Proton beam radiation therapy for vestibular schwannomas-tumor control and hearing preservation rates: a systematic review and meta-analysis.

OBJECTIVE: Proton beam therapy is considered, by some authors, as having the advantage of delivering dose distributions more conformal to target compared with stereotactic radiosurgery (SRS). Here, we performed a systematic review and meta-analysis of proton beam for VSs, evaluating tumor control and cranial nerve preservation rates, particularly with regard to facial and hearing preservation. METHODS: We reviewed, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) articles published between 1968 and September 30, 2022. We retained 8 studies reporting 587 patients. RESULTS: Overall rate of tumor control (both stability and decrease in volume) was 95.4% (range 93.5-97.2%, p heterogeneity= 0.77, p<0.001). Overall rate of tumor progression was 4.6% (range 2.8-6.5%, p heterogeneity < 0.77, p<0.001). Overall rate of trigeminal nerve preservation (absence of numbness) was 95.6% (range 93.5-97.7%, I2 = 11.44%, p heterogeneity= 0.34, p<0.001). Overall rate of facial nerve preservation was 93.7% (range 89.6-97.7%, I2 = 76.27%, p heterogeneity<0.001, p<0.001). Overall rate of hearing preservation was 40.6% (range 29.4-51.8%, I2 = 43.36%, p heterogeneity= 0.1, p<0.001). CONCLUSION: Proton beam therapy for VSs achieves high tumor control rates, as high as 95.4%. Facial rate preservation overall rates are 93%, which is lower compared to the most SRS series. Compared with most currently reported SRS techniques, proton beam radiation therapy for VSs does not offer an advantage for facial and hearing preservation compared to most of the currently reported SRS series.

[Persistent Postural-Perceptual Dizziness (PPPD) - A clinical case and essentials for the primary care medicine]. / Vertiges posturaux-perceptuels persistants (VPPP) - Cas clinique et notions essentielles pour le généraliste.

Persistent Postural-Perceptual Dizziness (PPPD) is a chronic functional disorder that manifests with symptoms of dizziness, unsteadiness or non-spinning vertigo that lasts for at least three months. These symptoms are exacerbated by upright posture, active or passive motion, and exposure to complex or moving visual stimuli. This -pathology has been known for a long time ago. Still, after an expert's consensus in 2017, this term was born, and some precise diagnostic criteria have been defined based on identifying key symptoms in the patient's clinical history. Treatment is multimodal, incorporating -vestibular rehabilitation, cognitive-behavior therapy, and serotonergic medication.

Les VPPP ou vertiges posturaux-perceptuels persistants (Persistent Postural-Perceptual Dizziness (PPPD)) sont une pathologie fonctionnelle chronique, caractérisée par une sensation de déséquilibre, d'instabilité ou de vertige non rotatoire. Les symptômes peuvent être exacerbés par la position debout, la mobilisation active ou passive et l'exposition à des stimuli visuels complexes ou en mouvement. Si la pathologie est connue de longue date, c'est suite à un consensus d'experts qu'est né ce terme en 2017, et que des critères diagnostiques clairs ont été définis, qui se basent sur l'identification de symptômes clés dans l'histoire ­clinique du patient. Le traitement est multimodal, ­comprenant une réhabilitation vestibulaire, des thérapies cognitivo-comportementales et une médication sérotoninergique.

Biologically effective dose correlates with linear tumor volume changes after upfront single-fraction stereotactic radiosurgery for vestibular schwannomas.

Vestibular schwannomas (VSs) are benign, slow-growing tumors. Management options include observation, surgery, and radiation. In this retrospective trial, we aimed at evaluating whether biologically effective dose (BED) plays a role in tumor volume changes after single-fraction first intention stereotactic radiosurgery (SRS) for VS. We compiled a single-institution experience (n = 159, Lausanne University Hospital, Switzerland). The indication for SRS was decided after multidisciplinary discussion. Only cases with minimum 3 years follow-up were included. The Koos grading, a reliable method for tumor classification was used. Radiosurgery was performed using Gamma Knife (GK) and a uniform marginal prescription dose of 12 Gy. Mean BED was 66.3 Gy (standard deviation 3.8, range 54.1-73.9). The mean follow-up period was 5.1 years (standard deviation 1.7, range 3-9.2). The primary outcome was changes in 3D volumes after SRS as function of BED and of integral dose received by the VS. Random-effect linear regression model showed that tumor volume significantly and linearly decreased over time with higher BED (p < 0.0001). Changes in tumor volume were also significantly associated with age, sex, number of isocenters, gradient index, and Koos grade. However, the effect of BED on tumor volume change was moderated by time after SRS and Koos grade. Lower integral doses received by the VSs were inversely correlated with BED in relationship with tumor volume changes (p < 0.0001). Six (3.4%) patients needed further intervention. For patients having uniformly received the same marginal dose prescription, higher BED linearly and significantly correlated with tumor volume changes after SRS for VSs. BED could represent a potential new treatment paradigm for patients with benign tumors, such as VSs, for attaining a desired radiobiological effect. This could further increase the efficacy and decrease the toxicity of SRS not only in benign tumors but also in other SRS indications.

[Sudden sensorineural hearing loss : Diagnosis and management in 2021]. / Surdité brusque : diagnostic et prise en charge en 2021.

This article proposes, through a literature review, an updated summary of the initial evaluation, treatment and follow-up of sudden sensorineural hearing loss (SSNHL) based on current guidelines. SSNHL occurs within 72h with at least 30dBHL loss over 3 consecutive frequencies. Diagnosis is medical in the emergency setting, the etiological workup aims at treating known causes, while different pathophysiological hypotheses exist for idiopathic SSNHL. Controversy exists regarding optimal management due to frequent spontaneous recovery. However, corticotherapy remains widely accepted. Prognosis depends on initial severity, age, associated vertigo and shape of the audiometric curve. Hearing rehabilitation in proposed for significant residual hearing loss.

Cet article propose, par une revue de la littérature, une synthèse actualisée de l'évaluation initiale du traitement et du suivi des surdités brusques (SB). La SB est une surdité de perception survenant en moins de 72 heures, et d'au moins 30 dBHL sur 3 fréquences consécutives. De diagnostic clinique, le bilan étiologique vise à dépister les étiologies connues comme un traumatisme acoustique, un accident vasculaire ou un neurinome de l'acoustique. Plusieurs hypothèses physiopathologiques existent pour les SB idiopathiques: virale, vasculaire, pressionnelle et autoimmune. Le traitement est controversé vu la récupération spontanée fréquente, néanmoins la corticothérapie reste largement acceptée. Le pronostic dépend de la sévérité de la perte auditive, l'âge, les vertiges et la forme de la courbe audiométrique. En cas de séquelles auditives, différentes options de réhabilitation auditive sont disponibles.

Proposal of a timing strategy for cholesteatoma surgery during the COVID-19 pandemic.

PURPOSE: The COVID-19 infection is an aggressive viral illness with high risk of transmission during otolaryngology examination and surgery. Cholesteatoma is known for its potential to cause complications and scheduling of surgery during the pandemic must be done carefully. The majority of otological surgeries may be classified as elective and postponed at this time (e.g., stapedotomy, tympanoplasty); whereas, others are emergencies (e.g., complicated acute otitis media, complicated cholesteatoma with cerebral or Bezold's abscess, meningitis, sinus thrombosis) and require immediate intervention. What is the ideal time for the surgical management of Cholesteatoma during the COVID-19 pandemic? METHODS: Senior otologic surgeons from six teaching hospitals from various countries affected by the COVID-19 from around the world met remotely to make recommendations on reorganizing schedules for the treatment of cholesteatoma which has a risk of severe morbidity and mortality. The recommendations are based on their experiences and on available literature. RESULTS: Due to the high risk of infecting the surgical staff it is prudent to stop all elective ear surgeries and plan cholesteatoma surgery after careful selection of patients, based on the extent of the disease and available resources. Specific precautions including use of appropriate personal protection equipment should be followed when operating on all patients during the pandemic. To facilitate the decision-making in the management of cholesteatoma, timing for surgery can be divided into two categories with 3 and 2 sub-groups based on disease severity. CONCLUSIONS: Evidence on the timing of surgery of patients with cholesteatoma during the COVID-19 pandemic is lacking. This manuscript contains practical tips on how cholesteatoma surgery can be reorganized during this pandemic.

Gamma Knife radiosurgery for intravestibular and intracochlear schwannomas.

BACKGROUND: Schwannomas of the VIIIth cranial nerve are benign tumours, with vast majority occurring in vestibular division. Rarely, they can also arise from distal branches of cochlear, superior or inferior vestibular. We review our experience with Gamma Knife radiosurgery (GKR), as first intention treatment for intracochlear (ICS) and intravestibular (IVS) schwannomas. METHODS: A total number of five patients were analysed, treated over 8 years, between June 2010 and September 2018, with Leksell Gamma Knife Perfexion or Icon (Elekta Instruments, AB, Sweden). The marginal dose prescribed was 12 Gy at a mean prescription isodose line of 61.4% (range 50-70). Clinical evaluation included auditory and facial function. RESULTS: The mean age was 49.9 (range 34-63). The mean follow-up period was 52.8 months (range 12-84). The mean target volume (TV) was 0.087 ml (range 0.014-0.281). The mean maximal dose received by the cochlea was 11.2 Gy (range 2.6-20.3). The mean marginal dose received by the vestibule (e.g. utricula) was 14.2 Gy (range 3.8-17.5). No patient experienced an acute or subacute clinical adverse radiation effect after GKR. Four cases had overall symptom stability. In one patient (1/5), the vertigo, which was the main clinical complain, disappeared 1 year after GKR. However, it reappeared 3 years later, with same pretherapeutic characteristics and is currently fluctuating. One patient experienced hearing decrease after GKR, during the first 12 months. This case received 11.2 Gy to the cochlea. Follow-up MRI course showed a decrease in size in four patients, and stability in one. CONCLUSIONS: Gamma Knife radiosurgery is a valuable first intention treatment for ICS or IVS, in selected cases. Special attention should be paid for the dose delivered to the cochlea and the vestibular apparatus. Acute and subacute clinical effects are exceptional, while tumour control was achieved in all cases in our small series.

Audiological monitoring in Swiss childhood cancer patients.

BACKGROUND: Full audiological monitoring is the best strategy to detect hearing loss early and to provide timely intervention in the absence of a clinical method of otoprotection. Full monitoring requires audiological evaluation before, and then during and after ototoxic cancer treatment. In a worldwide context of monitoring protocols that vary substantially, we analyzed the audiological monitoring of childhood cancer patients over the last decade across treatment centers in Switzerland. PROCEDURE: We retrospectively searched for audiological evaluations in all nine Swiss Pediatric Oncology Centers. We analyzed proportions of patients who had audiological monitoring and described type and timing of monitoring. We determined predictors of audiological monitoring using multivariable logistic regression and described time trends. RESULTS: We included 185 patients from the Swiss Childhood Cancer Registry diagnosed from 2005 to 2013 who had platinum chemotherapy and/or cranial radiation ≥30 Gray and who were alive at time of study. Less than half of children, 43%, had full audiological monitoring (before, during, and after treatment), while 72% were tested after cancer treatment. Nonstudy patients were less likely to have had monitoring in all phases of cancer treatment. Patients who received treatment with cisplatin or both platinum chemotherapy and cranial radiation were more likely to have had monitoring after treatment. Monitoring during and after treatment increased over the study period, but monitoring before treatment was insufficient in all time periods. CONCLUSIONS: Our population-based study indicates that audiological monitoring is insufficient in Switzerland, particularly for nonstudy patients. Clinicians must become more aware of the importance of full audiological monitoring.

[Spontaneous involution of Vestibular Schwannomas]. / Schwannomes vestibulaires spontanément involutifs.

The majority of vestibular schwannomas have a stable evolution or a progression of size. Some publications report cases of spontaneous involution. We report here the clinical and radiological characteristics of this type of tumor observed in 14 patients showing a spontaneous tumor involution of their vestibular schwannoma. The results showed an incidence of 8 % with an average tumor regression of 50 %. Functionally, a hearing loss was found in all patients, without correlation with the duration of the observational follow-up. There are spontaneously involutive vestibular schwannomas, but tumor regression does not prevent the deterioration of hearing. Patients should be considered as a subset of those receiving observational management.

La majorité des schwannomes vestibulaires ont une évolution stable ou une progression de taille. Quelques publications rapportent des cas d'involution spontanée. Nous rapportons ici les caractéristiques cliniques et radiologiques de ce type de tumeur observée chez 14 patients montrant une involution tumorale spontanée de leur schwannome vestibulaire. Les résultats ont montré une incidence de 8 % avec une régression tumorale moyenne de 50 %. Sur le plan fonctionnel, une perte auditive a été mise en évidence chez l'ensemble des patients, sans corrélation avec la durée du suivi observationnel. Il existe des schwannomes vestibulaires spontanément involutifs, mais la régression tumorale n'empêche pas la dégradation de l'audition. Les patients doivent être considérés comme un sous-groupe de ceux bénéficiant d'une prise en charge observationnelle.

High-Resolution fMRI of Auditory Cortical Map Changes in Unilateral Hearing Loss and Tinnitus.

Animal models of hearing loss and tinnitus observe pathological neural activity in the tonotopic frequency maps of the primary auditory cortex. Here, we applied ultra high-field fMRI at 7 T to test whether human patients with unilateral hearing loss and tinnitus also show altered functional activity in the primary auditory cortex. The high spatial resolution afforded by 7 T imaging allowed tonotopic mapping of primary auditory cortex on an individual subject basis. Eleven patients with unilateral hearing loss and tinnitus were compared to normal-hearing controls. Patients showed an over-representation and hyperactivity in a region of the cortical map corresponding to low frequencies sounds, irrespective of the hearing loss and tinnitus range, which in most cases affected higher frequencies. This finding of hyperactivity in low frequency map regions, irrespective of hearing loss range, is consistent with some previous studies in animal models and corroborates a previous study of human tinnitus. Thus these findings contribute to accumulating evidence that gross cortical tonotopic map reorganization is not a causal factor of tinnitus.

Preserving normal facial nerve function and improving hearing outcome in large vestibular schwannomas with a combined approach: planned subtotal resection followed by gamma knife radiosurgery.

OBJECTIVE: To perform planned subtotal resection followed by gamma knife surgery (GKRS) in a series of patients with large vestibular schwannoma (VS), aiming at an optimal functional outcome for facial and cochlear nerves. METHODS: Patient characteristics, surgical and dosimetric features, and outcome were collected prospectively at the time of treatment and during the follow-up. RESULTS: A consecutive series of 32 patients was treated between July 2010 and June 2016. Mean follow-up after surgery was 29 months (median 24, range 4-78). Mean presurgical tumor volume was 12.5 cm3 (range 1.47-34.9). Postoperative status showed normal facial nerve function (House-Brackmann I) in all patients. In a subgroup of 17 patients with serviceable hearing before surgery and in which cochlear nerve preservation was attempted at surgery, 16 (94.1%) retained serviceable hearing. Among them, 13 had normal hearing (Gardner-Robertson class 1) before surgery, and 10 (76.9%) retained normal hearing after surgery. Mean duration between surgery and GKRS was 6.3 months (range 3.8-13.9). Mean tumor volume at GKRS was 3.5 cm3 (range 0.5-12.8), corresponding to mean residual volume of 29.4% (range 6-46.7) of the preoperative volume. Mean marginal dose was 12 Gy (range 11-12). Mean follow-up after GKRS was 24 months (range 3-60). Following GKRS, there were no new neurological deficits, with facial and hearing functions remaining identical to those after surgery in all patients. Three patients presented with continuous growth after GKRS, were considered failures, and benefited from the same combined approach a second time. CONCLUSION: Our data suggest that large VS management, with planned subtotal resection followed by GKRS, might yield an excellent clinical outcome, allowing the normal facial nerve and a high level of cochlear nerve functions to be retained. Our functional results with this approach in large VS are comparable with those obtained with GKRS alone in small- and medium-sized VS. Longer term follow-up is necessary to fully evaluate this approach, especially regarding tumor control.

[The video Head Impulse Test in the vertiginous patient]. / Le video Head Impulse Test dans la prise en charge du patient vertigineux.

The video Head Impulse Test (vHIT) is a new diagnostic device which, in clinical practice, can be used to evaluate the vestibular canal function in a fast and objective way by recording the movements of the eyes and the head. The medical literature makes it possible today to define the place of this device in the care of patients with vertigo.

Le video Head Impulse Test (vHIT) est un nouveau dispositif diagnostique qui, en pratique clinique, permet d'évaluer la fonction canalaire du vestibule de manière rapide et objective via l'enregistrement des mouvements des yeux et de la tête. La littérature médicale permet aujourd'hui de définir la place de ce dispositif dans la prise en charge de nos patients vertigineux.

[Inferior vestibular neuritis]. / Névrite vestibulaire inférieure.

Inferior vestibular neuritis is a rare form of acute peripheral vestibular loss that only implies the lesion of the inferior vestibular nerve. The diagnosis is based on the observation of a spontaneous downbeating nystagmus, pathological head impulse test for the posterior semicircular canal and abnormal cervical vestibular-evoked myogenic potentials. Bithermal caloric testing and head impulse test for horizontal and anterior canals are normal, as well as the ocular vestibular-evoked myogenic potentials. The differential diagnosis of inferior vestibular neuritis includes the various central lesions that produce vertical down beating nystagmus (posterior fossa) and a cerebral magnetic resonance imaging is mandatory.

La névrite vestibulaire inférieure est une forme rare de névrite vestibulaire. Cliniquement, on observe un nystagmus vertical battant vers le bas et torsionnel, un head impulse test normal dans le plan horizontal et pathologique dans le plan du canal semi-circulaire postérieur du côté lésé. L'épreuve calorique est normale. Les potentiels évoqués myogéniques, vestibulaires cervicaux sont pathologiques du côté atteint. Le diagnostic différentiel de la névrite vestibulaire inférieure doit se faire avec une atteinte neurologique de la fosse postérieure et une IRM cérébrale est indiquée.

[Anterior semicircular canal Benign Paroxysmal Positional Vertigo]. / Vertige paroxystique positionnel bénin du canal semi-circulaire antérieur.

Anterior semicircular canal Benign Paroxysmal Positional Vertigo (antBPPV) is the rarest form of semicircular canalolithiasis, corresponding to about 1-2 % of the BPPV. The diagnosis is obtained by either the Dix-Hallpike maneuver or the straight head hanging positioning maneuver, which provoke a characteristic positional down-beating nystagmus. This vertical nystagmus can be associated with a torsional component that helps in localizing the affected side. The differential diagnosis of antBPPV includes the various central lesions that produce vertical down beating nystagmus (posterior fossa). Several liberatory maneuvers have been proposed for the treatment of antBPPV, but still need standardization.

Le vertige paroxystique positionnel bénin du canal semi-circulaire antérieur (VPPBant) est la forme la plus rare des canalolithiases, correspondant à 1-2 % environ de l'ensemble des VPPB. Le diagnostic repose sur l'observation d'un nystagmus positionnel vertical battant vers le bas, associé ou non à une composante rotatoire dirigée vers le côté lésé, provoqué par la manœuvre de Dix-Hallpike ou le positionnement en décubitus dorsal tête en hyperextension. Le côté affecté n'est pas toujours identifiable, en raison de l'inconstance de la composante rotatoire du nystagmus. Le diagnostic différentiel du VPPBant se fait avec les atteintes centrales pouvant produire un nystagmus vertical battant vers le bas (fosse postérieure). Plusieurs manœuvres thérapeutiques sont proposées, mais doivent encore être standardisées.

Vestibular Schwannoma: The Evolution of Hearing and Tumor Size in Natural Course and after Treatment by LINAC Stereotactic Radiosurgery.

OBJECTIVE: To review the natural course of tumor size and hearing during conservative management of 151 patients with unilateral vestibular schwannoma (VS), and to evaluate the same parameters for the part of the group (n = 84) who were treated by LINAC stereotactic radiosurgery (SRS). METHODS: In prospectively collected data, patients underwent MRI and complete audiovestibular tests at inclusion, during the conservative management period and after SRS. Hearing was graded according to the Gardner-Robertson (GR) scale and tumor size according to Koos. Statistics were performed using Kaplan-Meier survival analysis and multivariate analyses including linear and logistic regression. Specific insight was given to patients with serviceable hearing. RESULTS: During the conservative management period (mean follow-up time: 24 months, range: 6-96), the annual risk of GR class degradation was 6% for GRI and 15% for GR II patients. Hearing loss as an initial symptom was highly predictive of further hearing loss (p = 0.003). Tumor growth reached 25%. For SRS patients, functional hearing preservation was 51% at 1 year and 36% at 3 years. Tumor control was 94 and 91%, respectively. CONCLUSION: In VS patients, hearing loss at the time of diagnosis is a predictor of poorer hearing outcome. LINAC SRS is efficient for tumor control. Patients who preserved their pretreatment hearing presented less hearing loss per year after SRS than before treatment, suggesting a protective effect of SRS when cochlear function can be preserved.

Impact of the Mean Cochlear Biologically Effective Dose on Hearing Preservation After Stereotactic Radiosurgery for Vestibular Schwannoma: A Retrospective Longitudinal Analysis.

BACKGROUND AND OBJECTIVES: Stereotactic radiosurgery (SRS) is a useful alternative for small- to medium-sized vestibular schwannoma. To evaluate whether biologically effective dose (BED Gy2.47 ), calculated for mean (BED Gy2.47 mean) and maximal (BED Gy2.47 max) cochlear dose, is relevant for hearing preservation. METHODS: This is a retrospective longitudinal single-center study. Were analyzed 213 patients with useful baseline hearing. Risk of hearing decline was assessed for Gardner-Robertson classes and pure tone average (PTA) loss. The mean follow-up period was 39 months (median 36, 6-84). RESULTS: Hearing decline (Gardner-Robertson class) 3 years after SRS was associated with higher cochlear BED Gy2.47 mean (odds ratio [OR] 1.39, P = .009). Moreover, BED Gy2.47 mean was more relevant as compared with BED Gy2.47 max (OR 1.13, P = .04). Risk of PTA loss (continuous outcome, follow-up minus baseline) was significantly corelated with BED Gy2.47 mean at 24 (beta coefficient 1.55, P = .002) and 36 (beta coefficient 2.01, P = .004) months after SRS. Risk of PTA loss (>20 dB vs ≤) was associated with higher BED Gy2.47 mean at 6 (OR 1.36, P = .002), 12 (OR 1.36, P = .007), and 36 (OR 1.37, P = .02) months. Risk of hearing decline at 36 months for the BED Gy2.47 mean of 7-8, 10, and 12 Gy 2.47 was 28%, 57%, and 85%, respectively. CONCLUSION: Cochlear BED Gy2.47 mean is relevant for hearing decline after SRS and more relevant as compared with BED Gy2.47 max. Three years after SRS, this was sustained for all hearing decline evaluation modalities. Our data suggest the BED Gy2.47 mean cut-off of ≤8 Gy 2.47 for better hearing preservation rates .

Video Head Impulse Test: A Comparison and Analysis of Three Recording Systems.

The present study aimed to compare the efficacy and reproducibility of three existing systems in a group of healthy individuals for vHIT. A prospective randomized study was conducted on 12 healthy individuals. The vHIT tests were carried out. The values of the gains for the 3SCCs of each ear were collected using the three devices. The expected average gain of 1 was the gain standard. The statistical significance in the difference in gains were assessed. There is good reproducibility of the results of the vHIT examination. EyeSeeCam appeared to be the worst performing system with a slightly overstated average gain of 1.15. Otometrics has longest average examination time per patient. Synapsis is the system with the best quality/time invested and easiest to access. Video head impulse system depends on the examiner's preference, reproducible and superimposable depending on the examiner and experience.

Direct cochlear nerve stimulation monitoring through evoked muscle responses during retrosigmoid vestibular schwannoma resection surgery: technical note.

OBJECTIVE: Cochlear nerve preservation during surgery for vestibular schwannoma (VS) may be challenging. Brainstem auditory evoked potentials and cochlear compound nerve action potentials have clearly shown their limitations in surgeries for large VSs. In this paper, the authors report their preliminary results after direct electrical intraoperative cochlear nerve stimulation and recording of the postauricular muscle response (PAMR) during resection of large VSs. METHODS: The details for the electrode setup, stimulation, and recording parameters are provided. Data of patients for whom PAMR was recorded during surgery were prospectively collected and analyzed. RESULTS: PAMRs were recorded in all patients at the ipsilateral vertex-earlobe scalp electrode, and in 90% of the patients they were also observed in the contralateral electrode. The optimal stimulation intensity was found to be 1 mA at 1 Hz, with a good cochlear response and an absent response from other nerves. At that intensity, the ipsilateral cochlear response had an initial peak at a mean (± SEM) latency of 11.6 ± 1.5 msec with an average amplitude of 14.4 ± 5.4 µV. One patient experienced a significant improvement in his audition, while that of the other patients remained stable. CONCLUSIONS: PAMR monitoring may be useful in mapping the position and trajectory of the cochlear nerve to enable hearing preservation during surgery.

The Relevance of Biologically Effective Dose for Hearing Preservation After Stereotactic Radiosurgery for Vestibular Schwannomas: A Retrospective Longitudinal Study.

BACKGROUND: Stereotactic radiosurgery has become a common treatment approach for small-to-medium size vestibular schwannomas. OBJECTIVE: To evaluate relationship between time (beam-on and treatment) and risk of hearing decline after stereotactic radiosurgery for vestibular schwannomas in patients with Gardner-Robertson (GR) baseline classes I and II. METHODS: This retrospective longitudinal single-center study included 213 patients with GR I and II treated between June 2010 and December 2019. Risk of passing from GR classes I and II (coded 0) to other classes III, IV, and V (coded 1) and the increase in pure tone average (continuous outcome) were evaluated using a mixed-effect regression model. Biologically effective dose (BED) was further assessed for an alpha/beta ratio of 2.47 (Gy 2.47 ). RESULTS: Binary outcome analysis revealed sex, dose rate, integral dose, time [beam-on time odds ratio 1.03, P = .03, 95% CI 1.00-1.06; treatment time ( P = .02) and BED ( P = .001) as relevant. Fitted multivariable model included the sex, dose rate, and BED. Pure tone average analysis revealed age, integral dose received by tumor, isocenter number, time (beam-on time odds ratio 0.20, P = .001, 95% CI 0.083-0.33) and BED ( P = .005) as relevant. CONCLUSION: Our analysis showed that risk of hearing decline was associated with male sex, higher radiation dose rate (cutoff 2.5 Gy/minute), higher integral dose received by the tumor, higher beam-on time ≥20 minutes, and lower BED. A BED between 55 and 61 was considered as optimal for hearing preservation.

Acute unilateral vestibulopathy/vestibular neuritis: Diagnostic criteria.

This paper describes the diagnostic criteria for Acute Unilateral Vestibulopathy (AUVP), a synonym for vestibular neuritis, as defined by the Committee for the Classification of Vestibular Disorders of the Bárány Society. AUVP manifests as an acute vestibular syndrome due to an acute unilateral loss of peripheral vestibular function without evidence for acute central or acute audiological symptoms or signs. This implies that the diagnosis of AUVP is based on the patient history, bedside examination, and, if necessary, laboratory evaluation. The leading symptom is an acute or rarely subacute onset of spinning or non-spinning vertigo with unsteadiness, nausea/vomiting and/or oscillopsia. A leading clinical sign is a spontaneous peripheral vestibular nystagmus, which is direction-fixed and enhanced by removal of visual fixation with a trajectory appropriate to the semicircular canal afferents involved (generally horizontal-torsional). The diagnostic criteria were classified by the committee for four categories: 1. "Acute Unilateral Vestibulopathy", 2. "Acute Unilateral Vestibulopathy in Evolution", 3. "Probable Acute Unilateral Vestibulopathy" and 4. "History of Acute Unilateral Vestibulopathy". The specific diagnostic criteria for these are as follows:"Acute Unilateral Vestibulopathy": A) Acute or subacute onset of sustained spinning or non-spinning vertigo (i.e., an acute vestibular syndrome) of moderate to severe intensity with symptoms lasting for at least 24 hours. B) Spontaneous peripheral vestibular nystagmus with a trajectory appropriate to the semicircular canal afferents involved, generally horizontal-torsional, direction-fixed, and enhanced by removal of visual fixation. C) Unambiguous evidence of reduced VOR function on the side opposite the direction of the fast phase of the spontaneous nystagmus. D) No evidence for acute central neurological, otological or audiological symptoms. E) No acute central neurological signs, namely no central ocular motor or central vestibular signs, in particular no pronounced skew deviation, no gaze-evoked nystagmus, and no acute audiologic or otological signs. F) Not better accounted for by another disease or disorder."Acute Unilateral Vestibulopathy in Evolution": A) Acute or subacute onset of sustained spinning or non-spinning vertigo with continuous symptoms for more than 3 hours, but not yet lasting for at least 24 h hours, when patient is seen; B) - F) as above. This category is useful for diagnostic reasons to differentiate from acute central vestibular syndromes, to initiate specific treatments, and for research to include patients in clinical studies."Probable Acute Unilateral Vestibulopathy": Identical to AUVP except that the unilateral VOR deficit is not clearly observed or documented."History of acute unilateral vestibulopathy": A) History of acute or subacute onset of vertigo lasting at least 24 hours and slowly decreasing in intensity. B) No history of simultaneous acute audiological or central neurological symptoms. C) Unambiguous evidence of unilaterally reduced VOR function. D) No history of simultaneous acute central neurological signs, namely no central ocular motor or central vestibular signs and no acute audiological or otological signs. E) Not better accounted for by another disease or disorder. This category allows a diagnosis in patients presenting with a unilateral peripheral vestibular deficit and a history of an acute vestibular syndrome who are examined well after the acute phase.It is important to note that there is no definite test for AUVP. Therefore, its diagnosis requires the exclusion of central lesions as well as a variety of other peripheral vestibular disorders. Finally, this consensus paper will discuss other aspects of AUVP such as etiology, pathophysiology and laboratory examinations if they are directly relevant to the classification criteria.

[Facial palsy: update for the practitioner]. / Paralysie faciale: mise a jour pour le praticien.

The clinical significance of facial palsy hinges on its psychosocial consequences. While its causes are very numerous, several infections account for a majority of cases: Lyme disease, geniculate zoster (Ramsay Hunt syndrome), while the role of HSV-1 in essential (Bell's) palsy remains controversial. Essentials of facial palsy management are discussed, including the importance of the functional grading of palsy, the complexity of Lyme disease serological diagnosis, and its treatment using doxycycline, antiviral and steroids treatment of geniculate zoster, while regarding essential facial palsy, only steroids, but not antiviral have been shown to improve functional recovery.