Fazil Necdet Ardic

Migraine patients with or without vertigo: comparison of clinical and electronystagmographic findings.

OBJECTIVE To find the differences between patients with migraine with and without vertigo. STUDY DESIGN A prospective study. SETTING Ambulatory dizziness centre of a tertiary referral hospital. METHODS Eighty-four patients with migraine (31 with headache, 53 with headache and vertigo) according to the diagnostic criteria of migraine published by the International Headache Society in 1988 were included in the study. Patient history, vestibular tests, electronystagmography (ENG), and imaging studies were performed for differential diagnosis. MAIN OUTCOME MEASURES Clinical findings and ENG parameters. RESULTS Fifty-three of 84 patients (63%) had episodic vertigo attacks. Vertigo was independent from headache in 24 patients (45%). Vertigo symptoms always appeared later in the history of migraine headache. Headache started at age 27 +/- 8.3 years and vertigo symptoms began 7.7 +/- 8.7 years later. The beginning age of the migraine and female-to-male ratio were significantly greater in the vertigo group. Fifty-eight of the 84 patients had ENG testing. Fifty-eight percent of the patients with migraine and 55% of the patients with migraine + vertigo had abnormal ENG findings. None of the tests except the Dix-Hallpike manoeuvre had a statistically significant difference between the two groups. CONCLUSION The presence of the same ENG abnormalities in patients with pure headache shows that the vestibular pathways are also affected in these patients, even when there are no vestibular symptoms.

Importance of mastoid pneumatization on secretory otitis media.

Secretory otitis media is the most common middle ear disease of childhood. It heals spontaneously, by medical therapy or by minor surgical procedures in most of the cases. Sequelae such as retraction pockets and adhesive otitis that lead to cholesteatoma rarely occur, but initially it is hard to diagnose which patient will acquire a sequela. It is well known that mastoid pneumatization is poor in the patients who had complications like retraction pocket, adhesive otitis and cholesterol granuloma. The aim of this study was to determine if any relationship exists between mastoid pneumatization and secretory otitis media. Lateral mastoid X-rays of 47 children with secretory otitis media were evaluated. After 2 months of follow-up with medical therapy, 30 of the 47 patients needed ventilation tube insertion. The remaining 17 patients showed total recovery with medicines only. Control X-rays of the operated patients were taken 6 months after the operation. Mastoid pneumatizations of patients healed with medicine were compared with the operated patients. There were statistically significant differences between the mastoid pneumatizations of surgically and medically treated groups. In addition we observed a statistically significant difference between the mastoid areas of the preoperative and the postoperative X-rays. We concluded that mastoid pneumatization might be considered as a prognostic indicator in secretory otitis media. The estimated prognosis is poor when the mastoid pneumatization is poor.

Clinical and electronystagmographical evaluation of vestibular symptoms in relapsing remitting multiple sclerosis

Abstract Objective: Multiple sclerosis (MS) may give rise to a variety of clinical signs and symptoms including vertigo and/or other problems related with equilibrium. In this study, we aimed to evaluate clinical and electronystagmographical (ENG) characteristics of relapsing remitting MS (RRMS) patients. Design: This is a prospective controlled study consisting of 30 patients who were diagnosed as definite RRMS according to McDonalds diagnostic criteria and 30 healthy individuals. Setting: Entire population of patients were examined and followed up at the same tertiary centre during the period of September 2003 and March 2005. Clinical examination and detailed electronystagmographic investigations were performed in each group. Methods: Vestibular laboratory testing was carried out by a computerized ENG system. All ENG subtests including tracking, saccade, optokinetic, gaze, positional and Dix-Hallpike tests were performed in each group but caloric, which is relatively an invasive test, was performed only in the patient group. Main outcome measures: We aimed to find the ratio of abnormal tests indicating, central and/or peripheral pathology in ENG. We also analyzed the correlation of total number of abnormal tests in ENG with clinical parameters. Results: Differences of ENG abnormality indicating central and/or peripheral pathology and ENG abnormality indicating only central pathology between the two groups were statistically significant. Correlation of total number of abnormal tests in ENG with EDSS score was statistically significant. Conclusion: ENG is sensitive in detecting the vestibular system involvement in RRMS patients if all subtests are performed and evaluated in detail with clinical symptoms and signs.

Provocation of endolymphatic hydrops with a prick test in Meniere's disease.

This study was conducted to test the hypothesis that antigenic challenge is an important stimulative factor for an episode of endolymphatic hydrops. The study was held in a tertiary care center for patients with probable or definite Meniere’s disease. The prick test, which included dietary and inhalant allergens, was applied to all patients with a Multi-Test Applicator (Lincoln Diagnostics, Decatur, Ill). Patients were tested with electrocochleography before and after the prick test. The positive allergen was diluted in 1/10 of a prick test dose, and patients were provoked and tested again. A negative summating potential/action potential (SP/AP) amplitude ratio greater than 0.5 was used as the main outcome measure. Pretest, posttest, and postprovocation SP/AP amplitude ratios were compared. A total of 80 diseased and 16 normal ears of 48 patients with Meniere’s disease were assessed. All patients were found to be atopic, but none had allergic symptoms. No symptom like vertigo or fullness was seen after the prick test was performed. In all, 30 patients had tinnitus and fullness in the diseased ear, and 6 patients had vertigo after the provocation. The SP/AP ratio was greater than 0.50 in 23 diseased (29%) and 3 normal (19%) ears before the prick test. After the prick test, 62 diseased (78%) and 13 normal (81%) ears had endolymphatic hydrops. These numbers did not change much after the provocation. Results reported here support the role of antigenic stimulation for episodes of Meniere’s disease. Endolymphatic hydrops was the atopic reaction that occurred in most study patients

Subjective visual vertical and subjective visual horizontal measures in patients with chronic dizziness

OBJECTIVES We aimed to find the frequency of otolith organ pathologies in the clinical picture of common dizziness etiologies in the chronic stage. METHOD Subjective visual vertical and subjective visual horizontal measures were assessed in patients who had persistent or recurrent dizziness at least 2 months after the acute period. Every patient was tested in three head positions: neutral, right, or left deviation in the roll plane. Test results were compared with those of the control group. RESULTS Seventy-three patients and 18 controls were examined. Fifty-eight of the patients had peripheral vestibular disease; 15 of them had central vestibular disease. Left subjective visual horizontal (SVH) and right SVH measures of the peripheral group were significantly different from those of the control group (p < .01). There was no difference in any test between the peripheral and central groups. When we put a cut off point for abnormality (0, 1) according to mean +/- 2 SD of the control group, the peripheral and central groups had very high significant differences from the control group. Approximately 25 to 50% of our patients had pathologic subjective visual vertical or SVH measures according to test type. CONCLUSION These results showed that the otolith system must be evaluated in the chronic period of dizziness, especially in patients who frequently visit their physician, and modifications in treatment programs must be conducted.

MRI and CT Imaging of an Intrasphenoidal Encephalocele: A Case Report

Summary Background Intrasphenoidal encephalocele (ISE) is a rare clinical entity. The incidence of congenital encephalocele is very low. Accurate diagnosis and surgical approach is of critical value. Case Reports We present a case of intrasphenoidal encephalocele in a 40-year-old man. He complained of cerebrospinal fluid (CSF) rhinorrhea and recurrent meningitis. In images of computed tomography (CT) and magnetic resonance imaging (MRI), intrasphenoidal encephalocele herniating through a defect of the left lateral sphenoid sinus wall was determined. Incisional biopsies were taken by endoscopic transnasal approach and histopathological examination revealed an encephalocele. In the differential diagnosis, ISE can be taken for inflammatory or malignant sinusoidal soft tissue masses. ISE is differentiated from other entities by demonstrating continuity with normal brain tissue. Conclusions MRI clearly demonstrates that the herniating soft tissue is isointense with brain and continuous with brain tissue via the sphenoid sinus, thereby the treatment decision-making process is very important.

Sudden sensorineural hearing loss in a patient with primary antiphospholipid syndrome

An autoimmune basis for sudden sensorineural hearing loss (SSNHL) has long been suspected. Immunoserological assays of patients with SSNHL have revealed the presence of different antibodies. Recently a number of case reports have highlighted the association of anticardiolipin antibodies (aCA) and SSNHL in systemic lupus erythematosus (SLE) [1]. Here we report a case with primary antiphospholipid syndrome (APS) who had SSNHL. A twenty eight years old male patient was applied to our hospital with the complaint of bilateral, sudden onset deafness. Past medical history revealed that he had Wernicke aphasia lasted one hour one year ago. Systemic and neurologic examinations were normal except bilateral sensorineural hearing loss. Complete blood count, PT, aPPT, sedimentation, biochemistry, protein C, S antithrombin III and complement levels were in normal limits. ECG and echocardiogram were normal. We confirmed bilateral sensorineural hearing loss with audiogram. Cranial and temporal bone MRI were normal. Anti HIV and VDRL were negative. Anticardiolipin antibody Ig G was positive (28 IU/mL). In repeated tests, ANA, anti-DNA and aCA IgM were found negative, but aCA Ig G was positive. Prednisone 80 mg/day was started and continued with decreasing doses for 3 months. He has completely recovered in one month. Then he was anticoagulated. No other ischemic attack, any systemic finding or audiovestibular complaint have been seen for two years. APS occurs in isolation (primary APS) or in association with connective tissue diseases (secondary APS), particularly with SLE [2]. The most common clinical manifestation of APS is thrombosis, which affects the vessels of any organ. Arterial thrombosis involves the brain in up to 50% of cases, causing transient ischemic attack or stroke [3]. Other neurological mani-

Carotid Artery Occlusion Due to Bacterial Paranasal Sinusitis

Complications of paranasal sinusitis still continue to be a serious health problem. We present an orbita-related complication of sinusitis in a patient with diabetic ketoacidosis. It was not a rhinocerebral mucormycosis, but a bacterial sinusitis-induced development of left cavernous sinus thrombophlebitis and carotid artery occlusion. We discuss the diagnosis, surgical options, and clinical outcome.

The subscales and short forms of the dizziness handicap inventory: are they useful for comparison of the patient groups?

Abstract Purpose: Dizziness Handicap Inventory (DHI) is one of the most frequently used surveys for vertigo. The aim of the study was re-analyze the consistency of subscales and correlation between original and different short forms. Method: The data of 2111 patients were analyzed. Original three subscales, screening form of DHI and short form of DHI were evaluated. The suitability of the data set for factor analysis and factor structure was analyzed with Kaiser–Meyer–Olkin (KMO) coefficient, Bartlett’s Sphericity Test, and Varimax method. Pearson correlation analysis was performed. Results: Factor analysis showed that two factor solutions are more prominent in our data. The factors proposed in different studies are not in harmony with each other. There is high correlation between the original and screening and short forms of DHI. Conclusions: This study indicated that the factor structure of the scale was not consistent. It is not advised to use subscale scores for comparison especially in international level. Therefore, total score should be used rather than the scores of the subscales. Using DHI screening form instead of original 25 questions is more convenient, because it is highly correlated with the original one and has fewer questions. Implications for rehabilitation Factor structure of the DHI is not consistent enough for comparison of the international studies. Total score of DHI is reliable. Using the screening version of DHI is better, because it is highly correlated with the original form and has fewer questions (10 questions).

Caloric test and simultaneous recording of sympathetic skin response

CONCLUSIONS It was found that there was a close correlation between sympathetic skin response (SSR) parameters and nystagmus parameters obtained in caloric tests. Further studies are needed to investigate the clinical correlation of these findings. OBJECTIVES To investigate whether the caloric response creates a measurable SSR and, if so, to compare the SSR parameters with the nystagmus parameters and the feelings of the patient. MATERIAL AND METHODS Patients completed an autonomic symptom questionnaire (ASQ) regarding their past history of autonomic symptoms. They used a visual analog scale (VAS) to assess the severity of symptoms during simultaneous SSR and caloric tests. Symptoms were also noted separately by the investigator. RESULTS Eighteen patients were included in the study (13 females, 5 males). Eight of the patients had central and 10 had peripheral vertigo. The mean VAS score was 6.6+/-1.9 and the mean ASQ score was 7.2+/-3.6. In terms of the recorded parameters, there were no significant differences between patients with central and peripheral vertigo, males and females or warm and cold irrigation. The number of SSR waves increased significantly when the slow-phase velocity was > 26 degrees/s (p<0.01) and the nystagmus latency was < or = 27 s (p<0.05). The VAS score was also correlated with the number of SSR waves (p<0.01).Conclusions. It was found that there was a close correlation between sympathetic skin response (SSR) parameters and nystagmus parameters obtained in caloric tests. Further studies are needed to investigate the clinical correlation of these findings. Objectives. To investigate whether the caloric response creates a measurable SSR and, if so, to compare the SSR parameters with the nystagmus parameters and the feelings of the patient. Material and methods. Patients completed an autonomic symptom questionnaire (ASQ) regarding their past history of autonomic symptoms. They used a visual analog scale (VAS) to assess the severity of symptoms during simultaneous SSR and caloric tests. Symptoms were also noted separately by the investigator. Results. Eighteen patients were included in the study (13 females, 5 males). Eight of the patients had central and 10 had peripheral vertigo. The mean VAS score was 6.6±1.9 and the mean ASQ score was 7.2±3.6. In terms of the recorded parameters, there were no significant differences between patients with central and peripheral vertigo, males and females or warm and cold irrigation. The number of SSR waves increased significantly when the slow-phase velocity was > 26°/s (p<0.01) and the nystagmus latency was ≤27 s (p<0.05). The VAS score was also correlated with the number of SSR waves (p<0.01).