El papel de la RMN en el diagnóstico de la patología audiovestibular / The role of MRI in the diagnosis of audio-vestibular pathology

Introducción y objetivo: El schwanoma vestibular es un tumor benigno, de lento crecimiento que aparece en la vaina de mielina que rodea al nervio vestibular. Estos tumores representan el 6% de todos los tumores intracraneales y el 85% de los tumores del ángulo pontocerebeloso. El síntoma de aparición más frecuente es la hipoacusia unilateral, seguida del acúfeno unilateral, inestabilidad, vértigo, cefalea e incluso, en determinados casos, parestesias faciales o parálisis facial. Todo ello depende del tamaño del tumor y su localización. Actualmente, el diagnóstico de estos tumores se realiza mediante la realización de una historia clínica completa, pruebas complementarias audiológicas y vestibulares y, como prueba de imagen, una RMN. Según el American College of Radiology (ACR) la RMN de base de cráneo y conductos auditivos internos es la prueba de elección para el diagnóstico del schwanoma vestibular. Ésta puede ser con y sin contraste (generalmente Gadolinio) y permite detectar tumores de muy pequeño tamaño. Nuestro objetivo con este trabajo es aportar evidencia científica que permita al profesional seguir un protocolo diagnóstico de los schwanomas vestibulares y, consecuentemente, optimizar los recursos hospitalarios. Método: De una muestra total de 685 se revisaron todas las historias clínicas de los pacientes a los que se les había solicitado una RMN por síntomas audiovestibulares (hipoacusia, acúfeno, vértigo, parálisis facial y otros). Se llevó a cabo un estudio descriptivo y observacional en el cual se mostraban los síntomas que había padecido cada paciente, el motivo de petición de la prueba de imagen, el diagnóstico final y el tipo de resonancia magnética empleada. Con toda esta información se creó una base de datos y se analizaron los resultados estadísticamente. Resultados: ... (AU)

Introduction and objective: Vestibular schwannoma is a benign, slow-growing tumor that appears in the myelin sheath surrounding the vestibular nerve. These tumors represent 6% of all intracranial tumors and 85% of tumors in the cerebellopontine angle. The most common initial symptom is unilateral hearing loss, followed by unilateral tinnitus, instability, vertigo, headache, and, in certain cases, facial paresthesia or facial paralysis. All of these symptoms depend on the size and location of the tumor. Currently, the diagnosis of these tumors is made through a complete medical history, complementary audiological and vestibular tests, and, as an imaging test, an MRI. According to the American College of Radiology (ACR), the MRI of the skull base and internal auditory canals is the gold standard for diagnosing vestibular schwannoma. This can be performed with and without contrast (usually Gadolinium) and allows the detection of very small tumors. Our objective with this article is to provide scientific evidence that enables professionals to diagnose vestibular schwannomas and optimize hospital resources. Method: From a total sample of 685 patients, all medical records of them who had been requested an MRI for audiovestibular symptoms (hearing loss, tinnitus, vertigo, facial paralysis, and others) were reviewed. A descriptive and observational study was carried out, showing the symptoms experienced by each patient, the reason for requesting the imaging test, the final diagnosis, and the type of MRI used. With all this information, a database was created, and the results were analyzed statistically. Results: ... (AU)

A New Method for Gain Calculation in Quantified Visuo-vestibular Interaction Test.

OBJECTIVE: To develop a new method to quantify visually-enhanced vestibulo-ocular reflex (VVOR) gain, in patients with vestibular function loss, that is mathematically suitable given the nature of the test, and determine the reliability of the method by comparing results with those of the gold standard, the video head impulse test (vHIT). MATERIALS AND METHODS: We developed a new method for VVOR gain quantification and conducted a cross-sectional study in patients diagnosed with vestibular function loss and controls, all participants undergoing both a VVOR test and a vHIT. We measured VVOR gain with three different methods: area under the curve (AUC), slope regression, and a Fourier method (VVORAUC , VVORSP , and VVORFR , respectively); and compared these gain values with vHIT gain calculated using the AUC method. RESULTS: Overall, 111 patients were included: 29 healthy subjects and 82 patients with vestibular function loss. Intraclass correlation coefficients (ICC(1,1)) between gain from the gold standard and each of the VVOR gain methods were: 0.68 (CI: 0.61-0.75) for VVORAUC , 0.66 (CI: 0.58-0.73) for VVORSP and 0.71 (CI: 0.64-0.77) for VVORFR . No interference was found between VVOR gain calculation methods and potentially influential variables considered (p ≥ 0.98). CONCLUSION: The new method for quantifying VVOR gain showed good concordance with the vHIT method. LEVEL OF EVIDENCE: 2: Individual cross-sectional studies with consistently applied reference standard and blinding (Diagnosis) Laryngoscope, 133:3554-3563, 2023.

A Predictive Model of Bilateral Sensorineural Hearing Loss in Meniere Disease Using Clinical Data.

OBJECTIVES: Meniere disease (MD) is defined by a clinical syndrome of recurrent attacks of spontaneous vertigo associated with tinnitus, aural fullness, and sensorineural hearing loss (SNHL). Most patients have unilateral SNHL, but some of them will develop contralateral SNHL during the course of the disease. Several studies have reported a frequency of 2 to 73% SNHL in the second ear, according to the duration of disease and the period of follow-up. We hypothesize that unilateral and bilateral MD are different conditions, the first would initially involve the apical turn of the cochlea, while bilateral MD would affect the entire length of the cochlea. The aim of the study is to search for clinical predictors of bilateral SNHL in MD to build a predictive model of bilateral involvement. DESIGN: A retrospective, longitudinal study including two cohorts with a total of 400 patients with definite MD was carried out. The inception cohort consisted of 150 patients with MD and the validation cohort included 250 cases. All of the cases were diagnosed of unilateral MD according to their hearing loss thresholds. The following variables were assessed as predictors of bilateral SNHL for the two cohorts: sex, age of onset, familiar history of MD, migraine and high-frequency hearing loss (HFHL, defined if hearing threshold >20 dB in two or more consecutive frequencies from 2 to 8 KHz). A descriptive analysis was carried out according to the presence of HFHL in the first audiogram for the main variables. By using multiple logistic regression, we built-up several predictive models for the inception cohort and validated it with the replication cohort and merged dataset. RESULTS: Twenty-three (19.3%) and 78 (41%) of patients with HFHL developed contralateral SNHL during the follow-up, in the inception and validation cohorts, respectively. In the inception cohort, the best predictive model included HFHL in the first audiogram (OR = 6.985, p = 0.063) and the absence of migraine (OR = 0.215, p = 0.144) as clinical predictors for bilateral SNHL [area under the curve (AUC) = 0.641, p = 0.002]. The model was validated in the second cohort (AUC = 0.621, p < 0.001). Finally, we merged both datasets to improve the precision of the model including HFHL in the first audiogram (OR = 3.168, p = 0.001), migraine (OR = 0.482, p = 0.036) and age of onset >35 years old (OR = 2.422, p = 0.006) as clinical predictors (AUC = 0.639, p < 0.001). CONCLUSIONS: A predictive model including the age of onset, HFHL in the first audiogram and migraine can help to assess the risk of bilateral SNHL in MD. This model may have significant implications for clinical management of patients with MD.

Utility of the Montgomery salivary tubes for preventing pharyngocutaneous fistula in total laryngectomy.

PURPOSE: To evaluate the prophylactic, protocolized, and standardized use of a Montgomery tube in preventing pharyngocutaneous fistulas after total laryngectomy and neck dissection. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral centre. SUBJECT AND METHODS: A Montgomery salivary bypass tube was placed in 44 patients undergoing total laryngectomy and neck dissection, observing the percentage of fistula appearance and the time of start of deglutition. Comparison was made with a group of 28 patients prior to the implantation of the protocol in whom the tube was not used. RESULTS: There was a statistically significant decrease in the percentage of fistulas and an earlier onset of deglutition in the salivary bypass tube patients compared to those in whom the tube had not been used. CONCLUSION: Prophylactic and standardized use of the Montgomery salivary bypass tube in patients undergoing total laryngectomy and neck dissection might decrease the incidence of pharyngocutaneous fistula and improve the course of one that is already established.

Relevance of Artifact Removal and Number of Stimuli for Video Head Impulse Test Examination.

OBJECTIVE: To evaluate the effect of artifacts on the impulse and response recordings with the video head impulse test (VHIT) and determine how many stimuli are necessary for obtaining acceptably efficient measurements. METHODS: One hundred fifty patients were examined using VHIT and their registries searched for artifacts. We compared several variations of the dataset. The first variation used only samples without artifacts, the second used all samples (with and without artifacts), and the rest used only samples with each type of artifact. We calculated the relative efficiency (RE) of evaluating an increasingly large number of samples (3 to 19 per side) when compared with the complete sample (20 impulses per side). RESULTS: Overshoot was associated with significantly higher speed (p = 0.005), higher duration (p < 0.001) and lower amplitude of the impulses (p = 0.002), and consequent higher saccades' latency (p = 0.035) and lower amplitude (p = 0.025). Loss of track was associated with lower gain (p = 0.035). Blink was associated with a higher number of saccades (p < 0.001), and wrong way was associated with lower saccade latency (p = 0.012). The coefficient of quartile deviation escalated as the number of artifacts of any type rose, indicating an increment of variability. Overshoot increased the probability of the impulse to lay on the outlier range for gain and peak speed. Blink did so for the number of saccades, and wrong way for the saccade amplitude and speed. RE reached a tolerable level of 1.1 at 7 to 10 impulses for all measurements except the PR score. CONCLUSIONS: Our results suggest the necessity of removing artifacts after collecting VHIT samples to improve the accuracy and precision of results. Ten impulses are sufficient for achieving acceptable RE for all measurements except the PR score.

Oscillopsia in Bilateral Vestibular Hypofunction: Not Only Gain But Saccades Too.

OBJECTIVES: Oscillopsia is a disabling condition for patients with bilateral vestibular hypofunction (BVH). When the vestibulo-ocular reflex is bilaterally impaired, its ability to compensate for rapid head movements must be supported by refixation saccades. The objective of this study is to assess the relationship between saccadic strategies and perceived oscillopsia. DESIGN: To avoid the possibility of bias due to remaining vestibular function, we classified patients into two groups according to their gain values in the video head impulse test. One group comprised patients with extremely low gain (0.2 or below) in both sides, and a control group contained BVH patients with gain between 0.2 and 0.6 bilaterally. Binary logistic regression (BLR) was used to determine the variables predicting oscillopsia. RESULTS: Twenty-nine patients were assigned to the extremely low gain group and 23 to the control group. The BLR model revealed the PR score (saccades synchrony measurement) to be the best predictor of oscillopsia. Receiver operating characteristic analysis determined that the most efficient cutoff point for the probabilities saved with the BLR was 0.518, yielding a sensitivity of 86.6% and specificity of 84.2%. CONCLUSIONS: BVH patients with higher PR values (nonsynchronized saccades) were more prone to oscillopsia independent of their gain values. We suggest that the PR score can be considered a useful measurement of compensation.

Normative data for static balance testing in healthy individuals using open source computerized posturography.

PURPOSE: Computerized posturography is the gold standard for balance assessment. Because of the great cost and dimensions of commercial equipments, low-cost and portable devices have been developed and validated, such as RombergLab, a software in open source term which works connected with a low-cost force platform. The objective of this study was to obtain normative posturography data using this software. METHODS: A multicentric prospective and descriptive study, with 350 healthy participants, was designed. Static postural stability (measured using the modified clinical test of sensory interaction on balance) was evaluated using the software connected to the force platform. Using the confidence ellipse area (CEA) in each condition, global equilibrium score (GES) was calculated and adjusted for significant variable factors using cluster analysis. RESULTS: Mean (SD) GES was 0.72 (0.22). Age (p < 0.01), height (p < 0.01) and recruitment center (p < 0.05) were found as influence factors for GES. Cluster analysis obtained 16 groups stratified by age and height. GES decreases with age and height (p < 0.005). No significant interaction of age nor height was found with GES in these clusters (p > 0.05). After correction for height and age, GES was no longer influenced by the recruitment center (p > 0.05). CONCLUSIONS: With the introduction of the global equilibrium score values of the present study into the software, we consider RombergLab v1.3 a reference posturography tool for healthy individuals. Further studies are needed for validating it as a suitable instrumented test for screening between healthy and pathologic subjects and its reliability over time for the follow-up of patients.

Visual Performance and Perception as a Target of Saccadic Strategies in Patients With Unilateral Vestibular Loss.

OBJECTIVES: To evaluate the ability of saccadic strategies developed during vestibular compensation to reduce the effect of an impaired vestibulo-ocular reflex (VOR) on a retinal smear and image motion sensation. DESIGN: Twenty patients with unilateral vestibular loss were examined with a video head impulse test before and after vestibular rehabilitation (VR) with the use of gaze stabilization and refixation saccades training. Head and eye velocity functions were processed to infer the retinal eccentricity, and through its correlation with visual acuity (VA), several measurements are proposed to evaluate the influence of VR on saccades behavior and visual performance. To isolate the effect of saccades on the findings and avoid bias because of gain differences, only patients whose VOR gain values remained unchanged after VR were included. RESULTS: Improved contribution of covert saccades and reduction of overt saccades latency were measured after VR. We found significant differences when assessing both the interval less than 70% VA (50.25 ms), which is considered the limit of a moderate low vision, and less than 50% VA (39.515 ms), which is the limit for severe low vision. Time to recover a VA of 75% (near normal) was reduced in all the patients (median: 56.472 ms). CONCLUSION: Despite the absence of VOR gain improvement, patients with unilateral vestibular loss are able to develop saccadic strategies that allow the shortening of the interval of retinal smear and image motion. The proposed measurements might be of use to evaluate VR outcomes and visually induced impairment.

Mathematical Methods for Measuring the Visually Enhanced Vestibulo-Ocular Reflex and Preliminary Results from Healthy Subjects and Patient Groups.

BACKGROUND: Visually enhanced vestibulo-ocular reflex (VVOR) is a well-known bedside clinical test to evaluate visuo-vestibular interaction, with clinical applications in patients with neurological and vestibular dysfunctions. Owing to recently developed diagnostic technologies, the possibility to perform an easy and objective measurement of the VVOR has increased, but there is a lack of computational methods designed to obtain an objective VVOR measurement. OBJECTIVES: To develop a method for the assessment of the VVOR to obtain a gain value that compares head and eye velocities and to test this method in patients and healthy subjects. METHODS: Two computational methods were developed to measure the VVOR test responses: the first method was based on the area under curve of head and eye velocity plots and the second method was based on the slope of the linear regression obtained for head and eye velocity data. VVOR gain and vestibulo-ocular reflex (VOR) gain were analyzed with the data obtained from 35 subjects divided into four groups: healthy (N = 10), unilateral vestibular with vestibular neurectomy (N = 8), bilateral vestibulopathy (N = 12), and cerebellar ataxia, neuropathy, and vestibular areflexia syndrome (CANVAS) (N = 5). RESULTS: Intra-class correlation index for the two developed VVOR analysis methods was 0.99. Statistical differences were obtained by analysis of variance statistical method, comparing the healthy group (VVOR mean gain of 1 ± 0) with all other groups. The CANVAS group exhibited (VVOR mean gain of 0.4 ± 0.1) differences when compared to all other groups. VVOR mean gain for the vestibular bilateral group was 0.8 ± 0.1. VVOR mean gain in the unilateral group was 0.6 ± 0.1, with a Pearson's correlation of 0.52 obtained when VVOR gain was compared to the VOR gain of the operated side. CONCLUSION: Two computational methods to measure the gain of VVOR were successfully developed. The VVOR gain values appear to objectively characterize the VVOR alteration observed in CANVAS patients, and also distinguish between healthy subjects and patients with some vestibular disorders.

Vestibulo-ocular reflex gain values in the suppression head impulse test of healthy subjects.

OBJECTIVE: To assess whether there are differences in vestibulo-ocular reflex (VOR) gain for suppression head impulse (SHIMP) and head impulse (HIMP) video head impulse test paradigms, and if so, what are their causes. METHODS: Prospective multicenter observational double-blind nonrandomized clinical study was performed by collecting 80 healthy subjects from four reference hospitals. SHIMP data was postprocessed to eliminate impulses in which early SHIMP saccades were detected. Differences between HIMP and SHIMP VOR gain values were statistically evaluated. Head impulse maximum velocity, gender, age, direction of impulse, and hospital center were considered as possible influential factors. RESULTS: A small significant statistical difference between HIMP and SHIMP VOR gain values was found on repeated measures analysis of variance (-0.05 ± 0.006, P < 0.001). Optimized linear model showed a significant influence of age variable on the observed differences for HIMP and SHIMP gain values and did not find influence between gain values differences and maximum head impulse velocity. Both HIMP and SHIMP VOR gain values were significant lower (-0.09, P < 0.001) when the impulses were performed to the left side. CONCLUSION: We had observed a difference in SHIMP and HIMP gain values not adequately explained by known gain modification factors. The persistence of this slight but significant difference indicates that there are more factors causing lower SHIMP VOR gain values. This difference must to be considered in further studies as well as in the clinical SHIMP testing protocols. We hypothesized that VOR phasic response inhibition could be the underlying cause of this difference. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:2383-2389, 2018.

Vestibulo-Ocular Reflex Stabilization after Vestibular Schwannoma Surgery: A Story Told by Saccades.

OBJECTIVE: To evaluate vestibular compensation via measurement of the vestibulo-ocular reflex (VOR) following vestibular schwannoma surgery and its relationship with changes in saccades strategy after surgery. PATIENTS: Thirty-six consecutive patients with vestibular schwannomas, without brainstem compression, underwent surgical resection. Patients were recruited from University Hospital of Salamanca, Spain. METHODS: We assessed the age, sex, tumor size, degree of canalicular weakness, and preoperative video head impulse test (gain and saccade organization measured with PR score). Gain and saccade organization were compared with postoperative values at discharge and also at 1, 3, and 6 months. PR scores are a measure of the scatter of refixation saccades. RESULTS: Patients with normal preoperative caloric function had higher PR scores (saccades were scattered) following surgery compared to patients with significant preoperative canal paresis (p < 0.05). VOR gain and the presence of covert/overt saccades preoperatively did not influence the PR score (p > 0.05), but a group of patients with very low VOR gain (<0.45) and covert/overt saccades before surgery had lower PR scores after surgery. The differences after 6 months were not significant. CONCLUSION: Patients with more severe vestibular dysfunction before vestibular schwannoma surgery show significantly faster vestibular compensation following surgery, manifested by changes in VOR gain and PR score. The scatter of compensatory saccades (as measured by the PR score) may be a surrogate early marker of clinical recovery, given its relationship to the Dizziness Handicap Inventory.

Regulation of Fn14 Receptor and NF-κB Underlies Inflammation in Meniere's Disease.

Meniere's disease (MD) is a rare disorder characterized by episodic vertigo, sensorineural hearing loss, tinnitus, and aural fullness. It is associated with a fluid imbalance between the secretion of endolymph in the cochlear duct and its reabsorption into the subarachnoid space, leading to an accumulation of endolymph in the inner ear. Epidemiological evidence, including familial aggregation, indicates a genetic contribution and a consistent association with autoimmune diseases (AD). We conducted a case-control study in two phases using an immune genotyping array in a total of 420 patients with bilateral MD and 1,630 controls. We have identified the first locus, at 6p21.33, suggesting an association with bilateral MD [meta-analysis leading signal rs4947296, OR = 2.089 (1.661-2.627); p = 1.39 × 10-09]. Gene expression profiles of homozygous genotype-selected peripheral blood mononuclear cells (PBMCs) demonstrated that this region is a trans-expression quantitative trait locus (eQTL) in PBMCs. Signaling analysis predicted several tumor necrosis factor-related pathways, the TWEAK/Fn14 pathway being the top candidate (p = 2.42 × 10-11). This pathway is involved in the modulation of inflammation in several human AD, including multiple sclerosis, systemic lupus erythematosus, or rheumatoid arthritis. In vitro studies with genotype-selected lymphoblastoid cells from patients with MD suggest that this trans-eQTL may regulate cellular proliferation in lymphoid cells through the TWEAK/Fn14 pathway by increasing the translation of NF-κB. Taken together; these findings suggest that the carriers of the risk genotype may develop an NF-κB-mediated inflammatory response in MD.

A new method to improve the imbalance in chronic unilateral vestibular loss: the organization of refixation saccades.

CONCLUSION: VOR adaptation and organization of refixation saccades in a gathered pattern is a process that can be artificially induced in patients with unilateral vestibular loss who have not developed it naturally, improving imbalance and vestibular disability. OBJECTIVE: To test that temporary grouping of refixation saccades should be linked to better clinical status without gain recovery. METHODS: A training to induce the refixation saccades into gathered fashion is performed. The outcome measures are handicap level measured by the dizziness handicap index (DHI) and refixation saccades organization pattern measured by a numeric score called 'PR' given by a software developed by the authors. Analysis is done before the training and 1 and 3 months after ending, Non-parametric tests were used for statistical analysis. RESULTS: This study has included 10 healthy subjects (four males, six females), and 16 patients with chronic unsteadiness due to unilateral vestibular loss (nine vestibular neuritis, four post-surgical vestibular schwannoma, and three cases after intra-tympanic gentamycin in patients with Ménière's disease). The reduction in the DHI score was significant at 1 (p = 0.028) and 3 months (p = 0.042) post-treatment. Also, statistically significant differences were found between the PR score before and PR score 1 (p = 0.005) and 3 months after the treatment (p = 0.003).

Benign paroxysmal positional vertigo in the elderly.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is the most frequent peripheral vertigo in the elderly. It is a well-characterized entity and generally easy to treat. OBJECTIVE: To evaluate the main symptoms, time to consult for the problem, vertigo characteristics, treatment and follow-up in patients over 70 with BPPV. METHODS: This was a retrospective cohort study. Four hundred and four patients were diagnosed to have BPPV (between January 2006 and December 2012); 211 of them were ≥70 years old (mean 77.7 years) and 193 <70 years old (mean 53.82 years). RESULTS: Patients over 70 with BPPV took longer to consult for the problem (Spearman rho, p = 0.01). The frequency of a clinical presentation consisting of unsteadiness or imbalance without vertigo sensation is higher among elderly patients (χ(2), p = 10(-6)). The effectiveness of the repositioning maneuver is lower than in patients under 70 (χ(2), p = 0.002), and the recurrences are more frequent (χ(2), p = 0.04). CONCLUSION: BPPV is a frequent entity in the elderly, and it is necessary to take it into account when older patients complain about imbalance. An appropriate treatment with repositioning maneuvers and prolonged follow-up are required in order to detect recurrences.

Sarcoma sinovial de fosas nasales. A propósito de un caso / Synovial sarcoma of the nasal cavity. A case report

El sarcoma sinovial es una rara neoplasia encontrada en tejidos blandos; es un tumor mesenquimal de células fusiformes que no está relacionado con la membrana sinovial y muestra diferenciación epitelial variable. Típicamente surge en las extremidades, pero aunque se ha descrito en casi todas las localizaciones de cabeza y cuello, la afectación de esta región es mucho menos común (AU)

Synovial sarcoma is a rare tumour found in soft tissue; it is a mesenchymal spindle cell tumour that is not related to the synovial membrane. This tumour has a low incidence, the most frequent place of occurrence being the lower extremities in young adults. Synovial sarcoma of the head and neck accounts for 3—5% of sarcomas in this anatomical region. The treatment of choice for synovial sarcoma of the head and neck is complete surgical excision of the tumour mass followed by adjuvant radiotherapy (AU)

[Synovial sarcoma of the nasal cavity. A case report]. / Sarcoma sinovial de fosas nasales. A propósito de un caso.

Synovial sarcoma is a rare tumour found in soft tissue; it is a mesenchymal spindle cell tumour that is not related to the synovial membrane. This tumour has a low incidence, the most frequent place of occurrence being the lower extremities in young adults. Synovial sarcoma of the head and neck accounts for 3-5% of sarcomas in this anatomical region. The treatment of choice for synovial sarcoma of the head and neck is complete surgical excision of the tumour mass followed by adjuvant radiotherapy.

Rehabilitación vestibular domiciliaria guiada asistida por medios audiovisuales / Guided home-based vestibular rehabilitation assisted by audiovisual media

Introducción: Presentamos un estudio prospectivo experimental para valorar el proceso de creación y validación de un modelo de soporte audiovisual para el diseño de programas de rehabilitación vestibular domiciliaria guiada (RVDG). Pacientes y métodos: Se estudiaron 89 pacientes con indicación de rehabilitación vestibular (RV) a lo largo del año 2009. Para el diseño del modelo de soporte audiovisual se construyó una videoteca de rutinas RV que pueden combinarse basándose en un sistema de creación de DVD para crear programas personalizados. Se valoró la incidencia de accidentes durante el tratamiento, la adherencia al mismo, la necesidad de convertirlo a un programa basado en posturografía, y la variación de las puntuaciones en la escala Dizziness Handycap Inventory (DHI) y en la agudeza visual dinámica (AVD) al finalizar el programa. Resultados: Encontramos una buena respuesta al tratamiento, tanto en lo que se refiere a la adherencia (con un incumplimiento del 5,6%), como en los parámetros clínicos, con una disminución de 33,14 puntos (de media) en el DHI y de la AVD, que disminuyó de una media de 4,24 líneas antes del tratamiento, a 1,52 con posterioridad. Discusión y conclusiones: Los resultados de este estudio muestran la posibilidad de construir una ayuda audiovisual como soporte para la creación de programas de RVDG (AU)

Introduction: To describe the creation and validation process of a new audiovisual support model for the design of guided home-based vestibular rehabilitation programs (GHVR), we introduce a prospective experimental study. Patients and methods: 89 patients who underwent vestibular rehabilitation (VR) were evaluated throughout 2009. For the model design, we built a video library with VR exercises that can be combined using DVD creation software to tailor VR protocols. Treatment incidents, adherence, need to convert to a posturography-based program and variations in the Dizziness Handicap Inventory (DHI) score and dynamic visual acuity (DVA) were assessed. Results: A good response was found, not only with respect to adherence (5.6% abandonment), but also in the clinical parameters, with a mean DHI score variation of 33.14 points, and a decrease in lines lost in the DVA test from 4.24 to 1.52 lines at the end of the treatment. Discussion and conclusions: Our study results show the possibility of building an audiovisual aid for creating GHVR programs (AU)

[Guided home-based vestibular rehabilitation assisted by audiovisual media]. / Rehabilitación vestibular domiciliaria guiada asistida por medios audiovisuales.

INTRODUCTION: To describe the creation and validation process of a new audiovisual support model for the design of guided home-based vestibular rehabilitation programs (GHVR), we introduce a prospective experimental study. PATIENTS AND METHODS: 89 patients who underwent vestibular rehabilitation (VR) were evaluated throughout 2009. For the model design, we built a video library with VR exercises that can be combined using DVD creation software to tailor VR protocols. Treatment incidents, adherence, need to convert to a posturography-based program and variations in the Dizziness Handicap Inventory (DHI) score and dynamic visual acuity (DVA) were assessed. RESULTS: A good response was found, not only with respect to adherence (5.6% abandonment), but also in the clinical parameters, with a mean DHI score variation of 33.14 points, and a decrease in lines lost in the DVA test from 4.24 to 1.52 lines at the end of the treatment. DISCUSSION AND CONCLUSIONS: Our study results show the possibility of building an audiovisual aid for creating GHVR programs.

[Positional vertigo. Symptom, clinical sign, or disease?]. / Vértigo posicional. Síntoma, signo o enfermedad?

INTRODUCTION: We present a prospective study with the aim of assessing the differences found between position-triggered vertiginous syndromes, those diagnosed as benign paroxysmal positional vertigos (BPPV) in primary care and non-specific clinics, and those classified as BPPV at an otoneurology unit. PATIENTS AND METHOD: Over a 17 month period, 432 consecutive patients were included after evaluation at a otoneurology unit receiving all referrals for vestibular pathologies. The existence of trigger factors was investigated, as was the distribution of the diagnoses associated with a positional trigger. The characteristics of the patients with a final diagnosis of BPPV were also studied. RESULTS: Of this population, 217 patients (50.23%) reported a positional change as the trigger for their symptoms, 106 (24.53%) were referred from their initial care centres with a diagnosis of BPPV, and 128 (29.62%) were classified as truly BPPV. The coincidence between the preliminary diagnosis and the definitive one was 52.8%. A history of positional paroxysmal vertigo during seconds was linked to BPPV in 78% of cases. Only in 4.7% of the BPPV cases diagnosed at the otoneurology unit had provoking manoeuvres been performed. CONCLUSIONS: We have found that an adequate anamnesis is capable of providing accurate guidance for diagnostic purposes in most cases of BPPV, but the performance of provoking manoeuvres and the correct specific treatment for this pathology is of paramount importance when classifying a patient with suspected BPPV.

Vértigo posicional. ¿Síntoma, signo o enfermedad? / Positional vertigo. Symptom, clinical sign, or disease?

Introducción: Presentamos un estudio prospectivo para valorar las diferencias encontradas entre los síndromes vertiginosos de desencadenante posicional, los cuadros diagnosticados como vértigo posicional paroxístico benigno (VPPB) por médicos de atención primaria y consultas no específicas, y los diagnosticados de VPPB en una unidad de otoneurología. Pacientes y método: Se estudió a 432 pacientes atendidos de forma consecutiva durante 17 meses en una unidad de otoneurología que recibe a todos los pacientes derivados al servicio de otorrinolaringología por afección vestibular. Se investigó si había factores desencadenantes y se valoró la distribución de los diagnósticos relacionados con un desencadenante posicional. También se estudió las características de los pacientes con diagnóstico final de VPPB. Resultados: Referían síntomas desencadenados por los cambios de posición 217 (50,23 %) pacientes; 106 (24,53 %) fueron remitidos con diagnóstico de VPPB establecido en sus centros de referencia, y 128 (29,62 %) resultaron ser VPPB realmente. La coincidencia entre el diagnóstico de derivación y el definitivo fue del 52,8 %. La historia clínica de vértigo posicional paroxístico de segundos de duración coincidió con el diagnóstico de VPPB en el 78 % de los casos. Solamente en el 4,7 % de los VPPB diagnosticados en la unidad de otoneurología se habían realizado maniobras de provocación antes de la derivación. Conclusiones: El adecuado interrogatorio del paciente puede aportar una orientación diagnóstica precisa en la mayor parte de los casos de VPPB, aunque la realización de maniobras de provocación y tratamientos adecuados y específicos para esta afección es de vital importancia para la correcta clasificación de los pacientes con sospecha de este cuadro

Introduction: We present a prospective study with the aim of assessing the differences found between position-triggered vertiginous syndromes, those diagnosed as benign paroxysmal positional vertigos (BPPV) in primary care and non-specific clinics, and those classified as BPPV at an otoneurology unit. Patients and method: Over a 17 month period, 432 consecutive patients were included after evaluation at a otoneurology unit receiving all referrals for vestibular pathologies. The existence of trigger factors was investigated, as was the distribution of the diagnoses associated with a positional trigger. The characteristics of the patients with a final diagnosis of BPPV were also studied. Results: Of this population, 217 patients (50.23 %) reported a positional change as the trigger for their symptoms, 106 (24.53 %) were referred from their initial care centres with a diagnosis of BPPV, and 128 (29.62 %) were classified as truly BPPV. The coincidence between the preliminary diagnosis and the definitive one was 52.8 %. A history of positional paroxysmal vertigo during seconds was linked to BPPV in 78 % of cases. Only in 4.7 % of the BPPV cases diagnosed at the otoneurology unit had provoking manoeuvres been performed. Conclusions: We have found that an adequate anamnesis is capable of providing accurate guidance for diagnostic purposes in most cases of BPPV, but the performance of provoking manoeuvres and the correct specific treatment for this pathology is of paramount importance when classifying a patient with suspected BPPV