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Abstract of the Week


June Topic:  Meniere's Disease

No 521: June 10, 2020


Efficacy of Intratympanic Gentamicin in Menière's Disease With and Without Migraine

Liu YF, Renk E, Rauch SD, Xu HX. Efficacy of Intratympanic Gentamicin in Menière's Disease With and Without Migraine. Otol Neurotol. 2017;38(7):1005‐1009. doi:10.1097/MAO.0000000000001460
Objective: To compare the efficacy of intratympanic gentamicin injection (ITG) on vertigo control, drop attacks, and functional level in Menière's disease patients with and without a history of migraine.
Patients: Menière's disease patients (patients with migraine and age- and sex-matched control patients without migraine) treated from 2002 to 2012 who failed medical management and received ITG, with a minimum 2-year follow up.
Intervention: ITG.
Main outcome measures: Vertigo control, drop attack prevalence, and change in functional level.
Results: Twenty-eight Menière's disease patients were included in this study (14 with migraine and 14 matched patients without migraine). There were three men and 11 women in each groups, with a mean age of 53 ± 8.9 years. Baseline characteristics (Menière's stage, vertigo frequency, drop attack prevalence, and functional level) before ITG were not significantly different between the two groups. Two years after ITG, 71% of Menière's disease with migraine patients and 78% of Menière's disease without migraine patients had class A, B, or C vertigo control (p > 0.999). Change in prevalence of drop attacks (43-7% versus 50-0%, respectively) was also similar (p > 0.999). However, significantly fewer vertigo control class A, B, and C migraine patients achieved functional level 1 or 2 (40%) compared with non-migraine patients (91%) (p = 0.007).
Conclusions: Although ITG appears equally effective in treating vertigo and drop attacks in Menière's disease with and without migraine, patients with migraine derive significantly less benefit in terms of functional improvement.
PMID: 28538472


No 520: June 4, 2020


Patient Perceptions of Effectiveness in Treatments for Menière’s Disease: a National Survey in Italy
Ward B, Wettstein V, Golding J, et al. Patient Perceptions of Effectiveness in Treatments for Menière's Disease: a National Survey in Italy. J Int Adv Otol. 2019;15(1):112‐117. doi:10.5152/iao.2019.5758
Objectives: The aim of the present study was to investigate current treatment practices and self-reported effectiveness in Ménière's disease.
Materials and methods: Members of two Italian Ménière's disease support (n=170) with ≥6-month history of Ménière's disease were administered an online survey about recent treatments. Vertigo episode count, work absenteeism, and limitations in family life, social life, work, or travel as included in the Social Life and Work Impact of Dizziness Questionnaire before and after recent treatments were queried.
Results: Twenty-four different treatments were reported for Ménière's disease, with dietary modifications (55%), diuretics (47%), and betahistine (41%) being the most common. The majority (71%) received multiple simultaneous treatments. Prior to the most recent treatments, 78%-89% of respondents indicated limitations in family or social life, work, or traveling. After their most recent treatment, respondents reported improvements in mean vertigo episode counts (5.7±7.6 vs. 2.6±4.6, p<0.001), days off work per month (10.1±9.2 vs. 4.2±6.7, p<0.001), and proportions indicating limitations in any functional measure assessed (p<0.05). These findings were consistent regardless of treatment approach (p<0.05 for all). Intratympanic gentamicin provided the greatest reductions in vertigo count, functional limitations, and work absenteeism (p<0.01 for all), as well as the fewest respondents reporting post-treatment functional limitations (16%-37%).
Conclusion: Despite many treatment approaches targeting different proposed pathophysiology for Ménière's disease in this cross-sectional survey, all treatments are reported as effective by patients. These findings support a prominent placebo effect in Ménière's disease and highlight challenges in studying treatment outcomes; there is a critical need to better understand Ménière's disease.
PMID: 28538472
PMCID: PMC6483453


May Topic:  Bilateral Vestibular Deficit and Cochlear Implants

No 519: May 28, 2020


Prospective cohort study on the predictors of fall risk in 119 patients with bilateral vestibulopathy

Dobbels B, Lucieer F, Mertens G, Gilles A, Moyaert J, van de Heyning P, Guinand N, Pérez Fornos A, Herssens N, Hallemans A, Vereeck L, Vanderveken O, Van Rompaey V, van de Berg R. Prospective cohort study on the predictors of fall risk in 119 patients with bilateral vestibulopathy. PLoS One. 2020 Mar 9;15(3):e0228768. doi: 10.1371/journal.pone.0228768. eCollection 2020.
OBJECTIVES: To identify predictive factors for falls in patients with bilateral vestibulopathy (BV). Specific variables contributing to the general work-up of a vestibular patient were compared between BV patients experiencing falls and those who did not.
DESIGN: Prospective multi-centric cohort study.
SETTING: Department of Otorhinolaryngology & Head and Neck Surgery at two tertiary referral centers: Antwerp University Hospital and Maastricht University Medical Center.
PARTICIPANTS: In total, 119 BV patients were included. BV diagnosis was defined in accordance with the diagnostic BV criteria, established by the Bárány Society in 2017.
MAIN OUTCOME MEASURES: Patients were divided into fallers and non-fallers, depending on the experience of one or more falls in the preceding 12 months. Residual vestibular function on caloric testing, rotatory chair testing, video head impulse test (vHIT) and cervical vestibular evoked myogenic potentials (cVEMP) was evaluated as a predictive factor for falls. Furthermore, hearing function (speech perception in noise (SPIN)), sound localization performance, etiology, disease duration, sport practice, scores on the Dizziness Handicap Inventory (DHI) and the Oscillopsia Severity Questionnaire (OSQ) were compared between fallers and non-fallers.
RESULTS: Forty-five (39%) patients reported falls. In a sub-analysis in the patients recruited at UZA (n = 69), 20% experienced three or more falls and three patients (4%) suffered from severe fall-related injuries. The DHI score and the OSQ score were significantly higher in fallers. Residual vestibular function, SPIN, sound localization performance, etiology, disease duration, age and sport practice did not differ between fallers and non-fallers.
CONCLUSIONS: Falls and (severe) fall-related injuries are frequent among BV patients. A DHI score > 47 and an OSQ score > 27.5 might be indicative for BV patients at risk for falls, with a sensitivity of 70% and specificity of 60%. Residual vestibular function captured by single vestibular tests (vHIT, calorics, rotatory chair, cVEMP) or by overall vestibular function defined as the number of impaired vestibular sensors are not suitable to distinguish fallers and non-fallers in a BV population.
PMID: 32150553
PMCID: PMC7062241


No 518: May 20, 2020


BalanCI: Head-Referenced Cochlear Implant Stimulation Improves Balance in Children with Bilateral Cochleovestibular Loss
Wolter NE, Gordon KA, Campos JL, Vilchez Madrigal LD, Pothier DD, Hughes CO, Papsin BC, Cushing SL.BalanCI: Head-Referenced Cochlear Implant Stimulation Improves Balance in Children with Bilateral Cochleovestibular Loss. Audiol Neurootol. 2020;25(1-2):60-71. doi: 10.1159/000503135. Epub 2019 Nov 1.
INTRODUCTION: To determine the impact of a head-referenced cochlear implant (CI) stimulation system, BalanCI, on balance and postural control in children with bilateral cochleovestibular loss (BCVL) who use bilateral CI.
METHODS: Prospective, blinded case-control study. Balance and postural control testing occurred in two settings: (1) quiet clinical setting and (2) immersive realistic virtual environment (Challenging Environment Assessment Laboratory [CEAL], Toronto Rehabilitation Institute). Postural control was assessed in 16 and balance in 10 children with BCVL who use bilateral CI, along with 10 typically developing children. Children with neuromotor, cognitive, or visual deficits that would prevent them from performing the tests were excluded. Children wore the BalanCI, which is a head-mounted device that couples with their CIs through the audio port and provides head-referenced spatial information delivered via the intracochlear electrode array. Postural control was measured by center of pressure (COP) and time to fall using the WiiTM (Nintendo, WA, USA) Balance Board for feet and the BalanCI for head, during the administration of the Modified Clinical Test of Sensory Interaction in Balance (CTSIB-M). The COP of the head and feet were assessed for change by deviation, measured as root mean square around the COP (COP-RMS), rate of deviation (COP-RMS/duration), and rate of path length change from center (COP-velocity). Balance was assessed by the Bruininks-Oseretsky Test of Motor Proficiency 2, balance subtest (BOT-2), specifically, BOT-2 score as well as time to fall/fault.
In the virtual environment, children demonstrated more stable balance when using BalanCI as measured by an improvement in BOT-2 scores. In a quiet clinical setting, the use of BalanCI led to improved postural control as demonstrated by significant reductions in COP-RMS and COP-velocity. With the use of BalanCI, the number of falls/faults was significantly reduced and time to fall increased.
CONCLUSIONS: BalanCI is a simple and effective means of improving postural control and balance in children with BCVL who use bilateral CI. BalanCI could potentially improve the safety of these children, reduce the effort they expend maintaining balance and allow them to take part in more complex balance tasks where sensory information may be limited and/or noisy.
PMID: 31678979

No 517: May 13, 2020


Balance, gait and dizziness in adult cochlear implant users: A cross sectional study

Murray D, Viani L, Garvan J, Murphy A, Vance R, Simoes-Franklin C, Smith J, Meldrum D. Balance, gait and dizziness in adult cochlear implant users: A cross sectional study. Cochlear Implants Int. 2020 Jan;21(1):46-52. doi: 10.1080/14670100.2019.1662978. Epub 2019 Sep 18.

Objective: Cochlear implantation is associated with vestibular impairment due to the close proximity of the structures. The aim of the study was to quantify dizziness/vertigo, gaze instability, balance and gait problems in a sample of adult cochlear implant (CI) users.
Methods: An observational, cross sectional study evaluated subjective dizziness (Vestibular Rehabilitation Benefit Questionnaire (VRBQ)), balance confidence (Activities Specific Balance Questionnaire (ABC)), gait (Functional Gait Assessment (FGA) and 10m walk test), balance (Equitest Sensory Organisation Test (SOT)), and computerised dynamic visual acuity (DVA). The Dix Hallpike test was performed to test for benign paroxysmal positional vertigo (BPPV).
Results: Twenty participants (n=10F), 2.8(±2.7) years post implantation, with mean age 59.3(±15.8) years were assessed. Subjective dizziness (VRBQ) was low (15.0% (±15.5)) and balance confidence was high (ABC: 82.1%±14.9). FGA scores (25.1 ± 4.4) and gait speed (1.8 (±0.3) m/sec) were below normal. Dx Hallpike was positive in 3. Gaze instability was found in 50% (DVA loss, 0.29 (± 0.16) LogMAR), while 79% demonstrated balance impairment (mean SOT score, 57.8%±14.5), with 42% falling on SOT condition 5.
Discussion: Evidence of vestibular dysfunction was identified in these adult CI users.
Conclusion: Access to vestibular function assessment and rehabilitation is required in adult CI users.

PMID: 31530102


No 516: May 5, 2020

Smartphone telemedical emergency department consults for screening of nonacute dizziness

Lerchundi F, Laffue AH, Olivier M, Gualtieri FJ. Bilateral posterior semicircular canal dysfunction: a new finding with video head impulse test. J Neurol. 2020 Apr 28. doi: 10.1007/s00415-020-09793-5. [Epub ahead of print]


Development of the video head impulse test (vHIT) assessing all three semicircular canals in both labyrinths has uncovered the existence of new vestibular failure patterns and made bilateral posterior canal dysfunction detection possible. We conducted a retrospective analysis of 41 patients with bilateral posterior semicircular canal failure and compared results to 37 controls, with normal posterior semicircular canal function. Mean calculated gain showed significant difference between patients and controls in right [0.54 (SD 0.016)] and left [0.57 (SD 0.014)] posterior semicircular canals. There was a peak in prevalence between 71 and 80 years. Presentation was chronic in 78% of patients, and gait instability was the most common complaint. Sixty eight percent of cases were classified as idiopathic. Significant difference between groups was seen regarding the presence of Meniere's disease, presbycusis, and positional down-beat nystagmus (posDBN). This new vHIT pattern is most often seen in elderly patients, mainly of idiopathic etiology and presents together with sensorineural hearing loss and posDBN. Our findings suggest idiopathic cases may well contribute to the so-called "presbyastasis".
PMID: 32347336

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