An Algorithm for the Diagnosis of Vestibular, Cerebellar, and Oculomotor Disorders Using a Systematized Clinical Bedside Examination.

The bedside examination associated with their clinical history remains the most critical means to accurately diagnose the cause for most of the signs and symptoms related to pathology of the cerebellum and vestibular system in patients presenting with dizziness and imbalance. This paper focuses on those critical bedside examinations, suggests when laboratory testing might be useful to confirm the clinical suspicion, and considers the shared neural circuitry within the visual and vestibular systems to offer an algorithmic approach in conducting the clinical bedside examination.

Practical approach for lateral canal benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) of the lateral semicircular canal is a well-recognized condition, even though there are controversies about the repositioning maneuvers and their efficacy. In recent decades, several maneuvers have been proposed for treating both apogeotropic and geotropic variants of lateral canal BPPV. Our purpose is to discuss a practical approach to this pathology with the Zuma maneuver. In a single session, this maneuver may be useful to treat patients with canalithiasis of the ampullary and non-ampullary arms, and cupulolithiasis with the otoliths in the canal and utricular side of the lateral canal.

The role of the reversed nystagmus during Zuma maneuver in patients treated for geotropic lateral canal benign paroxysmal positional vertigo.

INTRODUCTION: The geotropic variant of lateral canal BPPV occurs due to free floating otoconia in the non ampullary arm of this canal. Several repositioning maneuvers were effective to treat patients with this variant. We have previously proposed that the Zuma maneuver, first described for apogeotropic lateral canal BPPV, could also be effective for the geotropic variant as we believe that adopting a single maneuver may help the neurotological clinical practice. MATERIAL AND METHODS: Fifteen patients with geotropic lateral canal BPPV were enrolled and treated with Zuma maneuver. Patients were reevaluated 1 h after a single maneuver. RESULTS: All patients showed a nystagmus beating to the affected side in step I of Zuma maneuver that reversed its direction in step II. Besides, all patients achieved immediate resolution of vertigo and positional nystagmus after the application of the maneuver. CONCLUSIONS: The reversal of the nystagmus in step II of Zuma maneuver could be considered as a good prognostic indicator of the successful of this maneuver in patients with geotropic lateral canal BPPV. Moreover, despite the small sample of patients, Zuma maneuver was effective on short-term follow up for geotropic LC-BPPV after a single application.

Cochlear Implants in Patients with Fluctuant or Progressive Hearing Loss on the Better Ear.

Introduction Cochlear implants have been proposed for cases of unilateral hearing loss, especially in patients with tinnitus impairment. Several studies have shown that they result in definite improvement of sound localization and speech understanding, both in quiet and noisy environments. On the other hand, there are few references regarding cochlear implants in patients whose better ears present hearing loss. Objective To report the audiological outcomes of three patients with unilateral deafness, in whom the better ears presented hearing losses, submitted to cochlear implants. Methods Three patients with unilateral profound hearing loss underwent a cochlear implant performed by the same surgeon. Results The patients' data are presented in detail. Conclusion The indications for cochlear implants are becoming more diverse with the expansion of clinical experience and the observation that they definitely help patients with special hearing problems.

Zuma Modified Maneuver as a Treatment to Geotropic Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo.

Introduction Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder, resulting from detached otoliths that migrate to one of the semicircular canals - canalolithiasis - or one of the cupulas - cupulolithiasis. The present study is related to lateral canal BPPVs, which may be either geotropic or apogeotropic. The geotropic variant of lateral semicircular canal benign paroxysmal positional vertigo (LC-BPPV) is attributed to free floating particles in the posterior arm of the lateral semicircular canal. Objectives To verify the possibility of employing the Zuma repositioning maneuver, with a brief modification, as an alternative treatment for geotropic LC-BPPV. Methods Seven patients with geotropic LC-BPPV were enrolled and treated with the Zuma modified maneuver. Patients were reevaluated 1 hour after a single maneuver, to confirm the resolution of vertigo and positional nystagmus. Results All seven patients achieved immediate resolution of vertigo and positional nystagmus as measured 1 hour after the application of the maneuver. Conclusion The Zuma modified maneuver was effective for geotropic LC-BPPV after a single application. The use of the Zuma maneuver for both apogeotropic and geotropic LC-BPPV may simplify the treatment of these patients.

Management of Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo.

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vestibular vertigo. It is caused by free-floating otoconia moving freely in one of the semicircular canals (canalolithiasis) or by otoliths adhered to the cupula (cupulolithiasis). The posterior canal is the most common canal affected, followed by the lateral canal. Diagnosis of the side affected is critical for successful treatment; therefore, suppressing visual fixation is essential to examination of these patients' eye movement. On the basis of our experience, we have adopted the Zuma maneuver and the modified Zuma maneuver for both apogeotropic and geotropic variants of lateral canal BPPV. Knowledge of the anatomy and pathophysiologic mechanisms of the semicircular canals is essential for correct management of these patients. Hence, using a single maneuver and its modification may facilitate daily neurotological practice.

Seasonality and solar radiation variation level in benign paroxysmal positional vertigo.

BACKGROUND: Several studies have shown that the incidence of benign paroxysmal positional vertigo (BPPV) presents seasonal variations and there is evidence that the variation in time is dependent on the patient's amount of vitamin D. OBJECTIVES: This is a retrospective study to verify if there is a correlation between the incidence of BPPV and the level of solar radiation, essential for the synthesis of vitamin D in the skin. MATERIAL AND METHODS: This study comprised 214 patients with BPPV seen from 2012 to 2017, in a city Latitude: -30.0277, Longitude: -51.2287 30° 1' 40″ South, 51° 13' 43″ West. The amounts of monthly solar radiation were analyzed in relation to the dates of their first consultations. Statistical tests were employed to verify the existence of a correlation between solar radiation and the incidence of the disease. RESULTS: The statistical analysis revealed a significant difference between the incidence of BPPV and the amount of radiation during the month of the diagnosis of the disease. There was also a significant statistical correlation with the climatic variation. CONCLUSION: More patients with benign paroxysmal positional vertigo (BPPV) are seen in consultation in the months with low solar radiation and in the autumn and winter seasons, in this geographic city.

Apogeotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo: Where are the particles?

The apogeotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV) is attributed to free floating particles in the anterior arm of the lateral semicircular canal - particles attached to the cupula facing the canal or particles attached to the cupula facing the utricle. Zuma e Maia described a new treatment for both canalithiasis of the anterior arm of the horizontal semicircular canal (HC) and cupulolithiasis of the HC. Seventeen patients with apogeotropic HC-BPPV were enrolled and treated with Zuma's Maneuver. During the repositioning of the particles to the utricule, we observed the direction of the nystagmus evoked in each step of this maneuver in order to know where the otoliths were probably located. Eight patients were diagnosed with canalithiasis of the anterior arm, six patients with cupulolithiasis with the particles facing the canal and three patients with cupulolithiasis with the particles facing the utricle. Our data suggest that we can assume where the otoliths are probably located by observing the pattern of the nystagmus evoked in each step of the Zuma's Maneuver in patients with apogeotropic HC-BPPV.

Cochlear Implants in Patients with Fluctuant or Progressive Hearing Loss on the Better Ear

Abstract Introduction Cochlear implants have been proposed for cases of unilateral hearing loss, especially in patients with tinnitus impairment. Several studies have shown that they result in definite improvement of sound localization and speech understanding, both in quiet and noisy environments. On the other hand, there are few references regarding cochlear implants in patients whose better ears present hearing loss. Objective To report the audiological outcomes of three patients with unilateral deafness, in whom the better ears presented hearing losses, submitted to cochlear implants. Methods Three patients with unilateral profound hearing loss underwent a cochlear implant performed by the same surgeon. Results The patients' data are presented in detail. Conclusion The indications for cochlear implants are becoming more diverse with the expansion of clinical experience and the observation that they definitely help patients with special hearing problems.

Zuma Modified Maneuver as a Treatment to Geotropic Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo

Abstract Introduction Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder, resulting from detached otoliths that migrate to one of the semicircular canals - canalolithiasis - or one of the cupulas - cupulolithiasis. The present study is related to lateral canal BPPVs, which may be either geotropic or apogeotropic. The geotropic variant of lateral semicircular canal benign paroxysmal positional vertigo (LC-BPPV) is attributed to free floating particles in the posterior arm of the lateral semicircular canal. Objectives To verify the possibility of employing the Zuma repositioning maneuver, with a brief modification, as an alternative treatment for geotropic LC-BPPV. Methods Seven patients with geotropic LC-BPPV were enrolled and treated with the Zuma modified maneuver. Patients were reevaluated 1 hour after a single maneuver, to confirm the resolution of vertigo and positional nystagmus. Results All seven patients achieved immediate resolution of vertigo and positional nystagmus as measured 1 hour after the application of the maneuver. Conclusion The Zuma modified maneuver was effective for geotropic LC-BPPV after a single application. The use of the Zuma maneuver for both apogeotropic and geotropic LC-BPPV may simplify the treatment of these patients.

Assessment of the vestibuloocular reflex in fighter pilots with the video head impulse test.

CONCLUSION: There were no changes in the function of the six semicircular canals in active fighter pilots, through the use of the video head impulse test (vHIT). These results suggest that the vestibuloocular reflex (VOR) works well at the high frequencies related to the natural head movements in this population. OBJECTIVES/HYPOTHESIS: The vestibular function in pilots has been reported as being different from that of other normal subjects. These differences are attributed to adaptation of the vestibuloocular reflex (VOR) or by habituation. These studies were conducted with caloric and/or rotatory tests and were limited to the lateral semicircular canals. The aim of the present study was to verify the occurrence of high frequency changes in the function of the six semicircular canals in active fighter pilots, through the use of the video head impulse test (vHIT). STUDY DESIGN: Cross-sectional design. METHODS: The subjects participating in this study were divided in three groups, according to their flight experience. The control group (Group 1) consisted of 20 soldiers with no experience of in-flight training. For the test subjects 14 fighter pilots were selected and divided into two groups. Group 2 included the pilots with 1000-2000 hours of flight experience and Group 3 included pilots with 2001-3000 hours of flight experience. They were all submitted to a video head impulse test and the gains of the six semicircular canals were analysed. RESULTS: There were significantly low gain values (p < 0,013) only in the left posterior semicircular canal in the control group as compared with the subject groups. However, there were no significant differences in gain values between the two groups of the active pilots.

Vertigo in elderly patients: a review of 164 cases in Brazil.

The author conducted a study to identify and categorize those vestibular disorders that were the most common among elderly patients at his private clinic over a 20-year period. He reviewed the records of 735 patients aged 65 to 90 years. The most common diagnosis was vertigo and/or disequilibrium, which occurred in 164 patients (22.3%). Of this group, 121 patients (73.8%) had a peripheral vestibular disorder and 43 (26.2%) had a central vestibular disorder. The characteristics of these cases are discussed.

The video head impulse test.

CONCLUSION: Additional research is needed to validate the importance of the video head impulse tests (vHIT), but it provides an important contribution to the evaluation of anterior and posterior semicircular canal disorders. OBJECTIVES: To share observations of the vHIT test in clinical neurotology and to discuss the significance of the study findings. METHODS: This study comprised 200 patients with a clinical history of vestibular disturbances who were submitted to a vHIT including all six semicircular canals. RESULTS: Abnormal responses of the anterior and posterior canals were found in several patients, either alone or combined with altered responses in the lateral canals. A unilateral hypoactive response of a posterior canal was found in a patient with a small vestibular schwannoma.

Limites normais dos valores dos parâmetros à vestibulometria com electronistagmografia e vecto-electronistagmografia / Normal limits of the values of vestibulometry parameters with electronystagmographic and vector-electronystagmography

Säo estudados 40 indivíduos aparentemente normais, com o objetivo de apreciar o seu comportamento à vestibulometria e estabelecer os limites da variaçäo dos valores dos parâmetros analisados à electronistagmografia e à vecto-electronistagmografia. Säo apresentados os limites estatísticos da normalidade para nistagmo espontâneo com olhos fechados, nistagmo optocinético, nistagmo per-rotatório e nistagmo pós-calórico, em termos de velocidade angular máxima da componente lenta e rápida desses movimentos oculares, que podem ser de utilidade na identificaçäo diagnóstica das síndromes do sistema vestibular

Tobramycin, gentamicin, neomycin + polymyxin B, lidocaine and dexamethasone in the topical treatment of otitis

Cento e cinqüenta pacientes com otites médias agudas foram submetidos a tratamento local com antibióticos (Tobramicina, Gentamicina ou Neomicina + Polimixina B), associados ou näo a anestésico (Lidocaína) ou a corticóide (Dexametasona). Os resultados com o uso de Tobramicina e Gentamicina + Dexametasona foram mais efetivos do que os obtidos com o uso de Neomicina + Polimixina B associados a Lidocaína ou Dexametasona. Por outro lado, 32 casos de otites externas foram tratados com Dexametasona e os resultados foram favoráveis na grande maioria dos casos. Näo foram observados efeitos colaterais e alteraçöes auditivas à audiometria com o uso de todas as substâncias experimentadas

A displasia de Mondini / The Mondini dysplasia

Os autores apresentam e discutem alguns aspectos histológicos e fisiopatológicos da Displasia de Mondini e as possibilidades diagnósticas e terapêuticas atuais

Estudo duplo-cego entre aniracetam e placebo em labirintopatias / Double-blind study between aniracetan and placebo in labyrinthopathies

Quarenta pacientes, abaixo dos 70 anos de idade, portadores de labirintopatias, foram tratados sob esquema duplo-cego com aniracetan (1 g/dia) ou placebo durante seis semanas. A avaliaçäo final da eficácia mostrou diferença estatisticamente significativa a favor do aniracetam (remissäo dos sintomas ou melhora acentuada em 55% dos pacientes tratados com aniracetam, contra 20% daqueles que receberam placebo). O sintoma que mostrou melhor resposta ao aniracetam foi o "zumbido" durante as crises. A tolerabilidade foi excelente tanto para o aniracetam quanto para o placebo, näo havendo diferença estatística significativa entre os dois grupos

Das alteracoes auditivas nas sindromes do sistema nervoso central. / The auditory changes in the central nervous system syndromes

Em 30 pacientes com sindromes do sistema nervoso central, realizou-se estudo audiologico baseado na audiometria tonal liminar, discriminacao vocal e impedanciometria. Observou-se grande incidencia de alteracoes, principalmente a discriminacao vocal e audiometria tonal liminar. Os achados mais importantes foram a ma discriminacao vocal contrastante com os limiares auditivos razoavelmente conservados, a disacusia de tipo neurosensorial e a abolicao do reflexo estapedico contralateral, com a conservacao do reflexo ipsilateral, sendo o primeiro e o ultimo destes achados indicativos de comprometimento de tronco cerebral. Os sinais encontrados nas sindromes centrais, frequentes e, eventualmente de valor localizador justificam amplamente a obrigatoriedade da realizacao de audiometria tonal liminar, discriminacao vocal e impedanciometria a investigacao otoneurologica na rotina clinica

The fast phase eye-speed of post caloric nystagmus in normals: a vectornystagmographic

O estudo vectoelectronistagmográfico da velocidade angular da componente rápida do nistagmo pós-calórico nos permitiu estabelecer os limites críticos normais dos valores máximos deste parâmetro. Os resultados obtidos dos 38 casos aparentemente normais submetidos à prova calórica convencional de Fitzgerald & Hallpike (1942) foram: 1)Ampla variabilidade dos valores absolutos, em graus por segundo, de 13,0-/s a 619-/s. Em relaçäo à avaliaçäo estatística dos dados obtivemos a média aritmética de 88,8-/s, o desvio padräo de 65,1-/s e os limites de confiança (95%) superior e inferior de 216,4-/s e zero, respectivamente. 2)O valor extremo da preponderância direcional foi de 56,0%, com média aritmética de 2,0%, o desvio-padräo de 20,0% e o limite de confiança (95%) superior de 41,2%. 3)O valor extremo do predomínio labiríntico foi de 86,0%, com média aritmética de 3,0%, desvio padräo de 23,0% e o limite de confiança (95%) superior de 48,1%. O conhecimento destes limites quantitativas dos valores absolutos e relativos da velocidade angular real da componente rápida do nistagmo pós-calórico propicia, quando ultrapassados, a caracterizaçäo de alteraçöes quantitativas nas síndromes vestibulares

Clinical evaluation of the function of the inferior vestibular nerve

A vectoelectronistagmografia (VENG) representa uma nova técnica de gravaçäo dos movimentos oculares horizontais, verticais e oblíquos, empregando três canais de registro. O principal interesse na utilizaçäo da VENG é representado pela possibilidade de estudar as respostas nistágmicas à estimulaçäo dos canais semicirculares verticais e nervo vestibular inferior, uma área do sistema vestibular que näo pode ser analisada por outros meios. A estimulaçäo de cada canal vertical é realizada através da prova rotatória pendular decrescente, colocando-se a cabeça fletida de 60- para trás e 45- para cada lado. O nistagmo resultante desta estimulaçäo é oblíquo. Só é possível estabelecer o diagnóstico das lesöes unilaterais dos canais superiores e posteriores diante da falta do fenômeno da compensaçäo vestibular para esses canais, ao contrário do que ocorre com os canais laterais. A estimulaçäo dos canais posteriores implica na gravaçäo de respostas que envolvem os nervos vestibulares inferiores e suas conexöes centrais. Neste estudo, podemos verificar que a compensaçäo vestibular para os canais verticais esteve ausente em 43,5% dos casos, mesmo quando os canais laterais apresentavam perfeita compensaçäo, em 46 casos de síndromes labirínticas. Alteraçöes do nervo vestibular inferior foram identificadas em 17 casos (36,9%). Esses achados sugerem que a exploraçäo específica dos canais verticais e nervo vestibular inferior possam tornar-se um importante teste vestibular para a rotina clínica