Vestibular function outcomes after vestibular neurectomy in Meniere disease: can vestibular neurectomy provide complete vestibular deafferentation?

OBJECTIVE: Vestibular neurectomy is considered the reference treatment of incapacitating vertigo accompanying Meniere disease, with an efficiency rate of 85-95% in most literature reports. The aim of this study is to evaluate if vestibular neurectomy can provide a complete vestibular deafferentation by investigating complete vestibular function after surgery. METHODS: Prospective study. Twenty-four patients suffering from incapacitated Meniere vertigo crisis beneficiated from a vestibular neurectomy by retrosigmoid approach. The average time between surgery and vestibular evaluation was 1 year. We performed (i) kinetic test, (ii) caloric test and (iii) vibration-induced nystagmus (VIN) at 30, 60 and 100Hz under videonystagmography recording, (iv) vestibular evoked myogenic potentials (VEMP), (v) video head impulsed test (VHIT) for each semicircular canals and (vi) an evaluation of visual vertical and horizontal subjective (VVS and HVS). RESULTS: On clinical evaluation, all the patients except one had never experienced any recurrence of vertigo crisis after surgery. The 24 patients would definitely undergo the surgery again. On vestibular evaluation, on the operated side, all patients showed a total areflexia at caloric test; 23 patients had no VEMP response; 23 patients had abolished canals response to VHIT. All the patients had VVS and HVS deviated towards the operated side; 23 patients had a high velocity VIN from 30 to 60Hz. CONCLUSION: This study proves that vestibular neurectomy can provide a complete vestibular deafferentation. We discuss this vestibular evaluation protocol and the main difficulties encounter during surgery, which could lead to partial nerve section and partial relief, and explain residual vestibular function after vestibular neurectomy.

Vestibular rehabilitation therapy.

Dizziness and balance disorders are frequent complaints in the general population. Vestibular rehabilitation exercises have been shown to be efficient in controlled studies, provided that a precise, individual diagnosis has previously been made. Depending on the pathology, a subject with a peripheral vestibular pathology can benefit from manoeuvres aiming at dislodging or repositioning otoliths, from non-specific muscles strengthening techniques, from techniques for vestibular-ocular or vestibular-cervical stabilisation of gaze, or from physical exercises aimed at strengthening proprioceptive afferents, inhibiting a sensory predominance, or improving spatial orientation and navigation. These analytical exercises should then be implemented in an ecological context in order to favour transfer to daily-living activities. These physical exercises can enable the development of compensation strategies following vestibular damage (habituation, adaptation and substitution).

[Benign positional vertigo, an armchair for diagnosis and for treatment: description and significance]. / Vertige positionnel paroxystique bénin, un fauteuil au service du diagnostic et du traitement: description et intérêt.

OBJECTIVES: The benign positional vertigo is a very frequent pathology. It requires to establish the diagnosis, to fixe the head in some positions to get various nystagmus which are observed directly or by video-nystagmoscopy or analyzed by video-nystagmography. PURPOSE: To describe the diagnostic and therapeutical interests of a special armchair, now available, whose characteristics are to be able to swivel around two axes of vertical and horizontal rotations, the patient being completely interdependent of the armchair. It thus makes it possible to place the patient's head in position wished with a high degree of accuracy and facility. METHODS: After a short description of the characteristics of armchairs classically used, the authors describe in detail this new armchair Its geometrical characteristics are reported and its capacities, like its mode of use: fixing of the patient with armchair then mobilization of the unit "armchair-patient" and setting in position of the head at the point of the space desired by the ENT. RESULTS: The authors report the main advantages of this armchair. It allows a great accuracy of movement given to the semicircular canals, a possible mobilization with an amplitude until there ever reached, a significant reduction of the proprioceptive entries of patient, a perfect safety of the examination, a possible mobilization of obese or arthritic patients and, finally, a very increased comfort for the patient himself. Finally future technological developments possible are brought back. CONCLUSION: Thanks to the use of the armchair of mechanical assistance, the diagnosis and treatment of benign positional vertigo appear more certain, more precise and more practical at the same time for the medical doctor and the patients. A multicentric study is in process to show its interest in this pathology.

[Role of super selective arteriography with embolization in the treatment of severe epistaxis: our experience apropos of 16 cases]. / Place de l'artériographie super sélective avec embolisation dans le traitement des épistaxis graves: notre expérience à propos de 16 cas.

Diagnostic angiography and super selective embolization of the internal maxillary artery were performed on 16 cases between 1990 and 1995. The patients (mean age, 49 years) were treated for severe posterior epistaxis, refractory to local haemostatic therapy (nasal packing alone for the most of them), hypertension was found to be the most frequent predisposing factor, 13 patients had their nose bleeding stopped. Among the 3 failures, were 2 cases of Osler-Weber-Rendu disease, which were subsequently significatively improved by this method. We conclude that angiography with super selective embolization is considered as a valuable diagnostic and therapeutic option in the management of patients with severe epistaxis.

[Our experience on Rendu-Osler disease. Apropos of 19 cases]. / Notre expérience de la maladie de Rendu-Osler. A propos de 19 cas.

We report a synthesis of our experience about the Osler-Weber-Rendu disease, based on a retrospective study of 19 cases collected from 1978 to 1995. Except the almost systematic recourse to anterior or posterior packings in 31% of cases, management of epistaxis in urgency has consisted of arteriography with embolization of the maxillary arteries. In this way, in two third of cases, the control of the epistaxis was obtained. In the other third, it was necessary to associate arteriography to a ligature of the ethmoidal arteries. As part of a preventive treatment of epistaxis we prefer, presently, to inject in situ a fibrin glue, which can be reviewed at the demand. These injections bring only exceptionally complications. The quality and duration of remission is judged satisfactory by the patients in 80% of the cases. Although no physio-pathological explanation can be brought, the intramuscular injections of fibrin glue could increase the duration of remission, which in this way, could diminish the frequency of injections in situ.