Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit.

Vestibular migraine (VM) is an increasingly recognized pathology yet remains as an underdiagnosed cause of vestibular disorders. While current diagnostic criteria are codified in the 2012 Barany Society document and included in the third edition of the international classification of headache disorders, the pathophysiology of this disorder is still elusive. The Association for Migraine Disorders hosted a multidisciplinary, international expert workshop in October 2020 and identified seven current care gaps that the scientific community needs to resolve, including a better understanding of the range of symptoms and phenotypes of VM, the lack of a diagnostic marker, a better understanding of pathophysiologic mechanisms, as well as the lack of clear recommendations for interventions (nonpharmacologic and pharmacologic) and finally, the need for specific outcome measures that will guide clinicians as well as research into the efficacy of interventions. The expert group issued several recommendations to address those areas including establishing a global VM registry, creating an improved diagnostic algorithm using available vestibular tests as well as others that are in development, conducting appropriate trials of high quality to validate current clinically available treatment and fostering collaborative efforts to elucidate the pathophysiologic mechanisms underlying VM, specifically the role of the trigemino-vascular pathways.

Ocular Vestibular Evoked Myogenic Potentials: Normative Findings in Children.

BACKGROUND: To add to the limited body of literature on ocular vestibular evoked myogenic potential (oVEMP) responses in children and to assess a different montage for oVEMP recording. PURPOSE: To evaluate the characteristics of the oVEMP response in children and compare the results with that of a group of healthy adults. RESEARCH DESIGN: Prospective descriptive study from a tertiary referral center. STUDY SAMPLE: Twenty-two children (mean age = 6.3 yr, standard deviation = ±1.5, range = 3.5-8.9 yr) were recruited from families whose parent(s) were employed by the Cincinnati Children's Hospital Medical Center (CCHMC). Pediatric participants were categorized by age into three groups for data analysis. The comparison adult group of ten participants were members of the employee staff at CCHMC. DATA COLLECTION AND ANALYSIS: Audiometric assessment was completed in all participants. The latency, amplitude, and threshold of the oVEMP responses were recorded using a modified electrode montage with reference at the chin and compared between the pediatric and adult participants. RESULTS: All participants completed testing and had bilateral measurable oVEMP responses using a 105-dB nHL, 500-Hz tone burst stimulus. Comparison between right and left ears across all participants for each oVEMP characteristic found no statistically significant difference. oVEMP testing showed no significant differences with respect to latency, amplitude, interaural amplitude asymmetry, and threshold of response as a function of age. CONCLUSIONS: oVEMP responses for ages ≥3 did not differ from responses in adults.

The correlation between obesity, obstructive sleep apnea, and superior semicircular canal dehiscence: a new explanation for an increasingly common problem.

OBJECTIVE: To investigate rates of obesity and obstructive sleep apnea (OSA) in patients with a diagnosis of superior semicircular canal dehiscence (SSCD). STUDY DESIGN: Retrospective cohort study. SETTING: Two tertiary referral centers. PATIENTS: Thirty-one patients with SSCD were identified from patient records at Yale between January 1, 2003 and August 1, 2013 and from the University of Cincinnati between November 1, 2008 and November 1, 2013. The control cohort consisted of 100 consecutive adult patients who obtained high-resolution CT imaging of their temporal bones at Yale University for any reason. INTERVENTIONS: CT images were reviewed by two authors in double blind fashion and patient data was analyzed statistically. MAIN OUTCOME MEASURES: Rates of OSA, body mass index (BMI), and presence of tegmental defects in patients with SSCD were compared to the control cohort. RESULTS: The 31 patients with SSCD demonstrated higher BMIs [SSCD avg. 31.62, standard deviation (SD) 8.6 vs. no SSCD 28.01, SD 6.3, P = 0.036], rates of OSA (SSCD 29.03% vs. no SSCD 7.00, P = 0.001), and rates of tegmental defects (SSCD avg. 64.5% vs. no SSCD 16%, P = 1.24 × 10(-7)), in comparison to the control cohort. SSCD was found in 6 of 100 consecutively reviewed adult CT scans and in 0 of 41 scans obtained in those under 17 years of age. CONCLUSIONS: Patients with SSCD demonstrated higher BMIs, higher rates of OSA, and were more likely to have accompanying tegmental defects. These results may support a possible causality between increased intracranial pressure and the formation of superior semicircular canal dehiscence.

Congenital incudostapedial anomalies in adult stapes surgery: a case-series review.

OBJECTIVES: The management of developmental anomalies of the ossicular chain and otic capsule in stapes surgery tests the otologist's diagnostic skills and flexibility in technique and prosthesis choice. We review our experience in managing various incudostapedial developmental anomalies discovered during middle ear exploration for suspected otosclerosis in adult patients. DESIGN: A retrospective case-series review was used. SETTING: The study was set at a military tertiary referral center. PATIENTS AND OTHER PARTICIPANTS: A review of 185 stapes procedures yielded 8 cases of identified congenital anomalies of the stapes or incudostapedial complex including congenital absence of the oval window with malformed incus and stapes, columellar-type stapes with promontory fixation, stapes superstructure fixation to the fallopian canal, and malformed incus with stapes superstructure fixation to the promontory. INTERVENTIONS: The developmental anatomy and surgical technique in each case were reviewed. The surgical technique used in each case varied depending on the specific ossicular abnormality found and whether both the stapes and incus were affected. MAIN OUTCOME MEASURES: Comparison of preoperative and postoperative audiometric testing results was performed. RESULTS: All 8 ears (7 patients) that underwent a stapes procedure for either an isolated congenital stapes anomaly or a combined incudostapedial anomaly had a favorable hearing outcome, with 7 ears improving to within 10-dB and 1 ear to within 13-dB air-bone gap on postoperative audiometry. CONCLUSIONS: Despite unanticipated findings of congenital anomalies of the stapes and incus during middle ear exploration for conductive hearing loss, a flexible management approach can lead to successful hearing outcomes.

The association between semicircular canal dehiscence and Chiari type I malformation.

OBJECTIVE: To investigate the association between semicircular canal dehiscence (SCD) and Chiari type I malformation (CM-I). DESIGN: Retrospective case series. SETTING: Military tertiary referral center. PATIENTS: Adult patients with SCD. INTERVENTION: Review of records of patients diagnosed as having SCD for the radiologic diagnosis of CM-I and presenting symptoms. MAIN OUTCOME MEASURES: The prevalence of CM-I among patients with SCD and the presenting symptoms of patients with SCD with and without a coexistent CM-I. RESULTS: Of 32 patients diagnosed as having SCD, 30 underwent magnetic resonance imaging of the brain. Seven patients (23%; 95% confidence interval [CI], 12%-41%) were found to have a CM-I. Chiari type I malformation was associated with superior SCD in 3 of 26 patients (12%; 95% CI, 3%-30%). Of 10 patients with bilateral superior SCD, 2 (20%; 95% CI, 5%-52%) had a CM-I. Five of 6 patients (83%; 95% CI, 42%-99%) had a CM-I with unilateral or bilateral posterior SCD. Twenty-nine records were reviewed for presenting symptoms, and no significant difference was observed between patients with SCD alone and those with an associated CM-I (P = .09-.64). CONCLUSIONS: Among patients with SCD, the prevalence of CM-I is elevated. This association is especially marked in patients with posterior SCD. This finding suggests a relationship between CM-I and SCD, particularly with posterior SCD.

WITHDRAWN: Management of Congenital Incudostapedial Anomalies in Stapes Surgery.

OBJECTIVES:: The management of developmental anomalies of the ossicular chain and otic capsule in stapes surgery tests the otologist's diagnostic skills and flexibility in technique and prosthesis choice. Although congenital malleus fixation and perilymph gusher are important clinical entities that have received considerable attention in the otolaryngology literature, congenital anomalies of the incus and stapes are less well described, can often be subtle, and have a distinct influence on management choice and hearing outcome. STUDY DESIGN AND PATIENTS:: A review of more than 200 stapes procedures yielded eight cases of identified congenital anomalies of the stapes or incudostapedial complex including congenital absence of the oval window with malformed incus and stapes, columellar-type stapes with promontory fixation, stapes superstructure fixation to the fallopian canal, and malformed incus with stapes superstructure fixation to the promontory. The developmental anatomy and surgical technique in each case are reviewed and hearing outcome is presented. RESULTS:: The surgical technique used in each case varied depending on the nuances of the ossicular anomaly and whether both the stapes and incus were affected. All eight ears (seven patients) that underwent a stapes procedure for either an isolated congenital stapes anomaly or a combined incudostapedial anomaly had a favorable hearing outcome with seven ears improving to within 10-dB and one ear to within 13-dB air-bone gap on postoperative audiometry. CONCLUSION:: Despite unanticipated findings of congenital anomalies of the stapes and incus during middle ear exploration for conductive hearing loss, a flexible management approach can lead to successful hearing outcomes.

Bone cements as adjuvant techniques for ossicular chain reconstruction.

HYPOTHESIS: The osseointegrative capacity of medical-grade bone cement can be used to improve fixation and prevent displacement of an ossicular prosthesis in a guinea pig model. BACKGROUND: Successful ossiculoplasty requires a firm connection between the vibrating tympanic membrane and the inner ear. In patients requiring revision ossiculoplasty, half of failures are due to prosthesis displacement. Bone cements have been used as prosthetic material in craniofacial surgery, and their adhesive and osseointegrative properties make them ideal for use in ossicular reconstruction. METHODS: Twenty-four adult male guinea pigs underwent a postauricular surgical approach for access to the middle ear. Hydroxyapatite and Dahllite cements were used in an alternating fashion to fix ossicular bone. Four animals were killed immediately to demonstrate mechanical bonding of the ossicles at the time of application. Nineteen animals were killed 8 weeks postoperatively to assess bonding capacity and histologic inflammation. RESULTS: Both cements mechanically bonded the ossicles at the time of application, but Dahllite cement set faster in the moist environment of the middle ear space. Histologic examination showed bonding of the ossicles with both cements, with little evidence of inflammation or foreign body reaction. CONCLUSIONS: Hydroxyapatite and Dahllite bone cements showed evidence of osseointegration with ossicular bone in the guinea pig model. Further studies are under way to determine the osseointegrative capacity of Dahllite cement between the guinea pig malleus and a partial prosthesis, and any ototoxic effects with use in the middle ear.