Cochleo-Vestibular Disorders in Herpes Zoster Oticus: A Literature Review and a Case of Bilateral Vestibular Hypofunction in Unilateral HZO.

The varicella-zoster virus (VZV), a member of the Herpesviridae family, causes both the initial varicella infection and subsequent zoster episodes. Disorders of the eighth cranial nerve are common in people with herpes zoster oticus (HZO). We performed a review of the literature on different databases including PubMed and SCOPUS, focusing on cochlear and vestibular symptoms; 38 studies were considered in our review. A high percentage of cases of HZO provokes cochlear and vestibular symptoms, hearing loss and vertigo, whose onset is normally preceded by vesicles on the external ear. It is still under debate if the sites of damage are the inferior/superior vestibular nerves and cochlear nerves or a direct localization of the infection in the inner ear. The involvement of other contiguous cranial nerves has also been reported in a few cases. We report the case of a patient with single-side HZO presenting clinical manifestations of cochleo-vestibular damage without neurological and meningeal signs; after 15 days, the patient developed a new episode of vertigo with clinical findings of acute contralateral vestibular loss. To our knowledge, only three other such cases have been published. An autoimmune etiology may be considered to explain these findings.

Similarities and Differences between Vestibular Migraine and Recurrent Vestibular Symptoms-Not Otherwise Specified (RVS-NOS).

Menière's disease and vestibular migraine (VM) are two common inner ear disorders whose diagnoses are based on clinical history and audiometric exams. In some cases, patients have been reporting different episodes of vertigo for years but not fulfilling the Bárány Society criteria for either. These are called Recurrent Vestibular Symptoms-Not Otherwise Specified (RVS-NOS). It is still under debate if this is a single disease entity or a part of the spectrum of already established disorders. The purpose of our work was to establish similarities and differences with VM in terms of clinical history, bedside examination, and family history. We enrolled 28 patients with RVS-NOS who were followed for at least 3 years with stable diagnosis; results were compared with those of 34 subjects having a diagnosis of definite VM. The age of onset of vertigo was lower in VM than in RVS-NOS (31.2 vs. 38.4 years). As for the duration of attacks and symptoms, we detected no differences other than subjects with RVS-NOS reporting milder attacks. Cochlear accompanying symptoms were more frequently reported by VM subjects (one subject reporting tinnitus and another one reported tinnitus and fullness). Motion sickness was equally reported by subjects across two samples (around 50% for both). Bipositional long-lasting, non-paroxysmal nystagmus was the most common finding in the two groups, with no significant difference. Finally, the percentage of familial cases of migrainous headache and episodic vertigo did not differ between the two samples. In conclusion, RVS-NOS shares some common aspects with VM, including the temporal profile of attacks, motion sickness (commonly considered a migraine precursor), bedside examination, and family history. Our results are not inconsistent with the possibility that RVS-NOS may be a heterogeneous disorder, even if some of these subjects may share common pathophysiological mechanisms with VM.

Recurrence of benign paroxysmal positional vertigo: experience in 3042 patients.

OBJECTIVES: Benign paroxysmal positional vertigo (BPPV) is a disorder of the inner ear with a high rate of recurrence. Vascular disorders, migraine and autoimmune disorders have been considered facilitating factors for relapsing episodes. Our aim was to assess the role of vascular disorders, migraine and anti-thyroid antibodies in patients with recurrences. METHODS: We retrospectively analysed records of 3042 patients treated for BPPV without other lifetime vertigo. Clinical data included previous vascular disorders of the central nervous system, heart disorders, migraine and recent head trauma. The presence of anti-thyroid autoantibodies was assessed in all patients. RESULTS: Mean age of the first BPPV was 52.8 ± 14.5 years; there were 2339 females (76.9%), while 2048 (67.3%) of patients presented recurrences within two years of follow-up. Previous disorders of the central nervous system, presence of anti-thyroid antibodies, head trauma and migraine showed an association with recurrences. Above all, in subjects having the first BPPV while aged between 40 and 60 years, anti-thyroid antibodies were predictive for recurrences. CONCLUSIONS: Our data are consistent with the hypothesis that anti-thyroid autoantibodies may play a role in recurrences in subjects with initial manifestations between 40 and 60 years.

Skull Vibration-Induced Nystagmus Test (SVINT) in Vestibular Migraine and Menière's Disease.

BACKGROUND: Vestibular migraine (VM) and Menière's disease (MD) are the two most frequent episodic vertigo apart from Benign Paroxysmal Positional Vertigo (BPPV) differential diagnosis for them may be troublesome in the early stages. SVINT is a newly proposed vestibular test, which demonstrated to be fast and reliable in diagnoses above all of peripheral vestibular deficits. METHODS: We retrieved clinical data from two groups of subjects (200 VM and 605 MD), enrolled between 2010 and 2020. Among others, these subjects were included when performing a SVINT. The purpose of the study is to assess if SVINT can be useful to differentiate the two episodic disorders. RESULTS: 59.2% of MD subjects presented as positive with SVINT while only 6% did so with VM; among other tests, only video HIT demonstrated a different frequency in the two groups (13.1% and 0.5%, respectively), but the low sensitivity in these subjects makes the test unaffordable for diagnostic purposes. CONCLUSIONS: Since SVINT demonstrated to be positive in a peripheral vestibular deficit in previous works, we think that our data are consistent with the hypothesis that, in the pathophysiology of VM attacks, the central vestibular pathways are mainly involved.

A Family with a High Incidence of Migraine and Vestibular Migraine and a Case of Menière's Disease.

Vestibular migraine (VM) and Menière's disease (MD) are common neurotological disorders causing episodic vertigo. Sometimes, VM is accompanied by cochlear symptoms suggestive for MD. Therefore, in those cases, the differential diagnosis between the two disorders can be difficult. Moreover, a comorbidity with migraine in MD patients is widely reported, up to the hypothesis of a possible MD-VM overlapping syndrome. In this brief case report, we consider the clinical history of a family presenting high incidence of subjects fulfilling the diagnostic criteria of VM and single case fulfilling criteria for definite MD. The relationship between VM and MD is still under debate; anyway, it can be speculated that commonly shared genetic mutations could play a role as predisposing factors in both disorders. A congenital nystagmus in the family was present too, but its correlation with the other conditions is still not clear. Future goal of our work will be to assess genetics in this family.

Vertigo without cochlear symptoms: vestibular migraine or Menière disease?

BACKGROUND: Menière's disease (MD) is an inner ear disorder due to raised endolymphatic pressure (hydrops), characterized by cochlear symptoms associated with episodic vertigo. In delayed hydrops, vertigo attacks begin long after the onset of a hearing loss. Few were published on MD in which the onset of vertigo precedes cochlear symptoms by several months. Vestibular migraine (VM) is also a cause of episodic vertigo and an association between migraine and MD was proposed. Purpose of our retrospective work was to assess clinical features associated with MD in which vertigo precedes by months cochlear symptoms. METHODS: Our sample was composed by 28 subjects reporting episodic vertigo accompanied by migrainous headache or photo-phonophobia, without cochlear symptoms at onset; during follow-up, all patients developed cochlear symptoms leading to a diagnosis of MD. Results of bedside examination were compared with those of 48 VM subjects with diagnosis of VM confirmed in the follow-up. All subjects performed a bedside examination, including head-shaking, positional, and skull vibration test (SVIN). RESULTS: SVIN was more frequent in MD, while positive positional test in VM. In the entire group of 72 subjects, migrainous headache during vertigo and positive positional test were correlated with a final diagnosis of VM. CONCLUSIONS: Our data are not inconsistent with the hypothesis that in patients reporting only photo-phonophobia during vertigo attacks and with a positive SVIN, the clinical manifestations may be predictive for evolution toward a MD, while migrainous headache and positive positional tests more frequently are correlated to VM.

Alexithymia in Patients with Ménière Disease: A Possible Role on Anxiety and Depression.

The aim of this paper was to investigate the role of the psychological variable of alexithymia both as a risk factor for the development of Ménière's disease (MD) and as a component that influences the personal experience of MD and the individual quality of life. We collected data from 179 Italian patients who fulfilled criteria for definite MD. Patients filled out validated self-rating questionnaires to assess alexithymia (TAS-20), quality of life (WHOQOL-BREF), anxiety and depression (HADS), perception of stress (PSS) and coping strategies (COPE). Socio-demographic data and MD clinical features were collected using a specific rating form. Subjects affected by MD showed higher levels of alexithymia compared to general population. Among MD patients, those characterized by high levels of alexithymia revealed a significant increase in anxiety and depression, greater perceived stress, a lower quality of life in psychological health and social relationships domains and the use of less mature coping strategies in comparison with MD patients with low or absent alexithymia. Our preliminary data could help in hypothesizing a role of psychological functioning in MD development and in the adaptation to the disease. The presence of alexithymia in patients suffering from MD may constitute a risk factor for the development of anxiety and depression symptoms; greater perceived stress and for poorer psychological and relational quality of life. Therefore, our study design did not allow causal inferences and further studies are needed.

Evaluation of a large cohort of adult patients with Ménière's disease: bedside and clinical history.

OBJECTIVE: The purpose of this study was to assess vestibular findings and clinical history in a large cohort of patients affected by Ménière's disease. METHODS: We retrospectively analysed 511 adult patients fulfilling criteria for definite unilateral Ménière's disease according to Barany Society. Thorough clinical history, audiometric exam, central nervous system MRI, quantification of serum autoantibodies and complete vestibular function test were performed. RESULTS: Mean age at clinical record was 55.4 years, while age at onset of the first vertigo attack was 47.4 ± 14.3 years. Ménière's disease overlapped with migraine in 43.4% of patients. In 31.7% of cases, positivity was found for at least one autoantibody. Forty-nine patients (9.6%) had family history for Ménière's disease. Bedside examination resulted in 14.7% positivity for video head impulse test, 58.9% for skull vibration-induced nystagmus, 38.7% for the positional test and 23.1% for the post head shaking test. Complete negative examination was reported in 115 cases. CONCLUSIONS: Ménière's disease was seen to present a characteristic phenotypic pattern in our cohort, confirming the crucial role of thorough anamnesis and bedside examination in diagnosis.

Functional Head Impulse Test With and Without Optokinetic Stimulation in Subjects With Persistent Postural Perceptual Dizziness (PPPD): Preliminary Report.

OBJECTIVE: Persistent postural perceptual dizziness (PPPD) is a clinical condition characterized by unsteadiness present on most days for a period of at least 3 months. The aim of our work was to assess vestibular function, the role of anxiety, and possible interactions between visual and vestibular systems in patients with PPPD. STUDY DESIGN: Cross-sectional prospective study. SETTING: Tertiary referral center. PATIENTS: Twenty-five PPPD patients. INTERVENTIONS: Clinical history was collected before examination; vestibular function was assessed through bedside examination, video and functional head impulse test (video-HIT, f-HIT). The latter test was based on having the patient identify an optotype displayed on a computer screen during passive head rotations. The test was repeated while optokinetic stimulation (OKS) was given on the screen. Results were compared with those of 25 controls. State and trait anxiety levels were measured with the State-Trait Anxiety Inventory (STAI) questionnaire. Anxiety before and after vestibular examination was assessed using a VAS scale. MAIN OUTCOME MEASURE: Results of video and functional HIT with and without OKS. RESULTS: Video-HIT and f-HIT showed normal values in all subjects. f-HIT with OKS provoked more reading errors in patients than in controls. The interaction of group per time detected different decreasing trends between the two groups (p = 0.0002).Patients presented a reduction in anxiety levels after examination. Nine patients fulfilled diagnostic criteria for vestibular migraine, eight of whom presented nystagmus either to positional tests or vibration test. Only anxiety levels before testing were predictive of worsening of f-HIT with optokinetic stimulation (p = 0.0007). CONCLUSIONS: Our data support the hypothesis that increased anxiety may play a role in visuo-vestibular interactions; moreover, they are not inconsistent with the hypothesis that OKS might provoke a "threatening effect," leading to gaze bias during examination.

Decrease of Horizontal Canal Vestibulo-Oculomotor Reflex Gain in the Elderly with Dysequilibrium without Lifetime Vertigo.

BACKGROUND/AIMS: Unsteadiness in the elderly is a frequent complaint and a strong predictor of falls and psychological distress. Although there is a general consensus that it is a multifactorial condition, recent studies have focused on the role of aging of the vestibular system as a possible cofactor. The aim of our work was to assess horizontal canal function in the elderly. METHODS: We evaluated the gain of horizontal vestibulo-ocular reflex (VOR) with a video head impulse test on a sample of 58 subjects aged >70 years without lifetime episodes of vertigo and correlated the value with different clinical conditions (hypertension, diabetes, prior cardiovascular and vascular disorders of the central nervous system, and falls). RESULTS: The mean value of the gain was 0.86 ± 0.12, and people aged between 70 and 80 years presented higher values (0.90 ± 0.1) compared to those >80 years (0.81 ± 0.13; p = 0.025). Previous vascular disorders of the central nervous system were a predictor of decreased VOR gain (p = 0.0003). A nonparametric analysis demonstrated that sex, age, and VOR gain (p ˂ 0.0001) were predictive of falls. CONCLUSIONS: Our data support the hypothesis of a decrease of VOR gain in the elderly. The decrease of canal function may therefore play a role in the risk of falls in the elderly.

Intratympanic gentamicin treatment 'as needed' for Meniere's disease. Long-term analysis using the Kaplan-Meier method.

In recent years, several titration or on-demand protocols using low-dose repeated intratympanic (IT) gentamicin injections have been adopted for the vertigo control in unilateral medical refractory Menière's disease (MD). Because of the frequent recurrence and the need to treat the patients several times, it is difficult to strictly follow the 1995 AAO-HNS criteria to classify the results. The Kaplan-Meier analysis provides an effective and simpler method to address these concerns. We report the results of a long-term study (7 years) on a large population of MD patients (174) treated with on-request low-dose delayed IT gentamicin injections analysed using the Kaplan-Meier survival method. Effective vertigo control was obtained with a single injection in 40.2% of the patients (excellent responders) and with repeated injections (2-9) in 43.7% of the patients (moderate responders). Only six patients (3.5%) needed to be submitted to vestibular neurectomy because of the persistence of vertigo attacks (non-responders). A subgroup of 22 patients (12.6%) reporting a late recurrence of vertigo attacks after an initial vertigo-free interval lasting more than 2 years (short-term responders) were successfully treated with a further cycle of injections. In no cases, we observed significant signs of cochlear or vestibular toxicity. Kaplan-Meier survival analysis provided an excellent method for reporting treatment success or failure in patients followed for variable length of time with our kind of protocol.

Residual dizziness after successful repositioning maneuvers for idiopathic benign paroxysmal positional vertigo.

OBJECTIVE: To establish a possible causal factor for residual dizziness (RD) after successful repositioning maneuvers in patients with benign paroxysmal positional vertigo (BPPV). MATERIALS AND METHOD: Ninety consecutive patients with idiopathic BPPV were treated with repositioning maneuvers, and the rate of RD was assessed as well as clinical data. Posturography and assessment of anxiety levels were performed on patients reporting RD. Results were compared with a control group of BPPV patients of the sample after repositioning maneuvers and without RD. RESULTS: Twenty-eight subjects (31.1%) reported RD on the second day after successful repositioning maneuvers. The mean duration of RD was 11.6 ± 3.9 days. Patients with RD presented a higher duration of BPPV (14.1 vs. 10.9 days, p = 0.01). A correlation was demonstrated between the duration of BPPV and duration of RD (p < 0.01). Subjects with RD presented increased body sways, above all in eyes-closed conditions. CONCLUSION: RD is mainly correlated with duration of vertigo in BPPV patients. Anxiety was demonstrated to play a role in increased body sways.

Acute respiratory distress in patient with laryngeal schwannoma.

Schwannoma is a neurogenic benign tumour arising from the proliferation of Schwann cells present in the peripheral nerve sheath of myelinated nerves. This proliferation can hypothetically appear in every anatomic region of the human body, but the nerve sheath tumors rarely occur within the larynx. In this paper the authors discuss the case of a 74-year-old female who presented to Emergency Unit (EU) for an important acute respiratory distress. Airway flexible endoscopy revealed a bulky mass of the aryepiglottic fold measuring 3.5 cm in diameter. The patient underwent tracheotomy and a single-step surgical excision treatment of the mass which was recognized as a schwannoma at pathological examination. Tracheotomy was closed 2 weeks postoperatively. After 18 months of followup, the patient is alive and free of disease and her voice had improved markedly.