Frey Syndrome, First Bite Syndrome, great auricular nerve morbidity, and quality of life following parotidectomy.

PURPOSE: Parotidectomy may be burdened by numerous complications that may worsen subjects' quality of life (QoL). These include paresis or paralysis of the facial nerve, face profile asymmetry, keloids, salivary fistula, Frey Syndrome (FS), First Bite Syndrome (FBS), and hypo-anaesthesia of the skin. This study is an effort to assess the incidence of complications following parotidectomy and their impact on subjects' QoL. METHODS: Subjects undergoing parotidectomy for benign neoplasms from 2012 to 2015 were selected and invited to attend our outpatient clinic. After a brief anamnesis, the medical examiners tested their tactile perception and performed the Minor test for FS. Depending on the complications showed, subjects were asked to complete from 1 to 4 questionnaires about their QoL. RESULTS: 76 subjects completed the medical examination. The most frequent complication was the hypo-anaesthesia of the skin (71%). 21 subjects (28%) were positive to the Minor test, while 8 subjects (11%) reported FBS-compatible symptoms. Two subjects (3%) showed a facial nerve paralysis. Free abdominal fat graft was used in 16 subjects (21%) and it was associated with a lower incidence of FS. Surgery of the deep lobe of the parotid was associated with FBS. CONCLUSIONS: FBS appears to have a greater influence on subjects' QoL than FS and hypo-anaesthesia of the skin. Moreover, this work confirms that surgery of the deep lobe of the parotid is a risk factor for developing FBS and the free abdominal fat graft is a reliable technique to prevent FS.

Dental impression silicone putty in transoral laser laryngeal surgery: prevention of oral complications.

Objective: To describe a new method to improve the exposure of the surgical field and to protect the oral cavity during transoral laser micro-surgery (TOLMS) of the larynx. Methods: Dental Impression Silicone Putty (DISP) was employed as an alternative to traditional mouthguards. Results: DISP mouthguards perfectly fit to each patient, reduce encumbrance in the mouth, and reduce pressure on the teeth; disadvantages are minimal. Conclusions: Although clinical studies are necessary to demonstrate the efficacy of the method in reducing the incidence of oral complications, DISP mouthguards represent a significant aid for laryngeal exposure.

Combined transoral transnasal robotic-assisted nasopharyngectomy: a cadaveric feasibility study.

Surgical management of the nasopharynx is complex. Both traditional and endoscopic transnasal techniques are demanding. Purely transoral robotic nasopharyngectomy has been described but it needs a palatal splitting and is performed with an inferior to superior perspective with a difficult vision of the upper regions. The aim of this study is to investigate a new robotic surgical setting, which is able to overcome the actual limits. The DaVinci Surgical System was used in two cadavers. Dissection was carried out through a combined transnasal-transoral approach and a purely transoral procedure. A complete nasopharyngectomy was performed with both settings. Working and setting times are comparable. The combined approach avoids palatal spitting and permits a more panoramic view of the surgical field with an easier dissection of the upper areas. A robotic palatal sparing nasopharyngectomy is feasible. The combined transnasal-transoral setting seems to offer significant advantages with respect to traditionally purely transoral procedures.

Sudden sensorineural hearing loss after covid-19 vaccine; A possible adverse reaction?

BACKGROUND: Sudden Sensorineural Hearing Loss (SSNHL) is a relatively rare symptom after immunisation from commonly used vaccines such as rabies, hepatitis B, measles and H1N1 and it could be an occasional symptom of COVID-19, even in mild manifestations of the disease. CASE REPORT: We describe the case of a 57-year-old patient that reported SSNHL and tinnitus in his right ear 2 days after the inoculation of the Oxford-AstraZeneca (VAXZEVRIA) Covid-19 vaccine. The patient almost fully recovered after therapy and was referred to a long term follow-up program. CONCLUSION: The current report underlines the importance to consider SSNHL as a possible rare adverse effect of the Covid-19 vaccine and take in account this possibility to promptly proceed with diagnosis and treatment of suspect cases.

Menière's Disease and Caloric Stimulation: Some News from an Old Test.

OBJECTIVES: The aim of the present study was to improve the instrumental diagnosis of assessing Menière's disease (MD) if the frequency and slow-phase velocity (SPV) of the thermally induced nystagmus analyzed through the caloric vestibular test (CVT) showed different alterations in relationship with an increasing severity of the cochlear involvement. MATERIALS AND METHODS: The study retrospectively analyzed the CVT results of 72 patients affected by unilateral "definite MD" according to the 2015 Barany Society Diagnostic Criteria and treated only conservatively. RESULTS: There were 7 (9.72%) patients in stage 1, 27 (37.50%) in stage 2, 35 (48.61%) in stage 3, and 3 (4.16%) in stage 4. The canal paresis (CP) calculated through the frequency of the thermally induced nystagmus on the affected side increased in more severe stages (p=0.033). Conversely, the CP calculated through the SPV was not significantly different among the stages showing abnormal values even in the early phases of the disease (71% in stage 1, 81% in stage 2, 91% in stage 3, and 100% in stage 4), exclusively on the affected side. CONCLUSION: Abnormalities of the thermally induced nystagmus on the affected side characterize most patients with MD, but only "SPV" alterations are common in the early stages. An increasing severity of the cochlear involvement progressively reflects also on the "frequency" parameter. Detecting a dissociation between these two parameters could represent an instrumental marker of the early forms of MD. Cite this article as: Cerchiai N, Navari E, Miccoli M, Casani AP. Menière's Disease and Caloric Stimulation: Some News from an Old Test. J Int Adv Otol 2019; 15(3): 442-6.

Assessment of Vestibulo-ocular Reflex Gain and Catch-up Saccades During Vestibular Rehabilitation.

OBJECTIVE: To assess, in patients referred to vestibular rehabilitation (VR) for persistence of disability after acute unilateral vestibulopathy (AUV), whether the video head impulse test (vHIT) can be a useful technique to define the efficacy of the treatment. STUDY DESIGN: Prospective clinical study. SETTING: Tertiary academic referral hospitals. PATIENTS: Thirty patients with residual symptoms after AUV were included. INTERVENTION: Patients underwent a 10-week VR program. MAIN OUTCOME MEASURES: Evaluation of dizziness handicap inventory score, high-velocity vestibulo-ocular reflex gain, asymmetry index, and catch-up saccade parameters before and after VR. RESULTS: All patients reported a clear clinical improvement after VR, also demonstrated by better dizziness handicap inventory scores (p < 0.001). A consistent increased gain and decreased asymmetry index were also observed (p < 0.001 for both). Patients did not show any change in covert catch-up saccades, while a statistically significant reduction of the number and amplitude of the overt catch-up saccades was interestingly detected (p = 0.009 and p = 0.030, respectively). CONCLUSION: VR is a valid approach for patients with residual disability after AUV. A reduction in number and amplitude of overt catch-up saccades seems useful to evaluate the efficacy of VR and to be related to clinical improvement.

Predicting the Outcome after Acute Unilateral Vestibulopathy: Analysis of Vestibulo-ocular Reflex Gain and Catch-up Saccades.

Objectives (1) To describe the relationships among the main instrumental features characterizing an acute unilateral vestibulopathy and (2) to clarify the role of the video head impulse test in predicting the development of chronic vestibular insufficiency. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods Sixty patients suffering from acute unilateral vestibulopathy were retrospectively analyzed: 30 who recovered spontaneously (group 1) and 30 who needed a vestibular rehabilitation program (group 2). The main outcome measures included Dizziness Handicap Inventory score, canal paresis, high-velocity vestibulo-oculomotor reflex gain, and catch-up saccade parameters. The tests were all performed between 4 and 8 weeks from the onset of symptoms. Results The high-velocity vestibulo-oculomotor reflex gain correlated with the Dizziness Handicap Inventory score ( P = .004), with the amplitude of covert and overt saccades ( P < .001), and with the prevalence of overt saccades ( P < .001). Patients in need for vestibular rehabilitation programs had a significantly lower gain ( P < .001) and a higher prevalence and amplitude of overt saccades ( P = .002 and P = .008, respectively). Conversely, we found no differences in terms of response to the caloric test ( P = .359). Conclusions Lower values of high-velocity vestibulo-oculomotor reflex gain and a high prevalence of overt saccades are related to a worse prognosis after acute unilateral vestibulopathy. This is of great interest to clinicians in identifying which patients are less likely to recover and more likely to need a vestibular rehabilitation program.

Aging with Cerebral Small Vessel Disease and Dizziness: The Importance of Undiagnosed Peripheral Vestibular Disorders.

Recent studies showed a link between cerebral small vessel white matter disease (SVD) and dizziness: patients whose dizziness cannot be explained by vestibular disease show severe SVD and gait abnormalities; however, little is still known about how SVD can cause this symptom. The primary aim of this study is to examine the possible underlying causes of dizziness in neurovascular patients; this is in order to assess whether treatable causes could be routinely disregarded. A secondary aim is to possibly define a central oculomotor pattern induced per se by SVD. This could help the diagnosis of SVD-related dizziness. In this single-blind prospective study, 60 patients referred to a neurovascular clinic because of dizziness and SVD on imaging were divided into an L-SVD and a H-SVD group (low and high SVD burden, respectively), and then blindly examined with vestibulometric tests. In H-SVD group, the percentage of unexplained dizziness reached 82.8%. There was a higher prevalence of peripheral vestibular abnormalities in the L-SVD patient group (51.6%) than in the H-SVD (17.2%; p = 0.012). We found no differences in central oculomotor findings between the two groups. Although oculomotricity does not show any consistent pattern, a severe SVD can directly represent a cause of dizziness. However, a patient with mild SVD is more likely to suffer by a peripheral vestibular disorder. Therefore, given the high incidence of vestibular disease in neurovascular or geriatric clinics, clinicians should be cautious when ascribing dizziness solely to the presence of SVD as easily treatable peripheral vestibular causes may be missed.

Assessment of Vestibulo-oculomotor Reflex in Ménière's Disease: Defining an Instrumental Profile.

OBJECTIVES: To analyze and compare, in two groups of patients affected by definite Ménière's disease (MD) but treated differently, the Video Head Impulse Test findings especially by putting them in relationship with canal paresis, hearing loss, and duration of the disease. STUDY DESIGN: Retrospective chart review. PATIENTS: Seventy patients affected by unilateral definite MD (16 in Group 1 and 54 in Group 2) observed between March 2014 and May 2015 in a tertiary referral center were retrospectively studied and then divided into two groups: Group 1 was previously treated with intratympanic gentamicin, whereas Group 2 underwent only a conservative therapy. Instrumental tests included audiometry, caloric test, and Video Head Impulse Test. All the findings were statistically analyzed; significance was set at p = 0.005. INTERVENTION: Diagnostic. MAIN OUTCOMES MEASURES: If MD is treated conservatively the high-frequency vestibulo-oculomotor reflex gain determined with Video Head Impulse Test is normal; it is pathological if MD is treated with gentamicin. RESULTS: High-frequency vestibulo-oculomotor reflex gain showed a statistically significant reduction in Group 1; at the same time, it showed no correlation in both groups with hearing loss, duration of disease or canal paresis. CONCLUSION: High-frequency vestibulo-oculomotor reflex is naturally preserved even in late stage MD if the patient has been treated conservatively; the dissociation between Caloric Test and Video Head Impulse Test findings could be considered an instrumental hallmark of MD. Gentamicin significantly reduces high-frequency vestibulo-oculomotor reflex gain: this reduction can be taken into account when determining the effectiveness of an ablative treatment.

Are white matter abnormalities associated with "unexplained dizziness"?

INTRODUCTION: Although cerebral small vessel disease is a significant contributor to the development of imbalance and falls in the elderly, whether it causes dizziness is not known. METHODS: A retrospective case analysis was conducted for 122 dizzy patients referred to two neuro-otology tertiary centres in London and Pisa. Patients were divided into 'explained' causes of dizziness (e.g. benign positional vertigo, vestibular neuritis, orthostatic hypotension, cerebellar ataxias) and 'unexplained' dizziness. White matter hyperintensities (WMH) in MRI (T2 weighted and FLAIR sequences) were blindly rated according to the Fazekas scale. RESULTS: 122 patients; 58 (mean age=72, SD=7.95 years) in the 'unexplained' group and 64 (mean age=72.01, SD=8.28 years) in the 'explained' group were recruited. The overall frequency of lesions (Fazekas 1-3) significantly differed between groups (p=0.011). The frequency of severe lesions (Fazekas 3) was significantly higher in the 'unexplained' group (22%) than in the 'explained' group (5%; p=0.003). CONCLUSION: Increased severity of WMH in cases of unexplained dizziness suggests that such abnormalities are likely contributory to the development of dizziness. WM lesions may induce dizziness either because patients perceive a degree of objective unsteadiness or by a disconnection syndrome involving vestibular or locomotor areas of the brain.

Intratympanic gentamicin for Meniere's disease: short- and long-term follow-up of two regimens of treatment.

OBJECTIVES: (1) To compare the results of the 2 regimens of treatment at 2-year follow-up and (2) to evaluate the need and the efficacy of retreatment after the recurrence of vertigo attacks in a longer period of follow-up (using the Kaplan-Meier method of analysis). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: We analyzed 77 patients treated with intratympanic gentamicin (ITG). Thirty-five patients were treated with high-dose (HD) ITG (in total 6 injections, twice a day, repeated every 3 days) and 42 with low-dose (LD) ITG (1-2 injections). The results of treatment were evaluated in terms of functional level scale, control of vertigo, and hearing impairment. RESULTS: At 2-year follow-up, a similar percentage of vertigo control was obtained in the 2 groups; the incidence of hearing loss and posttreatment disequilibrium was significantly higher in patients treated with HD-ITG. The long-term follow-up showed a control of vertigo attacks with a single round of treatment in 71.4% of patients treated with HD-ITG and in 55% of those treated with LD-ITG. With repeated rounds, an effective control of vertigo could be achieved in 88.5% using a HD-ITG protocol and 97.7% using a LD-ITG protocol. CONCLUSIONS: LD-ITG allows obtaining good results in term of vertigo attacks associated with a limited occurrence of side effects. The long-term follow-up showed that LD-ITG needed repeated rounds more frequently than the HD-protocol. HD-ITG ran less risk of needing repeated rounds, but retreatment was ineffective in 40% of the cases requiring surgical therapy.

Assessment of skin microvascular endothelial function in patients with acute unilateral vestibular syndrome.

Abnormalities in labyrinth vasculature, resulting in labyrinth ischemia may be responsible for acute unilateral vestibular syndrome (AVS). However, since no tools for the study of the labyrinth microvasculature are available in clinical settings, labyrinth microvascular abnormalities in AVS patients (AVS-pts) can only be hypothesized on the basis of the their cardiovascular risk profile. Considering that skin microcirculation may mirror vascular function in other body districts, we examined skin endothelial function in 20AVS-pts and in 20 healthy control subjects (CS), with the aim of predicting labyrinth microvascular abnormalities in the same AVS-pts, potentially involved in the pathogenesis of their AVS. AVS-pts and CS underwent laser-Doppler flowmetry measurement of the skin forearm vasodilator response (SVR) to iontophoresis of the endothelial-dependent vasodilator acetylcholine (ACh) and to the endothelial-independent vasodilator sodium nitroprusside (SNP). SVR to ACh was significantly lower than to SNP in AVS patients (p < 0.005, ANOVA for repeated measures), consistent with skin endothelial dysfunction, while no significant differences in SVR between ACh and SNP were observed in CS. Accordingly with an arbitrary cut-off of 30% or greater reduction in SVR to ACh compared to SNP, endothelial dysfunction was found in 4 (20%) of CS, and in 14 (70%) of AVS-pts (6 with associated co-morbidities potentially responsible for endothelial dysfunction, and 8 without these co-morbodities). This study shows that the investigation of skin endothelial function in AVS-pts may be helpful in identifying AVS-pts in whom an ischemic origin of AVS might be more probable, in spite of their low cardiovascular risk profile.

Cerebellar infarctions mimicking acute peripheral vertigo: how to avoid misdiagnosis?

OBJECTIVE: To determine the prevalence of cases of missed cerebellar stroke mimicking acute peripheral vertigo (APV), the so-called pseudo-APV, and to identify the clinical indicators useful for differentiating APV from cerebellar infarction that presents as isolated vertigo. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: We conducted a retrospective chart review of cases of missed cerebellar infarction over the past 5 years. All patients had first undergone an otoneurological evaluation and computed tomography brain scan in the emergency department before a complete bedside examination was performed in our otoneurological unit. RESULTS: We identified 11 patients with pseudo-APV (2.8% of all the cases presenting to our unit complaining of acute vertigo). Spontaneous nystagmus (of central type in 2 cases) was recorded in all patients. The Head Impulse Test was clearly negative in 9 cases. The duration of vertigo lasted more than 72 hours in 7 patients. In 4 patients, delayed neurological signs followed acute vertigo 2 to 3 days after the onset. Magnetic resonance imaging showed 8 cases of infarction in the posterior-inferior cerebellar artery territory; in 1 patient, an involvement of the anterior-inferior cerebellar artery territory was recorded; 2 patients showed a hemispheric ischemic cerebellar involvement. CONCLUSIONS: Pseudo-APV is not an uncommon diagnosis in otoneurological practice. The presence of moderate-severe imbalance and the persistence of vertigo for more than 72 h from the onset, together with the results of bedside examination tests (spontaneous nystagmus and Head Impulse Test), are useful indicators for recognizing a cerebellar ischemic origin in cases of acute vertigo.

Intratympanic treatment of intractable unilateral Meniere disease: gentamicin or dexamethasone? A randomized controlled trial.

OBJECTIVE: To determine the efficacy and safety of low-dose intratympanic gentamicin (ITG) compared with intratympanic dexamethasone (ITD) in patients with intractable unilateral Ménière disease (MD). STUDY DESIGN: Open prospective randomized controlled study. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Sixty patients affected by definite unilateral MD were enrolled between January 1, 2007, and June 30, 2008. Thirty-two patients were treated with a buffered gentamicin solution injected in the middle ear (maximum of 2 injections); 28 patients were treated with ITD (4 mg/mL, 3 injections at intervals of 1 every 3 days). Mean outcome measurements consisted of control of vertigo attacks, pure tone average (PTA), speech discrimination score, functional disability score, and statistical analysis using repeated measures analysis of variance. RESULTS: In the ITG group at 2-year follow-up, complete control of vertigo (class A) was achieved in 26 patients (81%) and substantial control of vertigo (class B) in 4 patients (12.5%). In the ITD group, class A was achieved in 12 (43%), and class B in 5 (18%) patients. In the gentamicin group, 4 patients showed a reduction in PTA of ≥10 dB. In the ITD group, PTA was unchanged or slightly improved in 16 patients (belonging to class A-B) and worse in 12. CONCLUSIONS: Low-dose ITG achieved better outcome than ITD in the control of vertigo attacks in patients suffering from unilateral MD, with a very low incidence of hearing deterioration. ITD offers poorer vertigo control rate, and hearing preservation is achieved only in cases with no vertigo recurrences.

Anterior canal lithiasis: diagnosis and treatment.

OBJECTIVE: To describe the clinical and oculographic features in patients with anterior semicircular canal benign paroxysmal positional vertigo and to determine the efficacy of a canalith repositioning procedure for its management. STUDY DESIGN: Case series with chart review of patients presenting positional vertigo and positional downbeating nystagmus during a 2-year period. SETTING: Outpatients' tertiary referral center for balance disorders. SUBJECTS AND METHODS: Eighteen patients suffering from positional vertigo and presenting positional downbeating nystagmus were treated with a maneuver based on a modification of the procedure proposed by Crevits. MEAN OUTCOME MEASURE: disappearance of positional downbeating nystagmus. RESULTS: Positional downbeating nystagmus was elicited unilaterally with the Dix-Hallpike maneuver in 6 cases. In 4 patients, it was triggered by both left and right Dix-Hallpike tests. In 8 patients, the positional nystagmus was elicited by a straight head-hanging maneuver. The positional nystagmus was purely downbeating in 12 patients. In the remaining, a torsional component was detected. After the treatment, only 1 patient showed positional nystagmus at 30 days. CONCLUSION: In anterior canal benign paroxysmal positional vertigo, the presence of a positional downbeating nystagmus in response to positional tests is key for diagnosis. In a significant number of patients, the affected side may not be detected because of the inconstant presence of a torsional component. Treatment with a simplified maneuver based on Crevits's technique can be considered an effective method for the treatment of anterior canal lithiasis, especially when the affected side cannot be detected clearly.