Vascular neuro-otology: vestibular transient ischemic attacks and chronic dizziness in the elderly.

PURPOSE OF REVIEW: To explore the differential diagnosis of posterior fossa transient ischemic attacks (TIA) associated with vertigo and/or imbalance.To review the contribution of cerebral small vessel (SVD) disease to balance dysfunction and dizziness in the elderly. MAIN FINDINGS: TIAs involving vestibular structures that mediate the vestibulo-ocular and vestibulospinal reflexes remain a diagnostic challenge because they overlap with causes of benign episodic vertigo. Here, we summarize the results of multidisciplinary specialty efforts to improve timely recognition and intervention of peripheral and central vestibular ischemia. More papers confirm that SVD is a major cause of gait disability, falls and cognitive disorder in the elderly. Recent work shows that early stages of SVD may also be responsible for dizziness in the elderly. The predominant location of the white matter changes, in the frontal deep white matter and genu of the corpus callosum, explains the association between cognitive and balance dysfunction in SVD related symptoms. SUMMARY: The evaluation of patients with intermittent vascular vertigo represent a major diagnostic challenge, recent reviews explore the ideal design approach for a multidisciplinary study to increase early recognition and intervention. Hemispheric white matter microvascular ischemia has been the subject of research progress - advanced stages are known to cause gait disorder and dementia but early stages are associated with "idiopathic" dizziness in the elderly.

[Increased report completeness and satisfaction with structured neurotological reporting in the interdisciplinary assessment of vertigo]. / Erhöhte Befundvollständigkeit und gesteigerte Zuweiserzufriedenheit bei strukturierter neurootologischer Befunderhebung in der interdisziplinären Schwindelabklärung.

BACKGROUND: Results of neurotological function diagnostics in the context of interdisciplinary vertigo assessment are usually formulated as free-text reports (FTR). These are often subject to high variability, which may lead to loss of information. The aim of the present study was to evaluate the completeness of structured reports (SR) and referrer satisfaction in the neurotological assessment of vertigo. MATERIALS AND METHODS: Neurotological function diagnostics performed as referrals (n = 88) were evaluated retrospectively. On the basis of the available raw data, SRs corresponding to FTRs from clinical routine were created by means of a specific SR template for neurotological function diagnostics. FTRs and SRs were evaluated for completeness and referring physician satisfaction (n = 8) using a visual analog scale (VAS) questionnaire. RESULTS: Compared to FTRs, SRs showed significantly increased overall completeness (73.7% vs. 51.7%, p < 0.001), especially in terms of patient history (92.5% vs. 66.7%, p < 0.001), description of previous findings (87.5% vs. 38%, p < 0.001), and neurotological (33.5% vs. 26.7%, p < 0.001) and audiometric function diagnostics (58% vs. 32.3%, p < 0.001). In addition, SR showed significantly increased referring physician satisfaction (VAS 8.8 vs. 4.9, p < 0.001). CONCLUSION: Neurotological SRs enable a significantly increased report completeness with higher referrer satisfaction in the context of interdisciplinary assessment of vertigo. Furthermore, SRs are particularly suitable for scientific data analysis, especially in the context of big data analyses.

Updates in neuro-otology.

PURPOSE OF REVIEW: Recent updates with clinical implications in the field of neuro-otology are reviewed. RECENT FINDINGS: Important updates relating to several neuro-otologic disorders have been reported in recent years. For benign positional paroxysmal vertigo (BPPV), we provide updates on the characteristics and features of the short arm variant of posterior canal BPPV. For the acute vestibular syndrome, we report important updates on the use of video-oculography in clinical diagnosis. For autoimmune causes of neuro-otologic symptoms, we describe the clinical and paraclinical features of kelch-like protein 11 encephalitis, a newly-identified antibody associated disorder. For cerebellar ataxia, neuropathy, vestibular areflexia syndrome, we report recent genetic insights into this condition. SUMMARY: This review summarizes important recent updates relating to four hot topics in neuro-otology.

[OTONEUROLOGY- A MULTIFACETED FIELD].

INTRODUCTION: Otoneurology is a broad, diverse and multidisciplinary field. On the one hand, it includes everything that relates to hearing: from complex surgery including life-changing implants to effective medical treatments and habilitation. On the other hand, it includes all that has to do with balance, from novel vestibular tests to complex medical treatments and recently, the development of a vestibular implant for patients suffering from bilateral peripheral vestibular loss. This special issue on otoneurology includes 8 original papers and 3 reviews. The first three articles deal with auditory implants. The first describes a series of children who underwent auditory brainstem implantation, including the first implantation in Israel 6 years ago. The second, presents patients with acoustic schwannomas undergoing cochlear implantation and the third relates to patients with Meniere's disease. Cochlear implants are one of the most significant developments in medicine in recent decades that enable most deaf individuals to hear, and develop normal language, heavily influencing all aspects of personal development and social integration.

[FIRST YEAR EXPERIENCE OF TERTIARY MULTIDISCIPLINARY NEUROTOLOGY (DIZZINESS AND BALANCE) CLINIC].

BACKGROUND: Dizziness is a common condition that accounts for an estimated 5% of primary care clinic visits. The differential diagnosis is extensive, which may involve the inner ear, central and peripheral nervous system and the cardiovascular system among others. While routine cases can be diagnosed and treated with primary (general practitioner) or secondary (otolaryngologists (medicine in the community, there are many cases in which it is advisable to refer patients to a tertiary dizziness clinic. These cases include: unclear diagnosis, lack of improvement after medication or physiotherapy, medical comorbidities in which the central compensation process has been affected, chronic dizziness, bilateral vestibular disorder and more. Therefore, we established a multidisciplinary clinic (MDC) in a tertiary referral center at the Rambam Healthcare Campus. OBJECTIVES: To investigate the first year of the tertiary MDC neurotology clinic. METHODS: Retrospective cohort of all patients examined at the tertiary MDC. RESULTS: The first 123 consecutive patients (62% women) aged 56 years on average (19-85years, ±16) seen in the MDC from October 1, 2020 to October 31, 2021 are reported. Prior to assessment, 79 (64%) patients had been referred by an ENT doctor in the community with an unclear cause of dizziness; 49 (40%) patients experienced ongoing symptoms for years and 61 (50%) patients had dizziness on a daily basis. A total of 56 )46%) patients were found to have a peripheral vestibular cause for their dizziness and 67 (54%) patients had a central or other causes. More than one cause of dizziness and/or imbalance was noted in 20 (36%) of patients. Among the common peripheral vestibular causes were benign paroxysmal positional vertigo (BPPV) and Meniere's disease, and the central and functional disorders included vestibular migraine and persistent postural perceptual dizziness (PPPD). The frequency and intensity of symptoms were reduced in 29 patients of the 33 (88%) who underwent vestibular physiotherapy in the MDC as opposed to 8 (50%) patients in the community (p <0.05). Physiotherapy was found to be more effective in patients younger than 65 years old, and with less than six months of symptoms (p <0.05). However, patients with a medical history of neurological or cardiovascular problems are less likely to improve (p <0.05). CONCLUSIONS: A tertiary neurotology clinic of a multidisciplinary team can provide proper care in persistent dizziness and/or unclear diagnosis. Vestibular physiotherapy plays a crucial role in the management of a dizzy patient, and hence it should be started as soon as possible.

Practical Approach to the Tele-Neuro-Ophthalmology and Neuro-Otology Visits: Instructional Videos.

ABSTRACT: A collection of instructional videos that illustrate a step by step approach to tele-neuro-ophthalmology and neuro-otology visits. These videos provide instruction for patient preparation for their video visit, patient and provider interface with an electronic medical record associated video platform, digital applications to assist with vision testing, and practical advice for detailed remote neuro-ophthalmologic and neuro-otologic examinations.

[What happens to vertiginous population after emission from the Emergency Department?] / Mi történik a szédülô beteggel a sürgôsségi osztály elhagyása után?

Background - Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose - The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods - 879 patients were examined at the Semmel-weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results - Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion - The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion - Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.

[The role of Hungarian-rooted scholars in the development of Otoneurology]. / Magyar származású tudósok szerepe az otoneurológia fejlodésében.

Despite of the symptoms of vertigo have been known since thousands of years, it was evident by the research of the pioneer scientists of the 19th century (Flourens, Ménière, Breuer and others) that dizziness can also be attributed to inner ear disfunctions. The discovery of the vestibulo-ocular reflex was an important milestone (Endre Hogyes, 1884). The vestibulo-ocular reflex stabilizes images on the retina by rotating the eyes at the same speed but in the opposite direction of head motion. The milestone discovery of Hogyes by stimulating individual labyrinth receptors and recording the activity of eye muscles were verified by János Szentágothai in 1950. Low-frequency lesions of the angular vestibulo-ocular reflex can be investigated by caloric test (Robert Bárány,1906), high-frequency lesions by head impulse test (Gabor Michael Halmagyi and Ian Stewart Curthoys, 1988).

[Neuro-otology: at the borders of ear and brain]. / Neurootologie: Grenzfälle zwischen Ohr und Gehirn.

Vertigo and dizziness are frequent chief complaints in clinical practice. Symptoms may originate from otological, neurological, medical and psychiatric etiologies, which poses an interdisciplinary challenge. Systematic analysis of case history and clinical examination generally allow classification into peripheral-, central- or non-vestibular disorders. The most important criteria for differentiation are the timeline, quality of symptoms, modulating factors and accompanying symptoms. As concerns the clinical examination, the following tests are relevant: head impulse test, test for spontaneous nystagmus, positional nystagmus, central ocular motor signs and the Romberg test. However, neuro-otological disorders with combined peripheral and central vestibular pathology do exist. Occlusion of the anterior inferior cerebellar artery results in ischemia of the labyrinth and cerebellum and therefore causes acute vestibular syndrome and unilateral hearing loss. Repetitive attacks of vertigo or dizziness which are accompanied by ear symptoms and headaches may be due to an overlap syndrome of Menière's disease and vestibular migraine. In this case patients often have to be treated with a dual prophylactic medication to control symptoms. In case of chronic dizziness and instability of gait a subsample of patients may suffer from CANVAS, which is a combination of bilateral vestibulopathy, a cerebellar syndrome and polyneuropathy. Chronic dizziness with signs of peripheral and central vestibular dysfunction can also originate from tumors of the cerebellopontine angle with compression of central structures. In conclusion, the diagnostic algorithm in the workup of patients with vertigo and dizziness should always include tests for peripheral and central vestibular and ocular motor function.

[Neuro-otology counseling for patients with chronic tinnitus]. / Neurootologisches Counseling bei chronischem Tinnitus.

The diagnosis and treatment of tinnitus requires professional competence in neuro-otology and also an appropriate and comprehensible clarification for the individual patient.According to the Tinnitus-Guidelines of 2015 the counselling by the physician in charge is essential regarding the individual aetiopathogenesis, as well as the patient's individual coping mechanism with tinnitus, the prognosis, exacerbating factors and also as to the damaging impact on the ear.Therefore the therapeutic aim is to depathologize the symptom tinnitus and to provide an explanation and a context in the contemporary approved and scientific conception.The requirements of the guidelines are necessary and reasonable, however it is often very difficult to implement this in the daily routine in a doctor´s practice, especially in the outpatient medical care.Subsequently we are going to present a four-to-five step-model to communicate the most important issues - analogous the guidelines and coherent for the outpatient or clinic patient in the one-to-one or group medical counselling. This furthermore addresses aspects of mental health.For that diagnosis as well as evaluation the mini-tinnitus-questionnaire (Mini-TF12) is available. It can be filled out and interpreted via homepage of the German Tinnitus-Liga (DTL) without charge.

Abnormal head oscillations in neuro-ophthalmology and neuro-otology.

PURPOSE OF REVIEW: The study describes the clinical phenomenology and contemporary pathophysiology of concurrent oscillations of the eyes and the head that are present in neurological conditions with diverse causes. RECENT FINDINGS: One classic example is spasmus nutans in which the eye oscillations are the primary cause, whereas head nodding is thought to be an operant conditional response that suppresses the eye oscillations to facilitate clear vision. The second example is a combination of head tremor and inadequate compensatory eye movements because of vestibular hypofunction leading to the illusion of pendular nystagmus - hence, the condition is called pseudonystagmus. Cerebellar degeneration in ataxia-telangiectasia or synchronized spontaneous discharge from the inferior olive and cerebellum in the syndrome of ocular palatal tremor with dystonia are examples of eye and head oscillations because of the impairment in cerebellar outflow. Infantile nystagmus syndrome also presents with eye and head oscillations, but here the relationship between the two types of oscillations differs among patients and is still unclear. SUMMARY: The clinical features and putative pathophysiology of diverse disorders of the eyes and head that produce unwanted oscillations are reviewed. Key clinical pearls that are essential to separate these disorders at the bedside are also emphasized.

[Pre- and posttreatment results of an inpatient neurotologic and psychosomatic tinnitus therapy]. / Prä- und Post-Ergebnisse einer stationären neurootologisch fundierten und psychosomatischen Tinnitustherapie.

BACKGROUND: Inpatient treatment of chronic complex tinnitus can be necessary for patients with a high symptomatic strain, mostly accompanied by a corresponding mental comorbidity, and/or for patients that can only perceive their psychogenic suffering through somatization into tinnitus. METHODS: We report the results of 368 consecutively treated inpatients with chronic complex tinnitus. Patients' audiometric data were collected, and at the beginning and end of treatment, the Mini-Tinnitus Questionnaire (Mini-TQ12; Hiller und Goebel) was completed, as was the German version of the Hospitality Anxiety and Depression Score (HADS). Effect sizes were calculated for both questionnaires. Mean treatment duration was 38.8 days (standard deviation, SD: 13.6 days). The main therapeutic elements were intensive disorder-specific neurotologic counselling and psychoeducation; improvement of hearing by fitting of hearing aids, complemented by an individualized hearing therapy; and intensive individual and group-based psychotherapy. RESULTS: In addition to tinnitus, 82.1% of the patients had reduced hearing requiring rehabilitation with hearing aids. After hospitalization, a highly significant improvement in tinnitus strain could be demonstrated by the Mini-TQ12. Furthermore, a significant reduction in the depression and anxiety components of HADS was also achieved, with high effect sizes of 1.6 to 2.2. No reduction of tinnitus symptoms to a medium- or low-range level was experienced by 8.9% of patients. CONCLUSION: With corresponding symptomatic suffering, disorder-specific inpatient tinnitus treatment comprising neurotologic and psychosomatic alignment can achieve medium- to high-range therapeutic effects.

Estimating postural control with the balance rehabilitation unit: measurement consistency, accuracy, validity, and comparison with dynamic posturography.

OBJECTIVE: To examine the psychometric properties (test-retest reliability, concurrent validity, construct validity) of the Balance Rehabilitation Unit (BRU) during testing of sensory integration processes in healthy adults and individuals with vestibular disorders. DESIGN: Experimental cross-sectional design. SETTING: Clinic. PARTICIPANTS: Participants (N=90) included 30 subjects with vestibular disorders (age range, 18-85y), 30 young healthy adults (age range, 18-50y), and 30 older healthy adults (age range, 60-85y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were tested twice with the BRU and once with the SMART EquiTest Sensory Organization Test (SOT). The center of pressure (COP) in the anteroposterior direction (COPap) and the COP in the mediolateral direction (COPml) were recorded. The COPap and COPml time series were used to estimate the area and velocity of the COP. RESULTS: The intraclass correlation coefficient of the COP area and velocity measures for the BRU for all subjects was at least .76 in all sensory organization conditions (P<.001). Significant correlations were found between the BRU and the SOT, ranging from .64 to .81 for COP area and from .44 to .76 for COP velocity. The older control group had significantly greater COP area and velocity compared with younger controls for the BRU and the SOT. The COP (area, velocity) was significantly higher for the younger individuals in the vestibular group than the younger controls. CONCLUSIONS: The reliability and validity of COP measurements obtained during testing of the sensory integration processes were demonstrated using the BRU. Future work should examine the responsiveness of these measures when individuals with balance disorders participate in rehabilitation.

Reviewing Kampo medicine (Traditional Japanese Herbal Medicine) for otology/neurotology diseases.

Kampo medicine, a traditional Japanese herbal medicine, is used for the treatment of otologic and neurotologic diseases in Japan and other Asian countries. However, only Japanese medical doctors can prescribe both Kampo and modern (Western) medicine. Since a medical doctor can perform not only the diagnosis but also Kampo treatment, it is expected that the quality of clinical studies on traditional herbal medicine is higher in Japan than that in other countries. However, there is no Kampo review written in English language for the treatment of otology/neurotology diseases. Herein, we would like to demonstrate evidence of Kampo treatment for otology/neurotology diseases according to previous studies in Japan.

Artificial Intelligence in Otology and Neurotology.

Clinical applications of artificial intelligence (AI) have grown exponentially with increasing computational power and Big Data. Data rich fields such as Otology and Neurotology are still in the infancy of harnessing the power of AI but are increasingly involved in training and developing ways to incorporate AI into patient care. Current studies involving AI are focused on accessible datasets; health care wearables, tabular data from electronic medical records, electrophysiologic measurements, imaging, and "omics" provide huge amounts of data to utilize. Health care wearables, such as hearing aids and cochlear implants, are a ripe environment for AI implementation.

The Impact of Visual Abstracts Compared to Automated Tweets on Social Media in Otology & Neurotology.

OBJECTIVE: To analyze the effect of visual abstracts versus automated tweets on social media participation in Otology & Neurotology . PATIENTS: N/A. INTERVENTIONS: Introduction of visual abstracts developed by the social media editorial team to established automated tweets created by the dlvr.it computer program on the Otology & Neurotology Twitter account. MAIN OUTCOME MEASURES: Twitter analytics including the number of new followers per month, impressions per tweet, and engagements per tweet. The Kruskal-Wallis analysis of variance test was used to compare means. RESULTS: From October 2016 to October 2017 (average of 20 new followers per month), 101 automated tweets averaged 536 impressions and 16 engagements per tweet. The visual abstract was introduced in November 2017. From November 2017 to November 2020 (average of 39 new followers per month), 447 automated tweets averaged 747 impressions and 22 engagements per tweet, whereas 157 visual abstracts averaged 1977 impressions and 78 engagements per tweet. Automated tweets were discontinued in December 2020. From December 2020 to December 2022 (average of 44 new followers per month), 95 visual abstracts averaged 1893 impressions and 103 engagements per tweet. With the introduction of the visual abstract, the average number of followers, impressions per tweet, and engagements per tweet significantly increased (all p -values <0.01; all large effect sizes of 0.16, 0.47, and 0.47, respectively). CONCLUSIONS: Visual abstracts created by a social media editorial team have a positive impact on social media participation in the field of otology and neurotology. The impact is greater than that of social media content generated by Twitter automation tools.

Exoscope-assisted surgery in otology and neurotology.

PURPOSE OF REVIEW: This review addresses the pressing need for an updated understanding of high-definition 3D exoscope role in contemporary otologic and neurotologic practice. With technological advancements driving innovations in surgical visualization, it is crucial to evaluate the efficacy of exoscope-assisted surgery compared to traditional microscopic approaches. By synthesizing recent literature, this review offers insights into the current state of exoscopic ear and lateral skull base surgery and its implications for clinical practice and research. RECENT FINDINGS: Recent literature has focused on several key themes. Firstly, studies have demonstrated the feasibility and safety of exoscopic approaches for various otologic and neurotologic procedures. Secondly, comparative studies have highlighted similar outcomes with exoscopic techniques compared to conventional microscopic surgery, particularly in terms of operative time and complication rates. Thirdly, the exoscope can be a valuable tool for the education and training of surgeons. SUMMARY: The findings from recent literature underscore the growing significance of exoscope-assisted surgery in otology and lateral skull base practice. However, challenges such as high magnification image quality and learning curve must be addressed to optimize its widespread adoption. Overall, this review highlights the importance of continued research and innovation in this rapidly evolving field.

New perspectives on vestibular evoked myogenic potentials.

PURPOSE OF REVIEW: Although the vestibular evoked myogenic potential (VEMP) measured from the cervical muscles (cVEMP, cervical VEMP) is well described and has documented clinical utility, its analogue recorded from the extraocular muscles (oVEMP, ocular VEMP) has been described only recently and is currently emerging as an additional test of otolith function. This review will, therefore, summarize recent developments in VEMP research with a focus on the oVEMP. RECENT FINDINGS: Recent studies suggest that the oVEMP is produced by otolith afferents in the superior vestibular nerve division, whereas the cVEMP evoked by sound is thought to be an inferior vestibular nerve reflex. Correspondingly, the oVEMP correlates better with caloric and subjective visual vertical tests than sound-cVEMPs. cVEMPs are more complicated than often thought, as shown by the presence of crossed responses and conflicting results of recent vibration studies. Altered inner ear mechanics produced by the vestibular diseases superior semicircular canal dehiscence and Ménière's disease lead to changes in the preferred frequency of the oVEMP and cVEMP. SUMMARY: The oVEMP provides complementary diagnostic information to the cVEMP and is likely to be a useful addition to the diagnostic test battery in neuro-otology.