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.

Overall survival, disease-free survival and quality of life in patients affected by HPV mediated p16+ oropharyngeal squamous cell carcinoma treated with upfront trans-oral robotic surgery vs radiotherapy or chemoradiotherapy.

PURPOSE: Treatment de-intensification for p16 + oropharyngeal squamous cell carcinoma (OPSCC) is an area of active research to reduce the side effects and improve patients' quality of life (QoL). In this paper we evaluated the Overall Survival (OS), the Disease-Free Survival (DFS) and the QoL of patients affected by p16 + OPSCC according to their prognostic stage group (PSG) and different treatments. METHODS: Patients were selected retrospectively through our Electronic Tumor Board Database according to prespecified inclusion criteria. Basic data of eligible patients were recorded and analyzed. Then, OS and DFS were evaluated according to the PSG and the treatments performed. Patients alive completed three questionnaires: the QoL Questionnaire Core 30 (QLQ-C30), the QoL Questionnaire Head & Neck 43 (QLQ-HN43) and the MD Anderson Dysphagia Inventory (MDADI) questionnaire. RESULTS: Sixty-one patients were included in this study. Eight patients died from the disease and the remaining 53 patients completed the 3 questionnaires. Fifteen (25%) patients were treated with upfront surgery, 6 (10%) patients with definitive radiotherapy and 40 (65%) patients with concomitant chemoradiotherapy. Comparing the DFS and the OS of PSG I patients by the different treatments performed, no statistically significant difference was identified. Patients treated with upfront surgery showed better outcomes in some aspects of their QoL. CONCLUSION: For p16 + OPSCC PSG I patients, upfront surgery can be considered a valid alternative to radiotherapy or chemoradiotherapy while maintaining a comparable DFS and OS and giving patients better results in terms of specific aspects of their QoL.

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.

Detection of Biofilms in Biopsies from Chronic Rhinosinusitis Patients: In Vitro Biofilm Forming Ability and Antimicrobial Susceptibility Testing in Biofilm Mode of Growth of Isolated Bacteria.

Chronic rhinosinusitis (CRS) is the most common illness among chronic disorders that remains poorly understood from a pathogenic standpoint and has a significant impact on patient quality of life, as well as healthcare costs. Despite being widespread, little is known about the etiology of the CRS. Recent evidence, showing the presence of biofilms within the paranasal sinuses, suggests a role for biofilm in the pathogenesis. To elucidate the role of biofilm in the pathogenesis of CRS, we assessed the presence of biofilm at the infection site and the ability of the aerobic flora isolated from CRS patients to form biofilm in vitro. For selected bacterial strains the susceptibility profiles to antibiotics in biofilm condition was also evaluated.Staphylococci represented the majority of the isolates obtained from the infection site, with S. epidermidis being the most frequently isolated species. Other isolates were represented by Enterobacteriaceae or by species present in the oral flora. Confocal laser scanning microscopy (CLSM) of the mucosal biopsies taken from patients with CRS revealed the presence of biofilm in the majority of the samples. Strains isolated from the specific infection site of the CRS patients were able to form biofilm in vitro at moderate or high levels, when tested in optimized conditions. No biofilm was observed by CLSM in the biopsies from control patients, although the same biopsies were positive for staphylococci in microbiological culture analysis. Drug-susceptibility tests demonstrated that the susceptibility profile of planktonic bacteria differs from that of sessile bacteria in biofilms.

Frey Syndrome, First Bite Syndrome, great auricular nerve morbidity, and quality of life following parotidectomy.

PURPOSE: Parotidectomy may be burdened by numerous complications that may worsen subjects' quality of life (QoL). These include paresis or paralysis of the facial nerve, face profile asymmetry, keloids, salivary fistula, Frey Syndrome (FS), First Bite Syndrome (FBS), and hypo-anaesthesia of the skin. This study is an effort to assess the incidence of complications following parotidectomy and their impact on subjects' QoL. METHODS: Subjects undergoing parotidectomy for benign neoplasms from 2012 to 2015 were selected and invited to attend our outpatient clinic. After a brief anamnesis, the medical examiners tested their tactile perception and performed the Minor test for FS. Depending on the complications showed, subjects were asked to complete from 1 to 4 questionnaires about their QoL. RESULTS: 76 subjects completed the medical examination. The most frequent complication was the hypo-anaesthesia of the skin (71%). 21 subjects (28%) were positive to the Minor test, while 8 subjects (11%) reported FBS-compatible symptoms. Two subjects (3%) showed a facial nerve paralysis. Free abdominal fat graft was used in 16 subjects (21%) and it was associated with a lower incidence of FS. Surgery of the deep lobe of the parotid was associated with FBS. CONCLUSIONS: FBS appears to have a greater influence on subjects' QoL than FS and hypo-anaesthesia of the skin. Moreover, this work confirms that surgery of the deep lobe of the parotid is a risk factor for developing FBS and the free abdominal fat graft is a reliable technique to prevent FS.

Endoscopic-assisted transoral-transpharyngeal approach to parapharyngeal space and infratemporal fossa: focus on feasibility and lessons learned.

The parapharyngeal space (PPS) is a challenging anatomical region, rich in vascular and nervous vital structures. Surgery is considered the treatment of choice for the majority of PPS lesions. Herein, we present a retrospective evaluation on ten patients with various types of lesions of the parapharyngeal and infratemporal fossa (ITF) regions operated on via an endoscopic-assisted transoral-transpharyngeal approach (EATTA), focusing on feasibility and safety. A retrospective evaluation of patients treated by means of EATTA to PPS and/or ITF lesions was carried out. The clinical records of patients who were operated on with EATTA for PPS and/or ITF lesions between March 2009 and October 2015 at two referral centres were reviewed and the intra-operative and post-operative complications were analysed. Ten patients who underwent EATTA on the PPS and ITF were included in this series. The procedure was performed in six patients for tumour removal, in three patients for diagnostic purposes and in one patient for pain control. No major complications occurred. No conversion to external approach was required. We observed only two minor complications which were promptly solved. No dysphagia or other problems during the food intake were observed in our series. One day after surgery all patients, except one, referred a value of VAS minor than 4. To date, no evidence of disease recurrence has been assessed in all six oncological cases. Although preliminary, our experience seems to demonstrate the feasibility and safety of EATTA when properly planned and performed.

Clinical Efficacy and Metabolomics Modifications Induced by Polyphenol Compound Supplementation in the Treatment of Residual Dizziness following Semont Maneuver in Benign Paroxysmal Positional Vertigo (BPPV) of the Posterior Semicircular Canal (PSC): Preliminary Results.

Benign paroxysmal positional vertigo (BPPV) represents the most frequent cause of peripheral vertigo. In most cases, it is successfully treated using the canalith repositioning procedure, but it is often followed by continuous lightheadedness in the absence of vertigo or nystagmus (residual dizziness, RD). Our aim is to describe the clinical effectiveness and the urine metabolomics profile of treating these patients with polyphenol compound supplementation. We enrolled 30 patients reporting RD after BPPV of the posterior semicircular canal (PSC) successfully treated using the Semont maneuver. Supplementation with a polyphenol compound was administered for 60 days, and patients were evaluated after 30 and 60 days of treatment using self-administered questionnaires (Visual Analog Scales for Dizziness and Nausea, Dizziness Handicap Inventory, DHI) and urine metabolomics analysis performed using 1H-NMR spectroscopy and multivariate followed by univariate analysis. Most patients reported excellent or good efficacy in the treatment of RD with a significant decrease in VAS and DHI values. The metabolomics analysis identified six significant metabolites related to the treatment, namely 1-methylnicotinamide, anserine, hippurate, lysine, methyl succinate and urea, indicating the inflammatory activities and antioxidant properties of the polyphenol compound. These preliminary data suggest that supplementation with a polyphenol compound could induce some metabolic changes that can help in recovery from RD. However, future steps will require confirmation with a more significant cohort of patients and an extension of the metabolomics evaluation to other problems concerning the different clinical aspects of BPPV, such as the high rate of relapse.

Consensus paper on the management of acute isolated vertigo in the emergency department.

Acute vertigo is defined as the perception of movement of oneself or the surroundings in the absence of actual motion and it is a frequent cause for emergency department admissions. The utilization of medical resources and the duration of hospital stay for this kind of symptom is high. Furthermore, the efficiency of brain imaging in the acute phase is low, considering the limited sensitivity of both CT and MRI for diagnosing diseases that are the causes of central type of vertigo. Relying on imaging tests can provide false reassurance in the event of negative results or prolong the in-hospital work-up improperly. On the other hand, clinical examinations, notably the assessment of nystagmus' features, have proven to be highly accurate and efficient when performed by experts. Literature data point out that emergency physicians often do not employ these skills or use them incorrectly. Several clinical algorithms have been introduced in recent years with the aim of enhancing the diagnostic accuracy of emergency physicians when evaluating this specific pathology. Both the 'HINTS and 'STANDING' algorithms have undergone external validation in emergency physician hands, showing good diagnostic accuracy. The objective of this consensus document is to provide scientific evidence supporting the clinical decisions made by physicians assessing adult patients with acute vertigo in the emergency department, particularly in cases without clear associated neurological signs. The document aims to offer a straightforward and multidisciplinary approach. At the same time, it tries to delineate benchmarks for the formulation of local diagnostic and therapeutic pathways, as well as provide a base for the development of training and research initiatives.

Anatomical landmarks for transoral robotic tongue base surgery: comparison between endoscopic, external and radiological perspectives.

PURPOSE: To describe the transoral viewpoint of the tongue base anatomy, focusing on a superior to inferior perspective, which is less familiar to the head and neck surgeon but, at the same time, worthy to be known given the expanding interest and diffusion of the transoral robotic technique. METHODS: Seven heads were dissected, two with the Da Vinci(®) robotic system, three by means of a transoral endoscopic approach and another two by means of a lateral "traditional" external approach. Ten normal patients, with normal oral cavity and oropharynx, were studied as control samples by means of a 3-T MRI scanner. RESULTS: Major neurovascular elements are placed laterally and deeply within the tongue base. Dissection within intrinsic and genioglossus muscles is safe because the main trunk of the lingual artery lies on the lateral surface of genioglossus muscle, covered by the hyoglossus muscle. The hypoglossal nerve, with its comitant vein, is more lateral, lying on the external surface of the hyoglossus muscle. Radiological evaluation can visualize important details of this complex anatomy. The position of the vessels can be directly identified, whereas major nerves are more difficult to be visualized unless they are surrounded by fibro-fatty tissue. CONCLUSIONS: A medial to lateral dissection of the tongue base can be considered safe. A strict collaboration with the radiologist is helpful in approaching these cases by means of a robotic technique and in improving a true 3D understanding of this complex anatomy.

The role of vestibular cold caloric tests in the presence of spontaneous nystagmus.

Objective: The bithermal caloric test is commonly used to detect a canal paresis. However, in case of spontaneous nystagmus, this procedure can provide results of non-univocal interpretation. On the other hand, confirming the presence of a unilateral vestibular deficit can help to differentiate between central and a peripheral vestibular involvement. Methods: We studied 78 patients suffering from acute vertigo and showing spontaneous horizontal unidirectional nystagmus. All patients were submitted to bithermal caloric tests, and the results were compared with those obtained using a monothermal (cold) caloric test. Results: We demonstrate the congruence between the bithermal and monothermal (cold) caloric test through mathematical analysis of the results of both tests in patients with acute vertigo and spontaneous nystagmus. Conclusions: We propose to perform the caloric test in the presence of a spontaneous nystagmus using a monothermal cold assuming that the prevalence of the response to the cold irrigation on the side towards which the nystagmus beats is a sign of the presence of pathological unilateral weakness and therefore more likely peripheral in its origin.

"The Pupillary (Hippus) Nystagmus": A Possible Clinical Hallmark to Support the Diagnosis of Vestibular Migraine.

(1) Background: Hippus (which in this paper will be called "Pupillary nystagmus") is a well-known phenomenon which has never been related to any specific pathology, so much so that it can be considered physiological even in the normal subject, and is characterized by cycles of dilation and narrowing of the pupil under constant lighting conditions. The aim of this study is to verify the presence of pupillary nystagmus in a series of patients suffering from vestibular migraine. (2) Methods: 30 patients with dizziness suffering from vestibular migraine (VM), diagnosed according to the international criteria, were evaluated for the presence of pupillary nystagmus and compared with the results obtained in a group of 50 patients complaining of dizziness that was not migraine-related. (3) Results: Among the 30 VM patients, only two cases were found to be negative for pupillary nystagmus. Among the 50 non-migraineurs dizzy patients, three had pupillary nystagmus, while the remaining 47 did not. This resulted in a test sensitivity of 0.93% and a specificity of 0.94%. (4) Conclusion: we propose the consideration of the presence of pupillary nystagmus as an objective sign (present in the inter-critical phase) to be associated with the international diagnostic criteria for the diagnosis of vestibular migraine.

Episodic Vertigo: A Narrative Review Based on a Single-Center Clinical Experience.

(1) Background: Usually, the majority of patients suffering from vertigo and dizziness can be identified in four major categories: acute spontaneous vertigo, episodic (recurrent) vertigo, recurrent positional vertigo, and chronic imbalance. Our purpose is to retrospectively evaluate the main causes of episodic vertigo and to find indications for a reliable clinical suspicion useful for a definitive diagnosis, comparing patients affected by different presenting symptomatology (acute vertigo, recurrent episodic vertigo, and imbalance). (2) Methods: we retrospectively evaluated the clinical records in a population of 249 consecutive patients observed for vertigo in our tertiary referral center in the period 1 January 2019-31 January 2020. On the basis of the reported clinical history, patients were divided into three groups: patients with their first ever attack of vertigo, patients with recurrent vertigo and dizziness, and patients with chronic imbalance. (3) Results: On the basis of the results of the instrumental examination, we arbitrarily divided (for each type of symptoms) the patients in a group with a normal vestibular instrumental examination and a group of patients in which the clinical-instrumental evaluation showed some pathological results; a highly significant difference (p: 0.157) was found between recurrent and acute vertigo and between recurrent vertigo and imbalance. (4) Conclusions: Patients with recurrent vertigo more frequently exhibit a negative otoneurological examination since they are often examined in the intercritical phase. A precise and in-depth research of the patient's clinical history is the key to suspect or make a diagnosis together with the search for some instrumental or clinical hallmark, especially in cases where the clinical picture does not fully meet the international diagnostic criteria.

Preceding Benign Paroxysmal Positional Vertigo as a Trigger for Persistent Postural-Perceptual Dizziness: Which Clinical Predictors?

OBJECTIVE: Persistent postural-perceptual dizziness (PPPD) is a syndrome described as secondary, when it is the consequence of an organic disorder (s-PPPD), or primary, when no somatic triggers can be identified. We evaluated a group of patients diagnosed as s-PPPD, with Benign Positional Paroxysmal Vertigo (BPPV) as the main somatic trigger, with the aim of identifying the predictive clinical elements of evolution towards PPPD. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: We evaluated 126 patients diagnosed with PPPD; 54 patients were classified as p-PPPD (43%) and 72 as s-PPPD (57%). Of these, 51 patients had BPPV as a somatic trigger of PPPD, and in this group, we evaluated the prevalence of some clinical features (age, sex, latency between the onset of BPPV and the final diagnosis, recurrence of BPPV and the presence of migraine headache) for comparison with a group of patients who suffered from BPPV without an evolution towards PPPD (control group). RESULTS: In the group with PPPD secondary to BPPV, we found a significantly higher mean age and a longer latency between the onset of BPPV and the final diagnosis compared to the control group. No difference between the two groups was found regarding sex, recurrence rate and the presence of migraine headache. CONCLUSIONS: The parameters most involved as potential precipitants of PPPD after BPPV were the age of the patients and a long latency between the onset of BPPV and the final diagnosis; the mean age of the subjects who developed PPPD following BPPV was significantly higher. These findings lead us to emphasize the importance of the early identification and treatment of BPPV, especially in older patients.

Ectopic intraorbital lacrimal ductal cyst: a case report.

Lacrimal ductal cysts are uncommon lesions that can occur everywhere in and around the eye. Ectopic location is very rare and can be misleading in the differential diagnosis of orbital masses. In this article we present the case of a 61-year-old-man with a medial intraconal ductal cyst of his right orbit. The patient was successfully treated with surgical excision.

The clinical significance of direction-fixed mono-positional apogeotropic horizontal nystagmus.

Objective: A mono-positional persistent, direction-fixed apogeotropic nystagmus (MPosApoNy) is very challenging for the neuro-otologist. MPosApoNy can be found in patients suffering from a partially compensated acute unilateral vestibulopathy; with a normal caloric test, one can speculate the presence of "trapped" otolithic debris located close to the ampulla of the horizontal semicircular canal. Methods: Among 957 patients suffering from vertigo and dizziness, we selected 53 cases of MPosApoNy. Results: In 28 patients, caloric test showed a canal paresis on the same side of the MPosApoNy. In the remaining 25 cases, MPosApoNy was the only clinical finding. We hypothesised the presence of horizonal canal lithiasis and patients were treated with a Gufoni manoeuvre, followed by a forced prolonged position. Conclusions: Performing bedside examination in a patient suffering from vertigo, the presence of MPosApoNy may be due to: a) facilitation of a subclinical nystagmus due to the mechanism of apogeotropic reinforcement; b) horizontal canal lithiasis with 'trapped' otoliths close to the ampulla. The disappearance of MPosApoNy following a repositioning manoeuvre or conversion in a typical form of canalolithiasis may represent the best method to confirm this hypothesis.

Metabolomics in Otorhinolaryngology.

Otorhinolaryngology (Ear, Nose and Throat-ENT) focuses on inflammatory, immunological, infectious, and neoplastic disorders of the head and neck and on their medical and surgical therapy. The fields of interest of this discipline are the ear, the nose and its paranasal sinuses, the oral cavity, the pharynx, the larynx, and the neck. Besides surgery, there are many other diagnostic aspects of ENT such as audiology and Vestibology, laryngology, phoniatrics, and rhinology. A new advanced technology, named metabolomics, is significantly impacting the field of ENT. All the "omics" sciences, such as genomics, transcriptomics, and proteomics, converge at the level of metabolomics, which is considered the integration of all "omics." Its application will change the way several of ENT disorders are diagnosed and treated. This review highlights the power of metabolomics, including its pitfalls and promise, and several of its most relevant applications in ENT to provide a basic understanding of the metabolites associated with these districts. In particular, the attention has been focused on different heterogeneous diseases, from head and neck cancer to allergic rhinitis, hearing loss, obstructive sleep apnea, noise trauma, sinusitis, and Meniere's disease. In conclusion, metabolomics study indicates a "fil rouge" that links these pathologies to improve three aspects of patient care: diagnostics, prognostics, and therapeutics, which in one word is defined as precision medicine.

Horizontal semicircular canal benign paroxysmal positional vertigo: effectiveness of two different methods of treatment.

The aim of this study is to compare the results obtained using 2 methods of treatment for horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV): the barbecue maneuver + forced prolonged position (FPP) versus the Gufoni maneuver. In a randomized prospective clinical trial, we recruited 147 patients affected by HSC-BPPV. The primary outcome was the absence of vertigo and nystagmus upon application of the supine roll test during the follow-up examination. A statistical evaluation was performed in order to assess whether any parameters (e.g. age, duration of nystagmus and symptoms) could influence in any way the results obtained with the 2 methods of treatment. One hundred and three of the 147 patients affected by HSC-BPPV had the geotropic form and 44 had the apogeotropic type. We were able to transform 29 cases of HSC-BPPV from apogeotropic to geotropic. Finally, we obtained a group of 112 patients who were randomized either to the barbecue + FPP procedure (54 patients) or to the Gufoni maneuver (58 patients). The most evident result is the higher percentage of success (statistically significant) with the Gufoni maneuver at the first session of treatment (86 vs. 61%). The final control showed that 44 out of 54 (81%) patients treated with the barbecue maneuver + FPP were symptom free compared to 54 out of 58 (93%) treated with the Gufoni maneuver. Both the barbecue maneuver + FPP and the Gufoni maneuver are valid methods for treating HSC-BPPV (geotropic forms). However, our results also indicate that the Gufoni maneuver has a significant advantage: the success rate shown at the follow-up, although without statistical significance, is undoubtedly higher (93 vs. 81%). This result, together with the fact that it is very easy to perform and that patient compliance is better, make the Gufoni maneuver the method of choice in HSC-BPPV treatment.

Current Insights into Treating Vertigo in Older Adults.

The number of older people has been increasing over recent decades in Western populations. Dizziness, imbalance, and vertigo constitute some of the most common complaints in older patients, and risk of falling is the most frequent and worrying consequence. It has been reported that 15-20% of the adult population experiences these debilitating symptoms. Among the diseases that may be associated with vertigo, the three classes of otological, central, and functional (psychological) dizziness may be distinguished. Overall, vestibular disorders account for 48% of vertiginous complaints in the older population. The main focus of this article is to review the forms of pharmacotherapy for vertigo, especially with regard to older patients, who may be treated simultaneously with other drugs for different comorbidities. Interactions with other drugs should be considered in the choice of a particular course of treatment. Moreover, overuse of pharmacotherapy for the management of vertigo in the elderly may prevent the development of the central compensatory mechanism that sustains both static and dynamic imbalance after a vertiginous crisis. In the majority of patients, vestibular and physical rehabilitation are strongly advised and rarely contraindicated.

Prognosis after acute unilateral vestibulopathy: Usefulness of the suppression head impulse paradigm (SHIMP).

OBJECTIVES: This cross-sectional study aims to describe the features of the suppression head impulse paradigm (SHIMP) in acute unilateral vestibulopathy (AUV) and to define its role in predicting the recovery of patients. METHODS: Thirty patients diagnosed with AUV were retrospectively analyzed. The dizziness handicap inventory score and video head impulse test parameters performed 4-8 weeks from the AUV onset constituted the main outcome measures. Patients with a worse recovery (Group 1) and patients who recovered spontaneously (Group 2) were compared. RESULTS: The SHIMP vestibulo-ocular reflex (VOR) gain was statistically significantly lower than the conventional head impulse paradigm (HIMP) VOR gain (P < 0.001). The SHIMP VOR gain was negatively correlated with the DHI (P < 0.001) and was positively correlated with the HIMP VOR gain (P < 0.001) and the SHIMP overt saccades (%) (P < 0.001). Patients with a worse recovery exhibited the following: higher DHI (P < 0.001), lower SHIMP and HIMP VOR gain (P < 0.001 and P = 0.007, respectively), and lower SHIMP and greater HIMP overt saccade prevalence values (P = 0.007 and P = 0.032, respectively). CONCLUSIONS: The SHIMP and HIMP help in improving our approach to AUV. SHIMP appears to better identify the extent of the vestibular damage in patient suffering from AUV than HIMP and could provide interesting information about the course of the disease. Particularly, the analysis of SHIMP VOR gain and overt saccade prevalence would provide useful information about the recovery of patients.

The Role of the Functional Head Impulse Test with and without Optokinetic Stimuli in Vestibular Migraine and Acute Unilateral Vestibulopathy: Discovering a Dynamic Visual Dependence.

(1) Background: Visually induced vertigo (i.e., vertigo provoked by moving visual scenes) can be considered a noticeable feature of vestibular migraines (VM) and can be present in patients suffering from acute unilateral vestibulopathy (AUV). Hypersensitivity to moving or conflicting visual stimulation is named visual dependence. (2) Methods: Visuo-vestibular interactions were analyzed via the functional Head Impulse Test (fHIT) with and without optokinetic stimulation (o-fHIT) in 25 patients with VM, in 20 subjects affected by AUV, and in 20 healthy subjects. We calculated the percentage of correct answers (%CA) without and with the addition of the optokinetic background (OB). (3) In VM groups, the %CA on the fHIT was 92.07% without OB and 73.66% with OB. A significant difference was found between %CA on the deficit side and that on the normal side in AUV, both without OB and with OB. (4) Conclusions: The fHIT results in terms of %CA with and without OB could be useful to identify the presence of a dynamic visual dependence, especially in patients suffering from VM. The difference in %CA with and without OB could provide instrumental support to help correctly identify subjects suffering from VM. We propose the use of the fHIT in clinical practice whenever there is a need to highlight a condition of dynamic visual dependence.