Unusual Locations of Benign Paroxysmal Positional Vertigo: Rare Entity or Regular Occurrence?

INTRODUCTION: According to the literature and our recent experience, even if patients present with symptoms strongly suggestive of benign paroxysmal positional vertigo (BPPV), the observed positional nystagmus does not always correspond to any previously described typical location. The aim of this multicentric study was to evaluate the frequency of both typical and less common forms of BPPV. MATERIAL AND METHODS: All consecutive patients presenting with BPPV in two hospitals between November 2016 and October 2017 were included. For each subject, answers to a standardized evaluation form and a recorded videonystagmoscopy were obtained by two otorhinolaryngologists. Appropriate diagnostic and therapeutic maneuvers were performed. RESULTS: A total of 532 patients were studied and 491 cases of typical BPPV were found: 370 cases of canalolithiasis of the posterior semicircular canal (SCC), 3 cases of canalolithiasis of the anterior SCC, 107 cases of canalolithiasis of the lateral SCC, and 11 cases of cupulolithiasis of the lateral SCC. Fourty one patients reported symptoms suggestive of BPPV with positional nystagmus that could correspond to unusual locations of otoconia in the SCC: 18 cases of canalolithiasis in the anterior ampulla of the lateral SCC, 16 cases of posterior short arm canalolithiasis, four cases of pseudo-spontaneous nystagmus in canalolithiasis of the lateral SCC, and three cases of canalolithiasis of the posterior third of SCC. DISCUSSION: Unusual BPPV accounted for almost 8% of BPPV treated in our clinics; it is paramount to know how to diagnose them, to carry out the appropriate therapeutic maneuvers and relieve these patients.

CT and MRI for the diagnosis of perilymphatic fistula: a study of 17 surgically confirmed patients.

BACKGROUND: We evaluated the usefulness of CT and MRI for the diagnosis of perilymphatic fistula (PLF) of the round (RW) and/or oval (OW) windows, with surgery as gold standard. METHODS: We retrospectively enrolled 17 patients who presented a surgically confirmed PLF of the round (RW) or oval (OW) windows. All patients were imaged by CT + MRI (T2W SSFP without contrast) prior to surgery (= gold standard). Two radiologists, analyzed the RW and OW on the side of the clinical symptoms and sensitivity (Se) + Specificity (Sp) were calculated. RESULTS: Round window fistula was the most frequent (71%). The best sign of PLF on imaging was a fluid filling of the window niches, which had good Se (83-100% for RW, 66-83% for OW) and Sp (60% for RW, 91-100% for OW). Disorientation of the footplate and pneumolabyrinth were also only observed in 50% of OW PLF. CONCLUSION: The combination of CT and MRI is a reliable tool for a fast and accurate diagnosis of round and oval window perilymphatic fistula, with good sensitivity (> 80%). The most common sign of PLF on imaging is the presence of a fluid-filling in the RW (especially if > 2/3 of the RW niche) or in the OW niches on both CT and MRI. A disorientation of the footplate or the presence of a pneumolabyrinth are clearly in favor of an oval window perilymphatic fistula.

Superior vestibular neuritis: improved detection using FLAIR sequence with delayed enhancement (1 h).

INTRODUCTION: Vestibular neuritis is the second cause of vertigo and new imaging protocols using delayed FLAIR with double-dose of gadolinium are proposed for its diagnosis. Our aim is to demonstrate that a single dose of gadolinium is sufficient. METHODS: Thirty-three patients with a unilateral vestibular neuritis are compared to a control group. All patients underwent a FLAIR sequence, 1 hour after intravenous injection of a single dose of gadolinium, on a 1.5 Tesla MRI. Two radiologists analyzed the enhancement intensity of the superior (sup VN) and inferior vestibular nerve (inf VN) and ratios to the signal of the cerebellum were calculated (supVN/C). The statistics were performed using Bayesian analysis. RESULTS: A strong enhancement of the sup VN was observed on the pathological side in 85% of patients with vestibular neuritis. The average signal intensity of the pathological sup VN (139 units ± 44) was more than two times the average intensity in the control group (58.5 units ± 5). The average ratios supVN/C were significantly different between the pathological side in vestibular neuritis (2.43 units ± 0.63) and the control group [1.16 ± 0.14 (Pr(diff > 0) = 1)]. A delayed enhancement > 71.5 units had a sensitivity of 96% and a specificity of 100% for the diagnosis of superior vestibular neuritis. CONCLUSION: A delayed FLAIR sequence, acquired 1 hour after a single dose of gadolinium injection, is a useful method for the diagnosis of vestibular neuritis. An enhancement of the sup VN > 71.5 units was in favor of the diagnosis.

MRI of endolymphatic hydrops in patients with vestibular schwannomas: a case-controlled study using non-enhanced T2-weighted images at 3 Teslas.

OBJECTIVE: Vestibular schwannomas (VS) may present with similar symptoms endolymphatic hydrops. Association between hydrops and internal auditory canal VS has been described by Naganawa et al. (Neuroradiology 53:1009-1015, 2011), but has never been confirmed since. The aim of this work was to study the prevalence of a saccular dilation on a T2-weighted sequence at 3 T MRI in VS compared to a control group. MATERIALS AND METHODS: All patients presenting with typical VS between May 2009 and July 2018 were included (n = 183) and compared to a control group (n = 53). All underwent a high-resolution T2-weighted 3D sequence (FIESTA-C). The height and width of the saccule were measured on a coronal plane by two radiologists. RESULTS: The saccule was dilated on the side of the schwannoma in 28% of the cases (p = 2.81 × 10- 5), with 15.7% of bilateral dilation. Saccular dilation was correlated to sensorineural hearing loss (OR 3.26, p = 0.02). There was also a significant correlation between saccular hydrops on the normal contralateral side of patients with VS and vertigo (p = 0.049), and between saccular hydrops on the side of the tumour and tinnitus (p = 0.006). CONCLUSION: A third (29%) of VS are associated with a saccular dilation on the side of the tumour, which is an MR sign of endolymphatic hydrops (bilateral in 15.7% of the cases) and it appears related to sensorineural hearing loss and tinnitus, as well as vertigo if a contralateral dilation is present. This opens new therapeutic potentialities with the use of anti-vertiginous drugs, which could have a beneficial effect on the clinical symptoms.

Malformations of the lateral semicircular canal correlated with data from the audiogram.

OBJECTIVES: Lateral semicircular canal (LSCC) malformations  are one of the most common inner ear malformations. The purpose of this study is to analyze the prevalence and type of hearing losses associated with LSCC malformations, compared to a control group. MATERIALS AND METHODS: We retrospectively included 109 patients (166 ears) presenting with a CT-confirmed LSCC malformation, compared to a control group (24 patients). The bony island surface and the width of the inner portion of the LSCC were measured to confirm the malformation. There results were correlated to audiogram data: sensorineural (SHNL), mixed (MHL) or conductive hearing loss (CHL) by an otologist. RESULTS: In the LSCC group, 60.9% of patients presented with an audiogram-confirmed hearing loss, especially SNHL (39.2%, n = 65) and MHL (12.7%, n = 21). Hearing was normal in 39.2% (n = 65) of the cases. Bilateral LSCC malformations (n = 57) were frequently associated with hearing loss (80.7%), SNHL in most of the cases (33.3%). Unilateral LSCC malformations were associated with hearing alterations (51.9%, n = 27), but we also observed a high rate (81%, n = 42) of contralateral abnormalities of the audiogram. CONCLUSION: LSCC malformations are commonly associated with hearing loss (61%), especially SHNL (39%). The high rate (81%) of contralateral hearing disturbances in unilateral LSCC malformations should be taken into account in the patient's daily life to avoid triggering or exacerbating any hearing loss. Otologists and radiologists must cooperate to ensure that all malformations are correctly described on CT, especially to improve the patient's education regarding hearing preservation.

[How to manage vertigo in adult?] / Comment prendre en charge un vertige chez l'adulte ?

The interrogation and the clinical examination are critical in the research of vertigo etiology. In the context of vertigo, the vital emergencies are of neurological and vascular origins. It is therefore necessary to be able to identify them quickly and simply. Vertigo is a symptom to relieve and the cause is to be diagnosed. Careful questioning combined with neurological examination, nystagmus study, Halmagyi test and skew deviation search are more reliable than imaging in the first 48hours to detect a stroke. There are 12% false negatives in cerebral MRI and 74% false negative in cerebral CT-scan in the first 48hours of an ischemic stroke. Labyrinth emergencies are infectious labyrinthitis, perilymphatic fistula and aeroembolism of the vestibule.

Imaging of the saccule for the diagnosis of endolymphatic hydrops in Meniere disease, using a three-dimensional T2-weighted steady state free precession sequence: accurate, fast, and without contrast material intravenous injection.

BACKGROUND: Endolymphatic hydrops can be studied on magnetic resonance imaging (MRI) using images acquired 4 h after intravenous injection of Gd-chelate. Our aim was to compare high-resolution T2-weighted images of the saccule in normal subjects with histological sections from cadavers and to identify its changes in Meniere disease, compared to healthy volunteers. METHODS: Sixty-four healthy volunteers without any otologic disease and 64 patients who fulfilled all the criteria for unilateral Meniere disease underwent 3 T MRI using a T2-weighted steady state free precession (SSFP) sequence, without contrast material injection. Images of healthy volunteers were compared with histological sections of normal inner ears from premature foetuses and compared with volunteers. RESULTS: The normal saccule was easily visible on T2-weighted images in volunteers, with a normal maximal height of 1.6 mm (1.4 ± 0.1 mm, mean ± standard deviation) and a good correlation with reference histological sections, while in Meniere disease the saccule was dilated in 52/62 patients (84%), with a saccular height greater than 1.6 mm (1.69 ± 0.24 mm, p = 0.001), found in 45/52 patients (86%). An associated increased width (greater than 1.4 mm) was found in 23/52 patients (44%). A round shape or the non-visualisation of the saccule were also found in 2/52 (4%) and in 5/62 patients (8%), respectively. CONCLUSIONS: A T2-weighted sequence is an easy method to diagnose Meniere disease. Saccular abnormalities were found in 84% of the cases: elongation (height > 1.6 mm) in 86%, increased saccular width in 44%, or a missing saccule in 8%.

A 19-Year Record of Training Haitian Residents in Otorhinolaryngology and Cervicofacial Surgery.

OBJECTIVES: Since 1996, 1 to 4 annual training missions have been carried out to train Haitian otorhinolaryngology (ENT) and cervicofacial surgery residents by the association Liens Otorhinolaryngology Ayti (LOA). Until 1996, ENT was practiced and taught by ophthalmologists. The aim of this article is to describe the contributions and limitations of LOA in training of Haitian resident physicians and the creation of the ENT specialty in Haiti. DESIGN: Retrospective analysis of clinical consultation and surgical interventions records and didactics carried out during missions from 1996 through 2014. PARTICIPANTS: A total of 37 missions were made during the 19-year period in which 29 senior ENT specialists participated, with an average of 3.37 missions per physician. RESULTS: A total of 10,300 consultations and 173 surgical procedures were made jointly by a senior LOA physician and a Haitian resident physician. Totally 16 Haitian ENT residents were trained, 81% of whom are still practicing in Haiti. ENT became a surgical specialty in 2001 after the nomination of a Haitian ENT specialist as Assistant Director of the ENT-Ophthalmology service. The latter benefitted from dual training by LOA in Haiti and abroad. CONCLUSION: The Haitian population experiences significant difficulties with access to medical care owing to very low number of resident medical personnel. LOA's work has contributed over 19 years to the training of ENT physicians now practicing in Haiti and to the creation of a local ENT specialty.

Lateral semicircular canal plugging in severe Ménière's disease: a clinical prospective study about 28 patients.

OBJECTIVE: To evaluate the safety and efficiency of the plugging of the lateral semicircular canal to control vertigo in severe Ménière's disease (MD). STUDY DESIGN: Prospective follow-up study. SETTING: University hospital. PATIENTS: Twenty-eight patients with MD with refractory vertigo and severe disability (functional scale 5 or 6). INTERVENTIONS: Lateral canal plugging was performed in pathological ear for each patient. MAIN OUTCOME MEASURES: The evaluation of therapy followed the guidelines for diagnosis and evaluation of therapy in MD (1995). Hearing, frequency of vertigo, and functional disability were assessed in the early follow-up (6 mo) for all the patients and in the late follow-up (2 yr) for 16 patients. In addition, the canal paresis was evaluated by caloric test. RESULTS: No vital complication occurred. The hearing was preserved in 82% of cases. Lateral canal plugging induced in all cases a canal paresis that was persistent after 2 years. After 2 years (n = 16), the control of vertigo was complete or substantial in 75% of cases (A1, restoration of a normal life: 62.5%; B2, no functional restriction: 12.5%). CONCLUSION: Lateral canal plugging is a safe procedure that induces a canal paresis and allows a good control of vertigo. In view of these results, the lateral canal plugging should be a therapeutic option for controlling rotatory vertigo in severe MD.