Vestibular rehabilitation improves spontaneous nystagmus normalization in patients with acute unilateral vestibulopathy

Introduction

Spontaneous nystagmus (SN) can be observed after acute unilateral vestibulopathy (AUVP). The slow phase eye velocity of the SN progressively decreases in darkness as the result of rebalanced neurophysiological activity between both vestibular nuclei, a process that can take several months. Although this compensatory process can occur spontaneously, there is poor evidence that vestibular rehabilitation (VR) can facilitate the process.

Methods

We documented the natural time course of SN reduction in patients with AUVP, as well as the effects of VR by means of a unilateral rotation paradigm. In a retrospective study (Study 1: n = 126 AUVP patients), we compared the time course of the SN reduction in patients with VR (n = 33) and without VR (n = 93). In a prospective study (Study 2: n = 42 AUVP patients), we compared the effects of early VR (n = 22; initiated within the first two weeks of symptoms onset) or late VR (n = 20; initiated after the second week of symptoms onset) on the time course of the SN reduction.

Results

Study 1 showed shorter median time of SN normalization in patients with VR compared to patients without VR (14 days and 90 days, respectively). Study 2 showed that AUVP patients with early and late VR had a similar median time of SN normalization. The SN slow phase eye velocity was significantly decreased as early as the end of the first VR session in both groups, and kept decreasing at each subsequent VR session. In the early VR group, 38% of the patients had slow phase eye velocity below 2°/s after the first VR session, 100% after the fifth session. Similar findings were observed in the late VR group.

Discussion

Taken together, these results indicate that VR with a unidirectional rotation paradigm speeds up the normalization of SN. This effect seems independent of the time between symptoms onset and commencement of VR, but early intervention is recommended to speed up the SN reduction.

Posture Deficits and Recovery After Unilateral Vestibular Loss: Early Rehabilitation and Degree of Hypofunction Matter

Postural instability and balance impairment are disabling symptoms in patients with acute unilateral peripheral vestibular hypofunction (UVH). Vestibular rehabilitation (VR) is known to improve the vestibular compensation process, but (1) its effect on posture recovery remains poorly understood, (2) little is known about when VR must be done, and (3) whether the degree of vestibular loss matters is uncertain. We analyzed posture control under static (stable support) and dynamic (unstable support) postural tasks performed in different visual conditions [eye open (EO); eyes closed (EC); and optokinetic stimulation] using dynamic posturography. Non-linear analyses of the postural performance (wavelet transform, diffusion analysis, and fractal analysis) were performed in two groups of patients with UVH subjected to the same VR program based on the unidirectional rotation paradigm and performed either early (first 2 weeks) or later (fifth to the sixth week) after vertigo attack. Distribution of the angular horizontal vestibulo-ocular reflex (aVOR) gain values recorded on the hypofunction side before rehabilitation differentiated two distinct sub-groups (cluster analysis) with aVOR gains below or above 0.20. The postural performance of the four sub-groups of patients with UVH (early rehabilitation with aVOR gain <0.20: n = 25 or gain >0.20: n = 19; late rehabilitation with aVOR gain <0.20: n = 15 or gain >0.20: n = 10) tested before VR showed significantly altered postural parameters compared with healthy controls. Greater instability, higher energy to control posture, larger sway without feedback corrections, and lower time of automatic control of posture were observed in static conditions. The four sub-groups recovered near-normal postural performance after VR in the EO and EC conditions, but still exhibited altered postural performance with optokinetic stimulation. In dynamic posturography conditions and before VR, the percentage of patients able to perform the postural tasks with EC and optokinetic stimulation was significantly lower in the two sub-groups with aVOR gain <0.20. After VR, the improvement of the postural parameters depended on the stage of rehabilitation and the degree of vestibular hypofunction. The best balance function recovery was found in the sub-group with early VR and pre-rehabilitation aVOR gain above 0.20, the worst in the sub-group with late rehabilitation and aVOR gain below 0.20. These differences were seen when the vestibular input remains the main sensory cue to control balance, that is, on unstable support without vision or altered visual motion cues. These findings extend to dynamic balance recovery the crucial roles of early rehabilitation and degree of vestibular hypofunction which we have already highlighted for vestibulo-ocular reflex recovery.

Two conditions to fully recover dynamic canal function in unilateral peripheral vestibular hypofunction patients

BACKGROUND

The crucial role of early vestibular rehabilitation (VR) to recover a dynamic semicircular canal function was recently highlighted in patients with unilateral vestibular hypofunction (UVH). However, wide inter-individual differences were observed, suggesting that parameters other than early rehabilitation are involved.

OBJECTIVE

The aim of the study was to determine to what extent the degree of vestibular loss assessed by the angular vestibulo-ocular reflex (aVOR) gain could be an additional parameter interfering with rehabilitation in the recovery process. And to examine whether different VR protocols have the same effectiveness with regard to the aVOR recovery.

METHODS

The aVOR gain and the percentage of compensatory saccades were recorded in 81 UVH patients with the passive head impulse test before and after early VR (first two weeks after vertigo onset: N = 43) or late VR (third to sixth week after onset: N = 38) performed twice a week for four weeks. VR was performed either with the unidirectional rotation paradigm or gaze stability exercises. Supplementary outcomes were the dizziness handicap inventory (DHI) score, and the static and dynamic subjective visual vertical.

RESULTS

The cluster analysis differentiated two distinct populations of UVH patients with pre-rehab aVOR gain values on the hypofunction side below 0.20 (N = 42) or above 0.20 (N = 39). The mean gain values were respectively 0.07±0.05 and 0.34±0.12 for the lateral canal (p < 0.0001), 0.09±0.06 and 0.44±0.19 for the anterior canal (p < 0.0001). Patients with aVOR gains above 0.20 and early rehab fully recovered dynamic horizontal canal function (0.84±0.14) and showed very few compensatory saccades (18.7% ±20.1%) while those with gains below 0.20 and late rehab did not improve their aVOR gain value (0.16±0.09) and showed compensatory saccades only (82.9% ±23.7%). Similar results were found for the anterior canal function. Recovery of the dynamic function of the lateral canal was found with both VR protocols while it was observed with the gaze stability exercises only for the anterior canal. All the patients reduced their DHI score, normalized their static SVV, and exhibited uncompensated dynamic SVV.

CONCLUSIONS

Early rehab is a necessary but not sufficient condition to fully recover dynamic canal function. The degree of vestibular loss plays a crucial role too, and to be effective rehabilitation protocols must be carried out in the plane of the semicircular canals.

[The relevance of Choukroun's Platelet-Rich Fibrin (PRF) during middle ear surgery: preliminary results]

OBJECTIVES

To evaluate the relevance of Leucocyte- and Platelet-Rich Fibrin (L-PRF, Choukroun's technique) Concentrates during tympanoplasty.

MATERIALS AND METHODS

152 myringoplasties (including 2 cases with bilateral tympanic perforations) were treated by the senior surgeon in 150 patients, 63 women and 87 males aged between 25 and 55-years-old, between december 2004 and june 2008. These patients showed non marginal tympanic perforations, sized from punctiform to subtotal. For the smallest perforations, a PRF cylinder was used alone to fill the perforation without preparing a tympanomeatus flap (Champagne plug technique). For perforations largest than the third of the tympanic surface, temporal aponeurosis graft in underlay was preferred, and optimized by the lateral application of a PRF membrane (hamburger technique).

RESULTS

6 failures were recorded in this case series, with tympans showing residual microperforations, after a minimum follow-up of 6 months. The success rate was thus close to 96%. The mean success rate without PRF is normally 85%. All failures were recorded on large non marginal lesions.

CONCLUSION

PRF will never save an inadequate surgical procedure, but it offers both mechanical and inflammatory protection to the tympanic graft and accelerates cell proliferation and matrix remodelling. Moreover, this autologous biomaterial induces no undesirable tissue reaction, is easy, quick and cheap to produce and is easily manipulated during the surgical procedure. It seems a precious help for the otologist, in order to improve tympanic healing. PRF potential applications in the middle-ear surgery seem numerous.

[Paraganglioma of the cerebellopontine angle: report of two cases]

Paragangliomas of the cerebellopontine angle are exceptional tumours. We report two cases of paragangliomas of the cerebellopontine angle. To our knowledge, including these two cases, only five cases have been reported in the international literature. The emerging field of genetic study of these tumours will prove critical for their diagnosis and prognosis. The presence of paraganglioma in this area is explained by an abnormal embryologic migration of paraganglionic cells into the cerebellopontine angle, associated with tumorogenesis. These tumors can be associated with others cervico-facial tumours and to genomic abnormalities. The preoperative diagnosis of these tumours is very difficult, with clinical signs like hearing loss, vertigo and tinnitus are very ambiguous. Radiologic assessment of the cerebellopontine angle is also vague. The final diagnosis is only made possible peroperatively and by the post-operative histopathologic study. ENT and neurosurgeons should be awarded of the possible existence of paragangliomas of the cerebellopontine angle, and the necessity of a systemic and genetic assessment.

New perspectives for middle ear implants: first results in otosclerosis with mixed hearing loss

Middle ear implantation is an efficient procedure to restore moderate to severe sensorineural hearing loss (HL) in selected patients. Implantation of such devices requires ossicular chain integrity. Patients suffering from otosclerosis with mixed HL should be eligible for this treatment after stapes surgery with air-bone gap closure. To address this issue, we report four cases of middle ear implantation after or during stapes surgery. Results and complications obtained with Vibrant SoundBridge, MedEl and Middle Ear Transducer, Otologics are reported. Audiologic results were similar to those obtained in cases of sensorineural HL. One case of postoperative labyrinthitis was observed.

Surgical Management of Lesions of the Internal Carotid Artery Using a Modified Fisch Type A Infratemporal Approach

OBJECTIVE

To report seven cases of vascular repair of the internal carotid artery (ICA) using a modified Fisch type A infratemporal approach and a venous grafting.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care center.

PATIENTS

We have analyzed the clinical presentation, paraclinical assessment, and postoperative results regarding the vascular repair and the facial and auditory function from seven consecutive patients. All patients have been operated on by a multidisciplinary team of ENT and vascular surgeons.

RESULTS

The study includes four men and three women, aged from 21 to 62 years old. Six patients suffered from vascular traumatic injury after motor vehicle accident (n = 5) or cervical manipulation (n = 1) and one patient presented an atheromatous stenosis. All benefited from a vascular repair with a venous grafting through a modified Fisch Type A infratemporal approach. No death and no new stroke were noted (mean follow-up, 34 mo). The postoperative angiographies showed six functional grafts and one asymptomatic thrombosis. Six immediate postoperative facial palsy occurred but recovered to Grade I or II within 6 months. There was one traumatic injury of the facial nerve and one postoperative anacusis. For the six other patients, the reconstitution of the external auditory canal and ossicular chain allowed to limit the hearing loss to a mean air-bone gap of 22.5 dB (range, 15-35 dB).

CONCLUSION

The lesions of the intrapetrous aspects of the ICA remain the subject of debates regarding the indication for a vascular repair. For young or in good health patients, the infratemporal approach provides a safe and reliable access to the horizontal segment of the ICA, offering to the vascular surgeons optimal conditions for the vascular repair.

Unusual association of congenital middle ear cholesteatoma and first branchial cleft anomaly: management and embryological concepts

OBJECTIVE

To report two cases of an undescribed association of first branchial cleft fistula and middle ear congenital cholesteatoma and to discuss management and embryological hypothesis.

DESIGN

Retrospective study and review of the literature

RESULTS

Both patients were young girls free of past medical or surgical history. Surgical removal of the first cleft anomaly found in the two cases a fistula routing underneath the facial nerve. Both cholesteatomas were located in the hypotympanum, mesotympanum. In one case, an anatomical link between the two malformations was clearly identified with CT scan.

DISCUSSION

The main embryological theories and classification are reviewed. A connection between Aimi's and Michaels' theories (congenital cholesteatoma) and Work classification might explain the reported clinical association.

[New surgical approaches to primary hyperparathyroidism]

We have seen recently the appearance of several new techniques for parathyroidectomy: the minimally invasive techniques all have a limited incision when compared to classic transverse cervical incision and are targeted on one specific parathyroid gland. These interventions are today possible for three main reasons: the available imaging techniques permit to locate the diseased gland, the use of rapid intraoperative PTH assay can confirm the successful extirpation, new instrumentation and miniaturised cameras have been adapted for this kind of surgery. Amongst minimally invasive techniques applied to parathyroidectomy, the video-assisted technique has the main advantage to offer a magnified view that permits a precise and careful dissection with minimal risks. Not all patients presenting a primary hyperparathyroidism are candidates for this surgery. Contraindications are mainly due to a large goiter, previous surgery in the parathyroid vicinity, suspicious multiglandular disease and equivocal preoperative localising studies. Currently 60% of patients with primary hyperparathyroidism can benefit of these techniques. Studies comparing conventional parathyroid surgery to endoscopic techniques have shown a diminution of postoperative pain and better cosmetic results with endoscopic techniques. If early results are similar to those obtained with conventional traditional open parathyroidectomies it is still too soon to evaluate what will be the recurrence rate of these new techniques.

Negative preoperative localization studies are highly predictive of multiglandular disease in sporadic primary hyperparathyroidism

BACKGROUND

The development of localization studies and quick parathyroid hormone assay (QPTH) has allowed the development of focused surgery in sporadic primary hyperparathyroidism. The aim of this investigation was to determine whether localization studies select a specific population of patients.

METHODS

From 1999 to 2001, 213 patients underwent surgery for sporadic primary hyperparathyroidism. All were investigated with sestamibi scanning and ultrasonography. When at least 1 study showed a positive result (n=175), the patient underwent a video-assisted approach with QPTH. When results were negative (n=38), the patient underwent cervicotomy and exploratory procedures of all 4 parathyroid glands.

RESULTS

All patients are cured (mean follow-up, 17.8+/-10.3 months [SD]). Patients with negative preoperative study results had a high risk of multiglandular disease (12/38 patients; 31,6%), compared with patients with 1 positive study result (3/83 patients; 3.6%; P<.0001) and those with 2 concordant positive study results (0/92 patients; P<.0001).

CONCLUSION

When preoperative localization study results are negative, the patient has a high risk of multiglandular disease, and a conventional cervicotomy with identification of the 4 glands is recommended strongly. When only 1 localization study is positive, the risk of multiglandular disease justifies the use of QPTH during a focused approach. When positive localization study results are concordant, the use of QPTH is questionable during a focused approach.

[Video-assisted parathyroidectomy in the management of patients with primary hyperparathyroidism]

INTRODUCTION

In recent years, different minimally invasive techniques of parathyroidectomy have been described. We performed a retrospective study to evaluate the indications and results of video-assisted parathyroidectomy (Vap) in the management of our patients with primary hyperparathyroidism (PHPT).

MATERIALS AND METHODS

During the last 5 years (1998-2002), we operated on 528 patients with PHPT. Vap was proposed for patients with sporadic PHPT, without associated goiter and without previous neck surgery, in whom a single adenoma was localized by means of sonography and/or sestamibi scanning. Vap was performed by lateral approach with insufflation for patients with adenoma located deeply in the neck and by gasless midline approach for patients with adenoma located anteriorly. A quick parathyroid (qPTH) assay was used during the surgical procedures. Calcemia, phosphoremia and PTH were systematically evaluated in patients on days 1 and 8, 1 month and 1 year after surgery. All patients underwent pre-operative and postoperative investigations of vocal cord movements.

RESULTS

Among 528 patients with PHPT, 228 (43%) were not eligible for Vap: associated nodular goiter (99 cases), previous neck surgery (42 cases), suspicion of multiglandular disease (25 cases), lack of pre-operative localization (48 cases), and miscellaneous causes (14 cases). Vap was performed in 300 patients with sporadic PHPT: 282 lateral access, 17 midline access and 1 thoracoscopy. Median operative time was 50 min (20-130 min). Conversion to conventional parathyroidectomy was required in 42 patients (14%): missed adenomas (11 cases), difficulties of dissection (7 cases), multiglandular disease correctly predicted by qPTH (10 cases); qPTH assay false negative results (3 cases), sestamibi scan false positive results (10 cases) and 1 sonography false positive result. One patient presented definitive recurrent nerve palsy. One patient had a persistent PHPT and one other patient had a recurrent PHPT.

CONCLUSION

Vap can be proposed for more than half of patients with PHPT. In our experience Vap and conventional parathyroidectomy are complementary. Immediate results of Vap are similar to those obtained with conventional parathyroidectomy but no conclusions can be drawn in terms of influence of Vap on the outcome of the patients operated for PHPT.