Objective
Skew deviation results from a dysfunction of the graviceptive pathways in patients with an acute vestibular syndrome (AVS) leading to vertical diplopia due to vertical ocular misalignment. ...It is considered as a central sign, however, the prevalence of skew and the accuracy of its test is not well known .
Methods
We performed a prospective study from February 2015 until September 2020 of all patients presenting at our emergency department (ED) with signs of AVS. All patients underwent clinical HINTS and video test of skew (vTS) followed by a delayed MRI, which served as a gold standard for vestibular stroke confirmation.
Results
We assessed 58 healthy subjects, 53 acute unilateral vestibulopathy patients (AUVP) and 24 stroke patients. Skew deviation prevalence was 24% in AUVP and 29% in strokes. For a positive clinical test of skew, the cut-off of vertical misalignment was 3 deg with a very low sensitivity of 15% and specificity of 98.2%. The sensitivity of vTS was 29.2% with a specificity of 75.5%.
Conclusions
Contrary to prior knowledge, skew deviation proved to be more prevalent in patients with AVS and occurred in every forth patient with AUVP. Large skew deviations (> 3.3 deg), were pointing toward a central lesion. Clinical and video test of skew offered little additional diagnostic value compared to other diagnostic tests such as the head impulse test and nystagmus test. Video test of skew could aid to quantify skew in the ED setting in which neurotological expertise is not always readily available.
To demonstrate the feasibility of robotic middle ear access in a clinical setting, nine adult patients with severe-to-profound hearing loss indicated for cochlear implantation were included in this ...clinical trial. A keyhole access tunnel to the tympanic cavity and targeting the round window was planned based on preoperatively acquired computed tomography image data and robotically drilled to the level of the facial recess. Intraoperative imaging was performed to confirm sufficient distance of the drilling trajectory to relevant anatomy. Robotic drilling continued toward the round window. The cochlear access was manually created by the surgeon. Electrode arrays were inserted through the keyhole tunnel under microscopic supervision via a tympanomeatal flap. All patients were successfully implanted with a cochlear implant. In 9 of 9 patients the robotic drilling was planned and performed to the level of the facial recess. In 3 patients, the procedure was reverted to a conventional approach for safety reasons. No change in facial nerve function compared to baseline measurements was observed. Robotic keyhole access for cochlear implantation is feasible. Further improvements to workflow complexity, duration of surgery, and usability including safety assessments are required to enable wider adoption of the procedure.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objectives
Dizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke ...diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew HINTS) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes ABCD2).
Methods
This was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging MRI), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.
Results
A total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range IQR = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% 105 infarctions, eight hemorrhages), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.
Conclusions
HINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.
Resumen
Objetivos
El mareo y el vértigo contabilizan aproximadamente 4 millones de visitas anuales a los servicios de urgencias (SU) en Estados Unidos, y de 160.000 a 240.000 (4% al 6%) tienen un origen cerebrovascular. El diagnóstico de ictus en los pacientes con vértigo o mareo es complejo debido a que la mayoría no tienen signos de focalidad neurológica evidentes en la atención inicial. Los autores comparan la certeza de dos aproximaciones previamente publicadas que resultaron ser de utilidad en el cribaje a pie de cama del posible ictus en el mareo: una regla de decisión clínica HINTS: Head Impulse (impulso de la cabeza), Nystagmus (nistagmo), Test of Skew (test de la desviación), y una regla de estratificación del riesgo ABCD2: Age (edad), Blood pressure (presión arterial), Clinical features (hallazgos clínicos), Duration of symptoms (duración de los síntomas), Diabetes (diabetes).
Metodología
Estudio transversal de pacientes de alto riesgo (más de un factor de riesgo de ictus) con síndrome vestibular agudo (SVA) (mareo o vértigo agudo persistente con nistagmo, más náuseas o vómitos; intolerancia a la movilización de la cabeza; e inestabilidad de la marcha aparecidos de novo) realizado en un único centro universitario. Se llevó a cabo en todos los pacientes una exploración neurootológica, de neuroimagen (97,4% mediante resonancia magnética RM) y de seguimiento. Las puntuaciones de riesgo ABCD2 (0–7 puntos), usando el punto de corte recomendado ≥ 4 para ictus, se compararon con una batería de movimiento ocular de tres componentes (HINTS). Se evaluaron la sensibilidad, la especificidad y las razones de probabilidad positiva y negativa (RPP y RPN) para ictus y otras causas centrales, y los resultados se estratificaron por edad. También se evaluaron los falsos negativos iniciales de la neuroimagen (RM).
Resultados
Se evaluaron 190 pacientes adultos con SVA (1999–2012). La mediana de edad fue de 60,5 años (rango 18 a 92 años; RIC 52,0 a 70,0 años); un 60,5% fueron hombres. Los diagnósticos finales fueron neuritis vestibular (34,7%), ictus de fosa posterior (59,5% 105 infartos, 8 hemorragias) y otras causas centrales (5,8%). La mediana de ABCD2 fue 4,0 (rango 2 a 7; RIC 3,0 a 4,0). ABCD2 ≥4 para ictus tuvo una sensibilidad de un 61,1%, una especificidad de un 62,3%, una RPP de 1,62, y una RPN de 0,62; la sensibilidad fue menor para aquéllos que eran más jóvenes de 60 años (28,9%). La sensibilidad para el ictus del HINTS fue de un 96,5%, la especificidad de un 84,4%, la RPP de 6,19 y la RPN de 0,04, y no se modificó por la edad. Para cualquier lesión central, la sensibilidad fue de un 96,8%, la especificidad de un 98,5%, la RPP de 63,9 y la RPN de 0,03 para el HINTS; y la sensibilidad de un 99,2%, la especificidad de un 97,0%, la RPP de 32,7 y la RPN de 0,01 para HINTS+ (cualquier nueva pérdida de audición añadida al HINTS). Las RM iniciales fueron falsamente negativas en 15 de 105 (14,3%) infartos, todas salvo una fueron hechas antes de las 48 horas del inicio de la clínica, y todos fueron confirmados por una RM diferida.
Conclusiones
El HINTS mejora sustancialmente el ABCD2 para el diagnóstico de ictus en los pacientes con SVA en el SU. También supera a la RM obtenida en los primeros dos días tras el inicio de los síntomas. Dado que el test de HINTS se ha realizado tradicionalmente por especialistas, se deberían investigar métodos que permitan a los urgenciólogos hacer uso de esta aproximación para el cribado de ictus en el mareo.
Objectives
Dizziness and vertigo account for roughly 4% of chief symptoms in the emergency department (ED). Little is known about the aggregate costs of ED evaluations for these patients. The authors ...sought to estimate the annual national costs associated with ED visits for dizziness.
Methods
This cost study of adult U.S. ED visits presenting with dizziness or vertigo combined public‐use ED visit data (1995 to 2009) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and cost data (2003 to 2008) from the Medical Expenditure Panel Survey (MEPS). We calculated total visits, test utilization, and ED diagnoses from NHAMCS. Diagnosis groups were defined using the Healthcare Cost and Utilization Project's Clinical Classifications Software (HCUP‐CCS). Total visits and the proportion undergoing neuroimaging for future years were extrapolated using an autoregressive forecasting model. The average ED visit cost‐per‐diagnosis‐group from MEPS were calculated, adjusting to 2011 dollars using the Hospital Personal Health Care Expenditures price index. An overall weighted mean across the diagnostic groups was used to estimate total national costs. Year 2011 data are reported in 2011 dollars.
Results
The estimated number of 2011 US ED visits for dizziness or vertigo was 3.9 million (95% confidence interval CI = 3.6 to 4.2 million). The proportion undergoing diagnostic imaging by computed tomography (CT), magnetic resonance imaging (MRI), or both in 2011 was estimated to be 39.9% (39.4% CT, 2.3% MRI). The mean per‐ED‐dizziness‐visit cost was $1,004 in 2011 dollars. The total extrapolated 2011 national costs were $3.9 billion. HCUP‐CCS key diagnostic groups for those presenting with dizziness and vertigo included the following (fraction of dizziness visits, cost‐per‐ED‐visit, attributable annual national costs): otologic/vestibular (25.7%; $768; $757 million), cardiovascular (16.5%, $1,489; $941 million), and cerebrovascular (3.1%; $1059; $127 million). Neuroimaging was estimated to account for about 12% of the total costs for dizziness visits in 2011 (CT scans $360 million, MRI scans $110 million).
Conclusions
Total U.S. national costs for patients presenting with dizziness to the ED are substantial and are estimated to now exceed $4 billion per year (about 4% of total ED costs). Rising costs over time appear to reflect the rising prevalence of ED visits for dizziness and increased rates of imaging use. Future economic studies should focus on the specific breakdown of total costs, emphasizing areas of high cost and use that might be safely reduced.
Resumen
Incremento Anual de los Costes de las Atenciones por Mareo en los Servicios de Urgencias de Estados Unidos
Objectivos
El mareo y el vértigo suman aproximadamente el 4% de los motivos de consulta en el servicio de urgencias (SU). Se conoce poco sobre los costes globales de las evaluaciones del SU en estos pacientes. Se buscó estimar los costes anuales nacionales asociados con las visitas al SU por mareo.
Metodología
Este estudio de costes de visitas al SU de adultos norteamericanos que acudieron con mareo o vértigo combinó los datos públicos de las visitas a los SU (1995 a 2009) recogidos por el National Hospital Ambulatory Medical Care Survey (NHAMCS) y los costes (2003 a 2008) recogidos por el Medical Expenditure Panel Survey (MEPS). Se calcularon el total de visitas, el uso de pruebas diagnósticas y los diagnósticos del SU del NHAMCS. Los grupos diagnósticos se definieron según el Healthcare Cost and Utilization Project's Clinical Classifications Software (HCUP‐CCS). Los datos del año 2011 se documentaron en dólares de 2011. El total de visitas y la proporción de neuroimagen llevada a cabo en los futuros años se extrapoló usando un modelo predictivo autorregresivo. La media del coste por visita al SU por grupo diagnóstico del MEPS se calculó, ajustándose a dólares de 2011, mediante el índice de precios de los Hospital Personal Health Care Expenditures. Se utilizó una media ponderada global entre los grupos diagnósticos para estimar los costes totales nacionales.
Resultados
El número de visitas al SU en Estados Unidos en 2011 por mareo o vértigo fue de 3,9 millones (IC 95% = 3,6 a 4,2 millones). El porcentaje de pruebas diagnósticas de imagen llevadas a cabo por tomografía computarizada (TC), resonancia magnética (RM) o ambas en 2011 se estimó en un 39,9% (39,4% TC, 2,3% RM). La media de coste por visita al SU por mareo fue de 1.004 dólares de 2011. Los costes totales, extrapolados para todo el país, fueron de 3.900 millones de dólares. Los grupos diagnósticos HCUP‐CCS para aquéllos que presentaron mareo o vértigo incluyeron los siguientes (proporción de visitas por mareo; coste por visita al SU; costes anuales nacionales atribuibles): otológico/vestibular (25,7%; 768 dólares; 757 millones de dólares), cardiovascular (16,5%, 1.489 dólares; 941 millones de dólares) y cerebrovascular (3,1%; 1.059 dólares; 127 millones de dólares). Se estimó una suma en la neuroimagen del 12% del total de costes para las visitas por mareo en 2011 (360 millones de dólares para la TC y 110 millones de dólares para la RM).
Conclusiones
Los costes totales en Estados Unidos para los pacientes que acuden por mareo al SU son sustanciales, y se estima que sobrepasan en estos momentos los 4.000 millones de dólares por año (aproximadamente un 4% de los costes totales del SU). El incremento de los costes con el paso del tiempo parece reflejar el crecimiento de la prevalencia de las visitas al SU por mareo y el aumento de porcentajes de utilización de la neuroimagen. Futuros estudios económicos deberían centrarse en el desglose de los costes totales, y hacer énfasis en las áreas de alto uso y coste que pueden ser reducidas sin riesgo.
Aim
This study aimed to compare the effectiveness of auditory brainstem response (ABR) and extracochlear electrocochleography (ECochG) in objectively evaluating the coupling efficiency of floating ...mass transducer (FMT) placement during active middle ear implant (AMEI) surgery.
Methods
We enrolled 15 patients (mean age 58.5 ± 19.4 years) with mixed hearing loss who underwent AMEI implantation (seven ossicular chain and eight round window couplings). Before the surgical procedure, an audiogram was performed. We utilized a clinical measurement system to stimulate and record intraoperative ABR and ECochG recordings. The coupling efficiency of the VSB was evaluated through ECochG and ABR threshold measurements. Postoperatively, we conducted an audiogram and a vibrogram.
Results
In all 15 patients, ABR threshold testing successfully determined intraoperative coupling efficiency, while ECochG was successful in only eight patients. In our cohort, ABR measurements were more practical, consistent, and robust than ECochG measurements. Coupling efficiency, calculated as the difference between vibrogram thresholds and postoperative bone conduction thresholds, was found to be more accurately predicted by ABR measurements (
p
= 0.016,
R
2
= 0.37) than ECochG measurements (
p
= 0.761,
R
2
= 0.02). We also found a non-significant trend toward better results with ossicular chain coupling compared to round window coupling.
Conclusion
Our findings suggest that ABR measurements are more practical, robust, and consistent than ECochG measurements for determining coupling efficiency during FMT placement surgery. The use of ABR measurements can help to identify the optimal FMT placement, especially with round window coupling. Finally, we offer normative data for both techniques, which can aid other clinical centers in using intraoperative monitoring for AMEI placement.
The video head impulse test (vHIT) is nowadays a fast and objective method to measure vestibular function. However, its usability is controversial and often considered as a test performed by experts ...only. We sought to study the learning curve of novices and to document all possible mistakes and pitfalls in the process of learning.
In a prospective cohort observational study, we included 10 novices. We tested their ability to perform correctly horizontal head impulses recorded with vHIT. We assessed vHITs in 10 sessions with 20 impulses per session giving a video instruction after the first session (S1) and individual feedback from an expert for session 2 (S2) up to session 10 (S10). We compared VOR gain, the HIT acceptance rate by the device algorithm, mean head velocity, acceleration, excursion, and overshoot between sessions.
A satisfying number of accepted HITs (80%) was reached after an experience of 160 vHITs. Mean head velocity between sessions was always in accepted limits. Head acceleration was too low at the beginning (S1) but improved significantly after the video instruction (
= 0.001). Mean head excursion and overshoot showed a significant improvement after 200 head impulses (
< 0.001 each).
We showed that novices can learn to perform head impulses invHIT very fast provided that they receive instructions and feedback from an experienced examiner. Video instructions alone were not sufficient. The most common pitfall was a low head acceleration.
Cochlear implants (CIs) are standard treatment for postlingually deafened individuals and prelingually deafened children. This human cadaver study evaluated diagnostic usefulness, image quality and ...artifacts in 1.5T and 3T magnetic resonance (MR) brain scans after CI with a removable magnet.
Three criteria (diagnostic usefulness, image quality, artifacts) were assessed at 1.5T and 3T in five cadaver heads with CI. The brain magnetic resonance scans were performed with and without the magnet in situ. The criteria were analyzed by two blinded neuroradiologists, with focus on image distortion and limitation of the diagnostic value of the acquired MR images.
MR images with the magnet in situ were all compromised by artifacts caused by the CI. After removal of the magnet, MR scans showed an unequivocal artifact reduction with significant improvement of the image quality and diagnostic usefulness, both at 1.5T and 3T. Visibility of the brain stem, cerebellopontine angle, and parieto-occipital lobe ipsilateral to the CI increased significantly after magnet removal.
The results indicate the possible advantages for 1.5T and 3T MR scanning of the brain in CI carriers with removable magnets. Our findings support use of CIs with removable magnets, especially in patients with chronic intracranial pathologies.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Introduction
Electrocochleography (ECochG) measures inner ear potentials in response to acoustic stimulation. In patients with cochlear implant (CI), the technique is increasingly used to monitor ...residual inner ear function. So far, when analyzing ECochG potentials, the visual assessment has been the gold standard. However, visual assessment requires a high level of experience to interpret the signals. Furthermore, expert-dependent assessment leads to inconsistency and a lack of reproducibility. The aim of this study was to automate and objectify the analysis of cochlear microphonic (CM) signals in ECochG recordings.
Methods
Prospective cohort study including 41 implanted ears with residual hearing. We measured ECochG potentials at four different electrodes and only at stable electrode positions (after full insertion or postoperatively). When stimulating acoustically, depending on the individual residual hearing, we used three different intensity levels of pure tones (i.e., supra-, near-, and sub-threshold stimulation; 250–2,000 Hz). Our aim was to obtain ECochG potentials with differing SNRs. To objectify the detection of CM signals, we compared three different methods: correlation analysis, Hotelling's T
2
test, and deep learning. We benchmarked these methods against the visual analysis of three ECochG experts.
Results
For the visual analysis of ECochG recordings, the Fleiss' kappa value demonstrated a substantial to almost perfect agreement among the three examiners. We used the labels as ground truth to train our objectification methods. Thereby, the deep learning algorithm performed best (area under curve = 0.97, accuracy = 0.92), closely followed by Hotelling's T
2
test. The correlation method slightly underperformed due to its susceptibility to noise interference.
Conclusions
Objectification of ECochG signals is possible with the presented methods. Deep learning and Hotelling's T
2
methods achieved excellent discrimination performance. Objective automatic analysis of CM signals enables standardized, fast, accurate, and examiner-independent evaluation of ECochG measurements.
Chylothorax is a very rare but major complication in thyroid surgery and should be apparent to clinicians in this field.
We report a case with chylothrax after thyroid surgery in our department that ...drew our attention.
Systematic review of the literature to evaluate the incidence and the contributing factors of chylothorax after thyroid surgery. Database (PubMed) and hand searches to identify patients with thyroid surgery and postoperative chylothorax. Keywords included chylothorax, thyroidectomy, thyroid surgery and complications. Two independent reviewers screened studies against inclusion and exclusion criteria. Patient characteristics, risk factors, symptoms, treatments and etiopathogenesis were investigated.
We identified 13 articles in the literature describing 19 patients with chylothorax after thyroidectomy and described our own case. Ninety percent of the patients underwent thyroidectomy for thyroid cancer. Sixteen patients (80 %) underwent thyroidectomy with at least a left lateral neck dissection, 2 patients (10 %) underwent thyroidectomy with sternotomy, and in the remaining 2 patients (10 %), thyroidectomy with lateral neck dissection on both sides was performed with partial sternotomy. Our calculated incidence for chylothorax with total thyroidectomy and neck dissection was 1.85 %; for a thoracic approach the calculated incidence was 7.3 %.
There are no reports of chylothorax after thyroidectomy without at least a left lateral neck dissection due to advanced thyroid cancer and/or sternotomy due to the thyroid size. The extension of thyroid surgery seems to be the main risk factor in developing chylothorax either through direct surgical trauma or through increased intraductal pressure after thoracic duct ligation. An early diagnosis of chylothorax may avoid severe metabolic or cardiopulmonary complications.
To re-evaluate current indication criteria and to estimate the audiological outcomes of patients with Bonebridge bone conduction implants based on preoperative bone conduction thresholds.
We assessed ...the outcome of 28 subjects with either conductive or mixed hearing loss (CMHL) or single-sided deafness (SSD) who were undergoing a Bonebridge implantation. We used linear regression to evaluate the influence of preoperative bone conduction thresholds of the better/poorer ear, indication group, and language (German- and French-speaking patients) on aided sound field thresholds. In addition, aided word recognition scores at 65dB sound pressure level were fit with a logistic model that included preoperative bone conduction thresholds of the better/poorer ear, indication group, and language as effects.
We found that both aided sound field thresholds and word recognition were correlated with the preoperative bone conduction thresholds of the better hearing ear. No correlation between audiological outcomes and the preoperative bone conduction thresholds of the poorer ear, language, or indication group was found.
Bone conduction thresholds of the better hearing ear should be used to estimate the outcome of patients undergoing Bonebridge implantation. We suggest the indication criteria for Bonebridge candidates considering maximal bone conduction thresholds of the better ear at 38dB HL to achieve an aided sound field threshold of at least 30dB hearing level and an aided word recognition score of at least 75% for monosyllabic words.
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