Anaplastic (undifferentiated) thyroid carcinoma (ATC) is a rare malignancy which may arise from transformation of a pre-existing differentiated carcinoma. We report the unique case where a lesion of thyroid origin presented with the histological features of mature plasma cells. Immunohistochemistry confirmed the lesion to be an anaplastic thyroid carcinoma arising from papillary thyroid carcinoma. A tumor mimicking a malignancy of a different cellular origin can lead clinicians to incorrect treatment approaches. Careful correlation with clinical details and knowledge of these unique presentations is important for reaching the correct diagnosis.

Objectives

To evaluate if patients with a diagnosis of vestibular migraine (VM) by the International Classification of Headache Disorders (ICHD) criteria have meaningful differences in symptomatology and disease characteristics when compared to patients with concurrent vestibular symptoms and migraine that do not meet ICHD criteria.

Methods

Patients who presented for the evaluation of vertigo were provided a detailed questionnaire about dizziness and migraine symptoms. Patients were assigned to either VM cohort (met ICHD criteria for VM) or migraine headache (MH) cohort (met ICHD criteria for migraine with or without aura but not VM). Disease characteristics, symptomatology, quality of life, and perceived stress score were compared between the cohorts.

Results

The VM cohort demonstrated a shorter duration of vertigo episodes, 11 ± 22 hours versus 84 ± 146 hours in the MH cohort. In the VM cohort, 81% reported experiencing migraine headaches during episodes of vertigo, versus 61% in the MH cohort. All patients in the VM cohort reported a previous diagnosis of migraine headache, whereas 9% of the MH cohort had not been previously diagnosed by another physician. There was no difference in quality of life or perceived stress scores between the cohorts.

Conclusions

A large proportion of vertigo patients with migrainous features do not meet the ICHD criteria for VM. The differences between cohorts represent selection bias rather than meaningful features unique to the cohorts. As such, VM and MH with vestibular symptoms may exist on a spectrum of the same disease process and may warrant the same treatment protocols.

Objectives

To evaluate if patients with a diagnosis of vestibular migraine (VM) by the International Classification of Headache Disorders (ICHD) criteria have meaningful differences in symptomatology and disease characteristics when compared to patients with concurrent vestibular symptoms and migraine that do not meet ICHD criteria.

Methods

Patients who presented for the evaluation of vertigo were provided a detailed questionnaire about dizziness and migraine symptoms. Patients were assigned to either VM cohort (met ICHD criteria for VM) or migraine headache (MH) cohort (met ICHD criteria for migraine with or without aura but not VM). Disease characteristics, symptomatology, quality of life, and perceived stress score were compared between the cohorts.

Results

The VM cohort demonstrated a shorter duration of vertigo episodes, 11 ± 22 hours versus 84 ± 146 hours in the MH cohort. In the VM cohort, 81% reported experiencing migraine headaches during episodes of vertigo, versus 61% in the MH cohort. All patients in the VM cohort reported a previous diagnosis of migraine headache, whereas 9% of the MH cohort had not been previously diagnosed by another physician. There was no difference in quality of life or perceived stress scores between the cohorts.

Conclusions

A large proportion of vertigo patients with migrainous features do not meet the ICHD criteria for VM. The differences between cohorts represent selection bias rather than meaningful features unique to the cohorts. As such, VM and MH with vestibular symptoms may exist on a spectrum of the same disease process and may warrant the same treatment protocols.

Objectives

To evaluate the efficacy of a multi-modal migraine prophylaxis therapy for patients with hyperacusis.

Methods

In a prospective cohort, patients with hyperacusis were treated with a multi-modal step-wise migraine prophylactic regimen (nortriptyline, verapamil, topiramate, or a combination thereof) as well as lifestyle and dietary modifications. Pre- and post-treatment average loudness discomfort level (LDL), hyperacusis discomfort level measured by a visual analogue scale (VAS), and scores on the modified Khalfa questionnaire for severity of hyperacusis were compared.

Results

Twenty-two of the 25 patients (88%) reported subjective resolution of their symptoms following treatment. Post-treatment audiograms showed significant improvement in average LDL from 81.3 ± 3.2 dB to 86.4 ± 2.6 dB (P < .001), indicating increased sound tolerability. The VAS discomfort level also showed significant improvement from a pre-treatment average of 7.7 ± 1.1 to 3.7 ± 1.6 post-treatment (P < .001). There was also significant improvement in the average total score on modified Khalfa questionnaire (32.2 ± 3.6 vs 22.0 ± 5.7, P < .001).

Conclusions

The majority of patients with hyperacusis demonstrated symptomatic improvement from migraine prophylaxis therapy, as indicated by self-reported and audiometric measures. Our findings indicate that, for some patients, hyperacusis may share a pathophysiologic basis with migraine disorder and may be successfully managed with multimodal migraine prophylaxis therapy.

Objectives

To evaluate the efficacy of a multi-modal migraine prophylaxis therapy for patients with hyperacusis.

Methods

In a prospective cohort, patients with hyperacusis were treated with a multi-modal step-wise migraine prophylactic regimen (nortriptyline, verapamil, topiramate, or a combination thereof) as well as lifestyle and dietary modifications. Pre- and post-treatment average loudness discomfort level (LDL), hyperacusis discomfort level measured by a visual analogue scale (VAS), and scores on the modified Khalfa questionnaire for severity of hyperacusis were compared.

Results

Twenty-two of the 25 patients (88%) reported subjective resolution of their symptoms following treatment. Post-treatment audiograms showed significant improvement in average LDL from 81.3 ± 3.2 dB to 86.4 ± 2.6 dB (P < .001), indicating increased sound tolerability. The VAS discomfort level also showed significant improvement from a pre-treatment average of 7.7 ± 1.1 to 3.7 ± 1.6 post-treatment (P < .001). There was also significant improvement in the average total score on modified Khalfa questionnaire (32.2 ± 3.6 vs 22.0 ± 5.7, P < .001).

Conclusions

The majority of patients with hyperacusis demonstrated symptomatic improvement from migraine prophylaxis therapy, as indicated by self-reported and audiometric measures. Our findings indicate that, for some patients, hyperacusis may share a pathophysiologic basis with migraine disorder and may be successfully managed with multimodal migraine prophylaxis therapy.

Objectives

Skull base osteomyelitis (SBO) is a rare infection comprising either the lateral (LSBO), central (CSBO), or both lateral and central (BSBO) skull base. Due to its rarity, the optimal length of antimicrobial therapy (AMT) has not been well defined. Therefore, the purpose of this study was to identify factors that may influence outcomes of SBO and formulate clearer recommendations on AMT duration.

Methods

A multi-institutional retrospective cohort study of SBO patients was conducted. Patient demographics, medical comorbidities, presenting symptoms, laboratory results, radiographic imaging, surgical treatment, culture results, length of follow-up, and type, length, and number of AMT courses were collected.

Results

Sixty-five patients were included. The average age was 66.5 years, and the average length of symptoms (LOS) prior to diagnosis was 3.74 months. The most common pathogen was Pseudomonas aeruginosa (n = 23) followed by coagulase-negative Staphylococcus species (n = 15). The average length of IV AMT was 6.8 weeks, and the average total length of AMT (TLA) was 15.7 weeks. Positive fungal cultures were associated with longer TLA (22.6 vs. 13.7 weeks, p = 0.02) and a greater number of distinct courses of AMT (4.1 vs. 2.7, p = 0.01).

Conclusion

In this series, the average length of IV AMT was 6.8 weeks. The average TLA was 15.7 weeks, indicating that a minimum of 6 weeks of IV AMT followed by a prolonged course of oral AMT is necessary to treat most cases of SBO. Fungal involvement significantly impacts the duration of AMT. Clinical guidelines are needed to better define the management of this complex disease.

Level of evidence: 4

Objectives/hypothesis

To examine the hearing outcomes of patients with sudden sensorineural hearing loss (SSNHL) treated with oral and intratympanic (IT) steroid only or a combination of steroid and migraine treatment. Our hypothesis was that adjuvant migraine medications may improve outcomes in SSNHL.

Methods

A retrospective chart review at a tertiary otology center was conducted to identify patients with SSNHL who received oral steroid and IT dexamethasone injection(s) with or without migraine medications (a combination of nortriptyline and topiramate).

Results

A total of 47 patients received oral steroid and IT dexamethasone injection(s) only, and 46 patients received oral steroid and IT dexamethasone injection(s) as well as migraine lifestyle changes plus a combination of nortriptyline and topiramate. There were no significant differences in demographics and baseline audiometric data between the two groups. Both groups demonstrated improvements in pure tone average (PTA) and hearing thresholds at 250 Hz and 8000 Hz posttreatment. However, compared to steroid-only group, the adjuvant migraine medications group had significantly greater improvements in hearing thresholds at the lower frequencies (250 Hz, 500 Hz, 1000 Hz). Patients in the latter cohort also had greater improvement in PTA (P = .01) and received fewer IT injections (P = .04) PTA improvement of ≥ 10 dB was observed in 36 patients (78%) in the adjuvant migraine medications group and 22 patients (46%) in the control group (P < .001).

Conclusion

In multimodal treatment of SSNHL, supplementing oral and IT steroid with migraine medications may result in greater improvements in lower frequency hearing thresholds and PTA. Furthermore, adjuvant migraine treatment can lead to decrease in number of IT injections, thus reducing procedure-related risks and complications.

Level of evidence

3 Laryngoscope, 131:E283-E288, 2021.

The prevalence of myopia has markedly increased in East and Southeast Asia, and pathologic consequences of myopia, including myopic maculopathy and high myopia-associated optic neuropathy, are now some of the most common causes of irreversible blindness. Hence, strategies are warranted to reduce the prevalence of myopia and the progression to high myopia because this is the main modifiable risk factor for pathologic myopia. On the basis of published population-based and interventional studies, an important strategy to reduce the development of myopia is encouraging schoolchildren to spend more time outdoors. As compared with other measures, spending more time outdoors is the safest strategy and aligns with other existing health initiatives, such as obesity prevention, by promoting a healthier lifestyle for children and adolescents. Useful clinical measures to reduce or slow the progression of myopia include the daily application of low-dose atropine eye drops, in concentrations ranging between 0.01% and 0.05%, despite the side effects of a slightly reduced amplitude of accommodation, slight mydriasis, and risk of an allergic reaction; multifocal spectacle design; contact lenses that have power profiles that produce peripheral myopic defocus; and orthokeratology using corneal gas-permeable contact lenses that are designed to flatten the central cornea, leading to midperipheral steeping and peripheral myopic defocus, during overnight wear to eliminate daytime myopia. The risk-to-benefit ratio needs to be weighed up for the individual on the basis of their age, health, and lifestyle. The measures listed above are not mutually exclusive and are beginning to be examined in combination.