Refractory episodic vertigo: role of intratympanic gentamicin and vestibular evoked myogenic potentials.

INTRODUCTION: Even today, the treatment of intractable vertigo remains a challenge. Vestibular ablation with intratympanic gentamicin stands as a good alternative in the management of refractory vertigo patients. OBJECTIVE: To control intractable vertigo through complete saccular and horizontal canal vestibular ablation with intratympanic gentamicin treatment. METHODS: Patients with refractory episodic vertigo were included. The inclusion criteria were: unilateral ear disease, moderate to profound sensorineural hearing loss, and failure to other treatments. Included patients underwent 0.5-0.8mL of gentamicin intratympanic application at a 30mg/mL concentration. Vestibular ablation was confirmed by the absence of response on cervical vestibular evoked myogenic potentials and no response on caloric tests. Audiometry, electronystagmography with iced water, and vestibular evoked myogenic potentials were performed in all patients. RESULTS: Ten patients were included; nine patients with Meniere's disease and one patient with (late onset) delayed hydrops. Nine patients showed an absent response on vestibular evoked myogenic potentials and no response on caloric tests. The only patient with low amplitude on cervical vestibular evoked myogenic potentials had vertigo recurrence. Vertigo control was achieved in 90% of the patients. One patient developed hearing loss >30dB. CONCLUSIONS: Cervical vestibular evoked myogenic potentials confirmed vestibular ablation in patients treated with intratympanic gentamicin. High-grade vertigo control was due to complete saccular and horizontal canal ablation (no response to iced water in electronystagmography and no response on cervical vestibular evoked myogenic potentials).

Hemifacial spasm: 20-year surgical experience, lesson learned.

BACKGROUND: Hemifacial spasm is characterized by unilateral, paroxysmal, and involuntary contractions. It is more common in women on the left side. Its evolution is progressive, and it rarely improves without treatment. METHODS: Microvascular decompressions (N = 226) were performed in 194 Hispanic patients (May 1992-May 2011). Outcomes were evaluated on a 4-point scale: Excellent (complete remission); good (1-2 spasms/day); bad (>2 spasms/day); and recurrence (relapse after initial excellent/good response). RESULTS: Most patients were female (n = 123); 71 were male. Mean (±SD) age was 49.4 (±11.7) years; age at onset, 43.9 (±11.9) years; time to surgery, 5.7 (±4.7) years. The left side was affected in 114 patients. Typical syndrome occurred in 177 (91.2%); atypical in 17 (8.8%). Findings were primarily vascular compression (n = 185 patients): Anterior inferior cerebellar artery (n = 147), posterior inferior cerebellar artery (n = 12), basilar artery (n = 10), superior cerebellar artery (n = 8), and 2 vessels (n = 8); 9 had no compression. Postsurgical results were primarily excellent (79.9% [n = 155]; good, 4.6% [n = 9]; bad, 15.5% [n = 30]), with recurrence in 21 (10.8%) at mean 51-month (range, 1-133 months) follow-up. Complications included transient hearing loss and facial palsy. CONCLUSIONS: The anterior inferior cerebellar artery is involved in most cases of hemifacial spasm. Failure to improve postsurgically after 1 week warrants reoperation. Sex, side, and onset are unrelated to treatment response. Microvascular decompression is the preferred treatment. It is minimally invasive, nondestructive, and achieves the best long-term results, with minor morbidity. To our knowledge, this series is the largest to date on a Hispanic population.

Refractory episodic vertigo: role of intratympanic gentamicin and vestibular evoked myogenic potentials / Vertigem refratária episódica: papel da gentamicina intratimpânica e potencial evocado miogênico vestibular

Abstract Introduction: Even today, the treatment of intractable vertigo remains a challenge. Vestibular ablation with intratympanic gentamicin stands as a good alternative in the management of refractory vertigo patients. Objective: To control intractable vertigo through complete saccular and horizontal canal vestibular ablation with intratympanic gentamicin treatment. Methods: Patients with refractory episodic vertigo were included. The inclusion criteria were: unilateral ear disease, moderate to profound sensorineural hearing loss, and failure to other treatments. Included patients underwent 0.5-0.8 mL of gentamicin intratympanic application at a 30 mg/mL concentration. Vestibular ablation was confirmed by the absence of response on cervical vestibular evoked myogenic potentials and no response on caloric tests. Audiometry, electronystagmography with iced water, and vestibular evoked myogenic potentials were performed in all patients. Results: Ten patients were included; nine patients with Meniere's disease and one patient with (late onset) delayed hydrops. Nine patients showed an absent response on vestibular evoked myogenic potentials and no response on caloric tests. The only patient with low amplitude on cervical vestibular evoked myogenic potentials had vertigo recurrence. Vertigo control was achieved in 90% of the patients. One patient developed hearing loss >30 dB. Conclusions: Cervical vestibular evoked myogenic potentials confirmed vestibular ablation in patients treated with intratympanic gentamicin. High-grade vertigo control was due to complete saccular and horizontal canal ablation (no response to iced water in electronystagmography and no response on cervical vestibular evoked myogenic potentials).

Resumo Introdução: Ainda hoje, o controle da vertigem intratável permanece um desafio. A ablação vestibular com gentamicina intratimpânica permanece como uma boa alternativa no tratamento de pacientes com vertigem refratária. Objetivo: Controlar a vertigem intratável por meio de ablação vestibular completa dos canais sacular e horizontal com gentamicina intratimpânica como tratamento. Método: Pacientes com vertigem refratária episódica foram incluídos. Os critérios de inclusão foram doença unilateral da orelha, perda auditiva neurossensorial de moderada a profunda e fracasso com outros tratamentos. Os pacientes incluídos receberam uma aplicação de 0,5-0,8 mL de gentamicina intratimpânica com concentração de 30 mg/mL. A ablação vestibular foi confirmada pela ausência de resposta no teste de potencial evocado miogênico vestibular cervical (PEMVc) e nenhuma resposta nas provas calóricas. Audiometria, eletronistagmografia com água gelada e potencial evocado miogênico vestibular foram realizados em todos os pacientes. Resultados: Ao todo, dez pacientes foram incluídos: nove com doença de Ménière e um com hidropisia tardia. Nove pacientes apresentaram ausência de resposta no teste de potencial evocado miogênico vestibular e nenhuma resposta na prova calórica. O único paciente com baixa amplitude no PEMVc apresentou recorrência da vertigem. O controle da vertigem foi obtido em 90% dos pacientes. Um paciente desenvolveu perda auditiva > 30 dB. Conclusões: O PEMVc confirmou ablação vestibular nos pacientes tratados com gentamicina intratimpânica. O alto grau de controle da vertigem foi devido à ablação completa do sáculo e canal horizontal (sem resposta à água gelada na eletronistagmografia e ausência de resposta no PEMVc).

Tratamiento del acúfeno mediante instilación transtimpánica de lidocaina. Reporte preliminar / Treatment of acufens with lidocaine transtimpanic inyection preliminary report

Actualmente existe una amplia variedad de tratamientos para el acúfeno con resultados no concluyentes. Se ha reportado que la lidocaina aplicada en forma intravenosa puede reducir del 50 al 75 por ciento el acúfeno; sin embargo, las complicaciones por esta vía de administración limitan el uso de este tipo de tratamiento. En este trabajo se reporta la experiencia con la aplicación de lidocaína transtimpánica en 24 pacientes con acúfeno incapacitante, obteniendo mejoría en 75 por ciento de los casos. El evento adverso más frecuente fue el vértigo que siguió a su aplicación con una duración entre 4 a 6 horas. Los resultados concuerdan con los reportados en diversos artículos al aplicar lidocaina intravenosa, pero sin los riesgos que conlleva esta vía de administración.

Espasmo hemifacial. Tratamiento quirúrgico vía microcraniectomía asterional / Surgical treatment through asterional microcraniectomy

Se presenta la experiencia en el tratamiento de 41 pacientes con espasmo hemifacial a quienes se les realizó una descompresión microvascular, la mayoría a través de una microcraniectomía asterional, procedimiento de invasión mínima. Se muestran los resultados en la desaparición del espasmo, así como la incidencia del procedimiento sobre la audición, el equilibrio y la función facial de los pacientes