My 5 Topmost Interesting ORL Papers 2015 - 2017

1. Perspective for the treatment of Sensorineural Hearing Loss by Cellular Regeneration of the Inner Ear by Almeida-Branco, Cabrera & Lopez-Escamez (2015). Acta Otorhinolaryngol Esp 2015;66(5):286-295. My attraction to this paper include detail exposition of the mechanisms and challenges of hair cell regeneration, the subtypes of regeneration process and the technique of achieving in vivo regeneration. In addition This paper was published open access and is available to all. Other recent papers in the line of this work include Crowson, Hertzano, & Tucci (2017), Revuelta M et al (2017), Simoni E et al (2017), Dai C et al(2017), Hackleberg S et al (2017), He, Bao & Li (2017) and Bettini S et al (2017)

2. Updates and knowledge gaps in cholesteatoma research by Kuo CL et al BioMed Res Int. 2015;2015:854024 doi: 1155/2015/854024 Most ear surgeons familiar with complications of cholesteatoma will be eager to catch-up on any updates regarding this disease entity. This paper however focused on acquired cholesteatoma, highlights the history and etymology, the different classifications historically arranged, the epidemiology, histopathology, immunohistochemistry and pathogenesis, and the genetics. The clinical, radiological and ancillary Diagnostic tools as well as surgical treatment options were also highlighted. The knowledge gaps in cholesteatoma management mentioned include results reporting, inconsistency among reports via-a-via definition and classification, discrepancies in description of surgical techniques, short follow up periods in most reported series, failure of most reports to distinguish pediatric from adult cholesteatoma , and different criteria used to define ‘residual cholesteatoma’. This paper is a delight to read and was also published open access. Other recent papers on cholesteatoma management include that by Lou, Lou & Gong (2017), Anikin IA et al (2017), and Grauvogel J et al (2017)

3. Through the Eustachian Tube and Beyond: A New Miniature Robotic Endoscope to See into the middle ear by Fichera L et al IEEE Robot AutoMech Lett. 2017;2(3):1488-1494 My attraction to this paper is that while Endoscopic Ear Surgery (EES) is still taking root and newer anatomy of the middle ear mucosal/ligament folds are being described and and anatomical variation classified, this study took a bold step to inspect the middle ear through the Eustachian tube using a robotic device containing small chip-tip and fiber optic light source and reported >74% visibility of the sinus tympani using this device, and potentially positioning this device as having a future role in office trans-Eustachian Tube middle ear endoscopy. Whether it would find application beyond Diagnostic use is still not very clear, and this study is of course not dissimilar with that of Yasin R et al (2017) in over all aim but concepts and practicality are not same. 

4. Intestinal permeability and Ménière’s disease by Di Beradino F et al Am J. Otolaryngol 2017 Dec 5 doi: 10.1016/j.amjoto.2017.12.002 My attraction to this paper is that despite numerous and confusing spectrum of explanations regarding MD’s etiology and etiopathogenesis, this paper premised the study on autonomic dysregulation often reported by some patients with MD and set out to test urinary lactulose and mannitol and fecal calprotectin (markers of altered intestinal permeability) and demonstrated that urinary Lactulose and Mannitol as well as fecal calprotectin were significantly elevated in symptomatic MD cases. The paper went ahead to propose a role for these in the Diagnostic workup of MD. Now what is not clear is that same lactulose/mannitol elevation has been reported elevated in Coeliac disease (Elburg RM et al, 1993) and in children with rotavirus and cryptosporidium gastrointestinal infections (Zhang Y et al, 2000). So it is not clear what Diagnostic relevance this elevation in MD patients constitutes and whether specific subtype of cases with GI manifestation should be screened. 

5. New Tumor entities in the 4th edition of the World Health Organization classification of head and neck tumors: Nasal cavity, paranasal sinuses and skull base by Thompson & Franchi (2017) Virchows Arch. 2017 Apr 25 doi: 10.1007/s00428-017-2116-0 What attracted me to this paper was that it looks like addressing the same issue a 2017 paper by Seethala RR et al addressed namely Update from the 4th Edition of the WHO Classification of H&N Tumors. The highlights of this paper was the recognition of HPV related SCC as a distinct clinicopathologic entity, and introduction of new tumor entities such as NUT Carcinoma and HPV-related Carcinoma with Adenoids Cystic feature. In addition nomenclature revisions for laryngeal neuroendocrine tumors were mentioned among the changes as well as inclusion of several tumor-like entities in the classification. 

Tinnitus and The Metaphor of Unwanted Sound

Tinnitus, the sensational perception of sound in the ear or head has been with man since prehistoric era. Known to either be objective or subjective, tinnitus is one symptom that despite years of documentation as a human health issue, there has been little progress regarding its cure. While in some cases, the etiology of tinnitus is obvious (for example the predominance of tinnitus in Hollywood A-listers can be attributable to noise exposure), in others the cause is unknown. 

The interesting fact regarding tinnitus is the way the sufferers convey their subjective feeling to their clinicians and other people. They often employ metaphors. 

A metaphor is a figure of speech in which an expression is used to refer to something that it does not literally denote in order to suggest a similarity. The earliest first known use of metaphor in English language was during the European renaissance (Ref: WolframAlpha). 

One Interesting difference between tinnitus in history and modern tinnitus is that the description in ancient literature was remarkably influenced by cultural factors. Theories such as "bewitched" by Ancient Egyptians, to "sensitivity to the divine " by Asian mystics and common pathophysiology with seizures (the Romans) were some of the reasons progress in tinnitus research stalled during those era. The modern theories of tinnitus generation focused on the anatomical sites of generation  such as peripheral auditory structures, brain stem and cortex as well as other non-likely auditory mechanisms. Interestingly, A single theory to explain the heterogeneity of tinnitus is still being awaited

When confronted with the reality of unwanted noise/sound in the ear or head, the patient presents to ear care specialists who in turn are focused on deciding whether the tinnitus is an isolated symptom or coexist with others like hearing loss. However the poor correlation of tinnitus with auditory threshold, the intermittent or fluctuating nature of most tinnitus, the poor correlation of even some of the 'known' etiology with tinnitus (e.g. Only 20-40% of noise-induced hearing loss is associated with tinnitus) and the interesting roles played by the sufferers psychological overlay put the clinician in further quandary while trying to unravel the tinnitus. 

Clients suffering from tinnitus, sensing the dilemma facing the clinician generally try as much to help by employing metaphors.

 "The humming sound in my ear(s) is like a waterfall". 

"My ear is buzzing like some crickets inside". 

Now the interesting aspects is the way famous or more sophisticated sufferers describe their sensation. 

Michelangelo wrote of his tinnitus: "A spider's web is hidden in one ear, and in the other, a cricket sings throughout the night". 

Beethoven the composer described his tinnitus as “My ears whistle and buzz all day and night. I can say I am leading a wretched life.” He had a harsh "roaring" in his ears. 

More recently, U2 - a musical group wrote the following song to describe tinnitus:

"...There's an insect in your ear, if you scratch it won't disappear, its gonna

itch and burn and sting, you wanna see what the scratching brings...waves that leave me out of reach,

breaking on your back like a beach, will we ever live in peace? as those that can't do, often have to preach, 

to the ones, staring at the sun..."

It's interesting that 2 members of U2 suffered from tinnitus. 

And the 2016 Nobel laureate for literature - Bob Dylan - wrote regarding his tinnitus:

 "My ears are ringing, ringing like empty shells... (2x) 

Well, it can't be no guitar player.Must be...convent bells"

So, while the physical aspect of tinnitus is often over shadowed by the emotional overlay, it is often the resulting construct - the sufferers' attempt to describe subjective sensation using metaphors, that wins the day. 

Further Reading

1. Hear. Res., 2017 vol. 344 pp. 265-274
2. Front Aging Neurosci, 2016 vol. 8 pp. 265
3. http://jnnp.bmj.com/content/83/8/765.extract.jpg. 

MMM and The Psychology of Smell

Smell is one of the most desirable evolutionary senses that are essential for our social wellbeing. We often talk of the chicken aroma from the mama's kitchen, the sweet smell of vanilla, the disagreeable body odor of some acquaintances and the stuffy smell of a long-abandoned abode. How about the sharp minty odor of peppermint or the stimulating aroma of Warm black coffee?  And for the bibliophiles - the crispy smell of a brand new book versus the attractive but stale smell of old library books! 

Authorities in the psychology of smell noted some cultural bias to smell. Each culture gravitates to its own desirable smell based on the cultural interpretation of that smell. For example the Dassanetch of Ethiophia are known to smear cow manure on their bodies because the smell of cattle signals fertility and high status. 

That smell, on one hand is capable of elevating moods and arousals, and on the other hand provoke feeling of disgust, depending on the CNS interpretation of the smell is itself interesting. 

The other interesting aspect is that the olfactory system is intimately linked with centers responsible for memory. Thus we can associate a perceived smell with some historical place or event in our past through a process of conditioned learning. 

 

Herz RS (2016) recently reported that odors that evoke positive autobiographical memories have the potential to increase positive emotions, decrease negative mood states, disrupt cravings, and reduce physiological indices of stress, including systemic markers of inflammation.  And of course, early experience can, as a result of this conditioned learning, make a sweet smelling food smell bad, according to a recent animal study (Rayes & Alkema, 2016). 

The implication of these are that the reverse is also true: early conditioning may cause a bad smelling food smell sweet!!!

This leads us to the most interesting aspect, the fact that our senses can be conditioned to sense object as the opposite of their nature. The underlying psychological term is gullibility. 

On one hand, it could be beneficial as in tinnitus retraining therapy. On the other aspect it is a tool commonly employed by tricksters to confuse the masses towards their bidding. 

According to Christina Valhouli, The human propensity to accept ideas at face value - no matter how illogical - is the fertile soil in which pseudoscience grows. And here we are talking of the pseudoscience of MMM. The believe that in the modern economic reality, people could make 29 per cent gain within 3-4 weeks on a deposit that is not tied to any business investment, simply by convincing others to do so. The speed at which enlightened press have publicized this Ponzi scheme. The widespread embrace of this fraudulent scheme that had collapsed in several countries before making it to Nigeria, and the pathetic fact that those who are supposed to KNOW in the society, doctors inclusive, were running into the scheme hysterically like other gullible populace, is sickening. 

Well it is a fact that, for pseudoscience to proliferate requires 2 catalysts : (mis)information explosion and low level of scientific literacy. The press assisted the first. Lack of awareness that conditioned learning from olfactory memory (the smell of success with MMM might have resulted from early conditioning for those chaps embracing it!!) perfectly explains the latter. 

So when you hear about MMM, please do reflect on conditioned learning from olfactory memory. 

Further Reading

1. Curr. Biol., 2016 vol. 26(9) pp. R362-4
2. Brain Sci, 2016 vol. 6(3)
3. http://www.columbia.edu/cu/21stC/issue-3.4/valhouli.html 

TTS and PTS - Discordant or Concordant Twins?

The reduction in sensitivity level of ear on exposure to noise, described as shift in threshold of hearing can be temporary or permanent. This reduction shows high individual variation and occurs more on exposure to sounds  in the range of 2-6KHz. Temporary threshold shift (TTS)  and Permanent threshold shift (PTS) represent the most common hearing effect of acute and chronic high level acoustic stimulation (Quaranta et al, 1998). 

The interesting aspects concern the definition of duration of hearing loss (for TTS) and whether there is any relationship between the two entities. 

TTS is commonly defined as "rise in auditory threshold during short exposure to noise which normally disappears in 24 hours but may last as long as a week"

The fact is post exposure improvement of threshold following such exposure may continue for 30 days or longer and there may not be return to preexposure threshold level (I.e PTS may occur). 

The exact issue is there is no consensus as to how short or long one waits before pronouncing TTS a PTS. The exact point at which a TTS becomes a PTS is very difficult to identify.  Age, exposure duration, exposure to other ototoxicity factors, intensity of the impact noise are other factors determine PTS. 

The second issue is whether outcome of TTS studies can be grafted wholesale into prevention of PTS. 

For ethical reasons, studies on PTS focused on animals, while human studies concentrate on creating temporary hearing losses (TTS). Typically the latter assumes that PTS must always be preceded by TTS. This has been shown not be strictly true. TTS is simply not a predictor of PTS, and we do not currently have good predictor of TTS. 

The underlying molecular mechanisms are different for TTS (glutamate accumulation and tectorial membrane tip disconnection) and PTS (cell death related to apoptosis or necrosis). So TTS may not tell us much about PTS. 

Further Reading

1. Marshall Chasin. What does TTS tell us about PTS?  Available at hearing health matters.org/hear the music/2012/what-does-tts-tell-us-about-pts/ 
2. Scand Audiol Suppl 1998;48:75-86 
3. Otol Neurotol. 2016 Sep;37(8):e263-70. 

Focusing On A Third of The Story

Hearing loss is an invisible disability and like other disabilities often command the interest and attention of philanthropist and NGOs. The interesting aspect is the do-gooders always have genuine interest in helping out but are often unsure where to start. 

Take for example the Telco that desires to assist with hearing loss. In developing countries, the common approach  is to focus on hearing aids distribution. Most do it by getting hearing aids dispensers to assemble hearing impaired in the community and in the presence of TVs and the press, proceed to 'screen' and administer hearing aids in few cases. 

There is often no follow up to determine who benefits and who does not after such photo-shoots. Some even hand out hearing aids without ear moulds or ear inserts. 

Now the facts is hearing aids only benefit a third of the hearing impaired (arguably a quarter) and focusing solely on these is neglecting the remaining 3/4 - those who require middle ear surgery, those who require Cochlear implants, and those that cannot be helped by any currently known measures and likely to require educational and occupational rehabilitation. 

So while we appreciate efforts geared towards assisting the hearing impaired in our communities by donating hearing aids, please be mindful that there are countless others who would not benefit  from hearing aids and equally require assistance. As such please note you are only focusing on a third of the hearing loss story. 

Cat-Roommate Analogy for Tinnitus in Cases Coming for Ear Surgery

Tinnitus - the sensation of sound/noise in the ear or head is an age old symptom that continues to perplex sufferers and researchers alike. The interest in tinnitus stems not only from the fact that it is an annoyance to sufferers, but that there are as many types of tinnitus as there are theories about its origin. 

Tinnitus could be subjective (audible only to the sufferer) or objective (can be heard by the clinician as well as the sufferer), high or low pitch, regular or irregular noise, persistent or pulsatile and could result from organic and non-organic causes. Interestingly the noise could result from diseases affecting the external ear (ear wax, foreign body, growth, etc), the middle ear (plethora of these) as well as the inner ear (Meniere's disease, Vestibular schwanoma, etc) as well as diseases of the Eustachian tube, central nervous system and systemic diseases. 

Theories put forward to explain tinnitus focused on peripheral mechanisms (discordant damage to outer and inner hair cells, imbalance of afferent and efferent hair cells of the auditory pathway, etc), brain stem anomalies (inferior colliculus and dorsal cochlear nucleus hyperactivity / disinhibition, etc), and the cerebral cortex(auditory cortex / amygdala hyperactivities, etc) and other non-auditory mechanisms for generation of tinnitus. 

To tinnitus sufferer, the simple worry is 'Am I going crazy or is something terribly wrong with me or my head'?

To the clinician, the worry is 'Is this tinnitus of organic or non-organic source'? 'Is it of central or peripheral origins'? 'Is it associated with hearing loss'?

Now the interesting aspect is, with this plethora of possible etiologies, patients with tinnitus and middle ear diseases (like cholesteatoma and chronic suppurative otitis media) coming for ear surgeries (Tympanomastoidectomy, tympanoplasty) often ask the most interesting question: 'Will this noise disappear after my ear surgery'? 

After a decade of middle ear surgery, I finally found the most interesting analogy as response to that scary question. It goes like this:

Imagine there are 3 of us living in a house - you (patient), myself (the clinician) and a cat. Now imagine the 2 of us were seated in the living room and a noise was headed continuously from the bedroom, with the cat nowhere in site! 

The interesting initial  assumption  is "it is that stupid cat'. 

Now there is only the one way to verify that assumption: Go into the bedroom and look for the cat. Now, this is where it gets so interesting, finding a cat in the room does not CONFIRM it is the source of the sound/noise. What the modern scientific medicine taught is that we remove the cat from the room, close the door and go back to the living room to listen again. It is the absence of the noise/sound after that, that CONFIRMS 'It is the cat'. Persistence of the sound after that means we need to look for other source(s) of the sound. 

This "Cat Roommate" analogy has assisted me in putting succinctly the reality regarding expectations from middle ear surgery in patients with background tinnitus. Perhaps you may find it useful for your cases too. 

Further Reading

1. Theories of generation and management of tinnitus. https://www.mayo.edu/mayo-edu-docs/mayo-clinic-audiology-conference-documents/handouts-new-theories-on-the-generation-and-management-of-tinnitus.pdf 

2. Tinnitus- Current neuroscience research and theories. http://www.hearingloss.org/sites/default/files/docs/LeaverAM_.pdf 

Dizziness: Probe before You Treat

From personal experience of running a dedicated vertigo clinic for a decade now, it appears that when people experience dizziness for the first time, the experience is so terrifying that they are often short of vocabulary to describe the sensation they feel. This lack of clarity in symptom description often mislead inexperienced physicians into the wrong treatment. 

Generally, the presenting complaint is always "I am feeling dizzy". Now the issue is this can mean several things to several people:

Feeling like blackout / lightheaded which may direct physician towards the cardiovascular system

Feeling like drunk while walking which may direct physician to the neurological system

Feeling as if the whole world is spinning or as if the subject is spinning which directs physician to the vestibular system

Feeling like seeing double which may direct clinician to the ophthalmology 

And so on. 

So when confronted with the dizzy patient, the challenge confronting clinician is what does the client mean by "I am feeling dizzy"

The interesting thing in ORL is that dizziness as a symptom, in most countries where English is a second language, is regarded as a block symptom which should not be accepted without probing for the details. It is similar to saying "I have catarrh" which can be taken to mean either 'I have stuffy nose', or 'I have blocked nose' or 'I have runny nose'

The interesting aspect is most GPs have little interest, training and understanding in diagnosis and management of the dizzy patient, but would nevertheless have commenced patients with dizziness on medications before referral to ORL surgeons. 

It would be nice for GP clinicians to make sure they're on the same page with patients presenting with dizziness before commencement of treatment. 

So when next you're experiencing dizziness, make sure you explicitly describe your symptom to your GP and that he understood these, before accepting treatments offered.