Objective Skew deviation results from a dysfunction of the graviceptive pathways in patients with an acute vestibular syndrome (AVS) leading to vertical diplopia due to vertical ocular misalignment. It is considered as a central sign, however, the prevalence of skew and the accuracy of its test is not well known . Methods We performed a prospective study from February 2015 until September 2020 of all patients presenting at our emergency department (ED) with signs of AVS. All patients underwent clinical HINTS and video test of skew (vTS) followed by a delayed MRI, which served as a gold standard for vestibular stroke confirmation. Results We assessed 58 healthy subjects, 53 acute unilateral vestibulopathy patients (AUVP) and 24 stroke patients. Skew deviation prevalence was 24% in AUVP and 29% in strokes. For a positive clinical test of skew, the cut-off of vertical misalignment was 3 deg with a very low sensitivity of 15% and specificity of 98.2%. The sensitivity of vTS was 29.2% with a specificity of 75.5%. Conclusions Contrary to prior knowledge, skew deviation proved to be more prevalent in patients with AVS and occurred in every forth patient with AUVP. Large skew deviations (> 3.3 deg), were pointing toward a central lesion. Clinical and video test of skew offered little additional diagnostic value compared to other diagnostic tests such as the head impulse test and nystagmus test. Video test of skew could aid to quantify skew in the ED setting in which neurotological expertise is not always readily available.
ObjectiveFailure of fixation suppression of spontaneous nystagmus is sometimes seen in patients with vestibular strokes involving the cerebellum or brainstem, however, the accuracy of this test for the discrimination between peripheral and central causes in patients with an acute vestibular syndrome (AVS) is unknown.MethodsPatients with AVS were screened and recruited (convenience sample) as part of a prospective cross-sectional study in the Emergency Department between 2015-2020. All patients received neuroimaging which served as a reference standard. We recorded fixation suppression with video-oculography (VOG) for straight, right and left gaze. The ocular fixation index (OFI) and the spontaneous nystagmus slow velocity reduction was calculated.ResultsWe screened 1646 dizzy patients in the emergency department and tested for spontaneous nystagmus in 148 included AVS patients. We analyzed 56 patients with a diagnosed acute unilateral vestibulopathy (vestibular neuritis) and 28 patients with a confirmed stroke. There was a complete nystagmus fixation suppression in 49.5% of AVS patients, in 40% of patients with vestibular neuritis and in 62.5% of vestibular strokes. OFI scores had no predictive value for detecting strokes, however, a nystagmus reduction of less than 2deg/s showed a high accuracy of 76.9% (CI 0.59-0.89) with a sensitivity of 62.2% and specificity of 84.8% in detecting strokes..ConclusionsThe presence of fixation suppression does not rule out a central lesion. The magnitude of suppression was lower compared to patients with vestibular neuritis. The nystagmus suppression test still predicts accurately vestibular strokes provided that eye movements are recorded with VOG.Classification of EvidenceThis study provides Class II evidence that in patients with an acute vestibular syndrome, decreased fixation suppression recorded with VOG occurred more often in stroke (76.9%) than in vestibular neuritis (37.8%).
Objective Cold and warm water ear irrigation, also known as bithermal caloric testing, has been considered for over 100 years the ‘Gold Standard’ for the detection of peripheral vestibular hypofunction. Its discovery was awarded a Nobel Prize. We aimed to investigate the diagnostic accuracy of Caloric Testing when compared to the video head impulse test (vHIT) in differentiating between vestibular neuritis and vestibular strokes in acute dizziness. Design Prospective cross-sectional study (convenience sample). Setting All patients presenting with signs of an acute vestibular syndrome at the emergency department of a tertiary referral center. Participants One thousand, six hundred seventy-seven patients were screened between February 2015 and May 2020 for Acute Vestibular Syndrome (AVS), of which 152 met the inclusion criteria and were enrolled. Inclusion criteria consisted of a state of continuous dizziness, associated with nausea or vomiting, head-motion intolerance, new gait or balance disturbance and nystagmus. Patients were excluded if they were younger than 18 years, if symptoms lasted < 24 h or if the index ED visit was > 72 h after symptom onset. Of the 152 included patients 85 completed testing. We assessed 58 vestibular neuritis and 27 stroke patients. Main outcome measures All patients underwent calorics and vHIT followed by a delayed MRI which served as a gold standard for vestibular stroke confirmation. Results The overall sensitivity and specificity for detecting stroke with a caloric asymmetry cut-off of 30.9% was 75% and 86.8%, respectively [negative likelihood ratio (NLR) 0.29] compared to 91.7% and 88.7% for vHIT (NLR 0.094). Best VOR gain cut-off was 0.685. Twenty-five percent of vestibular strokes were misclassified by calorics, 8% by vHIT. Conclusions Caloric testing proved to be less accurate than vHIT in discriminating stroke from vestibular neuritis in acute dizziness. Contrary to classic teaching, asymmetric caloric responses can also occur with vestibular strokes and might put the patient at risk for misdiagnosis. We, therefore, recommend to abandon caloric testing in current practice and to replace it with vHIT in the acute setting. Caloric testing has still its place as a diagnostic tool in an outpatient setting.
Hypothesis: We aimed to investigate the effect of the head excursion angle on the success of the Sémont Maneuver (SM). Background: SM is performed with the head turned by 45 degrees toward the unaffected ear. In clinical routine, it is unlikely that physicians can turn the head to a position of exactly 45 degrees. Moreover, it is unclear how possible deviations from 45 degrees would affect the outcome with SM. Methods: We used an in vitro model (upscaled by ×5) of a posterior semicircular canal with canalithiasis to study head excursion angles (0–75 degrees) and minimum waiting times in SM. Additionally, we measured actual head excursion angles performed by trained physicians during SM on a healthy subject. Results: Successful canalith repositioning to the utricle was possible at head excursion angles between 21 and 67 degrees. Waiting time increased from 16 to 30 seconds with increasing deviation from 45 degrees. Angles larger than 67 degrees or smaller than 21 degrees did not lead to successful repositioning even after a waiting period of 5 minutes. Physicians set head excursion angles of 50 degrees ±SD 4.8 degrees while performing the SM. Conclusion: Angular deviations up to ±20 degrees from the ideal SCC plane (45 degrees) still allows for successful SM. Although the tested physicians tended to underestimate the actual head excursion angle by 5 degrees (and more), the success of SM will not be affected provided that the waiting time is sufficiently long. Further, the results suggest that the Brandt-Daroff maneuver is a form of habituation training rather than a liberatory maneuver.
Nasopharyngeal carcinoma (NPC), an uncommon malignancy in Western Countries and Radiotherapy, remains an effective treatment. Its side effects are classified as either immediate or late; postradiation necrosis is as an important late side effect with a strong impact on the prognosis in patients with NPC. We report the case of 65-year-old Caucasian man presenting with a deep necrotic ulcer of the nasopharynx and osteoradionecrosis of the skull base that appeared 3 months after radiotherapy for nasopharyngeal carcinoma. Conservative treatment was applied with surgical management of the ulcer. Clinical and radiological outcomes are presented. Radiotherapy remains a good treatment option with varying degrees of side effects, in particular, postradiation necrosis and ulcer. Multiple options of treatment have been described. However, the surgical management could be indicated in cases of deep ulcer with life-threatening prognosis.
Objective The alternate cover test (ACT) in patients with acute vestibular syndrome is part of the ‘HINTS’ battery test. Although quantitative, the ACT is highly dependent on the examiner’s experience and could theoretically vary greatly between examiners. In this study, we sought to validate an automated video-oculography (VOG) system based on eye tracking and dedicated glasses. Methods We artificially induced a vertical strabismus to simulate a skew deviation on ten healthy subjects, aged from 26 to 66, using different press-on Fresnel prisms on one eye while recording eye position with VOG of the contralateral eye. We then compared the system’s performance to that of a blinded trained orthoptist using conventional, semi-quantitative method of skew measurement known as the alternate prism cover test (APCT) as a gold standard. Results We found a significant correlation between the reference APCT and the Skew VOG (Pearson’s R2 = 0.606, p < 0.05). There was a good agreement between the two tests (intraclass correlation coefficient 0.852, 95 CI 0.728–0.917, p < 0.001). The overall accuracy of the VOG was estimated at 80.53% with an error rate of 19.46%. There was no significant difference in VOG skew estimations compared with the gold standard except for very small skews. Conclusions VOG offers an objective and quantitative skew measurement and proved to be accurate in measuring vertical eye misalignment compared to the ACT with prisms. Precision was moderate, which mandates a sufficient number of tests per subject.
Superior canal dehiscence syndrome (SCDS) is a structural bony defect of the roof of the superior semi-circular canal into the middle cranial fossa and is responsible for the creation of a third window, which alters the dynamics of the inner ear. During humming, vibratory waves entering the vestibulum and cochlea are re-routed through the dehiscence, leading to stimulation of the otolithic and ampullary vestibular organs. This is responsible for the torsional-vertical nystagmus known as “fremitus nystagmus”. In this case report, we video-document a rare case of fremitus nystagmus and its resolution after plugging of the superior semi-circular canal.
Objectives: We aimed to investigate the diagnostic accuracy of Caloric Testing and video Head Impulse Testing (vHIT) in differentiating between vestibular neuritis and strokes in acute dizziness. Design: Prospective cross-sectional study. Setting: Emergency department of a tertiary referral center. Participants: 1677 adult patients were screened between 2015 and 2020 for AVS, of which 152 met the inclusion criteria. Inclusion criteria consisted of a state of continuous dizziness, associated with nausea or vomiting, head-motion intolerance, new gait or balance disturbance and nystagmus. Patients were excluded if symptoms lasted <24 hours or if the index ED visit was >72 hours after symptom onset. Eighty-five patients completed testing of which 58 were vestibular neuritis and 27 strokes. Main outcome measures: All patients underwent calorics and vHIT followed by a delayed MRI (gold standard for vestibular stroke confirmation). Results: The sensitivity/specificity for detecting stroke (caloric asymmetry cut-off of 30.9%) was 75% and 86.8% respectively (Negative likelihood ratio (NLR) 0.29) compared to 91.7% and 88.7% for vHIT (NLR 0.094). Best VOR gain cut-off was 0.685. Twenty-five percent of vestibular strokes were misclassified by calorics, 8% by vHIT. Conclusions: Caloric testing demonstrated lower accuracy than vHIT in discriminating stroke from vestibular neuritis in acute dizziness. Asymmetric caloric responses can also occur with vestibular strokes and might put the patient at risk for misdiagnosis. We therefore recommend replacing calorics with vHIT in the acute setting. Caloric testing has still its place as a diagnostic tool in an outpatient setting.
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