Automatic Detection and Analysis of Swallowing Sounds in Healthy Subjects and in Patients with Pharyngolaryngeal Cancer.

Assessment of swallowing function is often invasive or involves irradiation. Analysis of swallowing sounds is a noninvasive method for assessment of swallowing but is not used in daily medical practice. Dysphagia could be the first symptom that occurs in head and neck cancer. This study evaluated a method for the automatic detection and analysis of swallowing sounds in healthy subjects and in patients with pharyngolaryngeal cancer. A smartphone application, developed for automatic detection and analysis of swallowing sounds was developed and tested in 12 healthy volunteers and in 26 patients with pharyngolaryngeal cancer. Swallowing sounds were recorded with a laryngophone during a standardized meal (100 mL mashed potatoes, 100 mL water, and 100 mL yogurt). Swallowing number and duration were noted; the results were compared to a standard swallowing sound analysis using the software AUDACITY®. There were no statistically significant differences in swallowing number or duration between the two analysis methods for the three types of foods in healthy volunteers and only for water in patients. In healthy volunteers, the results of our automatic analysis were comparable with those obtained with the standard analysis. However, a better discrimination of swallowing sounds is necessary for the algorithm to obtain reliable results with thicker food in patients with head and neck cancer.

Transoral robotic surgery for squamous cell carcinomas of the posterior pharyngeal wall.

Posterior pharyngeal wall squamous cell carcinomas (SCCs) are rare and have an associated poor prognosis. Progress in transoral resection techniques, in particular, transoral robotic surgery (TORS), have renewed the role of surgery in their treatment. This article presents the oncological and functional results obtained by the French Group of Head and Neck Robotic Surgery for TORS for posterior pharyngeal wall SCC-curative surgery. This retrospective, multicentre study presents data collected between September 2009 and November 2013 for patients treated with TORS for posterior pharyngeal wall SCCs. Analysis of patient characteristics, tumour and treatment details were completed. Kaplan-Meier analysis was used to calculate overall survival rates and recurrence-free survival rates. Student's t test and Chi2 test were also calculated. 23 patients were included (mean age of 62 years). 12 patients had a prior HNSCC. Ten patients had pT1 cancers. The overall two-year survival rate was 59%, but 89% for pT1 compared to 28% for pT2-T3 (p = 0.01). It was noted that TORS was simple to perform, but generated significant post-operative dysphagia. Two cases of spondylodiscitis were reported as specific post-operative complications of TORS. In conclusion, TORS is a treatment solution for selected posterior pharyngeal wall SCCs. It provides a possible alternative to medical treatment for early pT1 lesions and is often the only remaining curative solution in patients previously treated with radiotherapy. In cases of bulky resection, or when there is a past medical history of radiotherapy, a tissue reconstruction by forearm free-flap may be indicated.

Clinical outcomes of transoral robotic surgery for supraglottic squamous cell carcinoma: experience of a french evaluation cooperative subgroup of gettec.

BACKGROUND: Transoral, minimally invasive, organ preservation surgeries are increasingly used to treat laryngopharyngeal carcinomas to avoid the toxicity associated with combined chemoradiotherapy regimens. This study investigated the efficiency, safety, and functional outcomes of using transoral robotic surgery (TORS) to perform supraglottic laryngectomy (SGL). METHODS: This was a multicenter study using a case series with planned data collection from 2009 to 2012 for patients with supraglottic squamous cell carcinomas (SCC) who underwent SGL using TORS. RESULTS: Eighty-four (84) of 262 patients underwent TORS for supraglottic SCC. Within 24 hours of surgery, 24% of the patients started on an oral diet. The median use of a feeding tube was 8 days for 76% of other patients. Definitive percutaneous gastrostomy feeding was necessary for 9.5% of the patients. 24% of the patients did require a tracheostomy, and the median use was 8 days. One percent (1%) of the patients had a definitive tracheostomy. Aspiration pneumonia was observed in 23% of the patients during the postoperative course, and was responsible for the death of one patient. Postoperative bleeding occurred in 18% of the patients. Based on the pathology results, 51% of the patients received adjuvant radiation therapy. CONCLUSION: TORS for SGL in intermediate stage SCC is a safe procedure with good functional outcomes and fast recovery times. However, adverse events can occur. Consequently, this technique requires good patient selection criteria to reduce the risk of postoperative complications.

[Post intubation collected septic cricoarytenoid arthritis: case report]. / Arthrite infectieuse collectée de l'articulation crico-aryténoïdienne secondaire a une intubation: cas clinique.

We report a rare case of post intubation cricoarytenoid arthritis. A 18-year-old man admitted to emergency was easely intubated for 14 days for a non neck injury. Sixty-six days after intubation, he consulted for severe odynophagia with dyspnoea. Nasofibroscopic examination revealed a right arytenoid granuloma with oedema and inflammation, and bilateral arytenoid immobility. There was evidence on the CT scan of cricoarytenoid arthritis with fluid accumulation. Antibiotic treatment and two punctures for drainage allowed healing. There were cricoid and arytenoid calcifications. The patient recovered total and stable laryngeal mobility and function. This case is unusual, with features unlike those previously reported: intubation being the probable cause, the unusual clinical presentation with painless cricoid palpation, and the contrast between imaging findings during follow-up and the evolution under treatment. Indeed, there was an apparent discrepancy between the favourable clinical course and the CT-images revealing calcifications.

Management of the neck in the setting of definitive chemoradiation: is there a consensus? A GETTEC study.

BACKGROUND: The management of the neck remains controversial in the definitive chemoradiation setting of advanced N2-3 head and neck squamous cell carcinoma. Most published data favor omission of neck dissection (ND) after complete response for N2-3 or selective ND for residual disease METHODS: We studied the patterns of care in the French-Belgian Groupe d'Etude des Tumeurs de la Tête Et du Cou (GETTEC) through a questionnaire-based survey. RESULTS: Eighteen percent of institutions never performed up-front ND, 20% rarely, 40% sometimes, 14% often, and 8% systematically. Induction chemotherapy was indicated in 30% of the cases, and most ND were performed either between induction and radiation or after chemoradiation for residual disease. Response to chemoradiation was assessed by computed tomographic scan and positron emission tomography in 72% of cases. Selective ND was more common than radical ND. CONCLUSIONS: Omission of ND based on computed tomographic scan and positron emission tomography-based complete response to chemoradiation is the most common strategy for advanced nodal disease among centers. However, neck management strategies vary among institutions, and some institutions continue advocating systematic ND before irradiation. The new treatment options and the changing epidemiology, namely docetaxel-based induction chemotherapy and human papilloma virus-related head and neck squamous cell carcinoma having better response profiles and prognosis, are adding to the nonconsensual approach. The best therapeutic index in terms of neck management remains to be defined in this evolving context.

Psychosocial quality of life in hereditary haemorrhagic telangiectasia patients.

OBJECTIVES: The aim of this study was to evaluate psychosocial quality of life (PQoL) in patients with Hereditary Haemorrhagic Telangiectasia (HHT). STUDY DESIGN AND SETTING: A retrospective study was performed on PQoL in HHT patients presenting with epistaxis. One hundred fifteen patients were interviewed using a questionnaire designed by two sociologists and a head and neck surgeon. Changes over time were assessed according to information on psychosocial well-being, social life, family support, occupation, and medical and demographic data regarding age, gender and patient appearance. RESULTS: Analysis of Psychosocial Quality of Life (PQoL) revealed no statistical difference in relation to gender, marital status, household income or place of residence (rural or urban); however, a significant difference was observed with age. Elderly patients had a poorer PQoL than younger patients. Workers had a better PQoL than unemployed patients. Epistaxis and professional duties were correlated: workers with less than one episode of epistaxis per month were more active. Frequent episodes of epistaxis and abundant bleeding decreased PQoL. These patients felt different and often experienced a desire to withdraw compared to others. CONCLUSION: Epistaxis in hereditary haemorrhagic telangiectasia patients was associated with the impairment of many PQoL criteria, together with relationship modifications.

[Submental flap for auricule reconstruction]. / Lambeau sous mental suite à l'exérèse de l'oreille externe.

OBJECTIVE: We present our experience in the use of submental flap in reconstruction of post-auricular excision defects. MATERIAL AND METHODS: Three patients underwent reconstruction with submental flap. RESULTS: The submental flap has been used in 3 patients for auricular defect reconstruction. All patients had a carcinoma involving the auricle. All the donor site defects were closed primarily. Outcomes were simple. In one case, we noticed a partial necrosis of the flap extremity. CONCLUSION: The submental flap produces excellent skin color and contour. It leaves a very well-hidden donor site. The operative technique makes it easy to use. So, the submental flap has definite advantages over distant flaps and it is a useful addition to the reconstruction in head and neck surgery.

[Metastatic melanoma to the oropharynx]. / Métastase oropharyngée d'un mélanome cutané.

INTRODUCTION: Metastatic mucosal melanoma to the oropharyngeal area is extremely rare. Only 0.6% to 3% of patients with cutaneous malignant melanoma will have metastases to the mucosa of the upper aerodigestive tract. CASE REPORT: A 60-year-old woman presented with a past history of dorsal melanoma and metastatic inguinal node was referred to our department for odynophagia. Physical examination revealed a mass of the right tonsil. A cervico-facial computed tomography, a magnetic resonance imagery and PET-scanner were performed and showed the tumefaction located at the right tonsil. Biopsy was performed under general anesthesia. The histological examination revealed a metastatic melanoma. After discussion a palliative treatment with chemotherapy was begun. The patient died of disseminated disease 2 months after the beginning of the chemotherapy, only 4 months after the initial diagnosis. DISCUSSION/CONCLUSION: The case presentation indicates that careful examination of the head and neck should be part of the routine follow-up examination in all melanoma patients. The discovery of mucosal metastasis in head and neck indicated widespread dissemination and a poor prognosis.

Throat cancer surgery training in France.

This article reviews the development of practical and theoretical teaching of surgical management of throat cancer, from the dialectic of the Middle Ages to computer simulation of the 21st century. This work is essentially based on original historical publications, analysed from secondary references relevant to the interpretation of the original texts. The literature search was essentially conducted in the "bibliothèque universitaire de médecine de Tours", the "bibliothèque inter-universitaire de médecine de Paris", the "Assistance publique-Hôpitaux de Paris archives" and the "bibliothèque nationale de France". PubMed was used for the most recent references. The search terms focused on surgical training, the history of otorhinolaryngology and throat cancer. Up until the 19th century, throat cancer surgery training was provided by general surgeons. The otorhinolaryngology specialty was created at the turn of the 20th century: throat cancer surgery became a subspecialty, but certain university obstacles prevented the creation of formal throat cancer surgery training. In the 20th and 21st century, throat cancer surgery training was enhanced by technical innovations as well as ethical imperatives. The principle of mentoring, essential in surgical training, has remained a constant feature throughout the ages, regardless of the scientific progress described in this historical review.

Otosclerosis surgery under local anesthesia with sedation: Assessment of quality of life and stress.

OBJECTIVES: The main study endpoint was tolerance of stapedotomy under local anesthesia with sedation and under general anesthesia using stress and quality of life assessment questionnaires. Secondary endpoints comprised operative time and functional results. MATERIAL AND METHOD: In a consecutive series of stapedotomy patients operated on over a 12-month period, quality of life and perioperative stress were analysed by 3 questionnaires: the Glasgow Benefit Inventory, Cohen's perceived stress scale and the Post-traumatic stress disorder checklist scale. Questionnaire responses and audiometric data were compared between groups treated under local anesthesia with sedation and under general anesthesia. RESULTS: Twenty-two patients were included in the local anesthesia with sedation group and 6 in the general anesthesia group. There was no difference between the groups for quality of life, onset of post-traumatic stress, or perceived pre- and postoperative stress. There was also no difference in operative time. The audiometric data confirmed the reliability of stapedotomy. Stapedotomy under local anesthesia with sedation improved air conduction with≤10dB air-bone gap (ABG), comparable to results under general anesthesia. The rate of ABG≤10dB was 71.4%; no labyrinthisation was observed. CONCLUSION: Under local anesthesia with sedation, stapedotomy was well tolerated without increasing the stress associated with otosclerosis surgery. By correcting hearing loss, the procedure improves quality of life.

Cholesterol granuloma of the maxillary sinus.

INTRODUCTION: Cholesterol granuloma (CG) can be found in several areas of the body. Maxillary sinus localization is considered rare. CASE REPORT: A 37-year-old male presented with acute febrile sinusitis. Nasal endoscopy showed a nasal polyp at the middle meatus. Computed Tomography (CT scan) of the sinus showed complete opacity of the right maxillary sinus without calcification and partial opacification of frontal and ethmoidal sinuses. Functional endoscopic sinus approach was performed. Marsupialization of the cyst which a brownish fluid, which evoked the diagnosis of cholesterol granuloma. CONCLUSION: The definite diagnosis is made by histology, although intra-operative finding could be suggestive. Complete excision is achievable by endoscopic approach.

Otosclerosis surgery: Assessment of patient comfort.

OBJECTIVES: To evaluate operative comfort and stress in patients undergoing stapedotomy for otosclerosis under local versus general anesthesia. MATERIAL AND METHODS: Consecutive otosclerosis patients managed over a 9-month period responded to 3 validated questionnaires to assess peri- and post-operative comfort: Glasgow Benefit Inventory, Cohen's Perceived Stress Scale and the Posttraumatic Stress Disorder Checklist Scale. These results and audiometric data were compared between local and general anesthesia groups. RESULTS: Twenty-one patients were included in the local anesthesia group and 7 in the general anesthesia group, after exclusion of patients with history of otosclerosis surgery. There was no significant inter-group difference on Glasgow Benefit Inventory (P=0.38) or Posttraumatic Stress Disorder Checklist Scale (P=0.86). Perceived Stress Scale scores were higher in the general anesthesia group (P=0.038). In total, 67% of patients reported no discomfort under local anesthesia, and 86% were ready to undergo the procedure under local anesthesia again. There were no significant differences in postoperative symptoms, or in air-bone gap≤10dB (local anesthesia 81%, general anesthesia 71%; P=0.156). CONCLUSIONS: Local anesthesia in otosclerosis surgery did not increase stress or postoperative symptoms compared to general anesthesia. Audiometric results were not affected by type of anesthesia.

French consensus regarding precautions during tracheostomy and post-tracheostomy care in the context of COVID-19 pandemic.

Tracheostomy post-tracheostomy care are regarded as at high risk for contamination of health care professionals with the new coronavirus (SARS-CoV-2). Considering the rapid spread of the infection, all patients in France must be considered as potentially infected by the virus. Nevertheless, patients without clinical or radiological (CT scan) markers of COVID-19, and with negative nasopharyngeal sample within 24h of surgery, are at low risk of being infected. Instructions for personal protection include specific wound dressings and decontamination of all material used. The operating room should be ventilated after each tracheostomy and the pressure of the room should be neutral or negative. Percutaneous tracheostomy is to be preferred over surgical cervicotomy in order to reduce aerosolization and to avoid moving patients from the intensive care unit to the operating room. Ventilation must be optimized during the procedure, to limit patient oxygen desaturation. Drug assisted neuromuscular blockage is advised to reduce coughing during tracheostomy tube insertion. An experienced team is mandatory to secure and accelerate the procedure as well as to reduce risk of contamination.

French consensus on management of head and neck cancer surgery during COVID-19 pandemic.

In the context of the current pandemic, there is a need for specific advice concerning treatment of patients with Head and Neck cancers. The rule is to limit as much as possible the number of patients in order to reduce the risks of contamination by the SARS-Cov-2 virus for both patients and the caregivers, who are particularly exposed in ENT. The aim is to minimize the risk of loss of opportunity for patients and to anticipate the increased number of cancer patients to be treated at the end of the pandemic, taking into account the degree of urgency, the difficulty of the surgery, the risk of contaminating the caregivers (tracheotomy) and the local situation (whether or not the hospital and intensive care departments are overstretched).

[Microdebrider-assisted partial turbinoplasty: technique and results in perennial non-allergic rhinitis]. / Turbinoplastie endoscopique au microdébrideur: technique et résultats dans la rhinite vasomotrice primitive.

AIM OF THE STUDY: To assess objective and subjective outcomes in patients with perennial non-allergic rhinitis who had undergone endoscopic microdebrider-assisted inferior turbinoplasty. PATIENTS AND METHODS: Twenty patients (13 men and 7 women; age range, 15-64 years; mean age, 42.6 years) were included in a prospective study. Each patient had a perennial non-allergic rhinitis with substantial mucosal hypertrophy of the inferior turbinates, resistant to a 4- to 6-week course of nasal saline irrigations and nasal steroid spray. Then, they underwent endoscopic microdebrider-assisted inferior turbinoplasty with follow-up 6 months after surgery. This technique describes an elevator incorporated into a small microdebrider blade (2.0 mm). It provides a method for achieving the goals of volumetric reduction with mucosal preservation, with 0O endoscopic guidance, and minimal risk of complications. Objective outcomes were evaluated by peak nasal inspiratory flow (PNIF), an easy and highly reproducible measurement. Subjective symptoms were measured by a standard 10-cm visual analog scale, and analyzed before, at 1, 3 and 6 months after surgery. RESULTS: Preoperative PNIF measurement was 65 L/min, 98 L/min at 1 month, 123 L/min at 3 months and 126 l/min at 6 months. Statistical analysis (Wilcoxon signed rank test) showed significant improvement between preoperative and 1, 3 and 6 months. Subjective nasal obstruction improvement was statistically significant between preoperative and 1, 3 and 6 months. CONCLUSIONS: Our results suggest that microdebrider-assisted inferior turbinoplasty is effective for decreasing objective and subjective nasal in patients with perennial allergic rhinitis who have substantial nasal congestion.

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group.

BACKGROUND: Cervical spondylodiscitis is a rare but severe complication of pharyngeal surgery. MATERIAL AND METHODS: This multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017. OBJECTIVES: To describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications. RESULTS: Seven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6days. The interval between surgery and spondylodiscitis diagnosis ranged from 20days to 4.5months, for a mean 2.1months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%). CONCLUSION: This French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.

Assessment of swallowing function after circumferential pharyngolaryngectomy. A multicenter study by the GETTEC group.

OBJECTIVE: Circumferential pharyngolaryngectomy is performed for advanced pharyngeal tumor or in a context of postradiation recurrence. Several free or pedicle flaps have been described for pharyngeal defect reconstruction, with choice at the surgeon's discretion. The aim of this study was to evaluate long-term swallowing function according to the type of flap used for reconstruction. MATERIAL AND METHOD: A multicenter retrospective study was conducted from January to September 2016 within the French GETTEC head and neck tumor study group. All patients in remission after circumferential pharyngolaryngectomy were included and filled out the Deglutition Handicap Index (DHI) questionnaire and underwent swallowing function fiberoptic endoscopy assessment. 46 patients (39 men, 7 women) were included. Reconstruction used a tubularized forearm free flap (FFF group) in 19 cases, pectoralis major myocutaneous flap (PMMF group) in 15 cases and free jejunum flap (FJF group) in 12 cases. RESULTS: Mean DHI was 24: 20 in the FFF group, 23 in the FJF group and 25 in the PMMF group, without significant differences. 27 patients had normal swallowing, 9 mixed diet, 8 liquid diet and 3 were fed by gastrostomy. On endoscopy, free flaps (FJF and FFF) were associated with significantly greater rates of normal swallowing of saliva and yogurt than in the PMMF group (P=0.04). CONCLUSION: Type of flap reconstruction after circumferential pharyngolaryngectomy had no significant impact on postoperative swallowing function assessed on the self-administered DHI questionnaire.

Otosclerosis in children and adolescents: a clinical and CT-scan survey with review of the literature.

OBJECTIVE: To assess the role of the CT-scan in the preoperative evaluation of juvenile otosclerosis and to study additional outcome data. DESIGN AND SETTING: We performed a retrospective case series study from an academic referral hospital using data from 1992 to 2005. PATIENTS AND METHODS: We selected patients younger than 18-year-old who had undergone primary stapedectomy for otosclerosis among the 10 stapedectomies performed over the study period and analyzed the patients' systematic pre- and post-operative audiograms and CT-scan findings. RESULTS: For this survey, complete data was available for 7 children, totaling 10 primary stapedectomies for otosclerosis. Their ages at diagnosis ranged from 10 to 17 years. In 4 children, CT-scan demonstrated bilateral findings typical of otosclerosis: poorly calcified foci near the fissula ante fenestram, associated with a hypodense edging surrounding the labyrinthine capsule in 2 children. The youngest patient had no CT-scan abnormalities. Stapedectomy was performed in one case and laser stapedotomy in 9 cases. Seven children were immediately improved following surgery and no postoperative facial palsy or prolonged vertigo was reported. The mean (S.D.) postoperative ABG was 6.5dB (+/-3.7). The mean closure was 19dB (+/-11.2). The mean change in high-tone bone conduction level was 1.8dB (+/-7.5). Six children had a postoperative ABG less than 10dB while in one, the ABG was inferior to 20dB. CONCLUSION: Preoperative CT-scan is useful for the preoperative diagnosis of otosclerosis in children. The images seen must be distinguished from other footplate pathologies or deformities of the ossicular chain which are often associated with poorer surgical results. This survey provides additional evidence that stapes surgery is an effective procedure for treating juvenile otosclerosis.

[Swallowing sound signal: description in normal and laryngectomized subjects]. / Le signal acoustique de la déglutition pharyngée: description chez les sujets normaux et chez les patients laryngectomisés.

OBJECTIVES: Recently, we described three sound components in the pharyngeal swallowing sound. The aim of the present study was to identify the origin of these components using modern techniques providing numeric, synchronized acoustic-radiological data in a normal population and in a partial supracricoid laryngectomized population (SCL group) and a total laryngectomized (TL group) population in pre- and postoperative situations. PATIENTS AND METHODS: We enrolled 15 normal subjects (10 men and five women; mean age, 29.5+/-8 years), 11 patients in the SCL group (11 men; mean age, 62; range, 45-75 years), and nine patients in the TL group (three women, six men; mean age, 56; range, 39-73). An X-ray camera was connected to a video acquisition card to obtain acoustic-radiological data (2 images/s). The microphone was attached to each subject's skin overlying the lateral border of the cricoid. The subjects were asked to swallow 10 ml of a barium suspension. We performed the acoustic-radiological analysis using Visualisation and Cool Edit Pro software. Each sound component was associated with a specific position of the bolus and the moving anatomic structure. Three sound components were identified: the laryngeal ascension sound (LAS), the upper sphincter opening sound (USOS), and the laryngeal release sound (LRS). We quantified the total duration of the pharyngeal sound and its components, as well as the duration of the interval. RESULTS: The average duration of the normal pharyngeal sound was 690+/-162 ms and was significantly decreased in the TL group (296+/-105 ms) and increased in the SCL group (701+/-186 ms). The USOS was present in 100% of the recordings. A typical profile of the swallowing sound for each group was obtained. CONCLUSION: This study allowed us to determine the origin of the three main sound components of the pharyngeal swallowing sound with respect to movements in anatomic structures and the different positions of the bolus, and to describe the main variations induced by a partial and a total laryngectomy.

[Epidermoid cysts of the fourth ventricle mimicking benign paroxysmal positional vertigo]. / Vertige positionnel paroxystique découvrant un kyste épidermoïde du quatrième ventricule.

OBJECTIVE: To report a case of atypical positional vertigo revealing a fourth ventricle epidermoid cyst. MATERIAL AND METHODS: We report a case of a thirty-year-old woman suffering from positional vertigo with downbeat nystagmus. Except for these symptoms, the physical examination was normal, apart from intermittent headaches. On videonystagmography, a decrease in the average speed of beats and lowered benefits obtained by slow motion were noted. MRI revealed a fourth ventricle epidermoid cyst. RESULTS: Physical examination may provide several signs that are likely to enable the examiner to distinguish between central nervous system or peripheral vertigos. Atypical symptoms such as a downbeat nystagmus, a lack of reversal in nystagmus beats when returning to the sitting position and a lack of a latency period in vertigo and nystagmus occurrence during the Dix-Hallpike maneuver suggest a central nervous system etiology. CONCLUSION: With atypical symptoms noted when questioning the patient or during physical examination, a central nervous system etiology should be mentioned and explored with cerebral MRI.