Classical peripheral vestibular disorders rehabilitation is a long and costly process. While virtual reality settings have been repeatedly suggested to represent possible tools to help the rehabilitation process, no systematic study had been conducted so far. We systematically reviewed the current literature to analyze the published protocols documenting the use of virtual reality settings for peripheral vestibular disorders rehabilitation. There is an important diversity of settings and protocols involving virtual reality settings for the treatment of this pathology. Evaluation of the symptoms is often not standardized. However, our results unveil a clear effect of virtual reality settings-based rehabilitation of the patients' symptoms, assessed by objectives tools such as the DHI (mean decrease of 27 points), changing symptoms handicap perception from moderate to mild impact on life. Furthermore, we detected a relationship between the duration of the exposure to virtual reality environments and the magnitude of the therapeutic effects, suggesting that virtual reality treatments should last at least 150 minutes of cumulated exposure to ensure positive outcomes. Virtual reality offers a pleasant and safe environment for the patient. Future studies should standardize evaluation tools, document putative side effects further, compare virtual reality to conventional physical therapy, and evaluate economical costs/benefits of such strategies.

ObjectivesDrug‐induced sleep endoscopy (DISE) involves assessment of the upper airway using a flexible endoscope while patients are in a pharmacologically‐induced sleep‐like state. The aim of this article is to review the current literature regarding the role of DISE in children with obstructive sleep apnea (OSA). The indications, typical anesthetic protocol, comparison to other diagnostic modalities, scoring systems, and outcomes are discussed.MethodsA comprehensive review of literature regarding pediatric DISE up through May 2017 was performed.ResultsDISE provides a thorough evaluation of sites of obstruction during sedation. It is typically indicated for children with persistent OSA after tonsillectomy, those with OSA without tonsillar hypertrophy, children with risk factors predisposing then to multiple sites of obstruction, or when sleep‐state dependent laryngomalacia is suspected. The dexmedotomidine and ketamine protocol, which replicates non‐REM sleep, appears to be safe and is often used for pediatric DISE, although propofol is the most commonly employed agent for DISE in adults. Six different scoring systems (VOTE, SERS, Chan, Bachar, Fishman, Boudewyns) have been used to report pediatric DISE findings, but none is universally accepted.ConclusionsDISE is a safe and useful technique to assess levels of obstruction in children. There is currently no universally‐accepted anesthetic protocol or scoring system for pediatric DISE, but both will be necessary in order to provide a consistent method to report findings, enhance communication among providers and optimize surgical outcomes.Level of EvidenceN/A.

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Nine different definitions of asymmetric sensorineural hearing loss (SNHL) have been reported in literature. The objectives of this study are to: (1) compare all these definitions of asymmetric SNHL; (2) measure the agreement between these definitions in detecting vestibular schwannoma (VS); and (3) determine the strongest association between an asymmetric SNHL definition and positive VS on magnetic resonance imaging (MRI). The study is a retrospective chart review in a tertiary care center. Cases were included if they were evaluated by an audiometric assessment and a posterior fossa MRI. Definitions of asymmetric SNHL reported in literature were applied to request for a further MRI investigation. The likelihood ratio (LR) for a positive test result (LR+) was the highest for the Rule 3,000 (2.91). On comparing all the other definitions with Rule 3,000, seven of the eight existing definitions have a kappa under the clinical usefulness threshold (Kappa < 0.6). When specification tests were applied, the Chi-square test identified Rule 3,000 with a highly significant P value (P < 0.0001). Rule 3,000, defined as asymmetric SNHL of 15 dB or more at the frequency 3,000 Hz, could serve as a universal referral guide for further MRI investigation. Results show that Rule 3,000 is more reliable to detect VS on MRI, a very simple rule that covers all the eight definitions of asymmetric SNHL reported in literature. This would help to reduce the number of negative MRI and to save time and money. If asymmetric SNHL is less than 15 dB, a biannual audiometry testing follow-up could be done.

1b. Laryngoscope, 128:1007-1015, 2018.

Objectives:To determine if shared decision-making tools (SDMTs) improve clinical outcomes for these children. Shared decision making (SDM) is a collaborative process in which patients and clinicians jointly establish treatment plans that integrate clinical evidence and patient values/preferences. We previously reported less decisional conflict using a SDMT for families of children with obstructive sleep apnea (OSA) without tonsillar hypertrophyl; however, the clinical impact of this finding is unknown.Methods: Prospective single-blind randomized controlled trial for consecutive patients referred to a multidisciplinary upper airway center. The study group used a SDMT, whereas the control group did not; all were followed until their next appointment and polysomnogram.Results: We assessed 50 families (24 study, 26 controls); mean age of patients was 8.8 (95% confidence interval 6.9-10.6) years, and 44% were female. After their initial visit, there was agreement between families and providers on the best treatment option for 22 of 24 (91.7%) study patients and 12 of 26 (46.2%) controls (P < 0.001). Before the first follow-up, four control families (15.4%) modified their treatment plan, whereas none of the study families did so (P = 0.04). Continuous positive airway pressure (CPAP) compliance was 27% (3 of 11) for controls and 57% (5 of 8) for study patients (P = 0.11). The median obstructive apnea-hypopnea index significantly improved in study patients from 13.4 (range, 20.0-57.2) to 3.5 (range 0.4-45.5, P = 0.01] events per hour, but not in controls, with 9.4 (range, 0.9-76.2) to 4.9 (range, 0-116, P = 0.10) events per hour.Conclusion: Families of children with OSA without tonsillar hypertrophy who were counseled regarding treatment options using SMDTs were more likely to undergo agreed upon treatment and had higher CPAP compliance.

Cyanotic spells, also known as blue spells, dying spells, or apparent life-threatening events, refer to a bluish tone visible in the mucosal membranes and skin caused by an oxygen decrease in the peripheral circulation. Although this decrease may be transient and benign, it may also be indicative of a severe underlying problem that requires immediate intervention. Children with oesophageal atresia (OA) are at risk for a number of coexisting conditions that may trigger cyanotic spells. This current article will focus on the management of cyanotic spells both in children with innominate artery compression and those with tracheomalacia.

Objectives Cornelia de Lange syndrome (CdLS) is a rare genetic disorder. Our goal was to systematically review the literature regarding otolaryngology manifestations of CdLS. Methods We systematically reviewed the PubMed, Embase, CINAHL, Scopus, and Google Scholar databases for original articles of otolaryngology manifestations for patients with CdLS. These articles were analyzed, and pooled prevalence was calculated. Results We analyzed 1,310 patients included in 35 case series and 34 case reports. Hearing loss was present for many patients (27 studies), with sensorineural hearing loss affecting 40.3% (95% confidence interval [CI]: 17.3–63.4) and conductive affecting 22.7% (95% CI: 5.7–39.7). Recurrent acute otitis media was the most frequent infectious manifestation, with 56.5% (95% CI: 34.1–78.4) in seven studies, followed by recurrent airway infections with 44.1% (95% CI: 11.0–87.1) in five studies. Forty‐nine (49.7%) percent of patients (95% CI: 25.9–73.6) in nine studies had dysphagia, and 76.6% (95% CI: 59.8–93.3) in four studies had some degree of dysphonia. Craniofacial anomalies were reported in 30 studies, with micrognathia (53.1%; 95% CI: 34.1–72.1) and high arched palate (70.6%; 95% CI: 56.5–84.8) commonly reported. Additional physical exam abnormalities reported included those involving: lips (76.8%; 95% CI: 65.3–88.4), dentition (65.1%; 95% CI: 27.2–100), mouth (85.5%; 95% CI: 76.2–93.8), and eyelashes (87.1%; 95% CI: 77.2–96.9). Sleep‐disordered breathing or obstructive sleep apnea affected 25.8% (95% CI: 11.4–40.2) of patients (7 studies). Airway anomalies were reported in 11 case reports. Conclusion This is the first comprehensive evaluation of otolaryngologic manifestations in the CdLS literature. Most reported hearing loss and craniofacial anomalies. Sleep disorders occurred in a minority of patients, whereas airway disorders were primarily reported in case reports. These conditions should be further examined given their potential life‐threatening implications. Level of Evidence 3a Laryngoscope, 130:E122–E133, 2020