying mitochondrial DNA deletions associated with aging. Harlan-Fischer rats aged 18 to 20 months (n = 14) were divided into 2 groups. The experimental group was supplemented orally for 6 months with lecithin, a purified extract of soybean phospholipid (Nutritional Therapeutics, Allendale, NJ).The data obtained were compared with the control group. ABRs were recorded at 2-month intervals and showed significant preservation of hearing sensitivities in the treated subjects. Flow cytometry revealed significantly higher mitochondrial membrane potentials in the treated subjects, suggesting preserved mitochondrial function. Finally, the common aging mitochondrial DNA deletion (mtDNA(4834)) were amplified from brain and cochlear tissue including stria vascularis and auditory nerve. This specific deletion was found significantly less frequent in all tissues in the treated group compared with the controls.These experiments support our hypothesis and provide evidence that lecithin may preserve cochlear mitochondrial function and protect hearing loss associated with aging.

Objectives: The study goals were to evaluate the safety and effectiveness of continuous gentamicin therapy (CGT) in the treatment of Meniere's disease and to evaluate the effect of flow rate. Study Design: In a retrospective study, physicians who were known to have used CGT in the treatment of Meniere's disease were asked to report patient information on a standardized data collection form. Results: In patients treated with low-flow CGT, vertigo was eliminated or substantially controlled in 90%, tinnitus was improved in 69%, pressure was improved in 77%, hearing was worse in 23%, and vestibular function was ablated in only 14% of patients. Conclusion: On the basis of an average 10-month follow-up period, of the methods currently available to treat Meniere's patients with gentamicin, low-flow CGT seems to provide an excellent combination of vertigo control and tinnitus and pressure improvement, with a relatively low risk to hearing and vestibular function. Significance: The clinical use of low-flow CGT appears to be justified based on these data. (Otolaryngol Head Neck Surg 2002;126:244-56.)

Program Description:Allergic rhinitis is a worldwide health problem affecting 30 to 60 million people in the United States annually, including up to 30% of adults and as many as 40% of children. Th...

The widespread interest in and use of complementary and alternative medicine (CAM) by patients in the United States has been established by multiple surveys. One-third of the U.S. population uses some form of CAM, and an estimated 23 billion dollars is spent annually on these therapies. Because of prevalent usage of CAM among patients, it is important that physicians have some knowledge of this subject. With this purpose in mind, this report reviews the current research on CAM as it relates to common disorders of the head and neck: rhinitis, sinusitis, tinnitus, vertigo, and head and neck oncology.

Hypothesis: Compounds that upregulate mitochondrial function in an aging model will improve hearing and reduce some of the effects of aging. Background: Reactive oxygen metabolites (ROM) are known products of oxidative metabolism and are continuously generated in vivo. More than 100 human clinical conditions have been associated with ROM, including atherosclerosis, arthritis, autoimmune diseases, cancers, heart disease, cerebrovascular accidents, and aging. The ROM are extremely reactive and cause extensive DNA, cellular, and tissue damage. Specific deletions within the mitochondrial DNA (mtDNA) occur with increasing frequency in age and presbyacusis. These deletions are the result of chronic exposure to ROM. When enough mtDNA damage accrues, the cell becomes bioenergetically deficient. This mechanism is the basis of the mitochondrial clock theory of aging, also known as the membrane hypothesis of aging. Nutritional compounds have been identified that enhance mitochondrial function and reverse several age-related processes. It is the purpose of this article to describe the effects of two mitochondrial metabolites, α-lipoic acid and acetyl L-carnitine, on the preservation of age-related hearing loss. Methods: Twenty-one Fischer rats, aged 24 months, were divided into three groups: acetyl-1-carnitine, α-lipoic acid, and control. The subjects were orally supplemented with either a placebo or one of the two nutritional compounds for 6 weeks. Auditory brainstem response testing was used to obtain baseline and posttreatment hearing thresholds. Cochlear, brain, and skeletal muscle tissues were obtained to assess for mtDNA mutations. Results: The control group demonstrated an expected age-associated threshold deterioration of 3 to 7 dB in the 6-week study. The treated subjects experienced a delay in progression of hearing loss. Acetyl-1-carnitine improved auditory thresholds during the same time period (p < 0.05). The mtDNA deletions associated with aging and presbyacusis were reduced in the treated groups in comparison with controls. Conclusions: These results indicate that in the proposed decline in mitochondrial function with age, senescence may be delayed by treatment with mitochondrial metabolites. Acetyl-carnitine and α-lipoic acid reduce age-associated deterioration in auditory sensitivity and improve cochlear function. This effect appears to be related to the mitochondrial metabolite ability to protect and repair age-induced cochlear mtDNA damage, thereby upregulating mitochondrial function and improving energy-producing capabilities.

This manuscript will review the probable role of reactive oxygen metabolites (ROM) in the etiopathogenesis of head and neck cancer (HNC). Cancer is a heterogeneous disorder with multiple etiologies including somatic and germ-line mutations, cellular homeostatic disturbances, and environmental triggers. Certain etiologies are characteristic of HNC and include infectious agents such as the Epstein-Barr virus, the use of tobacco, and consumption of alcohol. A large body of evidence implicates ROM in tumor formation and promotion. ROM species are formed in the process of cellular respiration, specifically during oxidative phosphorylation. These ubiquitous molecules are highly toxic in the cellular environment. Of the many effects of ROM, especially important are their effect on DNA. Specifically, ROM cause a variety of DNA damage, including insertions, point mutations, and deletions. Thus, it is hypothesized that ROM may be critically involved in the etiology of malignant disease through their possible impact on protooncogenes and tumor suppressor genes. Additionally, empirical evidence suggests that ROM may also affect the balance between apoptosis and cellular proliferation. If apoptotic mechanisms are overwhelmed, uncontrolled cellular proliferation may follow, potentially leading to tumor formation. Thus, this manuscript will critically review the evidence that supports the role of ROM in tumorigenesis. ROM scavengers and blockers have shown both in vivo and in vitro effects of attenuating the toxicity of ROM. Such compounds include the antioxidant vitamins (A, C, and E), nutrient trace elements (selenium), enzymes (superoxide dismutase, glutathione peroxidase, and catalase), hormones (melatonin), and a host of natural and synthetic compounds (lazaroids, allopurinol, gingko extract). Thus, this paper will also review the possible benefit derived from the use of such scavengers/blockers in the prevention of HNC.

Clinical ethics is an intrinsic aspect of medical practice. Concerns for ethical conduct arise in the management of medical benefits, patient preferences, quality of life, and the relationship between patient care and its attendant familial, social, economic, and legal circumstances. Ethical concerns in surgical practice are central to the essence of the Hippocratic doctrine, “First do no harm.” In caring for our patients, particularly in light of the modern practice of medicine, we often use the risk-benefit calculus. The range of ethical concerns for the otolaryngologist who deals with the elderly and infirm covers many diverse situations. Superimposed over this spectrum is the idea of patient autonomy, which is considered to be a cardinal issue in any ethical discussion. Furthermore, increasing medical care costs have created a debate regarding the rationing of healthcare. Ethicists continue the discussion as to whether age should be a decisive factor in the rationing of this care. Definitions of “heroic” and “extraordinary” assume greater significance, and controversies of language become pivotal when the comprehension and cognitive orientation of the patient are compromised by disease and senescence.

We describe 6 new cases of palatal myoclonus (PM), a rare disorder that is characterized by involuntary rhythmic contraction of the palatal musculature. Although it has been reported that PM is a lifelong condition, one of our patients experienced a complete resolution of PM, which casts doubt on the accepted beliefs about the persistence of PM. Included in this report is the first published case of voluntary PM with objective tinnitus.

The cause of noise-induced hearing loss remains unclear despite years of both epidemiologic and experimental investigation. Among the many possible pathophysiologic mechanisms that may contribute to noise-induced temporary or permanent threshold shifts are insufficiencies in cochlear blood flow. Although the literature is inconsistent, several histologic and physiologic studies demonstrate signs of reduced circulation in the cochlea after noise exposure. Recent studies using computer-enhanced intravital microscopy complement these earlier findings. Evidence suggests that these microcirculatory events are mediated in part by several circulating factors, including the potent vasoactive peptide angiotensin. This study investigated this possibility by pretreating with the angiotensin receptor antagonist sarthran during noise exposure and examining both cochlear microcirculation and auditory sensitivity. The results of these experiments show noise-induced ischemia in the lateral wall of the cochlea and temporary threshold shifts. Treatment with sarthran prevented this noise-induced microcirculatory ischemia and preserved auditory sensitivity at the low frequencies tested. These findings support a role for the angiotensinergic system during noise exposure and suggest that preservation of cochlear blood flow is functionally related to auditory sensitivity. (Otolaryngol Head Neck Surg 1998;118:576-83.)

Background: The membrane hypothesis of aging proposes an association between reactive oxygen metabolites and aging processes. Reactive oxygen metabolites are a normal by-product of oxidative phosphorylation and are also formed under conditions of ischemia, hypoperfusion, and as a result of environmental contaminants. Among the many detrimental activities of reactive oxygen metabolites, also known as free oxygen radicals, is direct damage to mitochondrial DNA. Progressive accumulation of mitochondrial DNA damage renders cells unable to conduct oxidative phosphorylation reactions effectively, thereby leading to a bioenergetically deficient cell. Over time, mitochondrial DNA damage accumulates and leads to cellular dysfunction with subsequent organ failure, aging, and ultimately, death. This sequence forms the basis of the membrane hypothesis of aging. Objective: To determine if the membrane hypothesis of aging may be involved in the development of presbyacusis. Design: Fischer rats from 4 age groups were tested for auditory sensitivity using the auditory brainstem response. Brain, stria vascularis, and auditory nerve tissues were harvested and mitochondrial DNA was amplified to identify the highly conserved cytochrome b and ND1-16S ribosomal RNA segment of the NADH genes, as well as a 4834–base pair (bp) deletion associated with aging. Subjects: Fischer rats (n=28) from 4 age groups were used: young (2-4 months [n=9]), mid-young (9-11 months [n=5]), mid-old (18-20 months [n=5]), and old (30-34 months [n=9]). Results: The results demonstrate a progressive reduction in auditory sensitivity with age. The mitochondrial DNA studies identify a significant increase in the presence of the 4834–bp deletion in the aged subjects compared with the young. Conclusions: These findings raise the possibility that the 4834–bp deletion may be associated with presbyacusis, as well as with aging. Arch Otolaryngol Head Neck Surg. 1997;123:1039-1045.

There is a paucity of studies regarding the regulation of vestibular blood flow (VBF), despite the possibility that vascular alterations may contribute to specific vestibulopathies. The current experiments used the Mongolian gerbil as an animal model since it provides easy surgical access to the vestibular end-organs and has been previously used for physiologic studies involving inner ear function. VBF changes were measured in the posterior semicircular canal using laser Doppler flowmetry following round window membrane (RWM) application of the nitric oxide donor 1, 3-propanediamine-N-[4-1-(3-aminopropyl)-2-hydroxy-2-nitrosohydrazino] butyl (spermine NONOate; SPNO) as a vasodilator. The specificity of the responses induced was tested via pretreatment with an NO scavenger, 2-(4-Carboxyphenyl)-4,4,5,5-tetramethylimidazonline-1-oxyl-3 -oxide (carboxy-PTIO; cPTIO). cP-TIO, SPNO, vehicle (control) or cPTIO/SPNO were applied to the RWM, during which blood pressure and VBF were monitored for baseline, treatment, and recovery conditions. Results showed concentration-dependent increases in flow, probably resulting from NO's vasodilatory action on local vasculature. cPTIO pretreatment was found to attenuate SPNO-induced VBF increases. These findings support a role of NO in maintaining the vestibular microcirculation.

The current literature contains little information on vestibular end organ blood flow. The absence of an accepted model, difficulties applying dynamic in vivo measurement techniques and the inaccessibility of the inner ear organs contribute to the shortage of experimental findings. The purpose of the current study is to introduce the gerbil as a viable model for the in vivo study of vestibular blood flow dynamics. The potent vasoactive peptide, angiotensin III (AIII), was used to provoke blood pressure and blood flow changes. The results of this study demonstrate that viable blood flow measures may be obtained from the vestibule of the gerbil. Dose-dependent changes in blood pressure and vestibular blood flow were observed in response to high concentrations of AIII. Pretreatment with the receptor antagonist, sarthran, attenuated both blood pressure and blood flow increases in response to subsequent AIII infusions. The gerbil model offers the advantages of easily accessible and identifiable peripheral vestibular organs, as well as responsive local blood flow. Investigations using this model may provide information on the regulation of blood flow during presentation with a variety of stimulus modalities. Information from such studies may lead to development of strategies for treatment of vestibulopathies suspected to be of vascular origins.

Objectives:Examine the efficacy of three separate pain regimen groups for patients who have undergone tonsillectomies by multiple otolaryngologic surgeons at one institution.Methods:This study was an institutional review board (IRB) approved prospective randomized cohort study comparing the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen/hydrocodone, and acetaminophen/codeine for post-operative tonsillectomy pain control. Setting: A tertiary referral hospital. Patients of any age undergoing tonsillectomy from June 2011 until the present were randomized into one of three post-op pain regimen groups. All tonsillectomy procedures were performed using the same technique, no preoperative local anesthetic injections were given, and no post-operative antibiotics were provided. Patients/families were given a packet of information to complete that included pain control, time to return to diet, school/work, and baseline activity. Pain control was measured using a validated faces pain scale ...

Objectives To report normative data for incus and stapes motion using laser Doppler vibrometry (LDV) during middle ear surgery and to discuss possible limitations of the procedure. Study design Institutional review board-approved, retrospective study of data from patients undergoing the Envoy Esteem implantable device at 3 institutions. Setting Quaternary referral health system. Eligibility criteria patients sucsessfully implanted with an Esteem device. Methods Data from 70 patients undergoing the Envoy Esteem procedure were reviewed. Sound at 100 dB and 50 frequencies ranging from 125 to 8,000 Hz were used during the procedure. LDV was performed to measure the displacment of the body of the incus and the posterior crus of the stapes to assess whether there was sufficient ossicular mobility to allow for implantation. Results The average displacement of the ossicles for all 70 patients was collected and analyzed. The trend was an average displacement around 100 nm from 125 to 500 Hz for both the incus and stapes with a linear decline starting at 1,000 Hz for the incus and 500 Hz for the stapes, with slightly greater displacement of the stapes at higher frequencies. Conclusion This is the first article to report in vivo measures of ossicular mobility. These data help to understand the micromechanics of ossicular motion as well as the use and limitations of LDV. This information may lead to a prescreening process for implanted middle ear devices that function by overdriving the stapes.