Phenotypes and clinical subgroups in vestibular migraine: a cross-sectional study with cluster analysis.

OBJECTIVE: The aim of this multicentric cross-sectional study was to collect phenotypes and clinical variability on a large sample of 244 patients enrolled in different university centers in Italy, trying to differentiate subtypes of VM. BACKGROUND: VM is one of the most frequent episodic vertigo characterized by a great clinical variability for duration of attacks and accompanying symptoms. Diagnosis is based only on clinical history of episodic vertigo in 50% of cases associated with migrainous headache or photo/phonophobia. METHODS: We enrolled in different university centers 244 patients affected by definite VM according to the criteria of the Barany Society between January 2022 and December 2022. An audiometric examination and a CNS MRI were performed before inclusion. Patients with low-frequency sensorineural hearing loss were not included, as well as patients with an MRI positive otherwise that for microischemic lesions. Patients were asked to characterize vestibular symptoms choosing among (multiple answers were allowed): internal vertigo, dizziness, visuo-vestibular symptoms/external vertigo; onset of vertigo and duration, neurovegetative, and cochlear accompanying symptoms (hearing loss, tinnitus, and fullness during attacks) were collected as well as migrainous headache and/or photo/phonophobia during vertigo; autoimmune disorders were also analyzed. A bedside examination was performed including study of spontaneous-positional nystagmus with infrared video goggles, post head shaking ny, skull vibration test, and video head impulse test. RESULTS: We included 244 subjects, 181 were females (74.2%). The age of onset of the first vertigo was 36.6 ± 14.5 while of the first headache was 23.2 ± 10.1. A positive correlation has been found between the first headache and the first vertigo. The mean duration of vertigo attacks was 11 ± 16 h. We carried on a cluster analysis to identify subgroups of patients with common clinical features. Four variables allowed to aggregate clusters: age of onset of vertigo, duration of vertigo attacks, presence of migrainous headache during vertigo, and presence of cochlear symptoms during vertigo. We identified 5 clusters: cluster 1/group 1 (23 subjects, 9.4%) characterized by longer duration of vertigo attacks; cluster 2/group 2 (52 subjects, 21.3%) characterized by absence of migrainous headache and cochlear symptoms during vertigo; cluster 3/group 3 (44 subjects, 18%) characterized by presence of cochlear symptoms during vertigo but not headache; cluster 4/group 4 (57 subjects, 23.4%) by the presence of both cochlear symptoms and migrainous headache during vertigo; cluster 5/group 5 (68 subjects, 27.9%) characterized by migrainous headache but no cochlear symptoms during vertigo. CONCLUSION: VM is with any evidence a heterogeneous disorder and clinical presentations exhibit a great variability. In VM, both symptoms orienting toward a peripheral mechanism (cochlear symptoms) and central ones (long lasting positional non-paroxysmal vertigo) may coexist. Our study is the first published trying to characterize subgroups of VM subjects, thus orienting toward different pathophysiological mechanisms.

Balance Disorders in Children and Adolescents.

The prevalence of balance disorders in children and adolescents is extremely variable [...].

The Navigation Ability Test (NAT 2.0): From Football Player Performance to Balance Rehabilitation in Chronic Unilateral Vestibular Loss.

AIM OF THE STUDY: in humans, spatial orientation consists of the ability to move around the environment through memorized and pre-programmed movements, according to the afferent sensory information of the body and environmental analysis of the Central Nervous System (CNS). The purpose of this study is to analyze the abilities of professional athletes, such as footballers, to use mental navigation systems, cognitive maps, and memorized motor patterns in order to obtain better physical performance and to obtain useful information for training both non-sports subjects and vestibular patients for rehabilitation purposes. MATERIALS AND METHODS: all the motor performances of sportsmen, healthy non-sporting subjects, or vestibular patients are based on the acquisition of visual-spatial and training information. In this study, we analyzed the visual-spatial performance of 60 trained sportsmen (professional footballers), 60 healthy non-sports subjects, and 48 patients affected by chronic unilateral vestibular loss by means of the Navigation Ability Test 2.0. A score based on the number of targets correctly reached in the various tests quantifies the degree of performance of the subjects. RESULTS: NAT 2.0 scores progressively improve from vestibular subjects to healthy non-sporting subjects to footballers. NAT 2.0 scores improve in all three subject groups as the number of tasks performed in all patient groups increases, regardless of gender and age. CONCLUSIONS: the analysis of performance data through NAT 2.0 in athletes (footballers) opens new perspectives for rehabilitation purposes, regardless of age, sex, and training conditions, both in healthy non-sporting subjects to improve their sporting potential and in patients affected by chronic vestibular dysfunction, in order to optimize their motor skills and prevent falls.

Prevalence of Pediatric and Adolescent Balance Disorders: Analysis of a Mono-Institutional Series of 472 Patients.

(1) Background: To assess the prevalence and frequency distribution of balance disorders in children and adolescents to delineate the planning of a targeted clinical and instrumental diagnostic work-up; (2) Methods: Retrospective analysis of the clinical documentation of patients under 18 years suffering from balance disorders from 2010 to 2019. Detailed collection of clinical history, accurate clinical examination, including both nystagmus and vestibulospinal signs examinations, and specific instrumental testing were the basis of the diagnostic process. (3) Results: A total of 472 participants were included in the study. Vestibular loss (26.1%) was the most frequent cause of vertigo in children, followed by vestibular migraine (21.2%) and benign paroxysmal positional vertigo (10.2%). In 1.1% of patients, the cause of vertigo remained undefined; (4) Conclusions: The diagnostic process applied was effective in understanding the cause of balance disorders in most cases and prevents more complex and expensive investigations reserved for only a few selected cases.

Long-Term Lateral Semicircular Canal Function in Children with Cochlear Implants: Results of Video Head Impulse Test.

In children with profound deafness, bilateral cochlear implant (CI) is an effective, established procedure. However, its safety on vestibular function has recently been debated. The goal of this study is to evaluate the long-term lateral semicircular canal high-frequency vestibulo-oculomotor reflex (LSC HF VOR) in children with CI by video head impulse testing (vHIT). This is a cross-sectional study assessing a cohort of children who received either a unilateral (12) or a bilateral (12) cochlear implant (CI), compared with a control group of 12 normal-hearing children. No significant LSC HF VOR gain difference was found between CI users and controls. In the unilaterally implanted group, the LSC HF VOR gain measured in the "CI-ON" condition was significantly higher than in the "CI-OFF" condition, both in the implanted and in the non-implanted ear. In the bilaterally implanted group, the difference between the two conditions was not significant. Our results do not show any impairment of LSC HF VOR function in children with CI compared to normal-hearing children in the long-term period. This suggests that both unilateral and simultaneous/sequential bilateral CI are procedures that do not impair HF LSC long-term function when analyzed by vHIT.

Benign Positional Paroxysmal Vertigo in Children.

The aim of this study was to assess the prevalence and analyze clinical parameters of benign positional paroxysmal vertigo (BPPV) in a pediatric age. A cohort of 423 children under the age of 15 (median age 11. interquartile range 9-13) was submitted to vestibular assessment for balance disorders. Dix-Hallpike and Roll-Supine tests were performed to look for positioning nystagmus using video-infrared goggles. BPPV was found in 43 of 423 children evaluated for balance disorders (10.2%). There were 28 females (65.1%) and 15 (34.9%) males. The posterior canal was involved in 79% of cases and the horizontal canal in 21% of cases. No apogeotropic bilateral or anterior canal form were seen. Thus, BPPV is not an infrequent type of vertigo in children and must be evaluated as soon as possible in order to plan the most appropriate maneuver and restore daily activities as soon as possible, avoiding anxiety and fear.

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.

Clinical Features, Familial History, and Migraine Precursors in Patients With Definite Vestibular Migraine: The VM-Phenotypes Projects.

OBJECTIVE: The aim of this work was to assess through a questionnaire the features of vertiginous episodes, accompanying symptoms, familial history, and migraine precursors in a sample of 252 subjects with a diagnosis of definite vestibular migraine. BACKGROUND: Migraine is a common neurological disorder characterized by episodic headaches with specific features. About two-thirds of cases run in families, and patients may refer symptoms occurring in infancy and childhood, defined as episodic syndromes that may be associated with migraine. Migraine is associated with episodic vertigo, called vestibular migraine, whose diagnosis mainly relies on clinical history showing a temporary association of symptoms. METHODS: In this cross-sectional multicentric study, 252 subjects were recruited in different centers; a senior specialist through a structured questionnaire assessed features of vestibular symptoms and accompanying symptoms. RESULTS: The age of onset of migraine was 23 years, while onset of vertigo was at 38 years. One hundred and eighty-four subjects reported internal vertigo (73%), while 63 subjects (25%) reported external vertigo. The duration of vertigo attacks was less than 5 minutes in 58 subjects (23%), between 6 and 60 minutes in 55 (21.8%), between 1 and 4 hours in 29 (11.5%), 5 and 24 hours in 44 (17.5%), up to 3 days in 14 (5.5%), and more than 3 days in seven (2.8%); 14 subjects (5.5%) referred attacks lasting from less than 5 minutes and up to 1 hour, nine (3.6%) referred attacks lasting from less than 5 minutes and up to 1 to 4 hours, six (2.4%) referred attacks lasting from less than 5 minutes and up to 5 to 24 hours, and five (2%) cases referred attacks lasting from less than 5 minutes and up to days. Among accompanying symptoms, patients referred the following usually occurring, in order of frequency: nausea (59.9%), photophobia (44.4%), phonophobia (38.9%), vomiting (17.8%), palpitations (11.5%), tinnitus (10.7%), fullness of the ear (8.7%), and hearing loss (4%). In total, 177 subjects referred a positive family history of migraine (70.2%), while 167 (66.3%) reported a positive family history of vertigo. In the sample, 69% of patients referred at least one of the pediatric precursors, in particular, 42.8% of subjects referred motion sickness. The age of onset of the first headache was lower in the subsample with a familial history of migraine than in the total sample. Among the pediatric precursors, benign paroxysmal vertigo - BPV, benign paroxysmal torticollis, and motion sickness were predictive of a lower age of onset of vertigo in adulthood; cyclic vomiting was predictive for vomiting during vertigo attacks in adults. CONCLUSIONS: Our results may indicate that vestibular symptoms in pediatric patients may act as a predisposing factor to develop vestibular migraine at an earlier age in adulthood.

Preliminary results of video Head Impulse Testing (vHIT) in children with cochlear implants.

OBJECTIVE: To evaluate the lateral semicircular canal high frequency vestibulo-oculomotor reflex (LSC HF VOR) in children with cochlear implant. METHODS: 16 children (10 females and 6 males, age range = 5-17 years) receiving a unilateral (n = 12) or a bilateral (n = 4) cochlear implant were included and compared to a control group of 20 age-matched normal-hearing (NH) children. Both implanted and NH children received a vestibular function test battery, including a Vestibulo-Ocular Reflex (VOR) gain assessment by means of a video-Head Impulse Test (vHIT), which represented the main outcome measure. In implanted subjects, vHIT was measured on both sides in the "CI-ON" and "CI-OFF" conditions. RESULTS: Overall, no significant LSC HF VOR gain difference was found between CI users and NH peers. In the unilaterally implanted group, the LSC HF VOR gain measured in the "CI-ON" condition was significantly higher than in the "CI-OFF" condition, both in the implanted and in the non-implanted ear. In the bilaterally implanted group there was no such a difference between the two conditions, on either side. CONCLUSION: This is the first study investigating the LSC HF VOR gain in children with unilateral and bilateral CI. The study demonstrates that the LSC HF VOR of bilaterally implanted children is comparable to normal hearing children.

Paroxysmal positional vertigo after cochlear implantation.

CONCLUSIONS: We observed 4 cases of paroxysmal positional vertigo (PPV) among 62 cochlear implant (CI) recipients. They occurred in the implanted ear without chronological relation with the surgical procedure or the implant's activation. All of them relapsed within 3 months after an initially successful repositioning maneuver, and finally recovered after the second one. None of the patients showed labyrinthine weakness in the implanted ear. The outbreak of PPV did not affect the patients' speech perception performances. OBJECTIVES: To report and discuss the occurrence of PPV after cochlear implantation. PATIENTS AND METHODS: Among 32 adult patients who received a Nucleus CI, 4 suffered from PPV on the basis of Dix-Hallpike's maneuvers. After a Semont's repositioning maneuver, recurrences were similarly addressed. An electro-nystagmography (ENG) recording of caloric irrigation tests was obtained once the symptoms subsided. RESULTS: The observed incidence of 12.5% exceeds the figures reported in the literature. No anatomic abnormalities were identified in these patients, nor were any intraoperative or postoperative complications reported. PPV developed 1-12 months after CI surgery in the posterior canal and relapsed within 3 months. ENG showed a normal reflectivity in two patients, while the other two had a significant prevalence of the implanted side. The outcomes of the speech perception tests after CI in all the four patients matched those of their corresponding categories.

Preoperative and postoperative voice in Tis-T1 glottic cancer treated by endoscopic cordectomy: an additional issue for patient counseling.

Radiotherapy contends with endoscopic surgery for the role of treatment of choice for Tis-T1 glottic cancer. The amount of vocal cord to be surgically removed logically depends on the surface and deep extension of the neoplasm. Thus, a prerequisite for proper management includes an analysis of the voice changes after each of the progressive types of cordectomy described in the European Laryngological Society Classification. Between January 1998 and December 2000, 89 patients with glottic cancer (8 Tis, 63 T1a, 18 T1b) underwent different types of endoscopic cordectomy. Perceptual analysis (GRBAS scale); objective analyses of jitter, shimmer, and noise-to-harmonics ratio; and subjective (Voice Handicap Index) evaluation of voice were performed in 51 patients. Statistical evaluation of preoperative and postoperative objective results by analysis of covariance, as well as perceptual and subjective data, showed significant voice improvement after type I and II cordectomies, with the voice attaining nearly normal parameters. By contrast, after type III, IV, and V cordectomies, the vocal outcome was not significantly different from the preoperative pattern. It can therefore be concluded that type I and II resections, whenever indicated, are adequate procedures even for professional voice users. By contrast, accurate counseling is mandatory before type III, IV, and V cordectomies.

Vocal outcome after endoscopic cordectomies for Tis and T1 glottic carcinomas.

A cohort of 101 patients with previously untreated glottic cancer (15 Tis, 66 T1a, and 20 T1b) who underwent endoscopic CO2 laser excision between January 1995 and December 1997 was prospectively analyzed. The depth and extension of the excision were graded according to the European Laryngological Society Classification including 5 types of cordectomy. All patients were subsequently examined every 2 months for a period ranging from 30 to 66 months (mean, 48 months). The rates of 5-year overall survival, disease-free survival, ultimate local control with laser alone, and laryngeal preservation were 85%, 87%, 93%, and 95%, respectively. Sixty-nine patients underwent, at least 1 year after surgery, videolaryngostroboscopy combined with perceptual and objective evaluation of the voice, and spirometry. Acoustic parameters were compared with those obtained in a matched control group by Kruskal-Wallis test. No statistically significant difference was found (p > .05) between patients submitted to subepithelial (type I) and subligamental (type II) cordectomies and controls.

Acute otitis media and facial nerve paralysis in adults.

OBJECTIVE: The pathophysiology and treatment of facial nerve paralysis associated with acute otitis media are still under debate. The objective of this study was to review treatment strategies and extent of recovery in adult patients with the aim of defining a standard treatment protocol for this rare pathologic condition. STUDY DESIGN: Retrospective chart review. SETTING: University hospital, tertiary referral center. PATIENTS: Between 1993 and 2000, 11 patients were admitted for facial nerve paralysis secondary to acute otitis media. There were six women and five men without a history of chronic middle ear disease, who ranged in age from 21 to 71 years. Facial palsy was graded with the House-Brackmann scale: four patients had Grade III palsy, six had Grade IV palsy, and one patient had Grade V palsy. Bacteriologic examination of middle ear fluid was performed in four patients Streptococcus pneumoniae was observed in one patient, and the remaining three cultures were negative. INTERVENTIONS: All patients were treated with parenteral ampicillin-sulbactam or a third-generation cephalosporin in conjunction with oral or intravenous corticosteroids, except in a single patient with diabetes mellitus who received antibiotics alone. Myringotomy alone or with ventilation tube application was performed in eight patients. A simple mastoidectomy without facial nerve decompression was used in a patient with sudden impairment to Grade VI paralysis and worsening otitis after an initial improvement. RESULTS: Normal facial function returned in all patients, independently of the grade of the paralysis, the treatment strategy, or the outcome of the middle ear disease. The time of recovery varied from 2 weeks to 3 months, except for one patient who underwent mastoidectomy and in whom normal function returned in 10 months. CONCLUSIONS: The treatment of facial nerve paralysis secondary to otitis media should be as conservative as possible, using antibiotics and corticosteroids. Myringotomy and a ventilation tube should be added when spontaneous perforation of the tympanic membrane is not present. Mastoidectomy should be performed only when it is necessary to treat otitis media. Facial nerve decompression should not be necessary.