Feasibility of performing treadmill walking test for patients with peripheral arterial occlusive disease by the advanced practice nurses

AIM

The treadmill walking test with post-exercise pressure measurement can be used as a diagnostic test and could classify peripheral arterial disease of the lower limbs. It can also exclude the diagnosis allowing to raise the possibility of differential diagnoses. In this study, we assessed the feasibility of performing treadmill test by advanced practice nurse to assess suspected lower extremity peripheral artery disease patients.

DESIGN AND METHOD

This is a longitudinal monocentric study to assess the feasibility of a treadmill walking test performed by an advanced practice nurse. The primary endpoint was the number of tests performed during this period. The secondary objectives were to evaluate the reasons for requesting the test, the main results obtained in terms of the test's contribution and diagnoses, and patients' clinical characteristics.

RESULTS

From February to May 2023, amongst 31 patients who underwent the treadmill walking test, 4 tests were able to rule out peripheral arterial disease and to detect differential diagnoses. For the remaining 27 patients, 4 had stage IIa of the Leriche classification, 23 had stage IIb, 2 of which were associated with a narrow lumbar spine. In contrast to the usual report, the APN's report on the walking test included an identification of cardiovascular risk factors, as well as a possible medical reorientation linked to the correction of a detected cardiovascular risk factor.

CONCLUSION

The treadmill walking test can be performed by an advanced practice nurse. He/She added a comprehensive/global patient management, with the detection of cardiovascular risk factors. This new profession led to an increase in the number of tests performed of more than 50% over the period and reduced the time to access the test.

Electro-clinical features in epileptic children with chromosome 15q duplication syndrome

OBJECTIVE

We aimed to describe epilepsy and EEG patterns related to vigilance states and age, in chromosome15-long-arm-duplication-syndrome (dup15q) children with epilepsy, in both duplication types: interstitial (intdup15) and isodicentric (idic15).

METHODS

Clinical data and 70 EEGs of 12 patients (5 intdup15, 7 idic15), followed from 4.5 m.o to 17y4m (median follow-up 8y3m), were retrospectively reviewed. EEGs were analyzed visually and using power spectrum analysis.

RESULTS

Seventy video-EEGs were analyzed (1-16 per patient, median 6), follow-up lasting up to 8y10m (median 4y2m): 25 EEGs in intdup15 (8 m.o to 12y.o, median 4y6m) and 45 EEGs in idic15 (7 m.o to 12 y.o, median 15 m). Epilepsy: 6 West syndrome (WS) (2intdup15, 4idic15); 4 Lennox-Gastaut syndromes (LGS) (1 intdup15, 3 idic15), 2 evolving from WS; focal epilepsy (3 intdup15). In idic15, WS displayed additional myoclonic seizures (3), atypical (4) or no hypsarrhythmia (2) and posterior predominant spike and polyspike bursts (4). Beta-band rapid-rhythms (RR): present in 11 patients, power decreased during non-REM-sleep, localization shifted from diffuse to anterior, peak frequency increased with age.

CONCLUSION

WS with peculiar electro-clinical features and LGS, along with beta-band RR decreasing in non-REM-sleep and shifting from diffuse to anterior localization with age are recognizable features pointing towards dup15q diagnosis in children with autism spectrum disorder and developmental delay.

SIGNIFICANCE

This study describes electroclinical features in both interstitial and isodicentric duplications of chromosome 15q, in epileptic children, including some recent extensions regarding sleep features; and illustrates how the temporo-spatial organization of beta oscillations can be of significant help in directing towards dup15q diagnosis hypothesis.

How to do and why perform the skull vibration-induced nystagmus test

The skull vibration-induced nystagmus test (SVINT) is a global vestibular test stimulating otoliths and semicircular canals at a frequency of 100Hz, not modified by vestibular compensation, which may reveal vibration-induced nystagmus (VIN). Bone-conducted vibration applied to the mastoid processes and the vertex instantaneously induces predominantly low-velocity (∼10°/s) horizontal nystagmus, with rapid phases beating away from the affected side in patients with unilateral vestibular loss (UVL). VIN starts and stops immediately with stimulation, is continuous, reproducible, beats in the same direction irrespective of which mastoid process is stimulated, with no or little habituation. The SVINT acts like a vestibular Weber test. In peripheral UVL, the SVINT is a good marker of vestibular asymmetry and demonstrates pathological nystagmus beating towards the healthy side in 90% of cases of vestibular neuritis, 71% of cases of Menière's diseases and 44 to 78% of vestibular schwannomas. In superior semicircular canal dehiscence, VIN usually beats towards the affected side due to facilitation of bone conduction related to the presence of a third window. Stimulation of the vertex is more effective than in UVL patients, with sensitivity extending to higher frequencies, up to 700Hz. Observation of vibration-induced nystagmus then reveals equally represented vertical, torsional, and horizontal components beating towards the affected ear, suggesting dominant, but not exclusive, stimulation of the dehiscent superior semicircular canal.

Dissecting the phenotypic heterogeneity in sensory features in autism spectrum disorder: a factor mixture modelling approach

BACKGROUND

Heterogeneity in the phenotypic presentation of autism spectrum disorder (ASD) is apparent in the profile and the severity of sensory features. Here, we applied factor mixture modelling (FMM) to test a multidimensional factor model of sensory processing in ASD. We aimed to identify homogeneous sensory subgroups in ASD that differ intrinsically in their severity along continuous factor scores. We also investigated sensory subgroups in relation to clinical variables: sex, age, IQ, social-communication symptoms, restricted and repetitive behaviours, adaptive functioning and symptoms of anxiety and attention-deficit/hyperactivity disorder.

METHODS

Three hundred thirty-two children and adults with ASD between the ages of 6 and 30 years with IQs varying between 40 and 148 were included. First, three different confirmatory factor models were fit to the 38 items of the Short Sensory Profile (SSP). Then, latent class models (with two-to-six subgroups) were evaluated. The best performing factor model, the 7-factor structure, was subsequently used in two FMMs that varied in the number of subgroups: a two-subgroup, seven-factor model and a three-subgroup and seven-factor model.

RESULTS

The 'three-subgroup/seven-factor' FMM was superior to all other models based on different fit criteria. Identified subgroups differed in sensory severity from severe, moderate to low. Accounting for the potential confounding effects of age and IQ, participants in these sensory subgroups had different levels of social-communicative symptoms, restricted and repetitive behaviours, adaptive functioning skills and symptoms of inattention and anxiety.

LIMITATIONS

Results were derived using a single parent-report measure of sensory features, the SSP, which limits the generalisability of findings.

CONCLUSION

Sensory features can be best described by three homogeneous sensory subgroups that differ in sensory severity gradients along seven continuous factor scores. Identified sensory subgroups were further differentiated by the severity of core and co-occurring symptoms, and level of adaptive functioning, providing novel evidence on the associated clinical correlates of sensory subgroups. These sensory subgroups provide a platform to further interrogate the neurobiological and genetic correlates of altered sensory processing in ASD.

The Human Dynamic Clamp Reveals the Fronto-Parietal Network Linking Real-Time Social Coordination and Cognition

How does the brain allow us to interact with others? Social neuroscience has already provided some answers to these questions but has tended to treat high-level, cognitive interpretations of social behavior separately from the sensorimotor mechanisms upon which they rely. The goal here is to identify the underlying neural processes and mechanisms linking sensorimotor coordination and intention attribution. We combine the human dynamic clamp, a novel paradigm for studyingrealistic social behavior, with high-resolution electroencephalography. The collection of humanness and intention attribution reports, kinematics, and neural data affords an opportunity to relate brain activity to the ongoing social behavior. Behavioral results demonstrate that sensorimotor coordination influences the judgments of cooperativeness and humanness. Analysis of brain dynamics reveals two distinct networks related to the integration of visuo-motor information from self and other which overlap over the right parietal region. Furthermore, judgment of humanness and cooperation of others modulate the functional connectivity between this right parietal hub and the prefrontal cortex. These results reveal how distributed neural dynamics integrates information from "low-level" sensorimotor mechanisms and "high-level" social cognition to support the realistic social behaviors that play out in real time during interactive scenarios.

The skull vibration-induced nystagmus test: A useful vestibular screening test in children with hearing loss

INTRODUCTION

Skull-Vibration-Induced-Nystagmus Test (SVINT), a non-invasive first line examination test, stimulates both otolith and canal structures and shows instantaneously a vestibular asymmetry. This study aimed to analyze the SVINT results observed in children with hearing loss (HL) amplified with hearing aids (HA) or unilateral cochlear implant (uCI) and healthy children.

MATERIAL AND METHODS

This case-control study compared the results of SVINT, caloric test (CaT) and video head-impulse-test (VHIT) in 120 controls to 30 children with HA and 30 with uCI, aged 5-18 years old. SVINT was recorded with videonystagmography after very high frequency (VHF) stimulation of mastoids and vertex.

RESULTS

SVINT results were non-pathological in 98% of the control group but modified in the HL group (P-value=0.04). In uCI participants, 13.3% had a bilateral weakness (BW) and 16.7% had a unilateral weakness (UW). In the HA group, 26.7% had BW, 10% had UW. SVINT was efficient to show a UW (6 out of 7 confirmed cases) but not efficient to show BW (1/12 confirmed cases).

CONCLUSION

SVINT can detect unilateral vestibular deficit in the VHF with a sensitivity of 86% and specificity of 96%. The positive predictive value is 75% and negative predictive value is 98%. In the case of bilateral deficit, the SVINT is inoperant. In amplified participants, a UW was equally detected whether using SVINT, CaT or VHIT. SVINT is a well-tolerated and useful test to screen vestibular asymmetry in children with HL when combined with other vestibular tests and shows its complementary at very high frequencies.

Exploration de la perfusion tissulaire microcirculatoire au cours du choc septique

Au cours des infections graves, les travaux chez l’animal et chez l’homme ont mis en évidence une altération de la perfusion microcirculatoire à l’origine des défaillances viscérales et potentiellement du décès. La sévérité des anomalies microcirculatoires ainsi que leur persistance sont des facteurs prédictifs de mortalité indépendamment du débit cardiaque ou de la pression artérielle. Il est donc indispensable de développer des outils permettant d’évaluer la perfusion microcirculatoire au lit du malade. De nombreux travaux au cours du sepsis suggèrent que l’analyse de la perfusion cutanée au travers de sa température (et/ou du gradient), du temps de recoloration cutané, de l’étendue des marbrures et de l’indice de perfusion périphérique constitue un outil simple qui permet au réanimateur une évaluation rapide des anomalies microcirculatoires.

Patients immunodéprimés, quel pathogène pour quel déficit immunitaire ? (en dehors de l’infection à VIH)

Le nombre de patients immunodéprimés ne cesse d’augmenter en raison de l’amélioration du pronostic global du cancer et de l’utilisation croissante d’immunosuppresseurs tant en transplantation qu’au cours des maladies auto-immunes. Les infections sévères restent la première cause d’admission en réanimation dans cette population et sont dominées par les atteintes respiratoires. On distingue les déficits primitifs, volontiers révélés dans l’enfance, des déficits secondaires (médicamenteux ou non), les plus fréquents. Dans tous les cas, les sujets sont exposés à des infections inhabituelles de par leur fréquence, leur type et leur sévérité. À côté des pyogènes habituels, les infections opportunistes et la réactivation d’infections latentes font toute la complexité de la démarche diagnostique. Celle-ci doit être rigoureuse, orientée par le type de déficit, les antécédents, les prophylaxies éventuelles et la présentation clinicoradiologique. Elle permettra seule de guider le traitement probabiliste et les examens étiologiques, l’absence de diagnostic étant associée à une mortalité élevée.

Attitudes of physicians towards the care of critically ill elderly patients - a European survey

BACKGROUND

Very elderly patients are one of the fastest growing population in ICUs worldwide. There are lots of controversies regarding admission, discharge of critically ill elderly patients, and also on treatment intensity during the ICU stay. As a consequence, practices vary considerably from one ICU to another. In that perspective, we collected opinions of experienced ICU physicians across Europe on statements focusing on patients older than 80.

METHODS

We sent an online questionnaire to the coordinator ICU physician of all participating ICUs of an recent European, observational study of Very old critically Ill Patients (VIP1 study). This questionnaire contained 12 statements about admission, triage, treatment and discharge of patients older than 80.

RESULTS

We received answers from 162 ICUs (52% of VIP1-study) spanning 20 different European countries. There were major disagreements between ICUs. Responders disagree that: there is clear evidence that ICU admission is beneficial (37%); seeking relatives' opinion is mandatory (17%); written triage guidelines must be available either at the hospital or ICU level (20%); level of care should be reduced (25%); a consultation of a geriatrician should be sought (34%) and a geriatrician should be part of the post-ICU trail (11%). The percentage of disagreement varies between statements and European regions.

CONCLUSION

There are major differences in the attitude of European ICU physicians on the admission, triage and treatment policies of patients older than 80 emphasizing the lack of consensus and poor level of evidence for most of the statements and outlining the need for future interventional studies.

Endolymphatic hydrops imaging: Differential diagnosis in patients with Meniere disease symptoms

PURPOSE

The goal of this retrospective study was to investigate the differential diagnosis of endolymphatic hydrops in patients with Meniere's disease (MD) symptoms by using magnetic resonance imaging (MRI) with intravenous injection of gadolinium chelate and delayed acquisition.

MATERIAL AND METHOD

Two hundred patients (133 women, 67 men; mean age=67.2±11 ([SD] years) with unilateral MD underwent MRI at 3-T, between 4.5 and 5.5hours after intravenous administration of gadoterate meglumine at a dose of 0.1mmol/kg. MR images were analyzed for the presence of saccular hydrops, perilymphatic fistulae, inner ear malformations, semicircular canal (SCC) abnormal enhancement and brain lesions. We also tested the potential relationship between past history of gentamicin intratympanic administration and perilymphatic fistula presence and SCC aspect.

RESULTS

Saccular hydrops were found in 96/200 patients with MD (48%). Three patients (1.5%) had perilymphatic fistulas associated with saccular hydrops, as confirmed by surgery. There was a correlation between the presence of perilymphatic fistula and past history of intratympanic gentamicin administration (P=0.02). We detected inner ear malformations in 5 patients (2.5%), SCC local enhancement in 15 patients (7.5%) always on the same side than the clinical symptoms of MD. There was a correlation between the presence of SCC abnormal enhancement and past intratympanic gentamicin administration (P=0.001). Five patients (2.5%) had brain lesions along central cochleovestibular pathways.

CONCLUSION

MRI may reveal brain lesions, SCC abnormalities and perilymphatic fistulae in patients with clinical MD.

Recurrent peripheral vestibulopathy: Is MRI useful for the diagnosis of endolymphatic hydrops in clinical practice?

OBJECTIVES

Recurrent peripheral vestibulopathy (RPV) is a public health problem, yet the aetiology remains unclear. Recent developments in MRI of endolymphatic hydrops (EH) allow for a better understanding of inner ear disorders. We intended to study the prevalence of EH in patients with RPV, in comparison to those with Meniere's disease (MD).

METHODS

MRI examinations were performed 4 hours after intravenous injection of gadoteric acid in 132 patients with RPV (n = 64) and MD (n = 68). Two radiologists retrospectively studied the prevalence and localization of EH in RPV and MD groups. Patients were graded based on the number and localization of hydrops, between 1 (EH in either cochlea or vestibule on one side) and 4 (EH in cochlea and vestibule on both ears).

RESULTS

We identified EH in 31 out of 64 patients and in 61 out of 68 patients in the RPV and MD groups, respectively. There was a significant difference regarding the number of subjects with EH between the two groups (p ≤ 0.01), with a higher average number of hydrops localization in MD group (p ≤ 0.01).

CONCLUSION

MRI may reveal EH in some cases among patients with RPV, suggesting a similar pathophysiological mechanism in comparison with MD.

KEY POINTS

• MRI may reveal endolymphatic hydrops in some patients with recurrent peripheral vestibulopathy. • We suggest a similar pathophysiological mechanism in recurrent vestibulopathy and Meniere's Disease. • MRI with delayed acquisition helps clinicians to assess patients with recurrent vestibulopathy. • The outcome would be to aid the development of adapted therapeutic strategies. • MRI of endolymphatic hydrops should probably be included in future diagnostic protocols.

[Benefit of skull vibration-induced nystagmus test in occupational medicine]

BACKGROUND

Nystagmus induced by vibrations (NIV), has been optimized by the present authors this last decade. The skull vibration-induced nystagmus test (SVINT) can be designated as a high-frequency global "vestibular Weber test" and can be considered as an office-based examination to detect vestibular asymmetry. The aim of this study is to define the tolerance of the SVINT as well as its comparison to the simplified caloric test of Veits (CTV) in normal workers during the pre-employment visit at the occupational medicine center.

MATERIAL AND METHODS

The vestibular function has been evaluated by the SVINT and the CTV in 87 healthy workers. The tolerance of the two procedures has been evaluated by a 4-items questionnaire (nausea, vomiting, sweating, asthenia).

RESULTS

The caloric test was normal in each worker. The SVINT was positive in one patient who had a partial unilateral vestibular dysfunction related to trauma. The mean duration of the procedure was 15 min for CTV and 1 min for SVINT. Side effects (nausea, vomiting, sweating, asthenia) were present in 50% of the workers following CTV and in only one patient after SVINT. The SVINT demonstrated significantly less side effects for each item (p < 0.0001).

CONCLUSIONS

SVINT is a valid, rapid, low-cost clinical screening test and does not cause patient discomfort. It is suggested that this test which explores vestibular high frequencies and is not modified by vestibular compensation is useful for the diagnostic screening of workers' vestibular dysfunction, when combined with other vestibular tests and complements the CTV.

Subacute tuberculous otitis media complicated by petrositis and meningitis

AIMS

The aim of our case study is to illustrate diagnostic and therapeutic difficulties as well as gravity related to tuberculous otitis media with intracranial complications.

CASE PRESENTATION

A diabetic male patient of 65 years old was treated for subacute otitis media with mixed hearing loss. Early bacteriologic samples from ear exudates revealed opportunistic pathogens. Clinical evolution after four months was marked by the appearance of mastoiditis with facial paralysis. The patient presented petrositis and bilateral laryngeal paralysis with lymphocytic meningitis after six and eight months respectively. Tuberculosis was suspected after a positive ELlspot tests with appearance of biologic markers of hepatic dysfunction like cholestasis and hepatic cytolysis. Although antituberculous treatment was instaured even without isolation of acid fast bacilli, the patient died after ten months.

CONCLUSION

Subacute otitis media complicated by labyrinthitis, early onset of facial paralysis or any other oranial nerve palsy should raise suspicion of tuberculosis. The prognosis depends on early diagnosis which remains difficult despite morphological and metabolic imaging. The diagnostic workup should include histological and bacteriologic samples, liver markers of intacellular damage as well as ELlspot test. The prognosis remains poor especially in immunocompromised patients despite appropriate treatment.

[Prolonged fever: specific issues in the young adult population]

Early studies on prolonged fever date back to the 1960s. Fifty years later, prolonged unexplained fever remains a diagnostic challenge to the general internists. Although the aetiologies of prolonged fevers have not changed much in the general population, the distribution between the various causes is not the same anymore. A regular decrease in infectious and neoplastic causes is noticed whatever the age. Prolonged fevers related to inflammatory disorders and fevers that remain of unknown origin still represent approximately 30 to 50% of the cases. In the young adult population, as in the older patients, prolonged fevers can be attributed to four groups: infection, inflammation, neoplasic and other aetiologies (including drug-related fevers). In the young adult population, the management of prolonged fever presents some specific issues that are the purpose of this review coupled with our own experience. The prognosis of undiagnosed prolonged fever is usually favourable, as a life-threatening aetiology is exceptionally diagnosed during the follow-up if the initial management was complete and accurate.

[Giant retroperitoneal hydatid cyst in a traveller]

INTRODUCTION

Giant hydatid cyst located in the retroperitoneal space is rare. The purpose of this report is to present a case cured by surgery in an adult traveller.

CASE REPORT

In August 2009, a 67-year-old female who traveled frequently to Lebanon was admitted for assessment of a giant retroperitoneal hydatid cyst discovered coincidentally following palpation of an abdominal mass in 1997. From 1966 to 1975, the patient had undergone several surgical procedures for pulmonary and hepatic hydatidosis, complicated by vomica and anaphylactic shock. In 1997, computed tomography showed that the retroperitoneal cyst measured 100 mm at the widest point. At that time, the patient refused to undergo further surgery and was treated medically using albendazole initially in association with praziquantel. In 2009, the cyst had expanded to 180 mm at the widest point and the patient finally consented to perikystectomy. Excision was total and recovery was uneventful. Histology examination confirmed the viability of the cyst. Follow-up examination at 12 months indicated no relapse.

COMMENTS

The retroperitoneal space is a rare location for hydatidosis. Occurrence in this location is generally primary. In case of discovery of a liquid-filled retroperitoneal mass, a history of travel to an endemic area for hydatid disease should be elicited. Diagnosis relies on radiological findings and positive serology. Since retroperitoneal cysts are often giant, they respond poorly to medical treatment. Similarly radiological treatment is difficult due to retroperitoneal location. Surgery, preferably perikystectomy, is the treatment of choice.

[Skull vibration induced nystagmus test]

OBJECTIVES

To establish during a consensus meeting the fundamental basis, the validity criteria, the main indications and results of the skull vibration induced nystagmus test (SVINT) which explores the vestibule high frequencies.

MATERIAL AND METHODS

The SVINT is applied on the mastoid process (right and left sides) at 100 Hz during 10 seconds on a sitting upright subject. Total unilateral peripheral lesions (tUVL: operated vestibular shwannomas, vestibular neurectomies) and partial unilateral peripheral lesions (pUVL: preoperative neuromas, Meniere's disease, vestibular neuritis, chemical labyrinthectomies) were studied. Thirty-six patients had brainstem lesions and 173 normal subjects were used as controls.

RESULTS

The SVINT is considered positive when the application of the vibrator produces a reproducible sustained nystagmus always beating in the same direction following several trials in various stimulation topographies (on the right and left mastoid). The skull vibratory nystagmus (SVN) begins and ends with the stimulation; the direction of the nystagmus has no secondary reversal. The slow phase velocity (SPV) is>2 degrees /second. In tUVL the SVINT always reveals a lesional nystagmus beating toward the safe side at all frequencies. The mean SVN SPV is 10.8 degrees /s+/-7.5 SD (N=45). The mastoid site was more efficient than the cervical or vertex sites. Mastoïd stimulation efficiency is not correlated with the side of stimulation. The SVN SPV is correlated with the total caloric efficiency on the healthy ear. In pUVL the SVINT is positive in 71 to 76% of cases; the mean SVN. SPV (6.7 degrees /s+/-4.7 SD)(N=30) is significantly lower than in tUVL (P=0.0004). SVINT is positive in 6 to 10% of the normal population, 31% of brain stem lesions and negative in total bilateral vestibular peripheral lesions.

CONCLUSIONS

SVINT is an effective, rapid and non invasive test used to detect vestibular asymmetry between 20 to 150 Hz stimulation. This test used in important cohorts of patients during the ten last years has demonstrated no observable adverse effect. SVINT complements other tests which evaluate lower frequencies (caloric test: 0,003 Hz) and the medium frequencies (Head-Shaking-Test (HST): 2 Hz; the head impulse test (HIT): 6 Hz). SVINT is useful in the diagnosis of labyrinthine hydrops or detection of acoustic neuromas. It is useful when the caloric test can not be practised because of middle ear problems. SVINT has its limits: in pUVL, the nystagmus direction is not always specific of the pathologic side and can change with the stimulus frequency. This test does not precisely point out the level of the lesion on the vestibular pathway.

[Dehiscence of the anterior semicircular canal and otosclerosis: a case report]

The dehiscence of the anterior semicircular canal is a new clinical entity, it is necessary to consider this when a gusher occurs during stapedial surgery.

CASE REPORT

We report a rare case of dehiscence of the anterior canal associated with otosclerosis. This was revealed by a gusher during the initial stapedectomy. At 3 months, an obliteration of the dehiscence was necessary by middle cranial fossa approach (persistant vestibular symptoms), seven months later. Revision stapedial surgery resulted in complete closure of the air-bone-gap.

CONCLUSION

High resolution CT scans of the temporal bone are the key to diagnosis. It is necessary to appreciate this pathology with advances in canal and vestibular surgery.

Neurotomie vestibulaire vs. labyrinthectomie chimique dans la maladie de Menière invalidante

OBJECTIVE

To evaluate the efficiency on the vertigos and the impact on the audition of the vestibular neurotomy (VN) and the chemical labyrinthectomy (CL) in patients with severe Menière's disease, in order to determine the precise place for each technique in treatment algorithm.

METHOD

Retrospective study of 71 VN (performed between 1986 and 2003) and 35 CL (performed between 1997 and 2003). These two treatments both aim at obtaining a vestibular deafferentation in order to free definitely the patient of vertigo manifestations. Vestibular results have been assessed by caloric tests performed before and 6 months after treatment. Subjective success was evaluated by searching for recurrent attacks of vertigo and by the AAO-HNS (American Academy of Otolaryngology-Head and Neck Society) scale of subjective evaluation of vertigos (follow-up of 6.4 years after VN and 2.4 years after CL). Pure tone audiometry before treatment and then 6 months later was performed. Complications of two types of treatment were recorded and evaluated.

RESULTS

In 90% of the cases after VN and 86% of the cases after CL, caloric tests indicated a strong vestibular hyporeflexy (hypovalence > 90%). Attacks of vertigo reoccurred in 5.6% of the cases when the hyporeflexy was strong and 85.7% of the cases when it was weak. The quality of the vestibular results on vertigo depends on the degree of hypovalence after treatment. An improvement of the AAO-HNS scale have been obtained in 93% of the cases in the NV group and in 81% of the cases in the LC group. Attacks of vertigo were recurrent in 7% of the patients operated on by VN and 11.4% of the patients treated by CL. Mean pure tone auditory thresholds changed from 50.24 dB HL to 55.64 dB HL (p=0.003) in the VN group and from 69.11 dB HL to 74.51 dB HL (p=0.41) in the CL group. Comparison of the variations of the mean pure tone auditory thresholds before treatment and 6 months after the end of the treatment doesn't show any significant difference between the 2 groups (p > 0.05). Impairment of the audition superior to 20 dB HL was observed in 8.5% of the patients of each group. The auditive results are similar in the 2 groups.

CONCLUSION

These two methods of treatment can not be strictly compared due to several bias in this study. Indeed more patients were treated by VN with a longer follow-up and only the patients with a class C or D audition according to the criteria of the AAO-HNS could be treated by CL. The VN provides a better control of the vertigos than the CL which is an efficient method of treatment in invalidating Meniere's disease. In all the cases, the quality of the results on vertigos depends on the degree of hypovalence after treatment. The auditive results are similar. Since the results of the two treatments are similar, the simplicity of CL encourages us to broaden the indications and to modify the place of the VN in the therapeutic algorithm of Menière's disease.

[Ossiculoplasty with KURZ titanium prosthesis]

OBJECTIVES

Report the functional and anatomic results of ossicular reconstruction by titanium prosthesis.

MATERIALS AND METHODS

Retrospective chart reviews were performed for 111 patients who had undergone titanium ossicular implants between November 1998 and 2002 (61 PORP, 50 TORP). The anatomical and audiometric data were analyzed on average at 3 and 20 months.

RESULTS

At 20 months, the improvement of air-bone-gap mean was 12.7 dB with better results at low frequencies. The global success rate was 66% (PORP 77%, TORP 52%). It decreased significantly in the open techniques. Extrusion rate was low (2/111) and the labyrinthization rate was 3.6%. Twenty patients required a surgical revision (18%). In 9 patients, the prosthesis was too short. At long-term follow-up, the gains were stable in 60 patients, improved in 32 patients and worsened in 19 patients.

CONCLUSION

The success rate is higher in the group of the PORP with the closed technique. The stability of the TORP in open technique still remains problematic. In all cases, the risk of extrusion requires a large cartilage graft recovering the plate of the prosthesis. The high rate of luxation (9/111 prosthesis too short) has led us to increase slightly the length of the prosthesis (+1.22 mm mean).

[Cavernous haemangiomas: hearing and vestibular inaugural symptoms]

INTRODUCTION

Cavernous haemangiomas (cavernomas)(CH) are relatively rare (2% of cranial tumoral pathology) vascular malformations mostly observed in the central nervous system. Their most common topographical site in brain stem is midline in the pons, for which clinical course may mimic symptoms of peripheral origin (sudden deafness, fluctuating hearing loss, Meniere-like vertigo).

AIM

To establish the correlation between the clinical manifestations of hearing and balance disturbance and the anatomical site within the pons of cavernous haemangiomas, and to describe their clinical features, and the findings on auditory brainstem response (ABR) and magnetic resonance imaging (MRI). To propose a literature review about CH and its implications.

MATERIAL AND METHOD

We made a retrospective review of the histories of three patients aged 24, 44 and 45 years, diagnosed as having cavernomas of the brainstem in which audiometric evaluation, videonystagmography (VNG), ABR and imaging techniques lead to the diagnosis of intracranial cavernoma.

RESULTS

The clinical and radiological files were reviewed and a direct relationship between symptoms and localization was found in all 3 patients, especially in relation to our understanding of the auditory and vestibular pathways within the brainstem.

CONCLUSION

The literature regarding cavernomas of the pons is reviewed and the clinical, neuroimage, pathological, natural course and management aspects of the disease are discussed. We recommend the use of cerebral MRI for initial diagnosis which shows a typical rosette-like appearance with a heterogeneous signal on T2-weighted images, along with follow-up and investigation into similar profiles among family members. At present there is no consensus about the treatment to follow when cavernomas are located in the brain stem. There is no specific medical treatment for this condition, and surgery is indicated only exceptionally. Anticoagulant therapy, platelet-dispersing medication and violent sports activities are contraindicated.

[Skull vibratory test in partial vestibular lesions--influence of the stimulus frequency on the nystagmus direction]

INTRODUCTION

Results of the skull vibratory test (SVT) in partial unilateral vestibular peripheral lesions (PUVL) are different from the results in total vestibular lesions (TUVL).

AIM

To reveal a correlation between the results of the analysis of the skull vibratory nystagmus (SVN) horizontal component and the side of the lesion; to correlate these results with the stimulus frequency. To find out a predictive correlation between the SVN horizontal and vertical components and the topography of a vestibular lesion. To appreciate the degree of vestibular deafferentation (extended to high frequencies) provoked by gentamicin labyrinthectomy and its efficiency in Meniere's disease.

PATIENTS AND METHODS

53 patients with a SVN and a PUVL were included and compared with 10 TUVL and 10 normal subjects. Protocol included a HST (2 Hz), a SVT at 30, 60 and 100 Hz and a caloric test. Recordings were performed with a 2D and 3D VNG device.

RESULTS

In PUVL, SVN at 30, 60 and 100 Hz was obtained in 80, 90 and 90% of cases respectively. SVN is correlated with the side of the lesion at 30, 60 and 100 Hz respectively in 65%, 63%, 80% of cases. SVN is not correlated with the side of the lesion in 20% of Meniere's disease, in 8% of vestibular neuritis and in 6% of vestibular schwannoma. In PUVL HSN is correlated with the side of the lesion in 69% of cases. The direction of the HSN and of the SVN was different in 23% when the nystagmus attended at the same time for both tests. In PUVL the direction of the SVN is different at 100 Hz and 30 Hz in 16% of cases when they are concomittant on the same patient. After Gentamicine labyrinthectomy, the coherence of the results in caloric test, HSN and SVN (areflexy and lesional nystagmus beating toward the safe side) was correlated with the efficiency of the therapy. A SVN vertical component was met in 10% of PUVL (essentially in anterior canal dehiscence and few cases of partial labyrinthitis). The horizontal SVN SPV is significantly slower in PUVL than in TUVL patients (p=0.0004).

CONCLUSIONS

The SVT is a vestibular global and rapid test which explores high frequencies. In PUVL the direction of SVN is not always predictive of the side of the lesion and is sometimes depending on the stimulus frequency, the state of the vestibular lesion, the vestibular structure concerned (1/2 circular canals or otolithic organs) and the kind of sensory cells implicated in the lesion. In TUVL The direction of the SVN is always coherent with the side of the lesion (this is useful to predict the efficiency of a Gentamicine Labyrinthectomy). A SVN vertical component can mean a lesion of the vertical canal in PUVL.

[The outcome of treatments for carcinoma of the external auditory canal]

OBJECTIVE

A retrospective analysis of management and survival of patients treated for temporal bone carcinoma.

PATIENTS AND METHODS

Thirty patients underwent treatment for carcinoma of the temporal bone. Twenty-five squamous cell carcinomas, 1 melanoma, 2 basocellular carcinomas and 2 adenoid cystic carcinomas were treated. Thirteen patients were treated before for the same disease.

RESULTS

Staging revealed 12 T1 and T2, 6 T3 and 12 T4 tumours. The mean follow up was 5 years (2-276 months). The Kaplan Meier survival curves showed survival rates at 2 years of 82%, 67% and 32%, and at 5 years of 82%, 67% and 17%, respectively for the stages T1 or T2, T3 and T4. At the end of follow up at 9 years the survival rates were 66%, 66% and 17% for the stages T1 or T2, T3 and T4 respectively. Overall stages a complete remission was found in 65% and 23%, and deceased was 35% and 77%, respectively for the primary treatment group and the salvage surgery group.

CONCLUSION

Long-term prognosis of the carcinoma of the external auditory canal mainly depends on the stage and primary treatment. Surgery (lateral temporal bone or subtotal temporal bone resection, both in combination with a neck dissection and a parotidectomy) and adjuvant radiotherapy is the treatment of choice for part of stage T1 and all T2 and T3 tumours. The improved survival (65%) of patients treated de novo compared with those treated with salvage surgery (23%) suggests that early referral and aggressive primary surgical treatment with postoperative radiotherapy offer the greatest chance of cure.

Caractérisation du test vibratoire. Comparaison avec les résultats du « Head shaking test »

OBJECTIVES

The purpose of this work was to study the complementary contribution of the vibratory test (VT), the head shaking test (HST) and the caloric test (CT) in patients with total or partial vestibular lesions. We investigated the usefulness of these three tests, particularly the high frequency VT, for multiple-frequency vestibular study.

MATERIALS AND METHODS

The study cohort included 40 patients with total vestibular lesions (TVL) and 47 patients with partial vestibular lesions (PVL), the latter group including 21 patients with recent Menière disease, 15 with sudden-onset loss of vestibular function (SLVF), 5 with tumors of the cerebropontine angle, and six with diverse conditions. The HST protocol was 2 Hz stimulation (head speed greater than 180 degrees /s). The VT used an ABC 100 Hz vibrator operating at 0.8 mm and an S stimulator delivering frequencies between 30 and 115 Hz during 10 s stimulations. An LIVN-2 videoscope (biodigital France) and a 2D and 3D videonystagmograph (synapsis France) were used for the recordings. Mastoid stimulation was used for the VT.

RESULTS

For the 40 patients with TVL, the three tests (VT, CT, HST) were in agreement for all frequencies. The nystagmus produced by the VT demonstrated a horizontal component in 96% of the patients, a vertical component in 47%, and a rotational component in 30%. For the 47 patients with PVL, 9 of the 21 with Menière disease had a normal CT. Conversely, nystagmus was triggered by the HST in 10 and by the VT in 6. Nystagmus triggered by the VT and the HST was non-coherent with opposing direction in two-thirds of the patients. In certain cases, the VT demonstrated a variation in the direction of the nystagmus depending on the stimulation frequency, 30 or 100 Hz. Among the 15 patients with SLVF, the HST triggered nystagmus in only 5 and the VT in 14 (5 patients had nystagmus non-coherent with the side of the lesion). For the 5 patients with tumors of the cerebropontine angle (small neuroma or meningioma), the CT was negative in all 5, the HST was negative in 3, and the VT demonstrated lesional nystagmus in 4. Looking at the overall results, in the 47 patients with PVL (including 21 cases of Menière disease outside an acute phase) the CT demonstrated significant hypovalence in 70%, while the nystagmus demonstrated asymmetrical response in 44% when triggered by the HST and in 85% when triggered by the VT.

CONCLUSION

The VT is less invasive than the HST, particularly for elderly patients with osteoarthritis. It would be interesting in patients with bilateral tympanic perforation since the CT cannot be performed. It can reveal vestibular asymmetry. For unilateral partial vestibular lesions, the VT triggers nystagmus more often than the HST. It is particularly sensitive between acute episodes in patients with Menière disease. A discordance between the direction of the nystagmus triggered by the HST and the VT is particularly frequent in patients with labyrinthine hydropsis who exibit a normal CT. In certain cases of apparent bilateral areflexia to the CT for low frequencies, the VT can disclose vestibular asymmetry for high frequencies. The nystagmus triggered by the VT begins and ends with stimulation with little or no tiring. The nystagmus triggered by the HST occurs after the stimulation and depends on the frequency of the head shaking. Thus, the HST (2 Hz and its harmonics), the VT (100 Hz) and the CT (<0.01 Hz) all make significant contributions to multiple-frequency analysis of vestibular function, particularly useful in patients with partial vestibular lesions. These tests probably solicit cells with different topographies or different frequency sensitivities.

[Nystagmus and vibratory test: evidence for mechanism. Material conditions and methods in the fast detection of unilateral vestibular lesions]

OBJECTIVE

The aim of the present study was to examine the characteristics of vibratory nystagmus (VN), optimise the topography and the frequency of the stimulus, determine the origin of the VN and analyze its clinical implications.

MATERIAL AND METHOD

Fifty-two severe unilateral vestibular lesions (SUVL) (post-surgical vestibular areflexy) were studied. The vibratory nystagmus was measured by 2D and 3D videonystagmography (Synapsis, France). The stimulus was applied with a 3S vibrator at the vertex, both mastoïds, and posterior cervical muscles, at frequencies ranging from 20 to 150 Hz. For topographic optimization, stimulation was given with S vibrator (Synapsis, France) at 100 Hz. The interferences between the vibratory test (VT) and the caloric test (CT) were studied on the normal ear (in 11 subjects). The same study was carried out with the optokinetic test.

RESULTS

The VT revealed a defective nystagmus at all frequencies of stimulation. Optimal response was obtained in a band frequency of 80-120 Hz. Stimulations at 100 Hz showed optimal responses for mastoid topography (responses in 96% of the cases). Stimulation at the posterior cervical muscles and at the vertex indicated respectively a response in 90% and 60% of the cases. The efficiency of the mastoid stimulation was not correlated with the side of stimulation (p=0.9). The interference between the VT and caloric test (CT) with cold water (30 degrees C and 20 degrees C) exhibited the inversion of the caloric nystagmus during the vibrator stimulation. The resulting nystagmus was respectively an algebraic subtraction or addition between the pre-existing caloric nystagmus and the value of the vibratory nystagmus obtained before the caloric test. Adaptation of the VN was moderate. The interference between the VT and the optokinetic test resulted in a subtraction or addition effect, according to the side of the lesion and the direction of the optokinetic stimulus.

CONCLUSION

The VT is an efficient stimulation in mastoid topography. The vestibular contribution is bilateral by bony conduction of the vibration, it explores frequencies ranging from 30 to 120 Hz, with a maximum of response at 100 Hz. The VT interacts with the caloric test and the optokinetic test. The stimulation is very strong, and is able to inverse the caloric nystagmus at cold water stimulation (20 degrees C) In labyrinthine-defective subjects, the VN is always defective at all frequencies, whatever the topographic location of the stimulus, and the position of the head.

Vitrification of cryoelectron microscopy specimens revealed by high-speed photographic imaging

Cryoelectron microsopy is a widely used technique to observe biological material in an almost physiological, fully hydrated state. The sample is prepared for electron microsopy observation by quickly reducing its temperature to -180 degrees C. The high-speed cooling induces the formation of vitreous water, which preserves the sample conformation. However, the way vitrification occurs is still poorly understood. In order to better understand the phenomenon, we have used a stroboscopic device to visualize the interaction between the electron microscopy grid and the cryogen. By blocking the free fall of the plunger once the grid has penetrated the coolant by half its diameter, we have elucidated the way in which vitrification propagates. The findings were confirmed by numerical simulation. In addition, according to our observations, we now present an alternative way to prepare vitreous specimens. This new method, with the grid parallel to the liquid cryogen surface, decreases evaporation from the sample during its free fall towards the coolant and at the same time achieves a more uniform vitrification over the entire surface of the specimen.

[Nystagmus and vibration test research of mechanisms, theoretical methods: on 52 cases of unilateral vestibular lesions]

OBJECTIVE

The aim of the present study was to examine the characteristics of the Vibratory Nystagmus (VN) optimise the topography and the frequency of the stimulus, determine the origin of the VN and analyse its clinical implications.

MATERIAL AND METHOD

52 severe unilateral vestibular lesions (SUVL) (post-surgical vestibular areflexy) were studied. The vibratory nystagmus was measured by 2D and 3D videonystagmography (Synapsis, France). The stimulus was applied with a 3S vibrator at the vertex, both mastoïds, and posterior cervical muscles at frequencies ranging from 20 to 150 Hz. For topographic optimisation, stimulation was given with S vibrator (Synapsis, France) at 100 Hz. The interferences between the vibratory test (VT) and the caloric test (CT) were studied on the normal ear (in 11 subjects). The same study was carried with the optokinetic test.

RESULTS

The VT revealed a defective nystagmus at all frequencies of stimulation. Optimal response was obtained in a band frequency of 80-120 Hz. Stimulations at 100 Hz showed optimal responses for mastoïd topography (responses in 96% of the cases). Stimulation at the posterior cervical muscles and at the vertex indicated respectively a response in 90% and 60% of the cases. The efficiency of the mastoïd stimulation is not correlated with the side of stimulation (p = 0.9). The interference between the VT and caloric test (CT) at cold water (30 degrees et 20 degrees C) exhibited the inversion of the caloric nystagmus during the vibrator stimulation. The resulting nystagmus is respectively an algebric subtraction or addition between the pre-existing caloric nystagmus and the value of the vibratory nystagmus obtained before caloric test. Adaptation of the VN is moderate. The interference between the VT and the optokinetic test resulted in a subtraction or addition effect, according to the side of the lesion and the direction of the optokinetic stimulus.

CONCLUSION

The VT is an efficient stimulation in mastoïd topography. The vestibular contribution is bilateral by bony conduction of the vibration, it explores frequencies ranging from 30 to 120 Hz, with a maximum of response at 100 Hz. The VT interacts with the caloric test and the optokinetic test. The stimulation is very strong, and is able to inverse the caloric nystagmus at cold water stimulation (20 degrees C). In labyrinthine-defective subjects, the VN is always defective at all frequencies, whatever is the topographic location of the stimulus, and the position of the head.