Hilla Levo

Subclinical vestibulocerebellar dysfunction in migraine with and without aura

Objective: In patients with migraine, neurotologic symptoms and signs occur commonly. The authors’ aim was to determine whether neurotologic findings are in accordance with the type of migraine and whether test findings differ from those of healthy controls. Methods: The authors examined 36 patients with various types of migraine classified by International Headache Society criteria. Comprehensive neurotologic tests were performed between attacks: video-oculography (VOG), electronystagmography, static posturography, and audiometry on 12 patients with migraine with aura (MA) and 24 patients with migraine without aura (MO). Results were compared to those of test-specific nonmigrainous control groups. Only eight migraineurs (six with MA and two with MO) had vertigo or dizziness. Results: Despite the absence of clinical neurotologic symptoms, most of the patients with migraine (83%) showed abnormalities in at least one of these tests. Both migraine types differed significantly from the control group (in VOG, in saccadic accuracy, and in static posturography). Vestibular findings tended to be more severe in MA than in MO. Conclusions: These data suggest that interictal neurotologic dysfunction in MA and MO share similar features and that the defective oculomotor function is mostly of vestibulocerebellar origin.

Postural stability after vestibular schwannoma surgery

Factors related to postural stability and the course of recovery after vestibular schwannoma surgery were analyzed in a retrospective study of 177 patients and in a prospective study of 44 patients. Before surgery, 7 of the 44 patients in the prospective group complained of postural instability. The body sway velocity was measured. In the retrospective study, the sway velocity was abnormal under nonvisual control in 63% of the patients and under visual control in 34%. The sway velocity correlated with tumor size, smooth pursuit deficit, and postoperative work history. We compared patients with abnormal postural control to those with normal postural control, and found that the former relied to a greater extent on visual information and the latter on proprioceptive information. In the prospective study, the sway velocity increased after the operation, and 1 year after surgery it had not returned to preoperative values. In the logistic regression analysis, a translabyrinthine approach, rehabilitation, the patients age, and preserved function of the facial nerve predicted a good outcome of postural stability. The retrosigmoid approach and depression were the most significant risk factors for postoperative gait difficulties. Vestibular rehabilitation increased the reliance on proprioception for maintenance of postural control and improved postural stability.

Postoperative Headache after Surgery for Vestibular Schwannoma

Postoperative headache was studied among 251 patients who underwent operation for vestibular schwannoma. A questionnaire based on the McGill Pain Questionnaire and the Finnish Pain Questionnaire was sent to the patients. Twenty-one expressions describing postoperative headache were extracted with a factor analysis. The pain intensity was expressed on a visual analog scale, and the risk factors for postoperative headache were evaluated. Immediately after the operation, 154 subjects reported headache. Eighty-nine of the patients had had headache before operation, whereas 65 patients experienced headache only after operation. An average of 8.9 years after surgery, 93 patients still reported headache. Headache was a major problem for 27 subjects; 18 of the 27 had suffered from headache before operation. A retrosigmoidal approach, postoperative gait problems, preoperative headache, and small tumor size predicted postoperative problems with headache. When headache is present before operation, it tends to continue after operation, and if headache continues for 1 year, it usually persists without being reduced.

Use of ICF in Assessing the Effects of Meniere's Disorder on Life

Objectives We sought to determine the value of the World Health Organizations International Classification of Functioning, Disability and Health (ICF) in subjects with Menieres disorder in relation to their quality of life. Methods We asked 228 members of the Finnish Meniere Federation to report the effects that Menieres disorder had on their lives. The replies were classified on the basis of the ICF classification and related to the EuroQol 5D score and disease-specific impact. Logistic regression and decision tree analyses were used to determine the relationships. Results Seventy percent of the patients listed impairments, 39% activity limitations, 47% participation restrictions, 16% effects on environmental contextual factors, and 28% effects on personal contextual factors. The EuroQol 5D score was explained by reported vertigo, anxiety, fatigue, restriction of life, and communication problems. The disease-specific impact was explained by episodes of vertigo, fatigue, communication problems, inability to work, restriction of life, and uncertainty of life. Both analysis models provided the same outcome variables, although the decision tree separated the results better (80%) into correct classes than did logistic regression analysis (60%). Conclusions Self-reported participation restriction, activity limitation, and personal contextual factors describe the limitations of general life in subjects with Menieres disorder. The use of the ICF classification provides an instrument that can be used in enablement of subjects with Menieres disorder.

Non-surgical Treatment of Vestibular Schwannoma Patients

The aim of the study was to evaluate the course of vestibular schwannoma (VS) when surgery was not attempted. The tumor may be slowly growing and surgery a risk for a patient. Twenty-eight patients out of 390 VS patients during years 1981-1995 were primarily recommended a non-surgical treatment. Another 3 patients refused the operation. Altogether 23 women and 8 men were evaluated. Their age varied from 30.6 to 74.6 years (median 56.7 years). Tumor size varied from 5 to 30 mm (median 15.0 mm) at the beginning of the follow-up. Patients symptoms, condition and other illnesses were recorded. Seven patients had neurofibromatosis 2 (3 of them had one hearing ear), 2 had severe mental problems, 5 patients had their only hearing ear and 11 patients were not recommended an operation because of their age and other illnesses. Patients were controlled with MRI at intervals from 1 to 3 years. The follow-up time varied from 1 to 20 years (median 2.0 years). The average tumor growth rate among unilateral VS patients was 0.035 cm/year and among bilateral tumors the average tumor growth rate was 0.015 cm/year. Two patients were later operated on, one 2 years after diagnosis because of the tumor growth and the other one 4 years after diagnosis-she had refused an operation earlier. Two patients could not be reached. Another patient had tumor growth but because of his illnesses he got a radiation beam instead of an operation. The majority of the patients could live fairly normal lives and required no treatment. Surgery is not the only alternative to VS patients. Wait-and-see policy is also a good alternative to those who have high operation risk or who refuse an operation.

Nystagmus Measured with Video-Oculography: Methodological Aspects and Normative Data

Detailed analysis of eye movements is essential in order to understand the pathophysiology underlying vestibular disturbances. We applied a commercial video-oculography (VOG) to measure spontaneous and provoked nystagmus in 20 healthy subjects. The slow-phase velocity (SPV) of the nystagmus was calculated. We also simultaneously recorded the eye movements on a standard VHS videotape to be able to confirm the results derived from the VOG paper charts. The nystagmus results derived from the VOG charts and the simultaneous videotaping agreed well. Nystagmus was found in 17 subjects. Spontaneous nystagmus was seen in 20%, positional nystagmus in 55%, and head-shaking nystagmus in 35% of the participants. Although nystagmus was frequent (85%), the mean SPV for nystagmus was low (1.7°/s). The VOG is a modern and sensitive method to record eye movements, but visual inspection of the videotape may be needed in selected cases to confirm occurrence of nystagmus.

Acetazolamide improves neurotological abnormalities in a family with episodic ataxia type 2 (EA-2).

Sirs: Episodic ataxia type 2 (EA-2) is a rare neurological disease characterized by episodes of vertigo, ataxia, nystagmus, nausea, vomiting, fatigue, and often migraine. EA-2 is inherited as an autosomal dominant trait of the CACNA1A gene mutations on chromosome 19p13. CACNA1A encodes the alpha1A-subunit of a voltage dependent P/Q-type calcium channel that is mainly expressed in the Purkinje cells of the cerebellum [8, 11]. Neurological examination of EA-2 patients can vary from normal to severe cerebellar ataxia. On oculomotor studies interictal gazeevoked, rebound, and downbeat nystagmus have been common findings together with saccade hypermetria. These findings localize to the oculomotor region of the posterior vermis and the fastigial nuclei [3, 4, 9]. Acetazolamide is effective in suppressing attacks in EA-2 [2, 4, 7], but has not been shown to improve oculomotor signs in EA-2 [2, 5]. We, therefore, wanted to evaluate the effect of acetazolamide on oculomotor and postural function in an EA-2 family (Fig. 1) with a novel CACNA1A splice site mutation IVS36–2A > G (Kaunisto et al., Neurogenetics, in press). There were 13 affected individuals in the family of whom four were on acetazolamide. The clinical picture of the family has been described in detail earlier (Kaunisto et al., Neurogenetics, in press). The video-oculography (VOG) including recording of spontaneous and provoked nystagmus, ENG (with caloric and saccadic tests), static posturography, and pure tone audiometry were carried out to three EA-2 patients (III-13, III-16, III-22 in Fig. 1) with and without acetazolamide (one week washout time, patient III-22 three days). Their neurological examination and brain MRI were normal.

Positive experiences and quality of life in Ménière's disorder.

Abstract The objective of this study was to determine the influence of positive experiences on the quality of life of patients with Ménières disorder. Its deign comprised a cross-sectional investigation of members of a self-help group, using a questionnaire of positive experiences, an oto-neurological questionnaire, EuroQol, and Ménières impact rating. The study sample was 542 members of the Finnish Ménière Federation. Results showed that the positive questions explained 21% of the variance of the EuroQol TTO, 31% of the EuroQol VAS measure, and 35% of the Ménières impact. This compared with 40% of the variance explained by symptomatic complaints. When both the symptoms and positive measures were taken together, there was an increase in the proportion of the variance explained for the VAS (42%) and Ménières rating (50%), but not for the TTO (42%). A perspective on the disorder was the main positive experience associated with the increased variance explained. Positive experiences have a significant impact on self-rated quality of life. The results suggest that encouraging a positive perspective on the condition, in addition to treating the underlying symptoms, could be useful in rehabilitative management. Sumario El objetivo de este estudio fue determinar la influencia de las experiencias positivas en la calidad de vida de los pacientes con el trastorno de Ménière. Su diseño involucra una investigación transversal de los miembros de un grupo de auto-ayuda, utilizando un cuestionario de experiencias positivas, un cuestionario de oto-neurología, el EuroQoL, y la escala de calificación del impacto del Ménière. La muestra del estudio fue de 542 miembros de la Federación Finlandesa de Ménière. Los resultados mostraron que las preguntas positivas explicaron el 21% de la varianza del EuroQoL TTO, 31% de la medición EuroQoL VAS, y 35% de la escala de impacto de Ménière. Esto se compara con 40% de la varianza explicada por quejas sintomáticas. Cuando se juntaron tanto los síntomas como las medidas positivas, existió una aumento en la proporción de la varianza explicada por el VAS (42%) sobre elescala Ménière (50%), pero no para el TTO (42%). Una perspectiva del trastorno fue la principal experiencia positiva asociada con el aumento de la varianza explicada. Los experiencias positivas tiene un impacto significativo en la calidad de vida auto estimada. Los resultados sugieren que la estimulación de una perspectiva positiva de la condición, además de tratar los síntomas subyacentes, puede ser útil en el manejo rehabilitativo.

Positive experiences associated with acquired hearing loss, Ménière's disease, and tinnitus: A review.

Abstract Objective: It is common to study and understand how various illness and disorders result in negative consequences. However, positive experiences have been reported in a range of disabling conditions including multiple sclerosis, heart disease, physical and sensory disabilities. This paper presents a literature review of studies that have explored positive experiences associated with acquired hearing loss, Ménières disease, and tinnitus. Design: A review of the peer reviewed scientific literature. Study sample: A comprehensive search strategy identified 15 articles after applying inclusion criteria. Results: A range of positive experiences have been reported by patients with hearing and balance disorders and by their significant others. Associations between demographic variables (e.g. age, gender), audiological variables (e.g. severity of the condition, duration) and the reported positive experiences are low. In Ménières disease, self-reported positive experiences can predict the impact of the condition. However, this phenomenon has not yet been demonstrated in relation to hearing loss and tinnitus. Conclusions: Positive experiences associated with audio-vestibular disorders have been demonstrated. Further research is needed on the long-term benefits of the encouragement of such experiences and positive attitudes in persons with hearing loss, tinnitus, and imbalance.

The effects of Ménière's disorder on the patient's significant others

Abstract Objective: To determine the effects of their partners’ MD on the significant others of the patients. Design: Open-ended questionnaire. Study sample: Significant others of members of the Finnish Ménières Federation. Results: The predominant responses concerned effects on their lives and lifestyle—participation restrictions (effects on personal and community life)—and on personal contextual factors (uncertainty of life). In contrast they fail to list such effects of the patients, focussing rather on the patients’ symptoms. Five percent of the responses given entailed positive experiences. Conclusions: Significant others of patients with MD listed a wide range of effects of their partners condition on them. We encourage doctors and therapists to include the significant others in the rehabilitation process to enable them to understand the patients condition, to help the significant other, and so better support the patients concerned.