[THE SIGNIFICANCE OF TORSIONAL NYSTAGMUS ON THE ROLL REST].

OBJECTIVES: To characterize a subgroup of patients that were diagnosed with benign paroxysmal positional vertigo of the posterior semicircular canal pBPPV, with findings of geotropic-torsional nystagmus on the roll rest (RT) that intensified on the Dix-Hallpike exam (DH). METHODS: The study population consisted of patients with the diagnosis of pBPPV. First, the roll test (RT) and then the DH test were performed. Characteristics were compared between group 1 - patients with a negative RT and positive DH (in keeping with pBPPV), and group 2- patients with a torsional-geotropic nystagmus on the RT, that intensified on DH. Patients from both groups were treated with the Epley maneuver. If the nystagmus continued, further Epley maneuvers were performed until it subsided. Patients continued follow-up visits until they were asymptomatic and the exam was normal. RESULTS: Ninety-one consecutive patients were diagnosed with pBPPV. Sixty nine patients belonged to group 1 and 22 to group 2. The average age was just under 60 and the percentage of males was 22 in group 1 and 45 in group 2, which was significantly different. Additional significant differences included: 1. Symptom duration, in days, until diagnosis (43.2 in group 1 and 22.3 in group 2). 2. The fraction of patients requiring only one Epley maneuver in the first treatment session was 77.4% in group 1 and 23.4% in group 2. CONCLUSIONS: The appearance of a torsional-geotropic nystagmus during RT is most probably due to pBPPV, with a more severe clinical presentation, requiring more Epley maneuvers than in patients with a negative RT. These patients had increased symptoms and were diagnosed earlier. However, the response to treatment was similar in both groups. It is most important to differentiate these patients in group 2 from patients with BPPV arising from the horizontal semicircular canal, which has different clinical features and is treated differently.

The association between otogenic lateral sinus thrombosis and thrombophilia - A long-term follow-up.

PURPOSE: Otogenic lateral sinus thrombosis (OLST) is an intracranial, potentially life-threatening complication of acute and chronic otitis media. Since congenital thrombophilic disorders are risk factors for cerebral venous thrombosis, OLST may be related to thrombophilia. The aim of our study was twofold: to evaluate whether patients who suffered from OLST in childhood also have thrombophilia, and whether these patients experienced thromboembolic episodes in future years. STUDY DESIGN: Retrospective case series. METHODS: The medical charts of all children hospitalized for OLST at Soroka University Medical Center of Israel, a tertiary referral hospital, from January 1983 to September 2014 were reviewed. The patients were invited for a follow-up visit and comprehensive medical history was taken along with a physical examination and laboratory work-up for thrombophilia. MAIN FINDINGS: Seven patients were included in the study. Of these, 3 (43%) had results suggesting thrombophilic disorders manifested by elevated levels of factor IX and decreased levels of protein S activity (n = 1), decreased levels of proteins C and S activity (n = 1), and elevated levels of antibodies to cardiolipin (n = 1). No patients experienced clear thrombophilic events; however, 2 patients (29%) with later proven thrombophilia suffered neurologic sequelae, possibly suggesting thrombophilic events. CONCLUSIONS: Pediatric OLST secondary to acute otitis media and mastoiditis may reflect an underlying thrombophilia. Laboratory work-up for thrombophilia should be performed, and anticoagulant treatment may be warranted in managing these patients.

Randomized study comparing inflammatory response after tonsillectomy versus tonsillotomy.

To determine if there was a difference in the inflammatory reaction after tonsil surgery with "traditional" techniques (tonsillectomy and adenoidectomy or TA) compared to partial intracapsular tonsillectomy and adenoidectomy (PITA). DESIGN: Randomized, double-blind study. SETTING: tertiary care academic hospital. Children under the age of 16 years with a diagnosis of obstructive sleep disordered breathing were randomly allocated into three study groups: TA with electrocautery (n = 34), PITA with CO2 laser (n = 30) and PITA with debrider (n = 28). All of the children underwent adenoidectomy with a current at the same surgical procedure. MAIN OUTCOME MEASURE: c-reactive protein level (CRP) was the primary endpoint. In addition, the following were assessed: white blood cells (WBC), neutrophils (NEU), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Pre- and post-procedure measurements were compared between the groups. Parents filled out a questionnaire daily during the first postoperative week assessing pain, swallowing and snoring. CRP levels ascended higher in the PITA groups after surgery (p = 0.023), WBC and NEU showed the same pattern, IL-6 levels were higher in PITA group and there was no difference in TNF-alpha levels between the two types of procedures. Postoperative pain and postoperative hemorrhage were significantly lower in the PITA groups as compared to the TA group (p = 0.01 and 0.048). PITA in comparison to TA is associated with lower morbidity; however, the inflammatory response does not differ significantly in the first 24 h after surgery. Additional long-term studies assessing efficacy of PITA are warranted. LEVEL OF EVIDENCE: Level 1, prospective randomized controlled trial.