The effect of intratympanic gentamicin as a prehabilitation strategy for objective and subjective vestibular function in patients undergoing microsurgery for a unilateral vestibular schwannoma.

OBJECTIVE: To review the literature on intratympanic gentamicin treatment as prehabilitation for patients undergoing surgery for a unilateral vestibular schwannoma. DATA SOURCES: A systematic literature search was conducted up to March 2023 in Pubmed, Embase, Cochrane, Web of Science, Academic Search Premier, Google Scholar and Emcare databases. REVIEW METHODS: Articles on the effect of intratympanic gentamicin followed by vestibular schwannoma surgery were reviewed. Data on objective vestibular function and subjective outcomes were compiled in tables for analysis. Relevance and methodological quality were assessed with the methodological index for non-randomized tool. RESULTS: A total of 281 articles were identified. After screening and exclusion of duplicates, 13 studies were reviewed for eligibility, of which 4 studies could be included in the review. The posturography test, the subjective visual horizontal test, and the optokinetic nystagmus test showed decreased vestibular function in the group of patients who received intratympanic gentamicin before microsurgery compared to the group of patients without gentamicin. Other objective tests did not show significant differences between patient groups. Subjective vestibular outcomes, as evaluated by questionnaires on quality of life and/or dizziness, did not seem to improve from intratympanic gentamicin pretreatment. CONCLUSION: Vestibular schwannoma patients who received intratympanic gentamicin before surgical resection of the tumor performed better in the posturography test, subjective visual horizontal test, and the optokinetic nystagmus test afterwards. However, studies that also evaluated subjective outcomes such as dizziness, anxiety, depression, and balance self-confidence did not show a positive effect of intratympanic gentamicin on the vestibular complaints and symptoms.

The Diagnostic Value of Multifrequency Tympanometry in Patients with Ménière's Disease: A Prospective Analysis.

INTRODUCTION: Diagnosing Ménière's disease (MD) by its characteristics such as episodes of vertigo, fluctuating hearing loss, and tinnitus with aural fullness remains challenging. Available tests evaluating the presence of endolymphatic hydrops (EH) are often expensive or time assuming. An in-office quick and simple non-invasive diagnostic test is multifrequency tympanometry (MFT). It can measure conductance at 2 kHz probe tones, which was demonstrated to reflect variations in cochlear pressure. Previous studies investigating MFT as a diagnostic test for MD showed conflicting outcomes possibly biased by their retrospective design. METHODS: We prospectively collected MFT results (Y width) in patients with dizziness and compared MFT test results in affected (group 1) and unaffected (group 2) ears of 37 MD subjects and in control ears of 33 non-MD subjects (group 3). RESULTS: The mean value of the Y width in affected ears was 315.6 ± 70.2 daPa compared to 292.3 ± 98.6 daPa in unaffected ears in MD subjects and 259.4. ± 60.6 daPa in the non-MD group. A positive test result (i.e., a Y width of 235 daPa or more) was found in 35 ears in the MD group, 21 times involving the affected ear and 14 times involving the unaffected ear, compared to 16 in the non-MD group. No significant differences between the three groups could be demonstrated (p > 0.05). We found a sensitivity of 58.3% and specificity of 66.3% for detecting EH in an affected ear in MD subjects. CONCLUSION: There is a trend towards increased conductance tympanometry in affected ears. However, we noticed a high false positive rate of MFT and do not support standardized use of MFT as an additional diagnostic tool for detecting EH in MD patients. A negative test result on the contrary is unlikely related to EH.

Vestibular Complaints Impact on the Long-Term Quality of Life of Vestibular Schwannoma Patients.

OBJECTIVE: To analyze the effect of dizziness-related symptoms on the long-term quality of life (QoL) of patients with unilateral vestibular schwannoma. METHODS: In this cross-sectional study, patients with a unilateral vestibular schwannoma diagnosed between 2004 and 2013 completed a disease-specific QoL questionnaire (Penn Acoustic Neuroma Quality of Life [PANQOL]) and the Dizziness Handicap Inventory (DHI) in 2020. Linear regression was performed to assess the correlation between QoL and the DHI total score, and the scores of the DHI functional, emotional, and physical subdomains. Potential confounders such as age, sex, tumor size at baseline, and treatment modality (active surveillance, surgery, or radiotherapy) were included in the model. RESULTS: In total, 287 of 479 patients (59%) experienced dizziness with a median follow-up of 10 years. The DHI total score was significantly associated with the PANQOL total score. On average, we found a reduction of 0.7 points on the PANQOL for each additional point on the DHI. The DHI emotional subdomain was the most prominent determinant of poorer QoL. Each point on the DHI emotional subscale was associated with a reduction of 1.3 on the PANQOL score. Treatment modality did not have a clinically relevant effect on dizziness-related QoL. CONCLUSIONS: Even mild dizziness can have a significant and clinically relevant effect on the QoL of patients with unilateral vestibular schwannoma in the long term. This holds true for all treatment modalities. Addressing the vestibular problems may improve QoL in vestibular schwannoma patients, and DHI subscale analysis may help tailor the optimal vestibular intervention.

Benign Recurrent Vertigo: The Course of Vertigo Attacks Compared to Patients With Menière's Disease and Vestibular Migraine.

Objective: To explore the course of vertigo attacks in patients with benign recurrent vertigo (BRV) as compared to patients with Menière's disease (MD) and vestibular migraine (VM). Study design: Prospective cohort study. Setting: Tertiary referral center. Patients: Adult patients who visited the Apeldoorn Dizziness Center between January 2015 and November 2016 and who were diagnosed with BRV, VM or MD. During 3 years participants were contacted every 6 months by telephone to complete a study-specific questionnaire. Main Outcome Measures: Vertigo attack frequency, use of medication, and Hospital Anxiety and Depression Scale (HADS). Results: The study population (n = 121) consisted of 44 patients with BRV, 34 with VM, and 43 with MD. For the total follow-up period no statistically significant differences between the three diagnosis groups were observed for being attack-free in the past 6 months: OR = 0.86 (95% CI 0.34-2.17; p = 0.745) for VM and OR = 1.06 (95% CI 0.44-2.51; p = 0.902) for MD, compared to BRV. Overall, 19 patients (43.2%) with BRV, 13 (38.2%) with VM, and 35 (81.0%) with MD used medication to prevent vertigo attacks at any point during their 3-year follow-up. Throughout the observation period patients with MD showed an average of 3.37 points (95% CI 0.68-6.07; p = 0.014) higher HADS scores relative to patients with BRV. Conclusion: The course of vertigo attacks was rather favorable in the three groups, as 67-70% of the patients were free of vertigo attacks after 3 years of follow-up. The course of disease in patients with BRV was not distinctive from patients with MD and VM. We assume that BRV is a mild or incomplete variant of VM and MD, rather than a separate disease entity with distinct pathognomonic features.

Saccades Matter: Reduced Need for Caloric Testing of Cochlear Implant Candidates by Joint Analysis of v-HIT Gain and Corrective Saccades.

Objectives: Video head impulse test (v-HIT) is a quick, non-invasive and relatively cheap test to evaluate vestibular function compared to the caloric test. The latter is, however, needed to decide on the optimal side to perform cochlear implantation to avoid the risk on inducing a bilateral vestibular areflexia. This study evaluates the effectiveness of using the v-HIT to select cochlear implant (CI) candidates who require subsequent caloric testing before implantation, in that way reducing costs and patient burden at the same time. Study Design: Retrospective study using clinical data from 83 adult CI-candidates, between 2015 and 2020 at the Leiden University Medical Center. Materials and Methods: We used the v-HIT mean gain, MinGain_LR, the gain asymmetry (GA) and a newly defined parameter, MGS (Minimal Gain & Saccades) as different models to detect the group of patients that would need the caloric test to decide on the ear of implantation. The continuous model MGS was defined as the MinGain_LR, except for the cases with normal gain (both sides ≥0.8) where no corrective saccades were present. In the latter case MGS was defined to be 1.0 (the ideal gain value). Results: The receiver operating characteristics curve showed a very good diagnostic accuracy with and area under the curve (AUC) of 0.81 for the model MGS. The v-HIT mean gain, the minimal gain and GA had a lower diagnostic capacity with an AUC of 0.70, 0.72, and 0.73, respectively. Using MGS, caloric testing could be avoided in 38 cases (a reduction of 46%), with a test sensitivity of 0.9 (i.e., missing 3 of 28 cases). Conclusions: The newly developed model MGS balances the sensitivity and specificity of the v-HIT better than the more commonly evaluated parameters such as mean gain, MinGain_LR and GA. Therefore, taking the presence of corrective saccades into account in the evaluation of the v-HIT gain can considerably reduce the proportion of CI-candidates requiring additional caloric testing.

Clinical Characteristics of Benign Recurrent Vestibulopathy: Clearly Distinctive From Vestibular Migraine and Menière's Disease?

OBJECTIVE: We aimed to systematically investigate the clinical characteristics of benign recurrent vestibulopathy (BRV), vestibular migraine (VM), and Menière's disease (MD) and to assess whether clinical symptoms exist that are unique to BRV. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. METHODS: Between January 2015 and November 2016, patients were prospectively recruited at a specialized dizziness clinic. Patients were included if they met the diagnostic criteria for BRV, VM, or MD which was evaluated by simultaneous consultation of an otorhinolaryngologist and neurologist. All patients received a comprehensive clinical examination that included vestibular tests and pure-tone audiometry. A questionnaire was designed to systematically document symptoms of the three vestibular disorders. RESULTS: A total of 122 patients were included in our study, 65 (53%) were females in whom 29 (24%) were postmenopausal. The mean age was 55.5 ±â€Š13.7 years and the mean age of onset of vertigo attacks was 49.2 ±â€Š14.8 years (n = 119). Forty-five (37%) patients had a clinical diagnosis of BRV, 34 (28%) of VM, and 43 (35%) of MD. No symptom could be identified which was specifically linked to BRV. In patients with BRV, similar to those with VM, we found a female preponderance (p = 0.05 in BRV, p = 0.001 in VM). Patients with VM reported significantly more often a positive history of motion sickness (p = 0.01). In addition, canal paresis was most profound in patients with MD (p = 0.001). CONCLUSION: We found no clinical characteristics that were distinctive for BRV. However, we did find several distinctive clinical features for VM and MD which may assist the physician in their history taking.

Comparison of laryngeal mask airway vs tracheal intubation: a systematic review on airway complications.

To determine whether the laryngeal mask airway (LMA) has advantages over the tracheal tube (TT) in terms of incidence of cough, sore throat, laryngospasm, dysphagia, dysphonia, and blood staining. This is a systematic literature review performed at the Universtity Medical Center of Utrecht. The online databases PubMed, Embase, and the Cochrane Library were searched for relevant randomized controlled trials. Two independent reviewers selected relevant articles after title, abstract, and full text screening. Articles were assessed on risk of bias in accordance with the Cochrane risk of bias tool. Study results of the LMA and the TT were related to the method of selection of the device size and the method for cuff inflation. Of the 1718 unique articles, we included 19 studies which used the LMA Classic, the LMA Proseal, the Flexible Reinforced LMA, and the LMA Supreme compared with TT. After methodological inspection, data could not be pooled due to heterogeneity among the selected studies. Overall, no clear advantage of the LMA over the TT was found but the LMA Supreme was related to the lowest incidence of airway complications. In this review, no clear difference in incidence of postoperative airway complications could be demonstrated between LMA and TT. The LMA Supreme may reduce the incidence of airway complication in comparison to the TT but high quality randomized trials are recommended to further objectify if use of the LMA decreases the risk on postoperative airway complications.

The Effect of Vestibular Rehabilitation in Patients with Ménière's Disease.

Objective To systematically review the evidence on the effect of vestibular rehabilitation in patients with Ménière's disease (MD) on balance and dizziness-related quality of life. Data Sources A literature search was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Web of Science, and CINAHL databases. Review Methods Articles were reviewed by 2 independent authors and data were compiled in tables for analysis regarding balance (ie, posturography) and dizziness-specific quality of life in patients with MD. A comprehensive search was performed up to November 2015. Studies on relevance and methodological quality were assessed by means of the Cochrane risk of bias tool. For outcome on balance and quality of life, we calculated mean differences and their 95% confidence intervals. Results A total of 986 unique studies were retrieved. Five studies, including a total of 498 patients, fulfilled the eligibility criteria, including 2 randomized controlled trials and 3 prospective cohort studies. There was no study with a low risk of bias. We found inconsistent evidence for the effect of vestibular rehabilitation on balance and dizziness-related quality of life. Conclusion Based on the low quality of the selected studies, it is inconclusive whether there is a positive effect of vestibular rehabilitation in patients with MD on balance and dizziness-related quality of life.

Effect of Botulinum Toxin and Surgery among Spasmodic Dysphonia Patients.

Objective The effect of botulinum toxin among patients with adductor spasmodic dysphonia (AdSD) is temporary. To optimize long-term treatment outcome, other therapy options should be evaluated. Alternative treatment options for AdSD comprise several surgical treatments, such as thyroarytenoid myotomy, thyroplasty, selective laryngeal adductor denervation-reinnervation, laryngeal nerve crush, and recurrent laryngeal nerve resection. Here, we present the first systematic review comparing the effect of botulinum toxin with surgical treatment among patients diagnosed with AdSD. Data Sources MEDLINE (PubMed), EMBASE, and the Cochrane Library. Methods Articles were reviewed by 2 independent authors, and data were compiled in tables for analysis of the objective outcome (voice expert evaluation after voice recording), the subjective outcome (patient self-assessment scores), and voice-related quality of life (Voice Health Index scores). Results No clinical trials comparing both treatment modalities were identified. Single-armed studies evaluated either the effect of botulinum toxin or surgical treatment. Thirteen studies reported outcomes after botulinum toxin treatment (n = 419), and 9 studies reported outcomes after surgical treatment (n = 585 patients). A positive effect of bilateral botulinum toxin injections was found for the objective voice outcome, subjective voice outcome, and quality of life. The duration of the beneficial effect ranged from 15 to 18 weeks. Surgical treatment had an overall positive effect on objective voice improvement, subjective voice improvement, and quality of live. Conclusion No preference for one treatment could be demonstrated. Prospective clinical trials comparing treatment modalities are recommended to delineate the optimal outcomes by direct comparison.

Two Common Second Causes of Dizziness in Patients With Ménière's Disease.

OBJECTIVE: There are no epidemiological studies quantifying the prevalence of second causes of dizziness in Ménière's disease (MD). Therefore, we aimed to quantify which dizziness-inducing causes are prevalent alongside MD. Moreover, we analyzed which second cause of dizziness was more common in a specific age group and if age was a risk factor. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. METHODS: Data were retrospectively obtained from all MD patients who visited our clinic between January 2000 and December 2013. Workup included vestibular tests, pure tone audiometry, blood pressure monitoring, and the hyperventilation provocation test, the Nijmegen Questionnaire (NQ) and the Hospital Anxiety and Depression Scale (HADS). The final causes of dizziness were based on consensus between an ENT-surgeon and a neurologist who were consulted simultaneously. RESULTS: We found that 143 (30%) of 469 MD patients suffered from a second cause of dizziness. The two most common causes were psychological distress (PD) (70%) and benign paroxysmal positional vertigo (BPPV) (18%). The mean age for MD patients with PD was 58.7 ±â€Š13.3 years compared with the mean age of 63.9 ±â€Š14.3 years for MD patients without PD (mean difference = -5.2 years, 95% CI: -8.3 to -2.2, p = 0.001). MD patients younger than 60 of age had a 15% higher risk of suffering from psychological distress than those who were older than 60 (risk difference, 15%, 95% CI, 7.0-22%). Age could not be identified as a risk factor for BPPV in older MD patients. CONCLUSIONS: In 30% of the patients with MD a second cause of dizziness is present. PD most commonly coincides with MD, especially in younger patients. The second most common cause is BPPV.

Interventions for Menière's disease: protocol for an umbrella systematic review and a network meta-analysis.

INTRODUCTION: The large number of treatment modalities for patients diagnosed with Menière's disease (MD) complicates the selection of the best available treatment as the comparative efficacy of these interventions is not clear. We aim to identify the treatment or treatments with the highest efficacy of current pharmacological and non-pharmacological treatments for MD. METHODS AND ANALYSIS: We will identify all available systematic reviews on the treatment of MD. An online database search will be conducted in association with the UK Cochrane Centre, particularly the Ear, Nose and Throat Group. We will screen the systematic reviews for eligible randomised controlled trials (RCTs) to execute a network meta-analysis. In addition, online databases will be checked for eligible RCTs on treatments that were published after the latest systematic search was conducted. The characteristics of each RCT will be summarised, including the general design, the participants, the interventions, the outcome measurements, the duration of therapy and adverse events. The risk of bias will be assessed by means of the Cochrane Collaboration's risk of bias tool. The included studies will be assessed for methodological and statistical heterogeneity; the latter will be quantified by means of the I(2) statistic. The primary outcome will be the efficacy of treatment in terms of control of vertigo attacks. Secondary outcome measures will be the loss or improvement of hearing, severity of vertigo attacks and tinnitus, perception of aural fullness, quality of life, and the incidence of adverse events and complications. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary data will not be collected. The review will be disseminated in peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42015024243.