Background. False negative fistula testing in patients with chronic suppurative otitis media is a dilemma when proceeding to surgery. It is imperative to rule out a dead labyrinth or a mass effect secondary to the cholesteatoma in an otherwise normally functioning inner ear. We present a case series of three patients in whom a bedside vestibuloocular reflex (VOR) evaluation using a head impulse test was used successfully for further evaluation prior to surgery. Results. In all three cases with a false negative fistula test we were able to further evaluate at the bedside and were not only able to register the abnormal VOR but also localize its deterioration to a particular semicircular canal eroded by the fistula. Conclusion. Vestibuloocular reflex evaluation is mandatory in patients with suspected labyrinthine fistula due to cholesteatoma of the middle ear before proceeding to surgery. We demonstrate successful use of a bedside head impulse test for further evaluation prior to surgery in patients with false negative fistula test.

All subjects gave their consent in writing to take part in this study. All tests performed are internationally approved and do not entail any morbidity or mortality to the subject. This study was approved by the directors of Clı´nica Neurotolo´gica del Parque.The authors disclose no conflicts of interest.Author contributions: Ricardo D'Albora: this author came up with the idea of combining the suppression head impulse paradigm (SHIMP) with the head impulse paradigm (HIMP) tests using a diagnostic headband in the clinical bedside setting as a means to improve the performance of the HIMP test. Ricardo designed the study model, performed all tests, and assessed the VOR gains. Corresponding author.Rodrigo Noboa: Collaborator in the design of the model.

ResumenIntroducción: el carcinoma escamoso de cabeza y cuello (HNSCC) es el cáncer de mayor prevalencia en la otorrinolaringología, ocupando en el Uruguay el quinto lugar en incidencia y el sexto lugar en mortalidad en hombres. El propósito de este estudio fue analizar la sobrevida global de pacientes con cáncer de cabeza y cuello en dos centros de referencia de Montevideo.Método: se analizó de forma retrospectiva la sobrevida global de 436 pacientes diagnosticados con HNSCC entre los años 2005 y 2015. Se analizó la sobrevida por método de Kaplan-Meier en relación con el estadio tumoral, topografía, estatus de tabaquismo y alcoholismo de los pacientes. Para el estudio de la interacción de las variables con posible importancia en el pronóstico se utilizó el modelo de regresión de Cox.Resultados: la mediana de sobrevida global de los pacientes con cáncer de cabeza y cuello en nuestra serie es de 35,8 meses (23,5-48,1, IC 95%), para el cáncer de laringe fue superior a la del resto de los pacientes con cáncer de otros sitios anatómicos, 77,3 (49,3-105,2, IC 95%) versus 26,2 meses (20,7-48,1, IC 95%, p < 0,001). No hubo diferencia entre la sobrevida global de tabaquistas y no tabaquistas. El grupo de los no alcoholistas presentó una mejor sobrevida global que el grupo de los alcoholistas, 72,4 (39,1-105,7, IC 95%) versus 26,7 (19,9-33,6 IC 95%). El análisis multivariante identificó el estadio y el alcoholismo como factores pronósticos independientes en nuestra serie.Conclusiones: la mediana de sobrevida global de nuestra serie es similar a la reportada en la bibliografía internacional. Los pacientes con cáncer de laringe presentan mayor sobrevida que los pacientes con cáncer de otros sitios otorrinolaringológicos. De los factores de riesgo clásicos, en nuestra serie el consumo de alcohol impacta negativamente en sobrevida de los pacientes con cáncer de cabeza y cuello.

Preliminary findings have suggested that 99m Tc-glucarate has tumor-seeking properties. The purpose of this study was to explore the potential of this tracer to evaluate malignant head and neck tumors by means of SPECT/CT software fusion imaging. Methods: Eleven male patients with advanced head and neck carcinoma were included in the study: 9 with locally advanced disease and 2 with clinical suspicion of local relapse. Scanning started 3-6 h after the injection of 1,110 MBq of 99m Tc-glucarate. Planar and SPECT images of the head, neck, and thorax were acquired. Three-dimensional images were also coregistered with CT. Results: We found 99m Tc-glucarate uptake in all suspected lesions. SPECT/CT fusion imaging was helpful in all cases for topographically localizing the tracer foci. Conclusion: 99m Tcglucarate can be considered a potential tracer for the evaluation of patients with head and neck tumors. Al though 18 F-FDG PET has set a new standard for the evaluation of cancer patients (1), the development of new 99m Tc-based SPECT radiopharmaceuticals may become an attractive alternative because of its lower cost and better availability. Glucarate is a 6-carbon dicarboxylic acid, a product of the metabolism of D-glucuronic acid that can be labeled with 99m Tc (2). 99m Tc-glucarate has been described as an agent avid for acute cerebral injury and myocardial infarction (3-7) and as a possible tumor tracer (8-13). The mechanism involved in uptake of 99m Tcglucarate by necrotic cells may be related to binding of the tracer to histones in the cells (14-16). Besides, because of the similarity of 99m Tc-glucarate to fructose, 99m Tcglucarate enters the cell by this metabolically active sugar transport system (8). Furthermore, Ballinger et al. (17) reported that 99m Tc-glucarate showed a 2-to 3-fold enhanced accumulation in hypoxic cells relative to aerobic cells in an in vitro system of cultured ovary fibroblasts.Malignant tumors arising in the head and neck constitute a diagnostically challenging pathology representing about 3% of all newly diagnosed cases of cancer in humans (18). The purpose of this study was to explore the potential of 99m Tc-glucarate to evaluate malignant head and neck tumors by means of SPECT. Additionally, SPECT/CT software fusion was performed to increase diagnostic precision. MATERIALS AND METHODSEleven male patients with advanced head and neck squamous cell carcinoma were included in the study: 9 patients with locally advanced disease enrolled before surgery and 2 patients with clinical suspicion of postsurgical local relapse (Table 1). Imaging was performed at the Clinical Hospital of the University of Uruguay after ethical clearance had been obtained. Before undergoing scintigraphy, all patients had pathologic confirmation of their primary tumors, as well as corresponding conventional imaging examinations. Once written informed consent had been obtained, imaging started 3-6 h after the injection of 1,110 MBq of 99m Tc-glucarate, with a 10-min planar image of the head, neck, and thorax bein...

Tilt suppression refers to both tilting the head away from an Earth vertical axis and a reduction of an induced horizontal nystagmus. This phenomenon of reducing an induced horizontal nystagmus involves a circuitry of neurons within the vestibular nuclei and the cerebellum (collectively referred to as velocity storage) and signals from the otolith end organs. Lesions involving this circuitry can disrupt tilt suppression of induced horizontal nystagmus. We investigated the clinical value of combining the horizontal head-shaking nystagmus test with tilt suppression in 28 patients with unilateral peripheral vestibular hypofunction and 11 patients with lesions affecting the central nervous system. Each of the subjects with peripheral vestibular lesions generated an appropriately directed horizontal nystagmus after head shaking that then suppressed the induced angular slow phase velocity on average 52 ± 17.6% following tilt down of the head. In contrast, patients with central lesions had very little ability to suppress post-head-shaking nystagmus (mean 3.4 ± 56%). We recommend tilting the head after head shaking as a useful clinical test to assist in the differential diagnosis of vertiginous patients. In the case of unilateral peripheral vestibular hypofunction, head tilt suppresses the induced nystagmus via influence of the otolith organ. In the case of central pathology, the inability to suppress the nystagmus is from lesions impairing the otolith mediation on the velocity storage circuitry.