Israel Medical Association Journal

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. It is assumed that sleep is involved in the pathogenesis of BPPV, and that habitual head-lying side during sleep correlates with the affected side in the posterior semicircular canal BPPV.

Objectives: To investigate the relationship between the preferred sleeping position and the affected semicircular canal in patients with BPPV.

Methods: We performed a retrospective data review of patients seeking help for vertigo/dizziness who had undergone clinical evaluation including a Dix–Hallpike test. Patients diagnosed with posterior canal BPPV (p-BPPV) were asked to define their preferred lying side (right, left, supine, or variable) during the night sleep. Affected semicircular canal (right posterior or left posterior) was registered along with demographic data.

Results: In all, 237 patients were diagnosed with p-BPPV. Patients with horizontal semicircular canal BPPV (n=11) were excluded. Patient mean age was 57 years (range 14–87). There were 150 patients with right p-BPPV and 87 patients with left p-BPPV. Among the patients, 122 (52%) habitually slept on the right side. Of those, 102 (84%) were diagnosed with right p-BPPV (P = 0.0006), while 82 patients (34%) habitually slept on the left side. Fifty-three (65%) were diagnosed with left p-BPPV (P < 0.0001). There were no differences in right vs. left p-BPPV in the 33 patients (14%) who expressed no preference concerning their sleeping positions.

Conclusions: Our study highlights the etiology of BPPV and showed that changing sleep position habits might be helpful in preventing recurrent BPPV.

Background: With an aging population, healthcare of the elderly population is becoming increasingly important, however, the principles of geriatric medicine and issues of concern specific to geriatric otolaryngologic patients have not been widely applied.

Objectives: To qualitatively analyze otolaryngological (ENT) emergencies in a geriatric population in an ENT emergency department (ED).

Methods: In this retrospective study the medical records of patients ≥ 65 years of age who attended our ENT-ED between 3 pm and 8 am and who were observed and/or treated by the on-call otorhinolaryngologist at Sheba Medical Center in 2009 were reviewed for age, gender, main complaint, and preliminary diagnosis. Allergic reactions, balance disorders, epistaxis, head/facial trauma and swallowing-related complaints were considered true emergencies.

Results: The staff in the ENT-ED examined and treated 1–10 geriatric patients daily (mean 2.35). A total of 597 subjects met the study entry criteria (median age 75 years); 16.6% were ≥ 85 years old. There was approximately equal gender representation. More elderly patients presented to the ENT-ED on the weekends (37.9% of the total) compared to weekdays (62.1%). There were 393 patients (65.8%) with true emergencies, of which epistaxis, balance disorders and head and facial trauma were the most common diagnoses (20.1%, 15.75% and 13.7%, respectively), while 46.5% of all vestibulopathy cases involved benign paroxysmal positional vertigo.

Conclusions: More than 65% of visits of the elderly presenting to ENT-ED involve true emergencies. This growing population may benefit from the presence of geriatric specialists in emergency departments.

Background: The fish-eating habits of Israelis who present with impacted fish bones in the aerodigestive tract are unknown.

Objectives: To retrospectively investigate the relation between an impacted fish bone in the aerodigestive tract, the species of fish, and the place of occurrence in an Israeli population.

Methods: The current prospective observational study included all patients with aerodigestive impacted fish bones who were treated in our emergency department from 1 September 2008 to 30 September 2009. The data retrieved from their medical records included age, gender, place of event (at home or elsewhere), species of fish, and method of removing the bone.

Results: A total of 108 patients aged 1.5–87 years (median 48 years), 52.8% female, met the study criteria. Most (87%) of the events occurred at home, and 50.9% occurred during the weekend (Friday- Saturday). The bones were from low-priced fish (e.g., carp, hake) in 62% of the cases, high-priced fish (e.g., salmon, red snapper) in 30.5%, and of unknown species in 10.2%. The proportion of cases in which the fish bone belonged to a high-priced fish eaten out of the home was significantly higher than the cases in which a low-priced fish was eaten at home (64.3% vs. 22.3%, P = 0.04). One hundred bones were removed during direct oral inspection and 8 bones were removed under general anesthesia by endoscopy.

Conclusions: Most fish bone impactions in the aerodigestive tract in central Israel involve low-priced fish and take place at home over the weekend.
 

Background: Severe hearing impairment can have devastating effects on social integration and vocational opportunities.

Objectives: To investigate how well – or poorly – individuals who underwent cochlear implantation as children integrated into the general Israeli hearing community.

Method: We sent a questionnaire to the 30 subjects ≥ 18 years old who underwent cochlear implants our department from 1990 to 2004 when they were < 18 years of age and had used their device for at least 3 years before replying.

Results: Eighteen implant users responded (14 males), yielding a 60% response rate. Their mean age was 13.3 ± 7.0 years (range 6–17) at implantation and 21.1 ± 3.6 years (range 18–34) when they filled in the questionnaire. Five were attending rabbinical school (yeshiva students), four were in regular military service, five were university students (three also held jobs), two were attending high school, one was employed (and had a university degree), and one had left the yeshiva and was unemployed when he returned the questionnaire. Fourteen respondents use the oral communication mode for conversation and the other 4 use both oral and sign languages. Longer daily implant use was significantly associated with coping with the difficulties in the setting in which they were currently active, with a higher level of satisfaction with their current lifestyle and with recognition of the implant’s contribution to this satisfaction (P = 0.037, P = 0.019 and P = 0.001, respectively).

Conclusions: Advances in cochlear implant technologies enable profoundly deaf implanted children to integrate well into the Israeli hearing society, albeit with a large inter-subject variability.

Background: Aural cholesteatoma is an epidermal cyst of the middle ear or mastoid that can only be eradicated by surgical resection. It is usually managed with radical or modified radical mastoidectomy. Clinical diagnosis of recurrent cholesteatoma in a closed postoperative cavity is difficult. Thus, the accepted protocol in most otologic centers for suspected recurrence consists of second-look procedures performed approximately 1 year after the initial surgery. Brain herniation into a post-mastoidectomy cavity is not rare and can be radiologically confused with cholesteatoma on the high resolution computed tomographic images of temporal bones that are carried out before second-look surgery.

Objectives: To present our experience with meningoceles that were confused with recurrent disease in patients who had undergone primary mastoidectomy for cholesteatoma and to support the use of magnetic resonance imaging as more suitable than CT in postoperative follow-up protocols for cholesteatoma.

Methods: We conducted a retrospective chart review of four patients.

Results: Axial CT sections demonstrated a soft tissue mass in the middle ear and mastoid in all four patients. Coronal reconstructions of CT scans showed a tympanic tegmen defect in two patients. CT failed to exclude cholesteatoma in any patient. Each underwent a second-look mastoidectomy and the only finding at surgery was meningocele in all four patients.

Conclusions: Echo-planar diffusion-weighted MRI can differentiate between brain tissue and cholesteatoma more accurately than CT. We recommend that otolaryngologists avoid unnecessary revision procedures by using the newest imaging modalities for more precise diagnosis of the patients who had undergone mastoidectomy for cholesteatoma in the past.