We present an unusual case of a patient with a positive Tullio phenomenon, brief Valsalva-induced transient horizontal nystagmus, reduced left caloric response, and bilateral vestibulo-ocular reflex loss. This study discusses the pathophysiology and differential diagnosis concerning the suspected pathology for the phenomenon of utricular hydrops or vestibular atelectasis and presents a literature review.

OBJECTIVE:To review insights gained from a 21-year experience with gentamicin-induced vestibulotoxicity including differences in vestibulotoxicity between single daily dosing (SDD) and multiple daily dosing (MDD) regimens.STUDY DESIGN:Retrospective case series.SETTING:Tertiary care center.PATIENTS:Patients with gentamicin vestibulotoxicity referred to the Hertz Multidisciplinary Neurotology Clinic between January 1993 and September 2014.INTERVENTION:None.MAIN OUTCOME MEASURES:Spectrum of vestibular dysfunction measured using videonystagmography, vestibular evoked myogenic potentials, video head impulse testing, and magnetic scleral search coil testing.RESULTS:Of 53 patients with gentamicin-induced vestibulotoxicity, 24 received SDD and 29 received MDD treatment. The most common indications for treatment were sepsis, endocarditis, and osteomyelitis. Angular acceleration receptor function (semicircular canals) was more commonly affected than linear acceleration receptor function (otolithic organ of the saccule; 100% vs. 62%). A significant proportion of patients (53%) developed vestibulotoxicity in the absence of nephrotoxicity and 40% experienced vestibulotoxicity in a delayed fashion up to 10 days posttreatment cessation (mean 3.9 ± 0.7). Therapeutic monitoring did not necessarily prevent delayed vestibulotoxicity. Nephrotoxicity was less common for SDD compared with MDD (60% vs. 35%, p = 0.01). However, the SDD group experienced vestibulotoxicity at a lower cumulative dose (6.3 vs. 7.0 g, p = 0.04) and shorter duration of therapy (20.7 vs 29.4 d, p = 0.02).CONCLUSIONS:Our study further highlights important insights regarding gentamicin-induced vestibulotoxicity. While SDD is associated with decreased risk for nephrotoxicity compared with MDD, it confers a higher risk for vestibulotoxicity.

Background Tinnitus service provision in the United Kingdom has been investigated from the healthcare provider’s perspective demonstrating considerable regional variation particularly regarding availability of psychological treatments. An audiological-based tinnitus service, however, was reportedly available for all tinnitus patients in the UK. The aim of the current study was to define and evaluate nationwide tinnitus healthcare services from the patients’ viewpoint. Methods Secondary analyses were performed on data from a 33-item questionnaire provided by the British Tinnitus Association. The questionnaire had been distributed via email and social media. Results Responses from 937 participants who had or had previously experienced tinnitus were analysed. All but one person had at some time consulted their GP. About one in five received medication in primary care. The majority were referred to secondary care, generally an ENT surgeon or audiovestibular physician; some were referred directly to audiological services. In secondary care the majority underwent audiometric testing and over half underwent MRI scanning. Drugs were prescribed less frequently in secondary care. About one third of patients were referred onwards from diagnostic services in secondary care to receive therapeutic interventions for tinnitus. Therapy was generally delivered by an audiologist or hearing therapist. Just under two fifths of people discharged from secondary care returned to their GP, with most returning within one year. Over a third of this group were re-referred to secondary care. Few patients saw a psychologist (2.6%) though some psychological treatments were delivered by appropriately trained audiologists. Negative counselling from healthcare professionals in both primary and secondary care settings was reported. Conclusions Although the UK has developed a national service for patients with tinnitus many people find it difficult to access, being blocked at the primary care level or after secondary care diagnostic services. Many of those discharged from secondary care return to their GP within a short space of time and are re-referred to secondary care creating an unsatisfactory and expensive revolving-door pattern of healthcare. Despite psychological treatment modalities having the best evidence base for successful tinnitus management, only a minority of tinnitus patients ever get to meet a psychologist.

INTRODUCTION:Bilateral posterior semicircular canal (PSCC) occlusion is a successful treatment of bilateral benign positional vertigo (BPV) refractory to particle repositioning manoeuvers. Little about the effects on the vestibular ocular reflex (VOR) postoperatively, which is the intent of this study.METHODS:All patients who underwent bilateral posterior canal occlusion for BPV at the University Health Network by the senior author (J.A.R.) between 2001 and 2017 with pre- and postoperative vestibular testing were included in the study.All patients underwent a detailed history and neuro-otological examination including dynamic visual acuity (DVA). Laboratory testing including video head impulse testing or magnetic scleral search coil testing, video nystagmography, cervical and ocular vestibular evoked myogenic potentials and audiological testing before and following their procedure at 1, 6, and 12 months postoperatively.RESULTS:Three patients were included in the study, all females, with a mean age of 41 years (range 36-44 yr). All patients had developed bilateral BPV after head trauma. Mean length of follow-up was 26 months (range 6-84 mo). All patients demonstrated a reduction in the vertical VOR of between 0.37 and 0.57/s at 1 month postocclusion. Between 6 and 12 months postoperatively, an improvement in their vertical VOR between 0.45 and 0.75/s was observed. Clinically, all patients reported complete resolution of their positional vertigo with a negative Dix-Hallpike bilaterally at follow-up. None reported oscillopsia, which was confirmed with DVA testing.CONCLUSION:Bilateral PSCC occlusion results in a reduction in the vertical VOR of the PSCCs.Over a 6 to 12 month time period improvement in the VOR gain can be demonstrated, most likely due to central compensation. There is clinical correlation with improvement in DVA testing. Bilateral PSCC occlusion is a safe and effective treatment for bilateral BPV proved refractory to particle repositioning manoeuvers.

BACKGROUND Anterior cricoid split is performed for grade 2 and 3 subglottic stenosis, which can be a cause of extubation failure. It can be performed endoscopically or as an open procedure. This paper describes a case series of endoscopic cricoid split procedures performed using a bespoke sickle knife. METHOD Nine patients (six pre-term infants) underwent endoscopic cricoid split in a tertiary referral paediatric unit between August 2012 and March 2015. RESULTS Six patients (67 per cent; four pre-term and two term infants) were on oxygen pre-operatively. Mean age at operation was 30 weeks (range, 11-104 weeks). Mean number of days' intubation was 5.6 days (range, 4-9 days). All five patients intubated pre-operatively were extubated. Seven patients required repeat dilatations. One patient required tracheostomy. CONCLUSION The extubation rates for endoscopic cricoid split are comparable to the open procedure. It is a safe and efficient method for managing subglottic stenosis, whether acquired or congenital. The main advantage is the shorter operative time, in addition to the avoidance of an external scar and drain.

Objectives Internal carotid artery (ICA) injury remains a rare but potentially fatal complication of transsphenoidal pituitary or anterior skull base surgery. Preoperative imaging must be scrutinized to minimize risk. On axial computed tomography (CT), the protrusions of the ICAs into the sphenoid resemble a “teddy bear.” This article aims to describe the sign, its grading system (0–2) and quantify its presence. Design Retrospective review of preoperative CT imaging. Setting Tertiary referral center in the United Kingdom. Participants One hundred patients who underwent endoscopic transsphenoidal surgery for pituitary disease were enrolled. Main Outcome Measure The presence and grading of the “teddy bear” sign were assessed on preoperative CT imaging. Results A grade 2 (strongly positive) “teddy bear” sign was identified in 40% at the level of the superior pituitary fossa, 78% at the inferior pituitary fossa, and 59% at the clivus. A grade 1 (intermediate) sign was seen in 23.5, 7.5, and 10% of cases, respectively. In 5% of cases, the sign was grade 0 at all levels—indicating poor intraoperative localization of the ICA. Conclusion The “teddy bear” sign is a useful preoperative tool for identification of anatomy predisposing patients to a higher risk of ICA injury. Those patients who have an absent or grade 0 “teddy bear” sign require extra care to ensure intraoperative localization of the ICAs which may include the use of neuronavigation or a Doppler probe. A grade 2 sign predicts good intraoperative localization of the ICA intraoperatively to inform the safe lateral limit of sellar bone resection.

OBJECTIVE:To report two cases of transmastoid clipping of a sigmoid sinus diverticulum.METHODS:Two patients with pulsatile tinnitus resulting from a sigmoid sinus diverticulum underwent clipping at the diverticulum neck using intra-operative Doppler ultrasonography.RESULTS:At six months' follow up, both patients reported complete resolution of pulsatile tinnitus with no complications.CONCLUSION:Transmastoid clipping of a sigmoid sinus diverticulum can be a safe and effective method of managing pulsatile tinnitus resulting from a sigmoid sinus diverticulum.

OBJECTIVE:Carotid artery aneurysm is a potentially fatal complication of skull base osteomyelitis. It is important to know the warning signs for this complication, as early diagnosis is of great importance. This report aimed to determine whether the pattern of cranial nerve involvement may predict the occurrence of aneurysm involving the internal carotid artery in skull base osteomyelitis.METHODS:Two diabetic patients with skull base osteomyelitis were incidentally diagnosed with pseudo-aneurysm of the petrous internal carotid artery on follow-up magnetic resonance imaging. They presented with lower cranial nerve palsy; however, facial nerve function was almost preserved in both cases. Computed tomography angiography confirmed aneurysms at the junction of the horizontal and vertical segments of the petrous carotid artery.RESULTS:Internal carotid artery trapping was conducted using coil embolisation. Post-coiling magnetic resonance imaging demonstrated no procedure-related complications. Regular follow up has demonstrated that patients' symptoms are improving.CONCLUSION:One should be mindful of this potentially fatal complication in skull base osteomyelitis patients with lower cranial nerve palsies, with or without facial nerve involvement, especially in the presence of intracranial thromboembolic events or Horner's syndrome.

BACKGROUND The percutaneous osseointegrated bone conduction device can be associated with more soft tissue complications when compared to the magnetic transcutaneous osseointegrated bone conduction device. This study aimed to determine whether fewer soft tissue complications may result in the transcutaneous osseointegrated bone conduction device being a lower cost option in hearing rehabilitation. METHODS This retrospective case note review included adult patients who underwent implantation with the transcutaneous Cochlear Attract (n = 22) or percutaneous Cochlear DermaLock (n = 25) bone-anchored hearing aids between September 2013 and December 2014. The number of post-operative clinic appointments, complications and treatments undertaken, and calculated cost average, were compared between the two groups. RESULTS Although the transcutaneous device was slightly more expensive than the percutaneous device, the percutaneous device was associated with a greater number of soft tissue complications and, as a result, the percutaneous device had significantly higher follow-up costs in the first six months following surgery. CONCLUSION The transcutaneous osseointegrated bone conduction device may represent a more cost-effective method of hearing rehabilitation compared to the percutaneous osseointegrated bone conduction device.

Clinical OtolaryngologyVolume 42, Issue 4 p. 917-920 Correspondence: Our Experience Outcomes following conversion of a percutaneous to a transcutaneous bone conduction device in eight children S.D. Carr, Corresponding Author S.D. Carr Simoncarr15@gmail.com Paediatric ENT Department, Sheffield Children's Hospital, Sheffield, UK Correspondence: S.D. Carr, Paediatric ENT Department, Sheffield Children's Hospital, Western Bank, Sheffield S10 2JF, UK. Tel.: 0114 271 7000; e-mail: Simoncarr15@gmail.comSearch for more papers by this authorI.A. Bruce, I.A. Bruce Paediatric ENT Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK Respiratory and Allergy Centre, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UKSearch for more papers by this authorD. Jones, D. Jones Paediatric Audiology Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UKSearch for more papers by this authorJ. Ray, J. Ray Paediatric ENT Department, Sheffield Children's Hospital, Sheffield, UKSearch for more papers by this author S.D. Carr, Corresponding Author S.D. Carr Simoncarr15@gmail.com Paediatric ENT Department, Sheffield Children's Hospital, Sheffield, UK Correspondence: S.D. Carr, Paediatric ENT Department, Sheffield Children's Hospital, Western Bank, Sheffield S10 2JF, UK. Tel.: 0114 271 7000; e-mail: Simoncarr15@gmail.comSearch for more papers by this authorI.A. Bruce, I.A. Bruce Paediatric ENT Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK Respiratory and Allergy Centre, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UKSearch for more papers by this authorD. Jones, D. Jones Paediatric Audiology Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UKSearch for more papers by this authorJ. Ray, J. Ray Paediatric ENT Department, Sheffield Children's Hospital, Sheffield, UKSearch for more papers by this author First published: 10 January 2017 https://doi.org/10.1111/coa.12828Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume42, Issue4August 2017Pages 917-920 RelatedInformation

In order to perform trans-sphenoidal endoscopic pituitary surgery safely and efficiently it is important to identify anatomical and pituitary disease features on the pre-operative CT and MRI scans; thereby minimising the risk to surrounding structures and optimising outcomes. We aim to create a checklist to streamline pre-operative planning.

Clinical OtolaryngologyVolume 41, Issue 3 p. 305-305 Correspondence: Letters The Sheffield ACS sickle knife for endoscopic anterior cricoid split S. Carr, S. Carr Simoncarr15@gmail.com Department of Otolaryngology, Sheffield Children's Hospital, Sheffield, UKSearch for more papers by this authorR. Thevasagayam, R. Thevasagayam Department of Otolaryngology, Sheffield Children's Hospital, Sheffield, UKSearch for more papers by this author S. Carr, S. Carr Simoncarr15@gmail.com Department of Otolaryngology, Sheffield Children's Hospital, Sheffield, UKSearch for more papers by this authorR. Thevasagayam, R. Thevasagayam Department of Otolaryngology, Sheffield Children's Hospital, Sheffield, UKSearch for more papers by this author First published: 22 February 2016 https://doi.org/10.1111/coa.12595Citations: 1 Poster Presentation at British Academic Conference in Otolaryngology 2015, Liverpool, UK. Oral Presentation at British Association of Paediatric Otolaryngology Annual Meeting 2015, Belfast, UK. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume41, Issue3June 2016Pages 305-305 RelatedInformation

OBJECTIVES:An optimum septoplasty result may require complete detachment of the superior osseocartilaginous junction (OCJ), but this may lead to disruption of the keystone area with loss of nasal support and consequent supratip depression deformity. The aim of this study was to analyse normal keystone anatomy using CT scan images and to estimate the incidence of risk of supratip depression when completely detaching the OCJ.DESIGN:Retrospective study.SETTING:Tertiary referral centre.PARTICIPANTS:Adult patients who underwent CT paranasal sinuses prior to transsphenoidal hypophysectomy in a tertiary referral centre between 2009 and 2013.MAIN OUTCOME MEASURES:Length of the keystone area. A length of <5 mm and certain anatomical configurations were considered at risk of a supratip depression with complete detachment of the OCJ.RESULTS:CT scans of 91 patients were reviewed. The mean keystone length was 9.04 mm (range 0-23 mm). Twenty-nine (32%) cases were at risk of supratip depression. Relatively shorter nasal bones (nasal bone length: overall dorsal length <0.37) (n = 26) were associated with a shorter keystone area (P = 0.0051).CONCLUSIONS:Thirty-two per cent of patients have keystone anatomy on radiology predisposing them to supratip depression with complete detachment of the OCJ. Relatively shorter nasal bones were significantly associated with a shorter, higher risk keystone area. In cases with a high septal deviation undergoing a septoplasty, a preoperative CT enables the surgeon to assess the keystone area and determine whether it is safe to completely detach the OCJ.

OBJECTIVES:A relationship between Meniere's disease and migraine has been postulated previously. This study investigates this relationship further and determines the most influential factors for developing Meniere's disease.DESIGN:Epidemiological study.SETTING:Two tertiary referral Neuro-Otological centres in Sheffield and Sydney.PARTICIPANTS:Adult patients referred to the Neuro-Otology clinic between 2003 and 2010.MAIN OUTCOME MEASURES:Past history and family history of Meniere's disease and migraine. Logistic regression analysis to determine the most influential factors for Meniere's disease.RESULTS:One hundred and eighty-one patients were included in the study, 102 with Meniere's disease and 79 with other balance disorders. Three significant findings were demonstrated. Firstly, a family history of Meniere's disease (33.3% versus 6.3%) or migraine (21.6% versus 9%) is more common in the Meniere's disease group than in the other balance disorders group. Secondly, a history of migrainous headaches is more common in the Meniere's disease group than in the other balance disorders group (45.1% versus 9%). Thirdly, patients with a past history or a family history of Meniere's disease or migraine have a higher likelihood of suffering from Meniere's disease.CONCLUSIONS:There is an overall relationship between Meniere's disease and migraine. A family history of Meniere's disease or migraine is more common in Meniere's disease. A history of migrainous headache is more common in Meniere's disease. Patients with a past history or family history of Meniere's disease or migraine have a higher likelihood of suffering from Meniere's disease.

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It is our practice to perform a two-stage procedure for children undergoing bone-anchored hearing aid (BAHA) placement. The second stage of the two-stage BAHA process requires localisation of the titanium cover screw, which was placed at the first stage, in order to fit the abutment. The localisation process usually depends on the operating surgeon palpating the screw through the scalp tissue. Once the surgeon is satisfied that the screw has been successfully palpated, a linear incision is made and a skin flap raised over the screw. However, it can prove difficult to palpate the screw if the scalp tissue is thick. This can be further confounded by the presence of scar tissue or callous from the first stage. If the screw cannot be palpated, a larger skin flap may be required, which can significantly increase the operating time.