Advanced Robotic Surgery of the Parapharyngeal Space: Transoral Robotic Styloidectomy in Eagle Syndrome.

Eagle syndrome (ES) is characterized by symptomatic elongation of the styloid process or ossification of the stylohyoid ligament causing irritation and inflammation of the trigeminal, facial, glossopharyngeal, and vagus nerves. The use of robotic surgery has been accepted as a first-line treatment for some head and neck squamous cell carcinomas but not for styloidectomy. The aim of this article is to document our experience with a transoral robotic approach to treat ES and to present the outcomes of 6 patients.The author present the transoral robotic surgery as a successful alternative for the surgical management of ES. Our experience with this approach has been excellent, granting an optimal vision of the surgical field with the consequent safe manipulation of the instruments avoiding injuries to healthy tissue.

Eficacia de las maniobras de reposicionamiento canalicular en el vértigo posicional paroxístico benigno: revisión de 176 casos tratados en un centro hospitalario de tercer nivel / Efficacy of particle repositioning manoeuvres in benign positional paroxysmal vertigo: A revision of 176 cases treated in a tertiary care centre

INTRODUCCIÓN Y OBJETIVOS: El vértigo posicional paroxístico benigno es la entidad más frecuente dentro de los vértigos de origen periférico. El objetivo del siguiente trabajo es revisar los resultados obtenidos con las diferentes maniobras de reposicionamiento canalicular específicas para cada tipo de canal semicircular afectado, evaluando posibles factores de riesgo relacionados con un peor pronóstico. MÉTODOS: Se han revisado retrospectivamente 176 pacientes diagnosticados de vértigo posicional paroxístico benigno en nuestro centro, de los cuales 150 tenían vértigo del canal semicircular posterior, 20 del horizontal, 3 del superior y 3 multicanal. Se ha usado la maniobra de Epley para el tratamiento del canal posterior y del superior y la maniobra de Lempert para el tratamiento del horizontal. En los casos refractarios se ha realizado siempre un estudio de imagen cerebral con resonancia. RESULTADOS: La maniobra de Epley ha mostrado una eficacia al primer intento del 74,6% para el canal posterior y del 100% para el superior. La eficacia de la maniobra de Lempert para el canal horizontal ha sido del 72,72% en los casos de canalolitiasis y del 58,33% en los de cupulolitiasis. Más complicado ha sido el tratamiento de los pacientes con más de un canal afectado y con antecedente quirúrgico en el mes previo. CONCLUSIONES: Las maniobras de reposicionamiento canalicular permiten alcanzar una tasa de éxito muy alta, obteniendo mejores resultados en el tratamiento del canal posterior. Hacen falta más estudios para confirmar la sospecha de que la cirugía previa pueda ser un factor de peor pronóstico

INTRODUCTION AND OBJECTIVES: Benign paroxysmal positional vertigo is the most common peripheral vertigo disease. The aim of this paper is to review the results obtained with the different specific particle repositioning manoeuvres, evaluating the possible risk factors linked to a poorer prognosis. METHODS: One hundred and seventy-six patients with a diagnosis of benign paroxysmal positional vertigo were reviewed retrospectively, of whom 150 had vertigo of the posterior canal, 20 had vertigo of the horizontal canal, 3 had vertigo of the superior canal, and 3 had a double vertigo. The Epley manoeuvre was used to treat the posterior and superior canals, and Lempert manoeuvre was used to treat the horizontal canal. An imaging study by nuclear magnetic resonance with gadolin was always used in refractory cases. RESULTS: The Epley manoeuvre showed an efficacy of 74.6 and 100% at first attempt for posterior and superior canals respectively. The efficacy of the Lempert manoeuvre for the horizontal canal was 72.72% in the patients with canalolithiasis, and 58.33% in the patients with cupulolithiasis. The treatment of patients with more than one affected canal and a history of surgery in the previous month was more difficult. CONCLUSIONS: Particle repositioning manoeuvres show a very high success rate, allowing better results in the treatment of the posterior canal. We need more studies to confirm the suspicion that surgery may be a factor of poorer prognosis

Efficacy of particle repositioning manoeuvres in benign positional paroxysmal vertigo: A revision of 176 cases treated in a tertiary care centre. / Eficacia de las maniobras de reposicionamiento canalicular en el vértigo posicional paroxístico benigno: revisión de 176 casos tratados en un centro hospitalario de tercer nivel.

INTRODUCTION AND OBJECTIVES: Benign paroxysmal positional vertigo is the most common peripheral vertigo disease. The aim of this paper is to review the results obtained with the different specific particle repositioning manoeuvres, evaluating the possible risk factors linked to a poorer prognosis. METHODS: One hundred and seventy-six patients with a diagnosis of benign paroxysmal positional vertigo were reviewed retrospectively, of whom 150 had vertigo of the posterior canal, 20 had vertigo of the horizontal canal, 3 had vertigo of the superior canal, and 3 had a double vertigo. The Epley manoeuvre was used to treat the posterior and superior canals, and Lempert manoeuvre was used to treat the horizontal canal. An imaging study by nuclear magnetic resonance with gadolin was always used in refractory cases. RESULTS: The Epley manoeuvre showed an efficacy of 74.6 and 100% at first attempt for posterior and superior canals respectively. The efficacy of the Lempert manoeuvre for the horizontal canal was 72.72% in the patients with canalolithiasis, and 58.33% in the patients with cupulolithiasis. The treatment of patients with more than one affected canal and a history of surgery in the previous month was more difficult. CONCLUSIONS: Particle repositioning manoeuvres show a very high success rate, allowing better results in the treatment of the posterior canal. We need more studies to confirm the suspicion that surgery may be a factor of poorer prognosis.

Pharyngeal perforation after anterior cervical spine surgery treated by transoral endoscopic surgery.

BACKGROUND: Anterior cervical fixation has been used since 1967 for multiple pathologies like traumatism, compressive myelopathy, or spinal infections. METHODS: We report the case of a patient who had undergone cervical spine surgery 10 years previously and presented to our clinic with a pharyngeal fistula due to surgical screw displacement that was treated by transoral endoscopic surgery. RESULTS: The immediate postoperative period occurred without incidence and complete odynophagia resolution. The patient was discharged home the fourth day after surgery. Follow-up after 1 year showed no evidence of spinal fixation hardware mobilization. CONCLUSION: We consider the transoral endoscopic approach a feasible low comorbidity technique to treat anterior cervical plate mobilization with pharyngeal and pharyngoesophageal perforations.

Extraosseous Ewing sarcoma: Expanding the differential diagnosis of supraclavicular fossa tumors.

A broad spectrum of diseases can be included in the differential diagnosis of neck masses. We report a case of extraosseous Ewing sarcoma that presented as a neck mass in a 70-year-old man. To the best of our knowledge, this is the first reported case of extraosseous Ewing sarcoma of the supraclavicular fossa. Published cases of extraosseous Ewing sarcoma in the neck have been described in other age groups, but those tumors were confined to the parapharyngeal space. Also, there have been reported cases in patients older than 70 years in which Ewing sarcoma affected other structures such as the larynx and the pelvis, but none in the soft tissues of the neck. This case adds extraosseous Ewing sarcoma as a possible diagnosis to consider when evaluating a neck mass in the supraclavicular fossa.

Development and evaluation of an audiology app for iPhone/iPad mobile devices.

CONCLUSION: The application described in this study appears to be accurate and valid, thus allowing calculation of a hearing handicap and assessment of the pure-tone air conduction threshold with iPhone/iPad devices. OBJECTIVE: To develop and evaluate a newly developed professional, computer-based hearing handicap calculator and a manual hearing sensitivity assessment test for the iPhone and iPad (AudCal). METHODS: Multi-center prospective non-randomized validation study. One hundred and ten consecutive adult participants underwent two hearing evaluations, a standard audiometry and a pure-tone air conduction test using AudCal with an iOS device. The hearing handicap calculation accuracy was evaluated comparing AudCal vs a web-based calculator. RESULTS: Hearing loss was found in 83 and 84 out of 220 standard audiometries and AudCal hearing tests (Cohen's Kappa = 0.89). The mean difference between AudCal and standard audiogram thresholds was -0.21 ± 6.38 dB HL. Excellent reliability and concordance between standard audiometry and the application's hearing loss assessment test were obtained (Cronbach's alpha = 0.96; intra-class correlation coefficient = 0.93). AudCal vs a web-based calculator were perfectly correlated (Pearson's r = 1).

Abordaje combinado para el tratamiento de los encefaloceles temporales espontáneos: mastoidectomía + minicraneotomía / Combined Approach for the Treatment of Spontaneous Temporal Encephaloceles: Transmastoid Plus Temporal Minicraniotomy

Los encefaloceles espontáneos son aquellos en los que no se puede determinar un origen. El objetivo del trabajo consiste en describir el tratamiento quirúrgico empleado. Presentamos los 3 últimos casos tratados mediante abordaje combinado transmastoideo y minicraneotomía, y cierre con cartílago y pericondrio conchal. En todos los casos se pudo acometer una correcta localización del encefalocele con un adecuado sellado del defecto óseo. No existieron complicaciones postoperatorias. No existieron recidivas en el periodo de seguimiento. El abordaje transmastoideo tiene la ventaja de permitir la localización del defecto en la base del cráneo sin provocar morbilidad neurológica. Sin embargo, y sobre todo en defectos amplios o de localización más anterior no permite un correcto sellado del defecto óseo y/o un control de todo el volumen de tejido herniado. Debido a estas limitaciones creemos una buena indicación combinar el abordaje transmastoideo con la realización de una minicraneotomía temporal (AU)

Spontaneous encephaloceles are defined as brain herniations with no apparent cause. The aim of this paper is to describe the surgical technique performed in our department. We reviewed the last 3 cases treated with combined approach (transmastoid plus minicraniotomy) with 2-layer closure. In all cases the bone defects were located and successfully sealed. We had no postoperative complications. There were no relapses in our follow-up period. The transmastoid approach has the advantage over the open approach with middle fossa craniotomy in that it locates the bone defect with no brain retraction. Nevertheless, it is not useful in large-sized, multiple or anterior defects. Due to those drawbacks, we think that the combined approach with temporal minicraniotomy is the best choice for this entity (AU)

[Combined approach for the treatment of spontaneous temporal encephaloceles: transmastoid plus temporal minicraniotomy]. / Abordaje combinado para el tratamiento de los encefaloceles temporales espontáneos: mastoidectomía + minicraneotomía.

Spontaneous encephaloceles are defined as brain herniations with no apparent cause. The aim of this paper is to describe the surgical technique performed in our department. We reviewed the last 3 cases treated with combined approach (transmastoid plus minicraniotomy) with 2-layer closure. In all cases the bone defects were located and successfully sealed. We had no postoperative complications. There were no relapses in our follow-up period. The transmastoid approach has the advantage over the open approach with middle fossa craniotomy in that it locates the bone defect with no brain retraction. Nevertheless, it is not useful in large-sized, multiple or anterior defects. Due to those drawbacks, we think that the combined approach with temporal minicraniotomy is the best choice for this entity.

Órgano vomeronasal: estudio anatómico de prevalencia y su función / The vomeronasal organ: anatomic study of prevalence and its role

Introducción: El órgano vomeronasal (OVN) descrito por Jacobson en mamíferos distintos al ser humano, es una incógnita tanto en lo que se refiere a su localización así como a su función en la raza humana. Se considera como un vestigio del olfato, que en los animales mamíferos parece influir en los hábitos sexuales (feromonas) y sociales. Hasta la fecha han sido escasos los estudios concluyentes al respecto en humanos. Objetivo: Conocer la prevalencia del órgano vomeronasal en nuestras consultas. Material y método: Presentamos un estudio prospectivo de prevalencia de la frecuencia de aparición de dicho órgano en 150 sujetos distribuidos por edad y sexo, explorados por endoscopia nasosinusal rígida. Por otro lado, analizamos la influencia sobre la libido (normal-disminuida-aumentada) en el posoperatorio de 35 septoplastías, a los 15 días tras retirada de taponamiento nasal y a los 30 días y lo comparamos con un grupo de 40 pacientes intervenidos timpanoplastías. Resultados: Estudiados 150 sujetos, encontramos la presencia del órgano vomeronasal en el 39,33% (59), de los cuales el 72,88% (43) fue unilateral (23 derecha y 20 izquierda) y el 27,12% (16) bilateral. En 91 (60,67%) no hallamos dicha estructura. La libido de los 35 pacientes intervenidos de septoplastía estaba disminuida, a los 15 días, en el 77,14% (27) frente al 40% (16) de las timpanoplastías, normal en el 17,14% (6) frente al 50% (20) de las cirugías otológicas, y en 2 (5,7%) poseptoplastía había aumentado, frente al 10% (4) del otro grupo. A los 30 días, en el 77,14% (27) de las septoplastías se había normalizado frente al 90% (36) del grupo otológico, en 2 (5,71%) de la cirugía nasal continuaba disminuida frente al 10% (4) del grupo de las timpanoplastías y en 6 (17,14%) tras septoplastía había aumentado. A todos los pacientes se les aplicó el mismo test no normalizado. Conclusión: El órgano vomeronasal de Jacobson continúa siendo un gran desconocido. Es una estructura que, al parecer, no es constante, al menos a la exploración endoscópica nasosinusal. Es difícil valorar si la cirugía en sí misma o el trauma psicológico posquirúrgico son los que afectan la libido de los pacientes tras la cirugía.

Introduction: The vomeronasal organ (OVN) described by Jacobson in mammals other than humans is unknown both in terms of its location and its role in the human race. It is viewed as a vestige of smell, that mammals in the animal seems to influence the sexual habits (pheromone) and social. To date, few studies have been inconclusive on this in humans. Aim: To determine the prevalence of vomeronasal organ in our medical consultations. Materials and methods: We report a prospective prevalence study of the occurrence of such a body in 150 subjects distributed by age and sex explored by endoscopic sinus rigid. On the other hand, we analyze the effect on the libido (normally less-plus) in the postoperative 35 septoplasty, 15 days after the withdrawal of nasal pack and 30 days and compared with a group of 40 tympanoplasty surgery. Results: Studied 150 subjects, we found the presence of the vomeronasal organ in 39.33% (59), of which 72.88% (43) had unilateral (23 right and 20 left) and 27.12% (16) bilaterally. In 91 (60.67%) did not find such a structure. The libido of the 35 patients who underwent septoplasty was decreased at 15 days, at 77.14% (27) versus 40% (16) of tympanoplasty, normal in 17.14% (6) compared to 50% (20) of otologic surgery, and in 2 (5.7%) postseptoplasty had increased, compared to 10% (4) the other group. At 30 days, in 77.14% (27) of the septoplasty group the libido was normalized against 90% (36) in the otologic group. In 2 cases (5.71%) of nasal surgery group was still decreased versus 10% (4) of cases of the tympanoplasty group, and in 6 (17.14%) postseptoplasty was increased. All patients were administered the same test is not standardized. Conclusion: The vomeronasal organ of Jacobson remains the great unknown. It is a structure that apparently is not constant, at least in the endoscopic sinus exploration. With regard to their role, it is difficult to assess whether the psychological trauma after surgery or the surgery by itself is responsible of the libido changes.

¿Cómo analizar un Potencial evocado Miogénico Vestibular? Aplicación de un método no lineal / How to analyse a Vestibular Evoked Myogenic Potential? Applying a non-lineal method

Introducción: El propósito de este artículo es investigar la utilidad clínica de las redes neurales artificiales como alternativa a la interpretación del potencial evocado miogénico vestibular (VEMP). Métodos: Para ello se diseña una aplicación informática que implementa una red neural que reproduce e interpreta el potencial vestibular a estudio, ofreciendo un error estimado de su propia interpretación. Resultados: El grado de correlación obtenido en las distintas fases del trabajo entre la red neural y un observador experimentado se encontró siempre por encima del 95%. Conclusión: La red neural creada es válida para ofrecer una interpretación útil y fiable de los potenciales evocados miogénicos vestibulares según los criterios clínicos actuales (AU)

Introduction: This article presents the investigation of the clinical utility of artificial neural networks as an alternative in interpreting vestibular evoked myogenic potential (VEMP). Methods: We developed an application that incorporates a neural network. This software reproduces and analyses the vestibular potential under study. The software also gives an estimated error for this process. Results: The correlation obtained in this study between the neural network and an experienced human observer was always above 95%. Conclusion: The neural network created offers useful, reliable interpretations of vestibular evoked myogenic potential, in agreement with current clinical parameters (AU)

[How to analyse a vestibular evoked myogenic potential? Applying a non-linear [corrected] method]. / ¿Cómo analizar un Potencial evocado Miogénico Vestibular? Aplicación de un método no lineal.

INTRODUCTION: This article presents the investigation of the clinical utility of artificial neural networks as an alternative in interpreting vestibular evoked myogenic potential (VEMP). METHODS: We developed an application that incorporates a neural network. This software reproduces and analyses the vestibular potential under study. The software also gives an estimated error for this process. RESULTS: The correlation obtained in this study between the neural network and an experienced human observer was always above 95%. CONCLUSION: The neural network created offers useful, reliable interpretations of vestibular evoked myogenic potential, in agreement with current clinical parameters.

[Posturographic examination of malingering patients]. / Exploración posturográfica de pacientes simuladores.

INTRODUCTION: An aphysiological pattern in computerized dynamic posturography (CDP) may be produced by numerous causes. We analyze the results obtained in this test by a group of malingering patients. PATIENTS AND METHOD: This study analyzes a particular group of 7 malingerers, ie patients simulating a false and unreal equilibrium disorder, without any a priori awareness of the gain expected from a pathological report. The condition can only be identified with the very complex postural disorder known as "continuous imbalance." We analyze the results of the dynamic posturography test following the diagnostic criteria described by other authors. RESULTS: Of the criteria analyzed, we found Cevette's to be the most frequently positive for our study group. CONCLUSIONS: The wide diversity in the criteria used makes it necessary to apply them together, assuming a high level of suspicion and great care in the diagnostic process.

Exploración posturográfica de pacientes simuladores / Posturographic examination of malingering patients

Introducción: El patrón afisiológico en la posturografía dinámica computarizada (PDC) puede observarse en el contexto de muy diversas etiologías. Analizamos un grupo de pacientes simuladores según los resultados obtenidos en esta prueba. Pacientes y método: En este trabajo analizamos particularmente un grupo de 7 pacientes simuladores, esto es los que, sin que se conozca a priori la ganancia esperada de un informe patológico, muestran una alteración del equilibrio falsa e irreal que sólo se reconoce como "inestabilidad continua" y genera una alteración postural compleja. Analizamos los registros obtenidos en sus PDC según los criterios diagnósticos descritos por otros autores. Resultados: De los criterios analizados, encontramos que el descrito por Cevette et al es el más frecuentemente positivo en nuestro grupo de estudio. Conclusiones: La diversidad de criterios utilizados hace necesario utilizarlos todos en conjunto, partiendo de un alto índice de sospecha y mucha cautela en el diagnóstico

Introduction: An aphysiological pattern in computerized dynamic posturography (CDP) may be produced by numerous causes. We analyze the results obtained in this test by a group of malingering patients. Patients and method: This study analyzes a particular group of 7 malingerers, ie patients simulating a false and unreal equilibrium disorder, without any a priori awareness of the gain expected from a pathological report. The condition can only be identified with the very complex postural disorder known as "continuous imbalance." We analyze the results of the dynamic posturography test following the diagnostic criteria described by other authors. Results: Of the criteria analyzed, we found Cevette's to be the most frequently positive for our study group. Conclusions: The wide diversity in the criteria used makes it necessary to apply them together, assuming a high level of suspicion and great care in the diagnostic process

Calculation of the circularvection times in a population with vestibular pathology. Influence of visual stimulus.

OBJECTIVE: [corrected] To describe the results obtained for circularvection times (tCV) in a study of the phenomenon of visual-vestibular interaction for a population with vestibular pathology and to analyze differences in its calculation among patients reporting a worsening of their symptoms with visual stimuli. MATERIAL AND METHODS: A detailed case history was taken for all patients, followed by a sensory organization test using computerized dynamic posturography and the calculation of their tCV. RESULTS: The mean tCV results were: tCV2= 6.32+/-3.17 s; tCV3=6.57+/-3.68 s; tCVr=6.27+/-6.02 s. Significant differences were obtained in tCV2 (P=.046) and tCVr (P=.023). CONCLUSIONS: tCV is a diagnostic test using simple tools that can help differentiate patients in whom the visual stimulus is influenced.

Cálculo de los tiempos de circularvección en una población con patología vestibular. Influencia del estímulo visual / Calculation of the circularvection times in a population with vestibular pathology. Influence of visual stimulus

Objetivo: Describir los resultados obtenidos en una población con enfermedad vestibular en la realización de los tiempos de circularvección (tCV), que estudian el fenómeno de interacción visuovestibular, y analizar las diferencias en su cálculo en los pacientes que refieren un agravamiento de sus síntomas por estímulos visuales. Material y métodos: En una población de 200 pacientes con patología vestibular se realizó una anamnesis detallada de los pacientes, un test de organización sensorial mediante posturografía dinámica computarizada y el cálculo de los tCV. Resultados: Los valores medios fueron: tCV2 = 6,32 ± 3,17 s; tCV3 = 6,57 ± 3,68 s; tCVr = 6,27 ± 6,02 s. Se obtuvieron diferencias estadísticamente significativas al analizar los resultados del tCV2 (p = 0,046) y el tCVr (p = 0,023). Conclusiones: El cálculo de los tCV es una prueba diagnóstica que puede realizarse mediante un sencillo instrumental y permite diferenciar a pacientes en los que se produce una influencia del estímulo visual

Objetive: To describe the results obtained for circularvection times (tCV) in a study of the phenomenon of visual-vestibular interaction for a population with vestibular pathology and to analyze differences in its calculation among patients reporting a worsening of their symptoms with visual stimuli. Material and methods:A detailed case history was taken for all patients, followed by a sensory organization test using computerized dynamic posturography and the calculation of their tCV. Results: The mean tCV results were: tCV2= 6.32±3.17 s; tCV3=6.57±3.68 s; tCVr=6.27±6.02 s. Significant differences were obtained in tCV2 (P=.046) and tCVr (P=.023). Conclusions: tCV is a diagnostic test using simple tools that can help differentiate patients in whom the visual stimulus is influenced

Cochlear implantation of patients with far-advanced otosclerosis.

OBJECTIVE: This current single-subject, repeated-measures study was to describe our experience with 30 patients who had been diagnosed with "far-advanced otosclerosis" and who were included in our program of cochlear implants. We analyzed the history of the patients and their families before implantation, the surgical findings, and the performance over a follow up of 3 years. MATERIAL AND METHODS: All patients met one or more of the after criteria: 1) previous surgical intervention as a treatment of their otosclerosis; 2) signs of pericochlear hypodensities in high resolution computed tomography (HRCT) scans; and 3) family precedents of otosclerosis. All underwent standard surgical cochlear implantation. RESULTS: In 78% of the cases, a stapedectomy had previously been realized. Cochlear otosclerosis could be appreciated in HRCT in 78% of the patients. A family history of otosclerosis was found in 40%, and 33.3% of patients had familial precedents of nonfilial hypoacusis. The mean results in the two-syllable test were 20% preimplantation, 54% 6 months after implantation, and 52%, 62%, 54% at 1, 2, and 3 years after implantation. In the CID sentence test, they were in the order of 32% preimplantation and of 64% at 6 months, 66% after 1 year, of 68% after 2 years, and reaching 72% after 3 years. No complications related to the surgery were detected. CONCLUSION: Patients diagnosed with far-advanced otosclerosis have a good prognosis with cochlear implantation comparable to that of other patients in whom postlingual implants are performed.

Vestibular function at the end of intratympanic gentamicin treatment of patients with Ménière's disease.

The aim of this study is to analyze the effects of intratympanic gentamicin injections on vestibular function in 33 patients with unilateral Meniere's Disease (according to AAO-HNS guidelines 1995) that had been unresponsive to medical therapy for at least one year. In such patients, the results of bedside examination of vestibular function vestibular examination is compared to those from laboratory tests. Intratympanic gentamicin injections (27 mg/ml) were performed at weekly intervals until symptoms or signs of vestibular hypofunction developed in the treated ear. Vestibular function was evaluated in two different rotatory chair tests. The parameters that were specifically considered were the time constant of the vestibulo-ocular reflex (VOR) after impulse rotation with a peak chair velocity of 100 degrees s(-1), and the phase and gain of the VOR after the sinusoidal harmonic acceleration (SHA) test with a peak chair velocity of 50 degrees s(-1). After treatment, both the time constant of the VOR after rotation towards the treated side and the gain in the SHA test were significantly reduced. These reductions were in accordance with the number of additional signs observed upon bedside examination at the end of the treatment. The changes observed in the VOR correlate well with the results of bedside examination of vestibular function, which in turn reflects the damage induced by intratympanic gentamicin injection.

Dynamic posture assessment in patients with peripheral vestibulopathy.

OBJECTIVE: To assess the effects on balance of different strategies to create sensory conflict. MATERIAL AND METHODS: Two different systems of dynamic posturography were compared: computerized dynamic posturography and a static platform on which different visual and support conditions were used. The study was performed in 127 patients with dizziness of a peripheral vestibular origin. RESULTS: When patients stood on a foam support surface, the length and area of the center-of-pressure excursions increased. Interestingly, optokinetic stimulation evoked a longer length and a wider area of the center-of-pressure excursions in patients with a combined vestibular and visual deficit pattern than when they kept their eyes closed. This was opposite to the effect observed in patients with a pattern indicative of a vestibular deficit alone. CONCLUSION: The effects of visual stimulation on balance in patients with unilateral vestibulopathy reflect the type of sensory deficit, and can be considered to be specific to such a deficit.

Head-impulse and caloric tests in patients with dizziness.

OBJECTIVE: To test the performance of the head-impulse and caloric tests in terms of sensitivity, specificity, and predictive efficiency. STUDY DESIGN: This was an open and prospective study conducted at a tertiary care center in which 265 patients were subjected to the head-impulse test and caloric test on the same day. The results of the head-impulse test were considered as normal or pathologic. In a similar way, the caloric test was rated as normal when the difference in canal paresis was less than 22 percent and directional preponderance less than 28 percent, and abnormal if canal paresis was more than 22 percent and/or directional preponderance was more than 28 percent. MAIN OUTCOME MEASURES: The results of each test were compared with obtain the specificity, sensitivity, and positive and negative predictive values. A receiver operating characteristics (ROC) curve was obtained from the false-alarm rate and the hit rate value of the head impulse test. RESULTS: The specificity of the head impulse test was 0.91 and the sensitivity was 0.45. The positive predictive value was 0.92, the negative predictive value was 0.41, and the area under the ROC curve was 0.866. A canal paresis value of 42.5 percent was considered to be the limit of the normal response, as seen when the head impulse test was used to predict a normal or abnormal result in a given patient. CONCLUSION: The head impulse test, when used as a bedside test, and the caloric test are by no means redundant methods. The information obtained form both can be used in combination to obtain a better insight into the degree of vestibular dysfunction of patients.