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.

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.

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.

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.

[New surgical approaches to primary hyperparathyroidism]. / Nouveaux abords chirurgicaux de l'hyperparathyroïdisme primaire.

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.