Voice Handicap Index: Cut-Off Points for Screening European Portuguese With Voice Disorders.

OBJECTIVES: To determine cut-off values of the Voice Handicap Index (VHI) and the shortened version (VHI-10) for European Portuguese (EP) with voice disorders. In addition, to analyze the discriminatory power of individual items of the VHI-10 and the ability to detect differences in various Ear Nose and Throat (ENT) diagnoses. STUDY DESIGN: Cross-sectional cohort study. METHODS: All participants completed the EP VHI and a 4-point self-assessment of voice disorder severity. The case group (subjects with voice disorders) underwent assessment through strobovideolaryngoscopy examinations by ENT surgeons and perceptual analyses by speech-language pathologists (SLPs). In contrast, the control group was evaluated solely by SLPs. Data were analyzed using a receiver-operating characteristic curve to determine the accuracy and cut-off values of the VHI and VHI-10. RESULTS: The study involved a sample of 350 adults (171 cases and 179 controls), predominantly women aged 18-88 years. The area under curve (AUC) for VHI and VHI-10 was 0.997 [95% confidence interval (CI): 0.992-1] and 0.998 [95% CI: 0.995-0.999], respectively. Optimal cut-off values were identified as 13.5 for VHI (0.994 sensitivity and 0.989 specificity) and 5.5 for VHI-10 (0.977 sensitivity and 0.955 specificity). Each individual item within the VHI-10 significantly contributed to the overall assessment, exhibiting varying discriminatory power ranging from excellent (AUC = 0.937) to poor (AUC = 0.637). Significant differences were found in the case group between neurogenic disorders and healthy larynx (P = 0.014), structural and physiologic minor laryngeal abnormalities (P = 0.006), and inflammatory disorders (P = 0.043). CONCLUSIONS: The VHI and the VHI-10 exhibited accurate screening properties for predicting EP speakers with voice disorders.

Is there progression of endolymphatic hydrops in Ménière's disease? Longitudinal magnetic resonance study.

BACKGROUND: Endolymphatic hydrops (EH) is universal in Ménière´s disease (MD). Given its chronic course, with variable interval before complete clinical picture is installed, it seems relevant to understand the progression of vestibular EH and hemato-perilymphatic barrier disruption in patients with MD and monosymptomatic presentations. METHODS: 239 consecutive patients were referred to us with suspected hydropic ear disease. 50 individuals accepted to participate in this study-final longitudinal sample included 24 patients (7 D1, 7 D2, 10 D3). Control group included ten patients. At recruitment, a clinical and MRI re-evaluation was done (3T, intravenous technique) (MR2) and 2 years after MRI was repeated (MR3). Previous MRI (MRI1) were retrospectively evaluated. Patients were classified as definite (D1), possible (D2) and atypical (D3-monosymptomatic) MD. Control group included non-typical symptoms (C2/C3) and 6 asymptomatic (C1). Vestibular endolymphatic ratio (vER) and grading, presence/absence of cochlear EH, asymmetry of cochlear perilymphatic enhancement, and rate of progression of vER were assessed by two independent neuroradiologists and compared between patient and control groups (index ear). RESULTS: EH was universal and pronounced in D1 and remained stable. vER progression was more variable and higher in some D3 patients (index ear worse) and in D2 (non-index), although this observation was not statistically significant. CONCLUSIONS: Considering that many probable and monosymptomatic presentations progress years later into definite MD and given the bilateral tendency of the disease, these findings may indicate that there is an initial accelerated worsening of EH in initial stages of the disease. These data should be confirmed with controlled and larger sample studies.

DESCENDING NECROTIZING MEDIASTINITIS - A MULTIDISCIPLINARY PATHOLOGY.

A 23-year-old man presented with fever and cervical swelling. Contrast-enhanced CT-scan with oblique sagittal planes reconstructions with extensive collection with gaseous areas, involving multiple cervical and mediastinal spaces is shown, reflecting a cervical-mediastinal necrotizing fasciitis. Note the circumference to the laryngotracheal axis. He underwent combined surgery by ENT and thoracic surgery and was discharged without sequelae after long hospitalization. This case demonstrates the importance of working in a multidisci- plinary team to treat complex pathologies.

MR Imaging of Cochlear Modiolus and Endolymphatic Hydrops in Patients With Menière's Disease.

Background: Menière's disease (MD) is an inner ear disorder characterized by recurrent episodes of spontaneous vertigo, unilateral low-frequency sensorineural hearing loss, tinnitus, and aural fullness. Current diagnosis still often has to rely on subjective and audiometric criteria only, although endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and by magnetic resonance (MRI). The modiolus has a close functional and anatomical relationship with the cochlear nerve and membranous labyrinth and can be evaluated with MRI but no data exist on the modiolar size in MD. Purpose: Our purpose is to examine the following hypothesis. Is cochlear modiolus smaller in symptomatic ears in MD? Methods: We used a retrospective 3 Tesla MR study (heavily T2-weighted 3D fast asymmetric spin-echo images and 0.5 mm slice thickness) comparing the mean modiolar area (MMA) in the index and best ears of eight patients with definite MD based on audiometric data. The obtained MMA values were compared against the audiometric data and the presence of vestibular endolymphatic hydrops. Results: No differences were seen in MMA between best and worst ears. Ears with a pure tone average (PTA) ≥25 dB and more pronounced endolymphatic hydrops showed lower MMA (not statistically significant). Two patients with extreme endolymphatic hydrops showed a noteworthy ipsilateral decrease in the cochlear modiolus area. Conclusion: No differences were seen in MMA between best and worst ears in definite MD. Worse hearing function (PTA ≥ 25dB) and more pronounced endolymphatic hydrops seem to be associated with lower MMA. This might be related to bone remodeling as a consequence of endolymphatic hydrops. Further research is needed to corroborate and explore these findings.

Magnetic resonance imaging and Ménière's disease-unavoidable alliance.

Ménière's disease (MD) is a clinical syndrome characterized by recurrent episodes of spontaneous vertigo, unilateral fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and more recently by magnetic resonance imaging (MRI). The current criteria of the disease, however, remain symptom based and do not include the demonstration of endolymphatic hydrops. The authors review MRI techniques and diagnostic criteria of endolymphatic hydrops and the role of MRI in MD is discussed.

Conducción anestésica perioperatoria en gestante a término con hipertensión pulmonar idiopática / Perioperative anesthetic management in term pregnant women with idiopathic pulmonary hypertension

Introducción: La hipertensión arterial pulmonar es una enfermedad con una baja incidencia en la gestante, aunque trae consigo una alta mortalidad una vez presentada. Un diagnóstico oportuno y un manejo perioperatorio adecuado minimizan el riesgo de desenlace fatal tanto para la madre como el feto. Objetivo: Describir el comportamiento de la hipertensión arterial pulmonar en la gestante a término y su conducción anestésica. Presentación del caso: Paciente de 23 años, antecedentes de salud, edad gestacional de 35.2 semanas. Luego de presentar dolor de espalda y ardor en el pecho relacionado con el esfuerzo, palpitaciones, disnea y bloqueo de rama derecha en electrocardiograma, se ingresa en UTI con sospecha de tromboembolismo pulmonar, el cual queda descartado tras diagnóstico confirmatorio de hipertensión pulmonar después de realizar angio TAC y ecocardiografía. Se decide realizar cesárea programada bajo técnica regional peridural, sin complicaciones tanto para la madre como el niño. Después de 2 días bajo vigilancia intensiva se traslada a su centro hospitalario de cabecera. Conclusiones: La vía del parto, así como una elección adecuada de la técnica anestésica, puede ser la diferencia entre el éxito y la fatalidad. Las técnicas regionales suelen recomendarse por encima de la técnica de anestesia general siempre que no se presenten contraindicaciones(AU)

Introduction: Pulmonary arterial hypertension is a disease with low incidence in the pregnant woman, although it brings about high mortality once presented. Timely diagnosis and adequate perioeprative management minimize the risk of fatal outcome for both mother and fetus. Objective: To describe pulmonary arterial hypertension and its anesthetic management in the term pregnant woman. Case presentation: 23-year-old female patient, with health history and gestational age of 35.2 weeks. After presenting back pain and chest burning associated with exertion, palpitations, dyspnea and right bundle branch block in the electrocardiogram, the patient was admitted to the intensive care unit with suspected pulmonary thromboembolism, which was ruled out due to the confirmatory diagnosis of pulmonary hypertension after performing computerized tomography angiography and echocardiography. Scheduled cesarean section was decided to be perform using the regional peridural technique, without complications for both the mother and the child. After two days under intensive surveillance, she was transferred to her primary hospital. Conclusions: The route of delivery, as well as an adequate choice of the anesthetic technique, can be the difference between success and fatality. Regional techniques are usually recommended over the general anesthesia technique, as long as there are no contraindications(AU)

Bilateral Severely Stenotic Jugular Foramen: Diagnosis and Management from the Otologist/Neurotologist Point of View.

Bilateral jugular foramen stenosis with jugular bulb and vein aplasia is rare in nonsyndromic craniosynostosis and usually diagnosed during childhood. We present a case of bilateral jugular foramen stenosis with jugular bulb and vein aplasia, with subsequent persistence and enlargement of the fetal venous anastomosis in the middle and posterior cranial fossa, along with a review of the literature about this anatomical abnormality, highlighting the surgical challenges and management from the otologist/neurotologist point of view.

Central mimics of benign paroxysmal positional vertigo: an illustrative case series.

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder that is diagnosed based solely on clinical findings. Rarely, central lesions can present with positional vertigo and nystagmus, mimicking BPPV. Recognised red flags that may help distinguish central mimics from BPPV include the presence of additional neurological symptoms and signs, atypical nystagmus patterns, and the absence of a sustained response to repositioning manoeuvres. We present seven cases that illustrate how heuristic bias may affect the detection of these features in practice. Furthermore, our cases suggest that isolated downbeat positional nystagmus (simulating anterior canal BPPV) and apogeotropic horizontal nystagmus on the supine roll test (simulating horizontal canal BPPV) should be considered additional red flags.

Factores de riesgo de mortalidad en pacientes politraumatizados / Risk factor for mortality in polytraumatized patients

Introducción: El trauma es considerado un problema de salud pública a nivel mundial. También es causa importante de morbilidad y mortalidad en el mundo. Objetivo: Identificar factores de riesgo y causas de mortalidad en pacientes politraumatizados. Métodos: Se realizó un estudio descriptivo, longitudinal y retrospectivo en pacientes politraumatizados mayores de 18 años intervenidos quirúrgicamente en la unidad de urgencias del Hospital Universitario General Calixto García durante un año de observación. Se describieron variables sociodemográficas, se estimaron los tiempos de atención médica inicial y se describió la condición clínica del paciente al llegar al quirófano. Igualmente se relacionó la aparición de muerte con el trauma predominante y otros factores perioperatorios. Se utilizaron procederes estadísticos univariados para factores de riesgo y análisis multivariado para predecir factores pronósticos de mortalidad. Resultados: Hubo una asociación significativa entre mortalidad y presencia de diabetes mellitus e hipertensión arterial como enfermedades asociadas; entre el trauma múltiple con trauma craneoencefálico, la presencia de shock hipovolémico, uso de aminas y Glasgow por debajo de ocho al llegar al quirófano, así como la respuesta inflamatoria sistémica, hipertensión endocraneal e insuficiencia respiratoria aguda como complicaciones perioperatorias. Como factores pronósticos de muerte se identificaron el shock hipovolémico, la respuesta inflamatoria sistémica y el menor Glasgow. Conclusiones: Se identificaron nueve factores de riesgo con significación estadística y tres factores pronósticos de riesgo independiente para mortalidad en pacientes politraumatizados(AU)

Introduction: Trauma is considered a public health problem worldwide. It is also an important cause of morbidity and mortality in the world. Objective: To identify risk factors and causes of death in polytraumatized patients. Methods: A descriptive, longitudinal and retrospective study was carried out in polytraumatized patients aged more than 18 years and surgically treated in the emergency unit of General Calixto García University Hospital during one year of observation. Sociodemographic variables were described, initial medical attention times were estimated, and the patient's clinical condition was described upon arrival at the operating room. The occurrence of death was considered based on its association with the predominant trauma and other perioperative factors. Univariate statistical procedures were used for risk factors. Multivariate analysis was used to predict prognostic factors for mortality. Results: There was a significant association between mortality and presence of diabetes mellitus and hypertension as associated diseases; as well as between multiple trauma with cranioencephalic trauma, the presence of hypovolemic shock, use of amines and Glasgow score below eight on arrival at the operating room, as well as the systemic inflammatory response, intracranial hypertension and acute respiratory failure as perioperative complications. Prognostic factors for death were hypovolemic shock, the systemic inflammatory response and lower Glasgow score. Conclusions: We identified nine risk factors with statistical significance and three prognostic factors of independent risk for mortality in polytraumatized patients(AU)

The Floccular Syndrome: Dynamic Changes in Eye Movements and Vestibulo-ocular Reflex in Isolated Infarction of the Cerebellar Flocculus.

The cerebellar flocculus is a critical structure involved in the control of eye movements. Both static and dynamic abnormalities of the vestibulo-ocular reflex (VOR) have been described in animals with experimental lesions of the flocculus/paraflocculus complex. In humans, lesions restricted to the flocculus are rare so they can become an exceptional model to contrast with the clinical features in experimental animals or in patients with more generalized cerebellar diseases. Here, we examined a 67-year-old patient with an acute vestibular syndrome due to an isolated infarct of the right flocculus. We evaluated him multiple times over 6 months-to follow the changes in eye movements and vestibular function-with caloric testing, video-oculography and head-impulse testing, and the anatomical changes on imaging. Acutely, he had an ipsilateral-beating spontaneous nystagmus, bilateral gaze-evoked nystagmus, borderline impaired smooth pursuit, and a complete contraversive ocular tilt reaction. The VOR gain was reduced for head impulses directed contralateral to the lesion, and there was also an ipsilesional caloric weakness. All abnormalities progressively improved at follow-up visits but with a considerable reduction in volume of the affected flocculus on imaging. The vestibular and ocular motor findings, qualitatively similar to a previously reported patient, further clarify the "acute floccular syndrome" in humans. We also add new information about the pattern of recovery from such a lesion with corresponding changes in the size of the affected flocculus on imaging.

The Diagnostic Accuracy of Truncal Ataxia and HINTS as Cardinal Signs for Acute Vestibular Syndrome.

The head impulse, nystagmus type, test of skew (HINTS) protocol set a new paradigm to differentiate peripheral vestibular disease from stroke in patients with acute vestibular syndrome (AVS). The relationship between degree of truncal ataxia and stroke has not been systematically studied in patients with AVS. We studied a group of 114 patients who were admitted to a General Hospital due to AVS, 72 of them with vestibular neuritis (based on positive head impulse, abnormal caloric tests, and negative MRI) and the rest with stroke: 32 in the posterior inferior cerebellar artery (PICA) territory (positive HINTS findings, positive MRI) and 10 in the anterior inferior cerebellar artery (AICA) territory (variable findings and grade 3 ataxia, positive MRI). Truncal ataxia was measured by independent observers as grade 1, mild to moderate imbalance with walking independently; grade 2, severe imbalance with standing, but cannot walk without support; and grade 3, falling at upright posture. When we applied the HINTS protocol to our sample, we obtained 100% sensitivity and 94.4% specificity, similar to previously published findings. Only those patients with stroke presented with grade 3 ataxia. Of those with grade 2 ataxia (n = 38), 11 had cerebellar stroke and 28 had vestibular neuritis, not related to the patient's age. Grade 2-3 ataxia was 92.9% sensitive and 61.1% specific to detect AICA/PICA stroke in patients with AVS, with 100% sensitivity to detect AICA stroke. In turn, two signs (nystagmus of central origin and grade 2-3 Ataxia) had 100% sensitivity and 61.1% specificity. Ataxia is less sensitive than HINTS but much easier to evaluate.

Vestibular Migraine: Clinical Challenges and Opportunities for Multidisciplinarity.

Migraine and vertigo are two very prevalent conditions in general population. The coexistence of both in the same subject is a significant clinical challenge, since it is not always possible to understand whether they are causally related or associated by chance, requiring different diagnostic and therapeutic approaches. In this review we analyze and summarize the actual knowledge about vestibular migraine (VM), focusing on the new concepts proposed by the International Classification of Headache Disorders 3-beta and by the Bárány Society and also addressing the former concepts, which are still present in clinical practice. We conclude that clinical studies using a multidisciplinary approach are crucial in this field, since different specialists observe the same pathology with different eyes. Clinical presentation of VM is variable in what concerns vestibular symptoms temporal relation with migraine headache, as well as in their accompanying manifestations. Biomarkers, either genomics or functional, and molecular imaging techniques will be helpful to clarify many aspects of the complexity of this entity, helping to define to what extent can VM be considered a separate and independent clinical entity.

Inferior peduncle lesion presenting with bilaterally impaired vestibular responses to horizontal and posterior head impulses.

Differentiating central from peripheral origins of vestibulo-ocular reflex (VOR) lesions can be challenging. A 36-year old man presented with a 1-year history of progressive unsteadiness. The video-Head Impulse Test revealed a significantly reduced VOR gain in both horizontal and posterior canals (0.49 ± 0.05 and 0.38 ± 0.06) but normal VOR responses in both anterior canals (0.89 ± 0.08 and 1.04 ± 0.15). No plausible combination of end-organ lesion should be responsible for these observations. A brain magnetic resonance imaging disclosed a left inferior cerebellar peduncle lesion suggestive of a glioma.

Spontaneous plugging of the horizontal semicircular canal with reversible canal dysfunction and recovery of vestibular evoked myogenic potentials.

OBJECTIVE: To evaluate the clinical pathophysiology of oculomotor changes in a patient presenting with a spontaneous semicircular horizontal canal plug. PATIENT: A 42-year-old man with acute spontaneous vertigo with spinning and persistent left-horizontal nystagmus, intensity but not direction dependent on head orientation with respect to gravity, indicating a benign paroxysmal positional vertigo due to otoconia causing a plug in the horizontal semicircular canal. INTERVENTION: Electrophysiological and video-oculographic testing; vestibular rehabilitation. MAIN OUTCOME MEASURES: Cervical and ocular vestibular evoked myogenic potentials (VEMPs); video head impulse testing. RESULTS: The video head-impulse test revealed an eye velocity cutoff at 80°/s in the time interval from 40 to 90 ms after initiation of head impulses to the right. This normalized within 2 days after liberatory maneuvers, documenting for the first time a reversible deficiency of the cupular-endolymph high-frequency system dynamics. Cervical and ocular vestibular myogenic potentials were absent during stimulation of the affected side before the liberatory maneuvers but normalized within 30 to 80 days. CONCLUSION: This case is special in 4 respects: 1) nystagmus intensity, but not direction, was dependent on head orientation with respect to gravity, indicating a horizontal canal plug; 2) VEMPs were asymmetrical before liberatory maneuvers; 3) VEMPs recovered after Day 30; and 4) video head-impulse test asymmetry recovered. These observations challenge the common belief that VEMPs are evoked by otolith stimulation only. Instead, the assumption of a reversible canal dysfunction by a plug offers a more plausible explanation for all effects.