Corrigendum: Clinical Features of Headache in Patients With Diagnosis of Definite Vestibular Migraine: The VM-Phenotypes Projects.

[This corrects the article DOI: 10.3389/fneur.2018.00395.].

Clinical Features of Headache in Patients With Diagnosis of Definite Vestibular Migraine: The VM-Phenotypes Projects.

Migraine is a common neurological disorder characterized by episodic headaches with specific features, presenting familial aggregation. Migraine is associated with episodic vertigo, named Vestibular Migraine (VM) whose diagnosis mainly rely on clinical history showing a temporary association of symptoms. Some patient refers symptoms occurring in pediatric age, defined "episodic symptoms which may be associated with migraine." The aim of this cross sectional observational study was to assess migraine-related clinical features in VM subjects. For the purpose, 279 patients were recruited in different centers in Europe; data were collected by a senior neurologist or ENT specialist through a structured questionnaire. The age of onset of migraine was 21.8 ± 9. The duration of headaches was lower than 24 h in 79.1% of cases. Symptoms accompanying migrainous headaches were, in order of frequency, nausea (79.9%), phonophobia (54.5%), photophobia (53.8%), vomiting (29%), lightheadedness (21.1%). Visual or other auras were reported by 25.4% of subjects. A familial aggregation was referred by 67.4%, while migraine precursors were reported by 52.3% of subjects. Patients reporting nausea and vomiting during headaches more frequently experienced the same symptoms during vertigo. Comparing our results in VM subjects with previously published papers in migraine sufferers, our patients presented a lower duration of headaches and a higher rate of familial aggregation; moreover some common characters were observed in headache and vertigo attacks for accompanying symptoms like nausea and vomiting and clustering of attacks.

Focus on audiologic impairment in eosinophilic granulomatosis with polyangiitis.

OBJECTIVES/HYPOTHESIS: To evaluate the clinical features of audiologic impairment and its relationship with the nasal, vestibular, and rheumatologic profile in a cohort of patients with eosinophilic granulomatosis with polyangiitis (EGPA), formerly named Churg-Strauss syndrome. STUDY DESIGN: Prospective cross-sectional study. METHODS: Thirty-nine patients with EGPA, considered controlled according to the Birmingham Vasculitis Activity Score and the Vasculitis Damage Index, underwent a complete audiologic evalutaion with otomicroscopy, impedance audiometry, speech audiometry, and auditory brainstem responses; rhinologic evaluation was made by means of fiberoptic endoscopy and nasal cytology; the clinical evaluation was completed with analysis of the facial function and, in patients with referred vertigo, with videonystagmography (VNG). Data were compared to the rheumatologic profile (eosinophil count, antineutrophil cytoplasmic antibodies status). RESULTS: Thirty-four of 39 patients fulfilled the inclusion criteria. Of those, 18 (52, 8%) were affected by variable degrees of hearing loss (sensorineural hearing loss [SNHL]) in four cases (11, 8%), mixed sensorineural and conductive hearing loss in two (5, 9%), presbycusis in six (17, 6%), and otitis media with effusion (OME) in six (17, 6%). Vestibular impairment was represented by benign paroxysmal positional vertigo and unspecific dizziness in three (8, 8%) and four cases (11, 8%), respectively, all with normal VNG. Ear involvement was statistically related to the EGPA vasculitic pattern and independent from the nasal impairment, cytology, and duration of nasal symptoms. No facial palsy was registered. CONCLUSION: In our experience, the largest in the existing literature, the otological involvement in EGPA is common and may occur variably as SNHL or OME. Otological involvement occurs early in the course of the disease process, but is nonspecific in making the diagnosis of EGPA. Its recognition is therefore fundamental. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2792-2797, 2016.

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.

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.

Ectopic intraorbital lacrimal ductal cyst: a case report.

Lacrimal ductal cysts are uncommon lesions that can occur everywhere in and around the eye. Ectopic location is very rare and can be misleading in the differential diagnosis of orbital masses. In this article we present the case of a 61-year-old-man with a medial intraconal ductal cyst of his right orbit. The patient was successfully treated with surgical excision.

Otoneurologic dysfunctions in migraine patients with or without vertigo.

OBJECTIVE: To evaluate the neurotologic findings in patient suffering from migraine with and without vestibular symptoms. STUDY DESIGN: Comparative cross-sectional and observational study. SETTING: Tertiary referral center. BACKGROUND: Migraine headache is often associated with other symptoms, including dizziness, head motion intolerance, or rotational-type vertigo. The neuro-otologic examination in migrainous patients often gives unremarkable results. To date, it is not fully understood why some migraine patients complain of vestibular symptoms and some do not, and it is not yet clear whether neuro-otologic abnormalities among migraine patients are more common in patients complaining of vestibular symptoms or whether they can be considered a hallmark of migraine itself. MATERIALS AND METHODS: Forty-four migrainous patients were divided into 2 groups regarding the presence (22 patients, Group 1) or absence (22 patients, Group 2) of vestibular symptoms, and the results were compared with those obtained from a control group (22 normal subjects). All the patients underwent a complete neurotologic study to verify the presence of vestibular abnormalities. RESULTS: : Neurotologic abnormalities were observed in only 34% of the total, and the incidence was very similar in the 2 groups (36.3 versus 31.8%). Central vestibular involvement was observed in 18% of Group 1 and in 18% of Group 2 patients. Peripheral vestibular involvement was demonstrated in 18% of Group 1 patients and in 16% of Group 2 patients. CONCLUSION: Our data seem to confirm that migraine itself can affect vestibular pathways even if patients do not complain of vestibular symptoms. Vestibular examination alone does not provide enough information for a diagnosis of migrainous vertigo. A careful clinical history is fundamental for assessing the profile of patients with migrainous vertigo.

Extensive solitary fibrous tumor of the retropharyngeal space.

BACKGROUND: Solitary fibrous tumor (SFT) is a rare neoplasm whose histologic diagnosis poses significant problems in differential diagnosis. Although most of these neoplasms arise at the level of the pleura, there have also been reports of extrapleural origins. The most frequent localization in the head and neck region is in the nasal cavity. METHODS: We describe the case of an 81-year-old patient with an SFT that arose in the retropharyngeal space. Symptoms were solid food dysphagia associated with modest dyspnea. RESULTS: Physical examination revealed the presence on the posterior pharyngeal wall of an apparently circumscribed, multilobed mass, which was compact in consistency and partially obstructed the upper aerodigestive tract. After radiologic assessment to carefully evaluate its size and relationship to surrounding structures, the tumor was surgically removed. CONCLUSIONS: The importance of immunohistochemical findings in the histologic differential diagnosis are discussed. Follow-up plays a crucial role in evaluating the possible recurrence of such tumors, because parameters for determining their aggressiveness are still controversial.

The treatment of horizontal canal positional vertigo: our experience in 66 cases.

OBJECTIVES/HYPOTHESIS: The horizontal semicircular canal variant of paroxysmal positional vertigo (HSC-PPV) shows three subtype nystagmic patterns: 1) bilateral geotropic nystagmus, 2) bilateral apogeotropic nystagmus that may switch into bilateral geotropic, and 3) bilateral apogeotropic nystagmus that never switches into bilateral geotropic. In recent years, many methods of physical treatment have been proposed for HSC-PPV, yet no standard protocol has been defined. We studied the effects of different methods according to each different form of HSC-PPV after a precise definition of the nystagmic and clinical features. STUDY DESIGN: A prospective trial of 66 patients with horizontal canal paroxysmal positional vertigo treated with a combination of rotational maneuver and forced prolonged position. METHODS: We evaluated 66 patients with HSC-PPV in its three subtypes. For patients with bilateral geotropic nystagmus, the "barbecue" method was combined with "forced prolonged position." Patients with bilateral geotropic nystagmus were submitted to maneuvers aimed at a switch to bilateral geotropic. The cases that did not switch were submitted to a modified fourth step of the Semont maneuver. RESULTS: Eighty percent of the patients with bilateral geotropic nystagmus became symptom free within the second session, and in 90% of the patients, symptoms were resolved by the third session. In the bilateral apogeotropic cases, the modified fourth step of the Semont maneuver resulted in 75% of the patients being symptom free. CONCLUSIONS: The correct identification of both nystagmic pattern and site of the lesion is crucial for the choice of physical treatment of HSC-PPV and its success. We have standardized the treatment protocol consisting of a "barbecue" maneuver followed by "forced prolonged position" in cases of geotropic nystagmus and a modified fourth step of the Semont maneuver for apogeotropic nystagmus. Our results appear encouraging because 90% of the entire study group was symptom free after three sessions.