Physical and Emotional Burden of the Epley Maneuver in the Elderly.

OBJECTIVE: To analyze and compare experiences of anxiety and discomfort caused by the Epley maneuver and the willingness for a potential retreatment between younger (≤70 yr) and older (>70 yr) patients. STUDY DESIGN: Prospective, observational cohort study. SETTING: Tertiary referral center. METHODS: Dutch adults, diagnosed with posterior canal benign paroxysmal positional vertigo, were included. Patients with dementia or subjected to an Epley maneuver ≤4 months before the hospital visit were excluded. Patients were asked about their experiences with the Epley maneuver directly after the maneuver, after 2 weeks and after 2 months. Differences in experiences between the age groups were tested with the Fisher's exact test and subgroup analyses were performed using multivariable logistic regression. RESULTS: Out of 179 included patients, 115 (64%) were aged ≤70 and 134 (75%) were female. In both groups, 25% reported anxiety directly after the Epley maneuver. Two weeks later, 19 and 27%, respectively (p = 0.26) reported anxiety. In the young group, 30% expressed discomfort directly after treatment compared with 45% in the elderly (OR 1.98, 95% CI 1.05-3.75, p = 0.04). Two weeks later, this was 36 and 38%, respectively (p = 0.87). This decreased to 24 and 33%, respectively (p = 0.37), after 2 months. There was no significant difference in willingness for potential retreatment between both groups after 2 weeks (93 and 95%, respectively, p = 0.75) nor after 2 months (97 and 92%, respectively, p = 0.13). CONCLUSION: The Epley maneuver results in little anxiety and discomfort both in young and in elderly patients. Most patients show willingness for potential retreatment in case symptoms recur.

Unilateral otolith centrifugation by head tilt.

BACKGROUND: To test for otolith asymmetries, several studies described horizontal translation of the body and head en bloc during fast vertical axis rotation. This stimulus causes one otolithic organ to rotate on-axis, and the other to experience centripetal acceleration. OBJECTIVE: To test a new, more simple method of unilateral stimulation with head tilt and the body remaining on axis. METHODS: During stationary and during 360 deg/s rotation, 12 healthy blindfolded subjects had their heads tilted 30 degrees sideways, positioning one otolithic organ on the axis of rotation after the other. The haptic subjective vertical (SV) was recorded several times by means of a manually adjustable rod. RESULTS: It was found that during stationary the SV tilted about 4 degrees on average in the direction of the head. During rotation, the SV tilted about 9 degrees on average. We therefore estimate the effect of eccentric otolith rotation to be 5 degrees on average. CONCLUSIONS: Tilt of the subjective vertical induced by head tilt during on-axis body rotation can provide a relatively uncomplicated alternative to test unilateral otolithic function as compared to body and head translation during rotation. Moreover, unlike eccentric rotation of the entire body, somatosensory cues are minimized by keeping the body fixed on axis and by subtracting the effect of head tilt per se.

Perioperative bone-conducted ocular vestibular-evoked myogenic potentials in otosclerosis patients.

OBJECTIVE: Vestibular symptoms are seen variably in patients with otosclerosis, both in patients with the disease and in patients after treatment with stapes surgery. The goal of this study was to objectify any changes of the bone-conducted (BC) ocular vestibular evoked myogenic potentials (oVEMPs) in patients with otosclerosis before and after stapes surgery. STUDY DESIGN: Twenty-six healthy subjects and 27 patients with otosclerosis were tested in a tertiary care center, and 11 of the patients were tested preoperatively and postoperatively. The ears of patients were divided in 4 groups: normal ears, otosclerotic ears, ears after primary stapes surgery, and ears after revision surgery. The stimulus used in oVEMP testing was a BC stimulus delivered by a mini-shaker at stimulus frequencies of 250 and 500 Hz. oVEMP characteristics were the n1 and p1 latencies, n1 - p1 amplitude, and threshold. RESULTS: No significant differences were seen in all oVEMP characteristics between the 4 groups of ears without surgery nor in the ears that were tested preoperatively and postoperatively. CONCLUSION: No or undetectably little damage to the utricle is caused by both otosclerotic disease and stapes surgery. There is no additive value of screening with BC oVEMPs perioperatively in otosclerotic patients.

Ocular vestibular evoked myogenic potentials: frequency tuning to air-conducted acoustic stimuli in healthy subjects and Ménière's disease.

Ocular vestibular evoked myogenic potentials (oVEMP) in response to 250-, 500- and 1000-Hz air-conducted short tone bursts were studied in 22 healthy subjects and 37 Ménière's disease patients. The goal of this study was to investigate normal tuning characteristics of the oVEMP and the possible oVEMP changes with respect to frequency dependence in Ménière's disease. In unilateral Ménière's disease patients, a distinction was made between affected ears and unaffected ears. It was found that in normal subjects, the oVEMP tunes to a stimulus frequency of 500 Hz, with the highest amplitude and lowest threshold at this particular frequency. Generally, Ménière's disease patients showed lower amplitudes and higher thresholds than normal subjects at all 3 stimulus frequencies in both the affected and the unaffected ear. Additionally, for ears affected by Ménière's disease, the best stimulus frequency was 1000 Hz. With the use of this altered tuning for these ears, we tried to find a criterion for distinguishing normal from Ménière's disease ears.

Ocular vestibular evoked myogenic potentials in response to air-conducted sound in Ménière's disease.

BACKGROUND: Currently, Ménière's disease is predominantly diagnosed through clinical criteria. Additional standard vestibular testing, such as nystagmography, can show variable responses. In the last decade, the cervical vestibular evoked myogenic potential (VEMP) has shown to be of additive value in diagnosing Ménière's disease. In this study, the results of the ocular VEMP (oVEMP) in response to air-conducted sound will be discussed. OBJECTIVES: To evaluate possible changes of the oVEMP in a large group (n = 37) of patients with Ménière's disease. MATERIAL AND METHODS: In 55 subjects without Ménière's disease and 37 patients with Ménière's disease, oVEMPs in response to air-conducted sound stimulation (tone-burst, 500 Hz; maximum stimulus level, 120 dB sound pressure level) were studied. Recording was performed in upgaze with surface electrodes underneath both eyes. The burden of the test was scored by all subjects on a visual analogue scale. RESULTS: In patients with Ménière's disease the response rates are lower, the oVEMP amplitudes are smaller, and thresholds are higher than in subjects without Ménière's disease. This effect is observed in both ears of patients with Ménière's disease. The affected ear is more altered than the clinically unaffected ear. CONCLUSION: The air-conducted oVEMP can be a relevant addition to the current diagnostic workup of patients with possible Ménière's disease. A lower response rate, smaller amplitude, and higher threshold of the oVEMP indicate the pathologic disease in this population.

Is there a need for dietary measures to further reduce LDL cholesterol in patients with type II diabetes mellitus on statin therapy?

PURPOSE: To study the need for dietary measures to further reduce LDL cholesterol in patients with type 2 diabetes mellitus on statin therapy. METHODS: A Pubmed, Embase, CINAHL and Cochrane library search was performed to identify relevant articles. After critical appraisal six articles were ranked according to relevance, validation and level of evidence. RESULTS: There were no studies performed among type II diabetics. Among patients with hypercholesterolaemia, diet led to an additional LDL reduction from 0.20 to 0.88 mmol/l, translating into 23% reduction in vascular risk. CONCLUSION: We recommend a low-fat diet on top of statin therapy in patients with type 2 diabetes mellitus assuming that effects found in hypercholesterolaemic patients also apply to type 2 diabetics.