LAU Otofest for Hearing and Balance Disorders

LAU Otofest for Hearing and Balance Disorders

Saturday, October 12, 2019

Irwin Hall auditorium
LAU Beirut Campus

Abstracts

Session I

Chairman: Alain Sabri
Panelists: Randa Barazi, MD - Srour Diab, MD -  Nabil Moukarzel, MD - Maroun Semaan, MD, FACS

1. (9:00 - 9:20) My Forty Year Journey in Audio-vestibular Medicine - Mohamad Hamid, MD, PhD, EE

I found myself travelling the path of AVM since I graduated as an Electrical and Electronic Engineer from Ain Shams University, Egypt in 1968. Few stepping stones were placed on this path to bring me to who I am now.

The first stepping stones: 1968 to 1971:

Egypt - joining the Hearing and Speech Institute as an Audiological Engineer/Scientists. The holding hands were Dr. Ali ELMofti and Dr. Abdel Galil Fakhr.

Denmark – trained in Audiological evaluations and hearing rehabilitation.

The holding hands were Dr. Ole Bensen / Ahrus community hospital and the Audiological Engineers at Oticon, Danavox and Widex.

The second stepping stone: 1971-1979:

England – acquiring the scientific and clinical foundations of Auditory and Vestibular Medicine pursuing a PhD in Vestibular Neuroscience using biological signal analysis methods to analyze vestibular induced eye movements in man. I had the opportunity to establish the first Vestibular lab at St. Georges Hospital working as a Vestibular scientist.

The Holding hands were: Professor Bruce Sayers [Imperial College], Professor Ron Hinchcliffe [The Royal national ENT Hospital] and Mr. Brian Pickard [St. George’s hospital medical school].

The third Stepping Stone: 1980 to now:

I was asked to join the ENT department at the Cleveland Clinic to establish their Vestibular laboratory which was completed in 1982.  I stayed on and completed my MD at CWRU followed by internship and a 3 years postgrad preceptorship training in ENT, Neurology and Internal medicine to develop and continue my career as a Medical Otologist –Neurotologist in the USA.

The Holding Hands were Dr. Harvey Tucker, Dr. Jack Conomy, Dr. Rich Lang, Dr. Robert Daroff. CCF

I am indebted to all my teachers and those who held my hands in support of developing my career path in AVM. I was fortunate to be at the right time and places to see thousands of AVM patients and see the development of several AVM programs worldwide since 1980. It was gratifying to work with scientists and physicians culminating in diverse publications and training over 50 fellows from many countries around the world in Auditory and Vestibular Medicine.

My friends and colleagues, today I thank you for allowing me to share my AVM journey and the few pearls I learned from my teachers, research and most important from my patients. Allow me to share few of the lessons and experiences I learned through my journey.

Over 90% of AV disorders and disease are within the Temporal bone. Few are within the brain and other systems of the human body.

Listen and spend time with AVM patients. Their stories lead us to reach the correct diagnosis and cost effective management. The audiograme, the caloric test, and the temporal bone CT and MRI remain the most useful when evaluating patients with Auditory and Vestibular disorders and diseases.

The challenges:

Age related and noise induced hearing loss remain the most common auditory disorder and we have yet to do something about it. The cost of hearing aids is generally high and unaffordable especially in developing countries and where government and or private medical insurance do not cover hearing services. Cochlear implants are not universally covered and have had a significantly positive impact for those who can not use hearing aids. Tinnitus continues to challenge us and our patients with few options available for management. Tinnitus maskers are also expensive and have not resolved the burden of tinnitus.

Contrary to traditional teaching, “BPPV” is NOT a disorder. It is a sign of many inner ear disorders. Canalith Repositioning Procedures [CRP] have positively impacted the management of BPPV. However the underlying cause of BPV must be determined before using CRP treatments.

The burden of vertigo and motion intolerance on patients and their families continues to be high. Cochlear hydrops continues to elude us however intratympanic gentamicin and dexamethasone have changed the natural history of Meniere disease and provided the first, and only treatment for, poor/low speech discrimination giving us a cost effective stop gap between successful hearing aids use and the more costly CIs. The focus of Meniere management has shifted from vertigo control to hearing preservations given that the final disability is hearing loss.  Vestibular migraine is a misnomer for “inner ear migraine” and has been adequately treated using the several options of treating migraine. Motion sickness and intolerance syndromes are better managed with rehabilitation and the use of migraine medications. Vestibular Implants are on the rise however their clinical use will always lag behind CIs.

The future is bright for AVM. I wish to see a universal programe to give each child hearing aids and or cochlear implants as soon as they need it.  My hope is to see the day when we can treat and prevent hearing and vestibular diseases using gene manipulation.

2. (9:20 - 9:40) Tinnitus: Evidence Based Management - Fouad El Fata, MD

Tinnitus is a common medical symptom that can be debilitating. Risk factors include hearing loss and depression. At presentation, the possibilities of otological disease, anxiety, and depression should be considered. No effective drug treatments are available, although much research is underway into mechanisms and possible treatments. Available treatments include hearing aids when hearing loss is identified (even mild or unilateral), wide-band sound therapy, and counselling. Cognitive behavioural therapy (CBT) is indicated for some patients. The evidence base is strongest for a combination of sound therapy and CBT-based counselling, although clinical trials are constrained by the heterogeneity of patients with tinnitus.

3. (9:40 - 10:00) Otologic Manifestations of Systemic Diseases - Alain Sabri, MD, MPH, FACS   

A large number of medical diseases manifest in the ear and balance systems. These symptoms can be varied, may precede a disease, or appear later in the course of an illness. A delayed diagnosis may result in considerable morbidity and even mortality. This talk will be divided into an infectious section, including Ramsay Hunt Syndrome, Lyme disease, CMV, other bacterial infections. Pathologies that affect the ear also include inflammatory and autoimmune disorders such as Sarcoidosis, Cogan’s syndrome, relapsing polychondritis, and Wegner’s granulomatosis. Diseases of bone include Osteognenesis imperfecta (Van der Hoeve-de Kleyn syndrome, autosomal dominant), Paget’s disease, fibrous dysplasia and many others. An emphasis will be placed on the differential diagnosis of ear symptoms and findings representing a wide variety of disorders affecting multiple organ systems. A multidisciplinary approach is important for the timely diagnosis and effective management of this interesting group of patients and pathologies.

4. (10:00 - 10:20) Acute Otitis Media, Recent Guidelines - Charbel Rameh, MD

Acute Otitis media remains one of the most commonly encountered childhood pathologies in our practice, representing the most frequent indication for antibiotic prescription in children, and creating a major healthcare and economic burden. There is a huge diversity of diagnosis and management guidelines.

We will review the evidence based scientific data regarding the most common questions that cross our mind, mainly what criteria to rely on to diagnose otitis media, whether we should treat or watch and wait, using pain as an indicator, what antibiotic class is recommended, how long to treat, how long to wait before switching treatment, what to do in case of first line treatment failure, and finally, in case of recurrent infections, whether to go for prophylaxis or to go for surgery, not forgetting the importance of offering vaccination.

Social factors and adequacy of patient follow up and compliance are taken into consideration in the decision making process. It is always important to highlight the role of breastfeeding, and the negative effect of pacifiers and bottles as well as exposure to tobacco smoke on children with otitis media infections.

Following these guidelines is crucial to avoid falling into the realm of complications of otitis media, especially in the era of developing resistance to many of the available antibiotics.

Session II

Chairman: Amine Haddad, MD
Panelists: Ghassan Murr, MD -  Elie Zir, PhD -  Elias Khoury, MD - Marc Bassim, MD

1. (11:00 - 11:20) Ear and Temporal Bone Imaging - Anis Nassif, MD

This talk will discuss the latest and best radiological techniques in imaging of the temporal bone and IAC including thin cuts CT and MRI . This presentation will go over the anatomy of the ear on CT as well as key landmarks and imaging approaches to help the interpretation of these often avoided complexe studies .

We will discuss the tumors of the IAC , CPA , middle ear and petrous apex as well as formulate the top 5 didderential diagnosis and the best imaging modalities to tell them apart .We will discuss in detail the imaging characteristics of cholesteatoma and how to differentiate tumor from scar or granulation tissue.

We will differentiate white mass from red mass . We will go over the imaging of otosclerosis and dysplasias of the ear as well as imaging for conductive hearing loss with MRI and CT .

2. (11:20- 11:40) Management of Far Advanced Otosclerosis, in the Era of Cochlear Implant - Michael Nehme, MD

Far advanced otosclerosis can lead to severe/profound hearing loss, which makes  patients candidates for Cochlear Implant. However, these patients are at increased risk of poorer hearing outcomes and higher complication rate. We conducted a retrospective study of 58 patients with audiological and radiological diagnosis of far advanced otosclerosis (air conduction PTA > 85dB, aided speech discrimination<50%, and radiological evidence of otosclerosis). These patients were divided into 2 groups, stapedotomy with hearing aid group and the cochlear implant group, with the main objective was to study the predictive value of the CT Scan concerning audiological outcomes, surgical difficulties and complications.

Results: 60% of patients who underwent stapedotomy had discrimination rates of > 50% and was considered as a success.

CT scan can predict surgical difficulties and facial nerve stimulation in the cochlear implant group, but has no predictive value for the stapedotomy group.

3. (11:40 - 12:00) Neonatal Hearing Screening - Michelle Bardawil

How can we make sure that the auditory system is intact for newborns? The research shows that the prevalence of Hearing Loss by nursery type is as follows: 1 to 2 babies per 1000 at the Well-Baby Nursery and 2-4 babies per 100 at the Neonatal Intensive Care Unit. The Joint Committee on Infant Hearing (JCIH) endorses a universal protocol for hearing screening. The available screening tests are non-invasive, automated and fast, with a high sensitivity and specificity rates. It does not require any subjective response, which makes it the most suitable way to check the integrity of the auditory pathway in infants. The goal is early detection and intervention for babies with hearing loss, it can maximize their linguistic and literacy development. There are multiple risk factors that should be taken into consideration, however the protocol suggests that all babies should be screened before the age of 1 month, and if needed, should receive an appropriate intervention by the age of 6 months. With a proper management, the children with hearing loss can achieve a behavioral and language development within the normal range. The objective is to promote awareness and educate parents and healthcare professionals about the importance of this test.

4. (12:00 - 12:20) Implantable Hearing Aids - Maroun Semaan, MD, FACS

Hearing amplification remains the workforce of rehabilitation of moderate to severe hearing loss. Limitations exists resulting in poor patient satisfaction and non-compliance. This presentation reviews the physiology of middle ear acoustics, limitations of hearing amplification and lists the options available to the clinicians to surgically rehabilitate hearing loss through bone-anchored or ossicular-coupled devices.

The Objectives of this talk are to review the acoustic physics of the middle ear, recognize the types of implantable ME devices and understand the indications with a review their surgical techniques.

Session III

Chairman: Antoine Nehme, MD
Panelists: Hanna Ghazi, MD - Soha Ghossaini, MD - Samer Serhal, MD - Kim Smith, PhD, CCC-A, FAAA

1. (13:30- 13:50) Autoimmune Inner Ear Disorder - Soha Ghossaini, MD 

Autoimmune inner ear disorder is one of few types of sensorineural hearing loss that is treatable and potentially reversible. Treatment involves oral steroids and methotrexate. Other treatment modalities have been tried with variable success. All such treatments are systemic with inherent side effects limiting their effectiveness. Recently, TNF-alpha blockers have been suggested as a modality of treatment. A recent study showed that the round window membrane is permeability to golimumab, a TNF-alpha blocker. An update on the management treatment of autoimmune inner ear disorders will be presented. Role of cochlear implant in patients with Autoimmune Inner Ear disorder will be presented.

2. (13:50-14:10) Office Management of Vestibular Disorders - Mohamad Hamid, MD, PhD, EE

History, neurotologic examination and selective/tailored tests of the vertigo patient remains the key to optimal and cost effective evaluation and management of vestibular disorders. This presentation will focus on the following:

History:

Neurotologic Examination:

Selective tests: Audiometry. Calorics. Imaging. Others when indicated.

Differential Diagnosis:

The common disorders are migraine, vestibular neuronitis, Meniere disease disequilibrium of aging. Post traumatic syndrome, motion sickness/intolerance including Disembarkement syndrome and central vestibular disorders are less common. BPPV IS NOT a disorder per se but rather a symptom that can be due to several underlying diseases that have to be treated to prevent BPPV recurrence.

Treatment/Management:

The treatments of acute and chronic vestibular diseases and disorders    include vestibular suppressants, hydropic medications, migraine medications and intratympanic perfusion with dexamethasone and or gentamicin. BPPV is treated with Canalith Repositioning Procedures. Home vestibular rehabilitation is very effective for the treatment of uncompensated unilateral and or bilateral vestibular deficit. Motion sickness/intolerance/ Disembarkement syndrome are treated with OKN stimulation, medications and behavioral therapy. Psychological support and therapy are helpful when needed.

3. (14:10 - 14:30) Vestibular Rehabilitation Therapy - Youssef Koaik, PT, MPT, DPT

Symptoms due to vestibular disorders such as vertigo, dizziness, visual disturbance and/or imbalance can diminish quality of life and impact all aspects of daily living. Evidence has shown that vestibular rehabilitation is an effective tool to improve these symptoms

Beside the provocative BPPV tests, the assessment of the patient leads to identify the side (left/right) and the part of the vestibular system (otolithic/nonotolithic) that is impaired as well as the severity of the impairment.

Static posturography aims to objectively identify the swaying surface velocity and preference of the patient. Dynamic gait index (DGI), predict an added risk of fall, together with other tests (Fukuda test, tandem walking…) lead to plan the tailored treatment protocol of the patient.

A vestibular rehab treatment session usually includes Vestibulo-ocular reflex exercises to enhance gaze stabilization, substitution Technics to compensate a vestibular hypofunction, and habituation exercises to improve dizziness these main three categories of exercises promote quality of life.

Compared static posturography pre and post treatment as well as DGI score comparison reveal the improvement in good number of patients.

4. (14:30-14:50) Vertigo from a Neurologist’s Perspective: Vestibular Migraines and Other Conditions - Hrayr Attarian, MD

Often neurologists are called to the ED to evaluate vertigo.  According to a recent paper out of, close to 18000 ED visits for vertigo, 2.5% were due to benign positional vertigo and 1% due to stroke.  Yet the effects of posterior circulation stroke can be devastating and vertigo may be its only presenting symptom. Vertebro-basilar circulation supplies the posterior part of the brain including the occipital lobes, cerebellum and parts of the brain stem.  Vertebro-basilar disease (VBD) could be either due to thrombotic stenosis/occlusion or vertebral artery dissection.  Posterior circulation infarcts make up 20% of all strokes yet it is misdiagnosed 2.3 times more than anterior circulation infarcts are.  It also leads to more disability. Bedside HINTS plus test can distinguish between peripheral vertigo and VBD.

HINTS is Head Impulse test which, if normal is suggestive of VBD.  Nystagmus which if fast paced and alternating is also suggestive of VBD and as is skew deviation on Test of Skew. Plus is the unilateral sensorineural hearing loss which, in case head impulse is abnormal, is suggestive of VBD.   HINTS Plus has 99.1% sensitivity for stroke and 99.2% for central vertigo. It has 83% specificity for stroke and 97% for central vertigo.

Another cause of central vertigo that is often misdiagnosed is vestibular migraine (VM). Lifetime prevalence is 1% with up to 13% of chronic headache patients and 30% of migraine patients having VM. VM can only be diagnosed if a) the patient has history of migraines and b) 50% of their vertigo events are associated with headache and other migrainous features.  Surprisingly HINTS is negative.  Audiometry may be needed to distinguish it from Meniere’s as the two conditions have different audiometric patterns. Meniere’s is rarely symmetrical while VM hearing loss (in 18%) is milder, symmetrical and bilateral.  Mild tinnitus also occurs vestibular migraine.  No medication has been proven effective in preventing vestibular migraine or aborting an attack.  Treatment recommendations are lifestyle modifications and vestibular therapy.

Medial Longitudinal Fasciculus (MLF) connects the vertical (Superior Colliculus) and horizontal (parapontine reticular formation PPRF) eye movement centers and is heavily myelinated.  When affected by Multiple Sclerosis the lesioned MLF can produce vertigo and a characteristic exam finding called an Intranucleuar ophthalmoplegia (INO).

Lastly cerebellopontine angle tumors can produce vertigo.  The most common of these are Vestibular Schwannomas, followed by meningiomas and lastly epidermoid cysts.  The first also produces tinnitus, pain and imbalance.  The second facial weakness and trigeminal neuralgia and the third hearing loss.

Session IV

Chairman: Michael Nehme, MD
Panelists: Jad Nehme, MD - Fouad El Fata, MD - Maroun Semaan, MD - Mohamed Hamid, MD, PhD, EE

1. (15:20- 15:40) Tailoring Surgical Approaches to Jugular Foramen Tumors - Ibrahim Saikali, MD, FRCSC

Jugular foramen tumors, though relatively uncommon, are challenging lesions to resect. They comprise a range of pathologies including glomus jugulare, vagal schwannoma, meningioma, chordoma, chondrosarcoma, and metastasis. Multiple surgical approaches to the lateral skull base can be used and combined to remove these tumors. With experience, we learned to tailor the surgical approach, and individualize it on the basis of the patient’s and the tumor’s characteristics while relying on a good knowledge of this region’s “tricky” surgical anatomy.

2. (15:40-16:00) Stapedectomy: Pearls and Pitfalls - Elias Eter, MD, MSc

One of the most satisfying surgeries in otology. Otosclerosis surgery has one of the best result rates but can be a trap to occasional ear surgeons but also, in some cases, to specialists with experience in stapedectomy. It takes rigor and experience to avoid bad results in a surgery that is meant to improve quality of life of patients. We will review the classic technique, the difficult cases and how to prepare for them. Cochlear otosclerosis, overhanging facial nerve, perilymphatic gusher, floating footplate, persistent stapedial artery and other challenging situations will be discussed.

3. (16:00 - 16:20) Cholesteatoma Management: Pearls and Pitfalls - Marc Bassim, MD

Cholesteatoma is a relatively common subset of chronic otitis media in the Lebanese population especially in poorer socio-economic areas. Left untreated, it can have potentially devastating complications such as sensorineural hearing loss, dizziness, facial palsy, or, rarely, intracranial abscesses.

The mainstay if treatment for cholesteatoma is surgical removal. The surgical approach is highly individualistic, depending on both the exact spread of disease, patient anatomy and surgeon preferences. The literature is replete with studies describing different approaches and techniques for successful outcomes.

In this presentation, we will discuss proven pearls and tips for appropriate diagnosis, successful removal, hearing restoration, and long term follow up of cholesteatoma cases.

4. (16:20 - 16:40) Tympanoplasty: How to Increase Success Rate - Samer Serhal, MD

Tympanoplasty has evolved greatly over the years, it is a quite common procedure for General Otolaryngologists and Audiologists. Tympanoplasty consits of repairing the ear drum with various techniques such as underlay fascia, overlay fascia, cartilage tympanoplasty and osciclary construction. A well indicated tympanoplasty with or without mastoidectomy is successful in over 90- 95 % of cases. The aim is to prevent infections, restore hearing and prevent recurrence.

5. (16:40 - 17:00) Meniere’ s Disease - Maroun Semaan, MD, FACS

A chronic illness with episodic symptoms, Meniere’s Disease (MD) can affect the patient’s quality of life (QOL) and result in hearing loss and disabling vestibular dysfunction. We review the pathophysiology, clinical manifestations and treatment modalities available. These include medical management such as salt restriction, diuretics and others. Intra-tympanic injections will be reviewed in addition to various surgical procedures.

The Objectives of this talk are to understand the pathophysiology of Meniere’s Disease, to recognize the clinical symptoms and to review the treatment options available.