Acute peripheral vertigo: involvement of the hemostatic system.

Viral infection is the most frequent cause of unilateral acute peripheral vestibulopathy (APV). Another possible cause is a vascular disorder in the labyrinth area associated with alterations in hemostasis. In a group of 45 patients with APV and in a series of 25 patients with Ménière's disease (control group), we evaluated blood parameters, including total cholesterol, triglycerides, apolipoprotein A and B, lipoprotein (a), homocysteine, folate, prothrombin time, activated partial thromboplastin time. D-dimer, fibrinogen, antithrombin III, protein C, protein S, activated protein C resistance, and anticardiolipin antibodies. In the acute phase of their disease, the patients with APV exhibited increased plasma levels of fibrinogen (341.5 +/- 136.8 standard deviation [SD] versus 268.1 +/- 72.6 SD mg/dl; p = .05); increased plasma levels of D-dimer (305 +/- 158 SD versus 201 +/- 106 SD ng/dl; p = .008); enhanced plasma levels of lipoprotein (a) (42.6 +/- 38.5 SD versus 16.9 +/- 17.7 SD mg/dl; F = 5.67, p = .02); high leukocyte count (9.2 +/- 2.7 SD versus 6.4 +/- 1.2 SD x 10(3)/microliter; F = 8.42, p < .006); and low serum folate concentration (5.1 +/- 1.7 SD versus 7.2 +/- 2.6 SD ng/ml; F = 4.34, p = .04). During follow-up, the prothrombin time was prolonged (p = .04), and leukocyte count was decreased (p < .019) in the patients with APV, whereas fibrinogen, D-dimer, lipoprotein (a), and folate were unchanged. In this study, we demonstrated that patients with APV exhibit significant involvement of the hemostatic system.

Vestibular disorders in primary thrombocytosis.

OBJECTIVE: Balance disturbances are some of the most common symptoms among the clinical manifestations of chronic myeloproliferative disorders (MPDs) with a high platelet count, such as essential thrombocythaemia (ET) and polycythaemia vera (PV). In this study, we evaluated the vestibulo-oculomotor and vestibulospinal reflexes in a group of patients suffering from these diseases. DESIGN: Evaluation of balance disturbances. SETTING: Department of Neurosciences, ENT Unit, University of Pisa, Italy. METHOD: In this study, we evaluated 43 patients suffering from ET and PV who underwent otoneurologic examination, based on a study of the vestibulo-oculomotor and vestibulospinal reflexes. RESULTS: There was exclusive central vestibular involvement in 26 cases (60.4%), peripheral and central signs were associated in 8 cases (18.6%), and the involvement was purely peripheral in 1 patient. In six patients (14%), the otoneurologic examination revealed no alterations. CONCLUSIONS: The high percentage of balance disorders in cases of ET and PV probably depends upon disorders of the microcirculation due to platelet dysfunction. We also postulate a full explanation of the involvement of the central vestibular system on the basis of a greater availability of central activated serotonin acting as neuromediator.

Alternobaric and hyperbaric oxygen therapy in the immediate and long-term treatment of Menière's disease.

Forty-five patients suffering from Menière's disease were submitted to pressure chamber therapy: 20 with constant pressure (2.2 ATA, hyperbaric treatment) and 25 with continuous variations in pressure levels (from 1.7 to 2.2 ATA, alternobaric treatment). Oxygenation therapy consisted of one session per day lasting 90 minutes for 15 days during the acute attacks followed by five consecutive sessions per month during a follow-up of two years. For a control group we used 18 patients treated with 10 per cent intravenous glycerol during the acute episode and 8 mg tid of betahistine thereafter. We compared hearing loss, vertigo and tinnitus in the three groups 15 days after starting treatment and at the end of the follow-up, according to the criteria suggested by the 1995 Committee on Hearing and Equilibrium. We found no statistically significant differences in recovery from the cochlear-vestibular symptoms in the three groups at the end of the first 15 days of therapy, whereas hyperbaric and, in particular, alternobaric treatment permitted a significant control of the principal attacks of vertigo during the follow-up period. Hearing loss also showed a more significant and more persistent improvement in the patients treated with alternobaric oxygenation compared to the patients in the other two groups.

Electrophoretic pattern of physiological human nasal secretions.

Various proteins have been detected in human nasal mucus, but their electrophoretic pattern has not been extensively investigated. Therefore, we have studied this pattern in nasal mucus samples from a group of 40 healthy subjects (20 males and 20 females). The electrophoretic separations have been performed under both native and denaturing conditions. The electrophoretic pattern of nasal mucus obtained under denaturing conditions and stained with Coomassie brilliant blue R-250, reveals 17 distinguishable areas into which protein bands are divided, with no significant variations from one individual to another. Eight of these areas contain high concentrations of nasal mucus proteins, whereas lower concentrations are seen in the other nine areas. The electrophoretic patterns of nasal mucus differs from that of eye mucus. The method used for sampling is rapid, simple, requires no local anaesthetic, and supplies an adequate quantity of proteins for laboratory testing. Electrophoresis under denaturing conditions proves to be the better of the two techniques, since it permits good separation of proteins. Among the protein bands revealed in our study there are some already known proteins (i.a. pre-albumim, albumin, lysozymne), but the presence of other proteins which have yet to be identified cannot be excluded. Hence, a study is underway for the purification and identification, by amino-acid sequencing, of the various proteins which make up each band. A through definition of the protein pattern of nasal mucus might prove useful for detecting anomalies in its composition, for example, in cases of olfactory disorders.

Acupuncture treatment for balance disorders following whiplash injury.

In this study, by means of computerized static posturography, we evaluated the postural changes after acupuncture treatment in a group of 15 patients with balance disorders caused by cervical torsion due to Whiplash Injury (WI). The acupuncture treatment consisted of 3 sessions (one weekly session for 3 weeks) during which the acupuncture points Bladder 10 (Bl.10) and Gall Bladder 20 (G.B.20). VB were stimulated by means of piercing with needles, and manipulating the needles for 20 seconds. Each patient underwent posturographic evaluations before and just after each session of acupuncture. The posturographic tests were performed with open eyes (OE), closed eyes (CE) and closed eyes with retroflexed head (CER). As a control group, we used 17 patients complaining of the same symptoms as the study group due to WI, but treated with drugs (FANS and myorelaxing) and physiotherapy only. The patients of the control group also underwent posturographic tests once a week for three weeks. We observed a significant difference between the two groups regarding the reduction of the CER Length of the statokinesigram just before each session of acupuncture and reduction of the frequency oscillations (FFT) of the patients on the sagittal plane in the study group, in CER, whereas in the control group we observed a progressive increase in these values. The high percentage of positive results in our WI patients leads us to advocate the therapeutic efficacy of acupuncture for balance disorders due to cervical pathology, where it can be associated with or be a valid alternative to pharmacological treatment.

Menière's disease: role of antibodies against basement membrane antigens.

Recently, high levels of anti-collagen II (CII) antibodies have been found in a significant percentage of patients with Menière's disease (MD). An immune response against other collagens (C) present in the basal membranes has also been suggested by the presence of anti-CIV and anti-laminin antibodies in a number of instances of progressive systemic sclerosis (PSS) and Raynaud's phenomenon (RP). The aim of the present study was to measure the levels and frequency of anti-CI, -CII, -CIV, -CV, and anti-laminin antibodies by enzyme-linked immunosorbent assay (ELISA) in 45 patients affected by MD, 24 patients with PSS, 24 patients with RP, and 25 normal subjects. Immunoglobulin G (IgG) anti-CII antibodies were detected in 15.5% of MD sera, and 6.6% of MD sera were positive on CV, 11.1% were positive on laminin, 4.4% were positive on CI, and 4.4% were positive on CIV. A low incidence of anti-CI, -CII, -CIV, -CV, and antilaminin antibodies was found. Positive sera did not react on immunoblot with peptides obtained by cyanogen bromide (CNBr) digestion of CII. These results contrast with those of Yoo, et al.; differences in the washing procedure used and in the ethnic background of the patients may explain this divergence. Our results would seem to indicate that autoimmune responses do not play a role in the pathogenesis of MD.

[Delayed endolymphatic hydrops: an analysis of 12 cases]. / Il "delayed endolymphatic hydrops": valutazione otoneurologica di 12 casi clinici.

Delayed Endolymphatic Hydrops (DEH) is a clinical entity which is characterized by an early phase with a profound sensorineural hearing loss in one ear. After a prolonged period of time (from 1 to 68 years) a late phase of the disease appears with different otologic symptoms. The ipsilateral type of endolymphatic hydrops appears in the deaf ear with consequent episodic vertigo. The contralateral type develops symptoms of endolymphatic hydrop in the previously normal ear, with the onset of fluctuating hearing loss and/or episodic vertigo. This paper is a review of 12 cases of DEH (7 ipsilateral and 5 contralateral, age ranging from 19 to 79 years). Diagnosis was established on the basis of clinical history and the results of audio-vestibular investigations, specifically designed to detect signs of endolymphatic hydrops (including the glycerol-test and neuroradiological imaging of the cerebello-pontine angle). In 8 patients the levels and frequency of anti-collagen I-II-IV-V, anti-laminin autoantibodies, complement, Ig and immuno-complexes were measured. Viral infections (measles, mumps, influenza) were thought to have caused the early phase in 6 cases. In the entire group of 12 patients the delay between the onset of the ear loss and vertigo averaged 12 years. In the group of the ipsilateral DEH, caloric tests showed in 5 cases a reduced or absent response of the deaf ear. About contralateral DEH, caloric tests showed bilateral reduced response in 2 cases, and, in 3 cases, a decreased response only in the previously normal ear. Regarding immunological study, an abnormal level of Ig and Complement was detected in 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of the head shaking test in the posturographic diagnosis]. / L'Utilizzo del head shaking test nella diagnostica posturografica.

This study on equilibrium disturbances employed the Head Shaking Test (HST), with manoeuvres similar to those used in studying the Vestibule Oculomotor Reflex (VOR) as well as the Vestibule Spinal Reflex (VSR), following a posturographic technique. Two hundred and forty-eight patients suffering of equilibrium disturbance of peripheral (168 cases) and central (80 cases) origin underwent study in four different conditions: Open Eyes (OE), Closed Eyes (CE), Open Eyes with Head Retroflection (OER) and Closed Eyes and HST (CE-HST). The results obtained (47.9% positive results to the test) confirm the high sensitivity and specificity of the CE-HST. The correlation with posture alterations, peripheral as well as central, resulted highly significant (P less than 0.0001), with a notable reduction of false negatives. A positive correlation between CE-HST and HST-Ny was not detectable thus confirming two distinct patterns for VOR and VSR. Furthermore, no correlation between CE-HST and postural pathology of cervical or positional origin was documented.

[Immunological aspects of Menière's disease]. / Les aspects immunologiques de la maladie de Ménière.

Among the various aetiopathogenetic hypotheses regarding Ménière's disease, the immunologic one has recently received a considerable amount of interest. Several studies have been performed using specific inner ear antigens (cell-mediated immunity) or by the evolution of circulating autoantibodies (i.e. against type II collagen or immune complex, etc...). We studied the immunological condition of 40 patients suffering from Ménière's disease, through the analysis of the following immunological blood tests: IgG, IgA, IgM, C3c, C4 and C-haemolytic complement level; circulating immune complexes, autoantibodies screening (Rheumatoid and antinuclear factors, mitochondrial smooth muscle and type II collagen antigens), cryoglobulins; T3, T4, T4/T8 monoclonal antibodies. Our results showed a rise in IgG levels in 6 patients (15%) and in IgA level, in 4 patients (10%). IgM blood level were abnormal in only one patient. Complement blood tests showed pathological results in 9 patients. All the patients had normal immunological tests regards to the autoantibody screening and T3, T4, T4/T8 monoclonal antibodies. The immunological results obtained in the patients suffering from Ménière's disease were compared with those of the control group (subjects suffering from vertigo by other causes than Ménière's disease); no significant difference was assessed between the two groups. The abnormal immunological pattern found in a few Ménière patients seems to be due to an aspecific response of the immune system, as the consequence of an alteration of the normal inner ear homeostasis.

[Use of SPECT in the diagnosis of vertigo syndromes of vascular nature]. / Impiego della S.P.E.T. nella diagnosi delle sindromi vertiginose di natura vascolare.

Dizziness is doubtlessly one of the most common symptoms to arise in ischemia of the brainstem. In such cases the circulatory deficit can not only cause a direct lesion of the vestibular structures but it may also block the compensatory process. There are, however, significant difficulties in establishing whether such dizziness can be attributed to a brainstem insufficiency (BI). In fact, both CAT and NMR provide data only in the case of permanent CNS tissue lesions and tests such as the Doppler examination of neck blood vessels are unable to establish the true state of cerebral blood flow. In order to obtain semi-quantitative data regarding cerebral blood flow 99mTc-HMPAO-S.P.E.T. (Single Photon Emission Tomography) was used in 18 patients suffering from dizziness and for whom there was strong indication that the underlying cause could be vascular. There was a discrepancy between the Doppler and S.P.E.T. findings in 50% of the cases. CAT, however, proved negative in all but one of the cases. These data indicate that Doppler testing of the neck blood vessels can provide useful information regarding the status of the cerebral-afferent vessels but that these cannot be correlated to the level of cerebral blood flow. On the other hand, with S.P.E.T., in 15 of the 18 patients, it proved possible to identify significant alterations in cerebral blood flow in the absence of any permanent tissue lesions as those revealed by CAT and NMR. In the light of the present results cerebral S.P.E.T. appears to be a highly valid tool when, faced with dizziness for which a vascular origin is suspected, one must evaluate cerebral prognosis and therapy.

[Posturography in unilateral peripheral vestibular deficiency]. / La posturografia nei deficit unilaterali vestibolari periferici.

A thorough study of vestibular function cannot be limited to the evaluation of VOR alone; it must also include the study of VSR which serves to control erect stance under both static and dynamic conditions. In unilateral peripheral vestibular lesions (UVL) computerized stabilometry makes it possible to perform a more accurate evaluation of the VSR complex through the quantification of "postural sway". Furthermore, the diagnostic potential of stabilometry can be further fine-tuned by introducing a sensitization test, in particular the head retroflexion (OCR) and head shaking (OC-HST) tests. In the present study 61 patients with UVL of various etiology (viral, toxic, vascular, idiopathic) were studied. Besides electrooculography, stabilometry was performed under base conditions (eyes open and closed) and with sensitizing tests (OCR, OC-HST). L and S were used as statokinesigram parameters while frequency and oscillation amplitude on the sagittal and transverse planes were used as stabilogram parameters. Of the 61 UVL patients, 47.5% showed VOR compensation while static postural alterations were found in 31.1%; this raised to 50.8% when the sensitization test was introduced. Apparently the compensation phenomena became manifest more quickly for VOR than for VSR. The introduction of the sensitization test, however, markedly reduced this variance. The two sensitization, maneuvers used provided quantitatively equivalent results although in the absence of reciprocal agreement. Agreement was not even recorded between stabilometric HST and the head shaking test. This confirms the presence of two different routes for VOR and VSR. Nonetheless, the introduction of the sensitization test made it possible to identify those "false negative" VSR cases which were really pathological, thus making it possible to properly identify the patients' condition and arrange for adequate treatment.

Leiomyoma of the nose. A case report.

A case of leiomyoma of the nose is reported. The nose is a very rare site for tumours of myogenic origin. Up to date, only seven cases have been published. Anatomopathological considerations and etiopathogenetic hypotheses are discussed.

[Benign paroxysmal positional vertigo: clinical aspects and medico-legal considerations]. / La vertigine parossistica benigna di posizionamento: aspetti clinici e considerazioni medico-legali.

Benign paroxysmal positional vertigo (BPPV) is quite frequently found as an otological consequence of cranial traumas; thus leading to medico-legal implications. An attempt has herewith been made to evaluate these implications on the basis of data available. Therefore, 158 patients suffering from BPPV were examined between 1984-1986. Of these 23% of the total were post-traumatic forms (of medico-legal interest). Among patients suffering from post-traumatic vestibular disturbances in the broad sense, the incidence of BPPV proved to be greater in the ages ranging from 50 to 70. In those under 30 years of age BPPV was hardly ever present (5% of the total) although when it was its origin was always post-traumatic. The temporal evolution of paroxysmal positional vertigo, which tends to spontaneously disappear, is paralleled in BPPV patients whether it is of post-traumatic origin or not. On the other hand, the subjective sensation of positional vertigo takes longer to clear up in post-traumatic BPPV patients, most likely due to factors stemming from the so-called "compensation syndrome". Any medico-legal evaluation of BPPV must, therefore, take into account its natural favorable evolution. This makes it necessary to examine the patient several times over a period of at least six months from the moment of trauma. In medico-legal terms, the features of BPPV (i.e. position setting it off, duration of vertigo, frequency with which it appears when that position is assumed, presence and duration of the positional nystagmus) lead to inability to work in from 2 to 10% of the cases.

[Comparative studies of the results of caloric vestibular tests and classical torsion swing tests]. / Etude comparative des résultats des épreuves vestibulaires caloriques et de l'épreuve pendulaire classique.

Vestibular Paresis (PL) and Directional Preponderance (PD) are the measurements found on caloric testing described by Fitzgerald and Hallpike (1942); frequency nystagmogram is the typical result of the torsion swing test of the French school. The differences between the two methods stimulated us to make a comparison of the results. Seventy-eight patients affected by unilateral peripheral vestibulopathy in various degree of compensation were submitted to both tests. Frequency nystagmogram was transformed, for calculation purposes, into normalized percentual difference (SSP). SSP and PD were found highly significantly correlated and were considered as equivalent from the statistical point of view. SSP and PL were completely independent at slow velocity stimulation. Using high velocities of stimulation a correlation was demonstrated between SSP and PL; unfortunately to the elevation of SSP corresponds a so minimal increasing of PL that the correlation is scarcely useful from the clinical point of view.

Treatment of ear, nose and throat infections with clofoctol.

Fifty-two adult patients affected by infectious otorhinolaryngological diseases were treated rectally with clofoctol, a new chemotherapeutic phenol derivative. The clinical diagnoses included tonsillitis, paranasal sinus infections, nose and nasopharyngeal infections, external ear canal and middle ear infections. Evaluation of the results was based on clinical and bacteriological data; the effectiveness of the drug was also confirmed by statistical reference to a control group consisting of 52 adult patients affected by otorhinolaryngological infections treated only with topical agents or not treated at all. In the patients treated with clofoctol, good therapeutic results were obtained in over 90% of cases. Only four patients showed mild adverse reactions. On the whole, results demonstrated that clofoctol is very valuable for the management of most of the infectious diseases common in ENT practice.

[The occurrence of nystagmus in sustained sinusoidal stimulation]. / La fréquence nystagmique dans la stimulation sinusoïdale entretenue.

Twenty normal subjects have been submitted to a set of vestibular sinusoidal stimulations, the maximal acceleration per hemiperiod being constant. However the nystagmic response (number of beats per hemiperiod) was not constant, but increased during every single trial. The clinical consequences of this observation are discussed. In particular authors suggest that the classical damped sinusoidal stimulation test should be considered a semi-quantitative test.