Publications by authors named "Daniele Nuti"

32 Publications

Double-Blind Randomized Trial on the Efficacy of the Forced Prolonged Position for Treatment of Lateral Canal Benign Paroxysmal Positional Vertigo.

Laryngoscope 2021 04 21;131(4):E1296-E1300. Epub 2020 Aug 21.

Department of Otolaryngology, Azienda Ospedaliera Universitaria Senese, Siena, Italy.

Objectives/hypothesis: The need for class I and II studies on the efficacy of liberatory maneuvers in the treatment of lateral canal benign paroxysmal positional vertigo (LC-BPPV) motivated the present double-blind randomized trial on the short-term efficacy of the forced prolonged position (FPP).

Study Design: Double-blind, randomized controlled trial.

Methods: Two hundred twenty-one patients with unilateral LC-BPPV met the inclusion criteria for a multicentric study. Patients were randomly assigned to treatment by FPP (116 subjects) or sham treatment (105 subjects). Subjects were followed up at 24 hours with the supine roll test by blinded examiners.

Results: Among the sample, 67.4% and 32.6% of the patients showed respectively geotropic and apogeotropic variant of LC-BPPV. At the 24-hour follow-up, the effectiveness of FFP compared to the sham maneuver was, respectively, 57.8% versus 12.4% (P < .0001) in the total sample, 76.9% versus 11.3% (P < .0001) in the geotropic variant group, and 60.5% versus 17.6% (P = .0003) in the apogeotropic variant group, including resolution or transformation to geotropic variant.

Conclusions: FPP proved highly effective compared to the sham maneuver. The present class 2 study of the efficacy of the FPP changes the level of recommendation of the method for treating LC-BPPV into a strong one.

Level Of Evidence: 2 Laryngoscope, 131:E1296-E1300, 2021.
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http://dx.doi.org/10.1002/lary.28981DOI Listing
April 2021

Benign Paroxysmal Positional Vertigo: What We Do and Do Not Know.

Semin Neurol 2020 Feb 14;40(1):49-58. Epub 2020 Jan 14.

Department of Otology and Skull Base Surgery, University of Siena, Siena, Italy.

Benign paroxysmal positional vertigo (BPPV) is common, sometimes terrifying, but rarely portends serious disease. It is usually easily diagnosed and treated, and both the patient and the physician are immediately gratified. While much has been learned about the pathogenesis of BPPV in the past decades, many of its features remain mysterious, and one must still be wary of the rare times it mimics a dangerous brain disorder. Here we review common, relatively well understood clinical features of BPPV but also emphasize what we do not know and when the physician must look deeper for a more ominous cause.
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http://dx.doi.org/10.1055/s-0039-3402733DOI Listing
February 2020

Benign Positional Paroxysmal Vertigo Treatment: a Practical Update.

Curr Treat Options Neurol 2019 12 5;21(12):66. Epub 2019 Dec 5.

Otolaryngology Department, University of Siena, Azienda Ospedaliera Universitaria Senese, V.le Bracci, 11, 53100, Siena, Italy.

Purpose Of The Review: To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV).

Recent Findings: Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for evidence-based medicine. The choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient. Maneuvers for controversial variants, such as anterior canal and apogeotropic posterior canal BPPV, have weaker evidence of efficacy. Despite this, these variants are increasingly diagnosed and treated. Maneuvers also play a role in the differential diagnosis with central vestibular disorders. Chair-assisted treatment may be of help if available while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers. Despite the high success rate of liberatory maneuvers, there is a low percentage of subjects who have unsatisfactory outcomes. These patients need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities (migraine, persistent postural perceptual dizziness), or risk factors for recurrences (low vitamin D serum level). Future research should also identify the optimum maneuvers for variants whose diagnosis and treatment are still a matter of some debate.
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http://dx.doi.org/10.1007/s11940-019-0606-xDOI Listing
December 2019

Patient Perceptions of Effectiveness in Treatments for Menière's Disease: a National Survey in Italy.

J Int Adv Otol 2019 Apr;15(1):112-117

Department of Otology and Skull Base Surgery, University of Siena, Siena, Italy.

Objectives: The aim of the present study was to investigate current treatment practices and self-reported effectiveness in Ménière's disease.

Materials And Methods: Members of two Italian Ménière's disease support (n=170) with ≥6-month history of Ménière's disease were administered an online survey about recent treatments. Vertigo episode count, work absenteeism, and limitations in family life, social life, work, or travel as included in the Social Life and Work Impact of Dizziness Questionnaire before and after recent treatments were queried.

Results: Twenty-four different treatments were reported for Ménière's disease, with dietary modifications (55%), diuretics (47%), and betahistine (41%) being the most common. The majority (71%) received multiple simultaneous treatments. Prior to the most recent treatments, 78%-89% of respondents indicated limitations in family or social life, work, or traveling. After their most recent treatment, respondents reported improvements in mean vertigo episode counts (5.7±7.6 vs. 2.6±4.6, p<0.001), days off work per month (10.1±9.2 vs. 4.2±6.7, p<0.001), and proportions indicating limitations in any functional measure assessed (p<0.05). These findings were consistent regardless of treatment approach (p<0.05 for all). Intratympanic gentamicin provided the greatest reductions in vertigo count, functional limitations, and work absenteeism (p<0.01 for all), as well as the fewest respondents reporting post-treatment functional limitations (16%-37%).

Conclusion: Despite many treatment approaches targeting different proposed pathophysiology for Ménière's disease in this cross-sectional survey, all treatments are reported as effective by patients. These findings support a prominent placebo effect in Ménière's disease and highlight challenges in studying treatment outcomes; there is a critical need to better understand Ménière's disease.
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http://dx.doi.org/10.5152/iao.2019.5758DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6483453PMC
April 2019

European Position Statement on Diagnosis, and Treatment of Meniere's Disease.

J Int Adv Otol 2018 Aug;14(2):317-321

Universita degli Studi di Siena, Siena, Italy.

Meniere Disease keeps challenges in its diagnosis and treatment since was defined by Prosper Meniere at the beginning of 19th Century. Several classifications and definition were made until now and speculations still exist on its etiology. As the etiology remains speculative the treatment models remain in discussion also. The European Academy of Otology and Neurotology Vertigo Guidelines Study Group intended to work on the diagnosis and treatment of Meniere's disease and created the European Positional Statement Document also by resuming the consensus studies on it. The new techniques on diagnosis are emphasized as well as the treatment models for each stage of the disease are clarified by disregarding the dilemmas on its treatment. The conservative, noninvasive and invasive therapeutic models are highlighted.
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http://dx.doi.org/10.5152/iao.2018.140818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354459PMC
August 2018

Clinical Features of Headache in Patients With Diagnosis of Definite Vestibular Migraine: The VM-Phenotypes Projects.

Front Neurol 2018 5;9:395. Epub 2018 Jun 5.

ENT Department, San Raffaele Scientific Hospital, Milan, Italy.

Migraine is a common neurological disorder characterized by episodic headaches with specific features, presenting familial aggregation. Migraine is associated with episodic vertigo, named Vestibular Migraine (VM) whose diagnosis mainly rely on clinical history showing a temporary association of symptoms. Some patient refers symptoms occurring in pediatric age, defined "episodic symptoms which may be associated with migraine." The aim of this cross sectional observational study was to assess migraine-related clinical features in VM subjects. For the purpose, 279 patients were recruited in different centers in Europe; data were collected by a senior neurologist or ENT specialist through a structured questionnaire. The age of onset of migraine was 21.8 ± 9. The duration of headaches was lower than 24 h in 79.1% of cases. Symptoms accompanying migrainous headaches were, in order of frequency, nausea (79.9%), phonophobia (54.5%), photophobia (53.8%), vomiting (29%), lightheadedness (21.1%). Visual or other auras were reported by 25.4% of subjects. A familial aggregation was referred by 67.4%, while migraine precursors were reported by 52.3% of subjects. Patients reporting nausea and vomiting during headaches more frequently experienced the same symptoms during vertigo. Comparing our results in VM subjects with previously published papers in migraine sufferers, our patients presented a lower duration of headaches and a higher rate of familial aggregation; moreover some common characters were observed in headache and vertigo attacks for accompanying symptoms like nausea and vomiting and clustering of attacks.
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http://dx.doi.org/10.3389/fneur.2018.00395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5996089PMC
June 2018

Clinical Features, Familial History, and Migraine Precursors in Patients With Definite Vestibular Migraine: The VM-Phenotypes Projects.

Headache 2018 Apr 4;58(4):534-544. Epub 2017 Dec 4.

ENT Department, San Raffaele Scientific Hospital, Milan, Italy.

Objective: The aim of this work was to assess through a questionnaire the features of vertiginous episodes, accompanying symptoms, familial history, and migraine precursors in a sample of 252 subjects with a diagnosis of definite vestibular migraine.

Background: Migraine is a common neurological disorder characterized by episodic headaches with specific features. About two-thirds of cases run in families, and patients may refer symptoms occurring in infancy and childhood, defined as episodic syndromes that may be associated with migraine. Migraine is associated with episodic vertigo, called vestibular migraine, whose diagnosis mainly relies on clinical history showing a temporary association of symptoms.

Methods: In this cross-sectional multicentric study, 252 subjects were recruited in different centers; a senior specialist through a structured questionnaire assessed features of vestibular symptoms and accompanying symptoms.

Results: The age of onset of migraine was 23 years, while onset of vertigo was at 38 years. One hundred and eighty-four subjects reported internal vertigo (73%), while 63 subjects (25%) reported external vertigo. The duration of vertigo attacks was less than 5 minutes in 58 subjects (23%), between 6 and 60 minutes in 55 (21.8%), between 1 and 4 hours in 29 (11.5%), 5 and 24 hours in 44 (17.5%), up to 3 days in 14 (5.5%), and more than 3 days in seven (2.8%); 14 subjects (5.5%) referred attacks lasting from less than 5 minutes and up to 1 hour, nine (3.6%) referred attacks lasting from less than 5 minutes and up to 1 to 4 hours, six (2.4%) referred attacks lasting from less than 5 minutes and up to 5 to 24 hours, and five (2%) cases referred attacks lasting from less than 5 minutes and up to days. Among accompanying symptoms, patients referred the following usually occurring, in order of frequency: nausea (59.9%), photophobia (44.4%), phonophobia (38.9%), vomiting (17.8%), palpitations (11.5%), tinnitus (10.7%), fullness of the ear (8.7%), and hearing loss (4%). In total, 177 subjects referred a positive family history of migraine (70.2%), while 167 (66.3%) reported a positive family history of vertigo. In the sample, 69% of patients referred at least one of the pediatric precursors, in particular, 42.8% of subjects referred motion sickness. The age of onset of the first headache was lower in the subsample with a familial history of migraine than in the total sample. Among the pediatric precursors, benign paroxysmal vertigo - BPV, benign paroxysmal torticollis, and motion sickness were predictive of a lower age of onset of vertigo in adulthood; cyclic vomiting was predictive for vomiting during vertigo attacks in adults.

Conclusions: Our results may indicate that vestibular symptoms in pediatric patients may act as a predisposing factor to develop vestibular migraine at an earlier age in adulthood.
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http://dx.doi.org/10.1111/head.13240DOI Listing
April 2018

Validation of the Italian Version of the Dizziness Handicap Inventory, the Situational Vertigo Questionnaire, and the Activity-Specific Balance Confidence Scale for Peripheral and Central Vestibular Symptoms.

Front Neurol 2017 10;8:528. Epub 2017 Oct 10.

Laboratory of Neuro-otology and Neuro-ophthalmology, C. Mondino National Neurological Institute, Pavia, Italy.

Neurophysiological measurements of the vestibular function for diagnosis and follow-up evaluations provide an objective assessment, which, unfortunately, does not necessarily correlate with the patients' self-feeling. The literature provides many questionnaires to assess the outcome of rehabilitation programs for disequilibrium, but only for the Dizziness Handicap Inventory (DHI) is an Italian translation available, validated on a small group of patients suffering from a peripheral acute vertigo. We translated and validated the reliability and validity of the DHI, the Situational Vertigo Questionnaire (SVQ), and the Activities-Specific Balance Confidence Scale (ABC) in 316 Italian patients complaining of dizziness due either to a peripheral or to a central vestibular deficit, or in whom vestibular signs were undetectable by means of instrumental testing or clinical evaluation. Cronbach's coefficient alpha, the homogeneity index, and test-retest reproducibility, confirmed reliability of the Italian version of the three questionnaires. Validity was confirmed by correlation test between questionnaire scores. Correlations with clinical variables suggested that they can be used as a complementary tool for the assessment of vestibular symptoms. In conclusion, the Italian versions of DHI, SVQ, and ABC are reliable and valid questionnaires for assessing the impact of dizziness on the quality of life of Italian patients with peripheral or central vestibular deficit.
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http://dx.doi.org/10.3389/fneur.2017.00528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641311PMC
October 2017

Benign paroxysmal positional vertigo: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society.

Acta Otorrinolaringol Esp 2017 Nov - Dec;68(6):349-360. Epub 2017 Oct 19.

Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, EE. UU.

This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.
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http://dx.doi.org/10.1016/j.otorri.2017.02.007DOI Listing
August 2018

Cochlear and Vestibular Effects of Combined Intratympanic Gentamicin and Dexamethasone.

J Int Adv Otol 2017 Apr 13;13(1):47-52. Epub 2017 Jan 13.

Department of Otorhinolaryngology, Dokuz Eylül University School of Medicine, İzmir, Turkey.

Objective: The aim of this study is to evaluate the effects of an intratympanic gentamicin-dexamethasone combination on the inner ear.

Materials And Methods: Twenty-six Wistar albino rats were divided into four groups: Group I (Control), group II (Intratympanic dexamethasone; ITD), group III (Intratympanic gentamicin; ITG), and group IV (Intratympanic gentamicin and dexamethasone; ITGD). On the first day after basal auditory brainstem response (ABR) measurements, the ITG group received 0.03 mL of intratympanic gentamicin (26.7 mg/mL). Intratympanic injection of 0.06 mL of a solution containing 13.35 mg/mL gentamicin and 2 mg/mL dexamethasone was performed in the ITGD group. 0.03 mL of physiological intratympanic serum and dexamethasone (4 mg/mL) was applied in control and ITD groups, respectively. On the 7th day, ABR measurements were repeated and vestibular functions were evaluated. On the 21th day, ABR and vestibular tests were repeated, and the animals were sacrificed for histopathological investigation.

Results: The ITG group's hearing thresholds deteriorated in all frequencies. The ITGD group's hearing thresholds were significantly better than the ITG group, except at 8 kHz on the 7th day and in all frequencies at the 21th day measurements. The vestibular function scores of the ITG and ITGD groups were higher than the controls. Apoptotic changes were seen in cochlea, spiral ganglion, and vestibule of the ITG group. Cochlear and vestibular structures were well preserved in the ITGD group, similar to the controls.

Conclusion: The ITGD combination led to a significant hearing preservation. Although in subjective vestibular tests, it seemed that vestibulotoxicity was present in both ITG and ITGD groups the histopathological investigations revealed no signs of vestibulotoxicity in the ITGD group in contrast to the ITG group. Further studies using a combination of different concentrations of gentamicin and dexamethasone are needed.
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http://dx.doi.org/10.5152/iao.2016.2181DOI Listing
April 2017

Benign paroxysmal positional vertigo: Diagnostic criteria.

J Vestib Res 2015 ;25(3-4):105-17

Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MA, USA.

This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.
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http://dx.doi.org/10.3233/VES-150553DOI Listing
October 2016

Typical and atypical benign paroxysmal positional vertigo: literature review and new theoretical considerations.

J Vestib Res 2014 ;24(5-6):415-23

Otology and Skull Base Surgery Department, Azienda Ospedaliera Universitaria Senese, Siena, Italy.

Atypical variants of benign paroxysmal positional vertigo (BPPV) are often encountered and frequently confusing. The authors present a hypothetical framework that accounts for all classical patterns of BPPV and several unusual variants such as BPPV without nystagmus, BPPV with downbeat nystagmus and BPPV with paradoxically direction-changing nystagmus. The authors introduce new concepts, such as "ipsicanal switch" and "horizontal short arm canalolithiasis" and suggest that their use may improve diagnosis and treatment in everyday clinical practice. The possible consequences of saccular otoconia detachment are reviewed according to the literature.
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http://dx.doi.org/10.3233/VES-140535DOI Listing
December 2015

Double-blind randomized trial on the efficacy of the Gufoni maneuver for treatment of lateral canal BPPV.

Laryngoscope 2013 Jul 4;123(7):1782-6. Epub 2013 Feb 4.

Dipartimento di Scienze neurologiche e sensoriali, Università di Siena, Siena.

Objectives/hypothesis: The need for class I and II studies on the efficacy of liberatory maneuvers in the treatment of lateral canal benign paroxysmal positional vertigo (LC-BPPV) motivated the present double-blind randomized trial on the short-term efficacy of the Gufoni liberatory maneuver (GLM).

Study Design: Double-blind randomized controlled trial.

Methods: Seventy-two patients with unilateral LC-BPPV were recruited for a multicentric study. Patients were randomly assigned to treatment by GLM (n = 37) or sham treatment (n = 35). Subjects were followed up twice (at 1 hour and 24 hours) with the supine roll test by blinded examiners.

Results: At 1- and 24-hour follow-up, 75.7% and 83.8% of patients, respectively, undergoing GLM had recovered from vertigo, compared to around 10% of patients undergoing the sham maneuver (P < 0.0001).

Conclusion: To the best of our knowledge, this is the first class I study on the efficacy of the GLM in the treatment of LC-BPPV in both geotropic and apogeotropic forms. GLM proved highly effective compared to the sham maneuver (P < 0.0001). The present class I study of the efficacy of the GLM changes the level of recommendation of the method for treating LC-BPPV from level U to level B for the geotropic variant and from level B to level A for the apogeotropic variant of LC-BPPV.
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http://dx.doi.org/10.1002/lary.23918DOI Listing
July 2013

Natural course of positional down-beating nystagmus of peripheral origin.

J Neurol 2013 Jun 5;260(6):1489-96. Epub 2013 Jan 5.

ENT Department, University of Siena, Siena, Italy.

The aim of this study was to assess the natural course of positional down-beating nystagmus (pDBN) and vertigo in patients with no evidence of central nervous system involvement and of presumed peripheral origin. Fifty-three patients with pDBN had a complete otoneurological examination. All subjects, apart from three (excluded from the study), showed no additional neurological signs and normal brain imaging. Patients were randomly assigned to two groups: with or without treatment with exercise. Patients were seen again after 24 h, and then weekly for up to 6 months. Forty-seven patients (94%) showed pDBN in the straight head-hanging position and in a Dix-Hallpike position. A torsional component was detected in 17 patients (34%). The mean latency and duration of pDBN was 4.7 ± 5 s and 40.1 ± 22 s, respectively. After 2 weeks, only 12 patients (24%) still had pDBN and all but one patient had recovered by 1 month. Twenty patients (40%) were diagnosed with a typical posterior canal benign paroxysmal positional vertigo (PC BPPV) before or after pDBN. This study assessed for the first time the natural course of presumed peripheral pDBN, which was characterized by a spontaneous remission in 24 patients in the first week and in 49 patients within 4 weeks. pDBN is much more common than previously suggested, with about the same frequency as lateral canal BPPV. Furthermore, the clinical characteristics of pDBN have been highlighted, as well as its possible relationship to PC BPPV.
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http://dx.doi.org/10.1007/s00415-012-6815-9DOI Listing
June 2013

Hyperventilation-induced nystagmus in vestibular schwannoma and unilateral sensorineural hearing loss.

Eur Arch Otorhinolaryngol 2013 Jul 30;270(7):2007-11. Epub 2012 Oct 30.

Otology and Skull Base Surgery Department, University of Siena, Policlinico "Le Scotte", Viale Bracci 11, 53100 Siena, Italy.

We evaluated the incidence and characteristics of hyperventilation-induced nystagmus (HVN) in 49 patients with gadolinium-enhanced magnetic resonance imaging evidence of vestibular schwannoma and 53 patients with idiopathic unilateral sensorineural hearing loss and normal radiological findings. The sensitivity and specificity of the hyperventilation test were compared with other audio-vestibular diagnostic tests (bedside examination of eye movements, caloric test, auditory brainstem responses) in the two groups of patients. The hyperventilation test scored the highest diagnostic efficiency (sensitivity 65.3 %; specificity 98.1 %) of the four tests in the differential diagnosis of vestibular schwannoma and idiopathic unilateral sensorineural hearing loss. Small tumors with a normal caloric response or caloric paresis were associated with ipsilateral HVN and larger tumors and severe caloric deficits with contralateral HVN. These results confirm that the hyperventilation test is a useful diagnostic test for predicting vestibular schwannoma in patients with unilateral sensorineural hearing loss.
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http://dx.doi.org/10.1007/s00405-012-2236-8DOI Listing
July 2013

A Device for the Functional Evaluation of the VOR in Clinical Settings.

Front Neurol 2012 23;3:39. Epub 2012 Mar 23.

Department of Computer and Systems Science, University of Pavia Pavia, Italy.

We developed the head impulse testing device (HITD) based on an inertial sensing system allowing to investigate the functional performance of the rotational vestibulo-ocular reflex (VOR) by testing its gaze stabilization ability, independently from the subject's visual acuity, in response to head impulses at different head angular accelerations ranging from 2000 to 7000 deg/s(2). HITD was initially tested on 22 normal subjects, and a method to compare the results from a single subject (patient) with those from controls was set up. As a pilot study, we tested the HITD in 39 dizzy patients suffering, non-acutely, from different kinds of vestibular disorders. The results obtained with the HITD were comparable with those from the clinical head impulse test (HIT), but an higher number of abnormalities was detectable by HITD in the central vestibular disorders group. The HITD appears to be a promising tool for detecting abnormal VOR performance while providing information on the functional performance of the rotational VOR, and can provide a valuable assistance to the clinical evaluation of patients with vestibular disorders.
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http://dx.doi.org/10.3389/fneur.2012.00039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311056PMC
October 2012

Double-blind randomized trial on short-term efficacy of the Semont maneuver for the treatment of posterior canal benign paroxysmal positional vertigo.

J Neurol 2012 May 19;259(5):882-5. Epub 2011 Oct 19.

Dipartimento di Scienze Neurologiche e Sensoriali, Università di Siena, Siena Viale Bracci, 11, 53100, Siena, Italy.

The need for Class I and II studies on the efficacy of Semont's liberatory maneuver (SLM) in the treatment of posterior canal benign paroxysmal positional vertigo (PC-BPPV) motivated the present double-blind randomized trial on the short-term efficacy of SLM. A total of 342 patients with unilateral PC-BPPV were recruited for a multicenter study. Patients were randomly assigned to treatment by SLM (n = 174) or sham treatment (n = 168). Subjects were followed up twice (1 and 24 h) with the Dix-Hallpike maneuver by blinded examiners. At the 1 and 24 h follow-up, 79.3 and 86.8%, respectively, of patients undergoing SLM had recovered from vertigo, compared to none of the patients undergoing the sham maneuver (p < 0.0001). Patients who manifested liberatory nystagmus at the end of SLM showed a significantly higher percentage of recovery (87.1 vs. 55.7%; p < 0.0001). To the best of our knowledge, this is the first Class I study on the efficacy of SLM. SLM proved highly effective with respect to the sham maneuver (p < 0.0001). Liberatory nystagmus was demonstrated to be a useful prognostic factor for the efficacy of treatment. The present Class I study of efficacy of SLM changes the level of recommendation of the maneuver for treating PC-BPPV from level C to level B.
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http://dx.doi.org/10.1007/s00415-011-6272-xDOI Listing
May 2012

Lateral medullary ischemia presenting with persistent hiccups and vertigo.

Int J Neurosci 2010 Mar;120(3):226-30

ENT Department, University of Verona, Verona, Italy.

This study describes a patient with lateral medullary ischemia (LMI) presenting with persistent hiccups followed by vertigo with horizontal head-shaking-induced contralesional nystagmus (HSN) and discusses pertinent pathophysiology. A 65-year-old man presented with persistent hiccups and disabling spells of vertigo, lasting 30 seconds that became much more frequent and associated with lateropulsion to the right. A strong left beating HSN was evident. Magnetic resonance imaging and angiography, and intra-arterial cerebral digital subtracted angiography showed subacute ischemic lesions in the right lateral medulla and ipsilateral inferior cerebellar hemisphere, and two tight stenoses of the V1 and V4 segments of the right vertebral artery. Patient was treated by intravenous heparin and oral clopidogrel. After 48 hours, hiccups disappeared. One month later, vertigo spells were less frequent but still disabling. Endovascular stenting of the right vertebral artery stenoses was then performed. In the subsequent four years, the patient had no further episodes of hiccups or vertigo. Less intense HSN persisted. Hiccups followed by vertigo, lateropulsion, and HSN had been the clinical presentation of LMI and cerebellar ischemia, without other major neurologic or ocular motor findings. This unusual clinical variant of LMI could mimic a more benign labyrinthine lesion, and possibly leading to a dangerously delayed treatment.
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http://dx.doi.org/10.3109/00207450903585316DOI Listing
March 2010

Vestibular neuritis: recurrence and incidence of secondary benign paroxysmal positional vertigo.

Acta Otolaryngol 2010 May;130(5):565-7

Department of Human Pathology and Oncology, University of Siena, School of Medicine, Siena, Italy.

Conclusions: Recurrence of vestibular neuritis (VN) is a rare event in long-term follow-up. The incidence of benign paroxysmal positional vertigo (BPPV) in VN patients represents a quite common outcome. To our knowledge, this study represents the only long-term longitudinal study on recurrence of VN and incidence of secondary BPPV in VN.

Objectives: To study a large number of VN patients longitudinally to identify the recurrence rate of VN and incidence of BPPV, other peripheral vestibular disorders, sudden hearing loss or Bell's palsy.

Methods: This prospective cohort study assessed a VN patient-based clinic population. All patients received a complete bedside clinical examination and caloric irrigation.

Results: Long-term (range 4-6 years, mean 4.9 years) longitudinal follow-up examination of 51 VN patients demonstrated a low recurrence rate (1/51 patients, 2.0%). With recurrence, VN affected the same ear after 6 months and caused less severe symptoms. BPPV appears to be more frequent (5/51 patients, 9.8%) in VN patients than in the general population, consistently affecting the posterior canal of the same ear. BPPV occurrence after VN predominantly affects VN patients who did not fully recover from the disease. Moreover, BPPV after VN appears to be more difficult to treat than idiopathic BPPV.
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http://dx.doi.org/10.3109/00016480903311278DOI Listing
May 2010

The social impact of dizziness in London and Siena.

J Neurol 2010 Feb 22;257(2):183-90. Epub 2009 Aug 22.

Neuro-otology Unit, Department of Clinical Neuroscience, Imperial College London, Charing Cross Hospital, London, W6 8RF, UK.

Although dizziness is a common presenting symptom in general and hospital practice, its social cost is not known. We assessed the social and work life impact of dizziness on patients in two contrasting European cities, Siena and London. First, we developed the 'Social life & Work Impact of Dizziness questionnaire' (SWID), which was validated by administering it to 43 patients with dizziness and 45 normal controls and by correlating the results with the EQ-5D (Europe quality of life) questionnaire. The SWID and EQ-5D scores were worse in patients than controls (p < 0.001) and the two correlated significantly (r = 0.50 p < 0.001). Then two hundred consecutive patients per city attending tertiary specialised 'dizzy patient' clinics, one in London led by a neurologist, one in Siena led by an ear, nose and throat specialist (ENT), were investigated with SWID. Amongst the 400 patients, 27% reported changing their jobs and 21% giving up work as a result of the dizziness. Over 50% of patients felt that their efficiency at work had dropped considerably. The mean number of days off work attributed to the dizziness in the previous 6 months was 7.15 days. Social life was disrupted in 57% of all 400 patients. Factor analysis identified that detrimental effects on work, travel, social and family life combine to create a single factor accounting for much of the overall impact of their dizziness. Significant differences in some measures of handicap between London and Siena emerged, with London patients often faring worse. Reasons for these location differences include, as expected, a higher proportion of neurological patients in London than in Siena. However, factors related to city demographics and social cohesion may also modulate the impact on quality of life and working practice. Regardless of inter-city differences, these findings highlight the high social and economic impact of dizziness.
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http://dx.doi.org/10.1007/s00415-009-5287-zDOI Listing
February 2010

Long-term follow-up of vestibular neuritis.

Ann N Y Acad Sci 2009 May;1164:427-9

Department of Orthopedics, Radiology and Otolaryngology, University of Siena, School of Medicine, Siena, Italy.

The long-term outcome of vestibular neuritis was evaluated in 35 patients using 4 bedside tests (head impulse, head heave, head shake, vibration), the caloric test and two surveys that explored the degree of disability (Dizziness Handicap Inventory [DHI]) and the anxiety and depression levels (Hospital Anxiety and Depression Scale [HADS]). Sixty-six percent of patients showed a positive bedside clinical test or calorics abnormalities. DHI scores were significantly higher in the patients group, while HADS scores were comparable between patients and controls. Disability from vestibular neuritis is primarily due to the vestibular disturbance itself, rather than purely psychological factors.
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http://dx.doi.org/10.1111/j.1749-6632.2008.03721.xDOI Listing
May 2009

Lateral canal paroxysmal positional vertigo revisited.

Ann N Y Acad Sci 2009 May;1164:316-23

Department of Orthopedics, Radiology and Otolaryngology, University of Siena, School of Medicine, Siena, Italy.

The first reports of an involvement of the lateral canal (LC) in paroxysmal positional vertigo (PPV), were published in 1985, by Luciano Cipparrone et al., from Italy and Joseph McClure from Canada. The increasing interest of otolaryngologists and neurologists has led to a progressive advance in the knowledge of this labyrinthine disorder regarding its epidemiological, physiopathological, clinical, and therapeutic aspects. According to the most recent data, LC-benign PPV accounts for 17% of all PPV patients, regardless of gender and between the two labyrinths. The LC-PPV syndrome is characterized by intense positional vertigo and direction-changing geotropic horizontal nystagmus, both caused by rotation of the head in the supine position. Less frequently, it presents with apogeotropic nystagmus. In some patients nystagmus is also detectable in the sitting position, mimicking a spontaneous nystagmus. In most cases nystagmus is caused by displaced otoconia floating in the semicircular canal. The pathological side, which must be identified for successful treatment, is usually indicated by nystagmus intensity: the more intense positional nystagmus beats toward the affected ear. In a few cases, where there is no difference in nystgmus intensity, other indicators are necessary to determine the pathological side. Vestibular neuritis and posterior fossa lesions should be considered in the differential diagnosis. Treatment of LC-PPV relies on some physical maneuvers, the objective of which is to allow the otoconial debris to exit from the LC by centrifugal inertia and/or by gravitation.
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http://dx.doi.org/10.1111/j.1749-6632.2008.03720.xDOI Listing
May 2009

Impairment of vertical saccades from an acute pontine lesion in multiple sclerosis.

J Neuroophthalmol 2008 Dec;28(4):305-7

Department of Neurological and Behavioural Sciences, Neuroradiology Unit, S. Maria alle Scotte Hospital, Siena, Italy.

A 62-year-old woman with relapsing-remitting multiple sclerosis suddenly complained of diplopia associated with bilateral adduction impairment, nystagmus of the abducting eye bilaterally, and sparing of abduction, convergence, and vertical eye movements, consistent with bilateral internuclear ophthalmoplegia. Within 1 week, she had developed a complete horizontal gaze paralysis even with the oculocephalic maneuver. Vertical saccades were slow and convergence was preserved. There was a right lower motor neuron seventh cranial nerve palsy. Brain MRI showed a new enhancing lesion involving the pontine tegmentum. Clinical and MRI follow-up showed recovery after 6 months. The slowing of vertical saccades may have been due to spread of the demyelinating lesion to the adjacent paramedian pontine reticular formation, which contains omnipause neurons lying in the raphe interpositus nucleus thought to inhibit excitatory burst neurons for horizontal and vertical saccades. Our patient verifies the fact that vertical saccadic abnormalities may occur from a lesion apparently confined to the pons.
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http://dx.doi.org/10.1097/WNO.0b013e318183bd26DOI Listing
December 2008

Distinct olfactory cross-modal effects on the human motor system.

PLoS One 2008 Feb 27;3(2):e1702. Epub 2008 Feb 27.

Dipartimento di Neuroscienze, Sezione Neurologia, University of Siena, Siena, Italy.

Background: Converging evidence indicates that action observation and action-related sounds activate cross-modally the human motor system. Since olfaction, the most ancestral sense, may have behavioural consequences on human activities, we causally investigated by transcranial magnetic stimulation (TMS) whether food odour could additionally facilitate the human motor system during the observation of grasping objects with alimentary valence, and the degree of specificity of these effects.

Methodology/principal Findings: In a repeated-measure block design, carried out on 24 healthy individuals participating to three different experiments, we show that sniffing alimentary odorants immediately increases the motor potentials evoked in hand muscles by TMS of the motor cortex. This effect was odorant-specific and was absent when subjects were presented with odorants including a potentially noxious trigeminal component. The smell-induced corticospinal facilitation of hand muscles during observation of grasping was an additive effect which superimposed to that induced by the mere observation of grasping actions for food or non-food objects. The odour-induced motor facilitation took place only in case of congruence between the sniffed odour and the observed grasped food, and specifically involved the muscle acting as prime mover for hand/fingers shaping in the observed action.

Conclusions/significance: Complex olfactory cross-modal effects on the human corticospinal system are physiologically demonstrable. They are odorant-specific and, depending on the experimental context, muscle- and action-specific as well. This finding implies potential new diagnostic and rehabilitative applications.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0001702PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2253499PMC
February 2008

Effectiveness of careful bedside examination in assessment, diagnosis, and prognosis of vestibular neuritis.

Arch Otolaryngol Head Neck Surg 2008 Feb;134(2):164-9

Department of Orthopedics, Radiology, and Otolaryngology, University of Siena School of Medicine, Viale Bracci 16, Siena 53100, Italy.

Objective: To determine whether the use of 4 bedside tests (head-impulse, head-heave, head-shake, and vibration tests) can be as effective as the caloric test, a widely accepted standard, in the diagnosis and prediction of the time to recovery from vestibular neuritis.

Design: Inception cohort (1-year follow-up), criterion standard study.

Setting: Primary referral center.

Patients: All patients had acute vertigo, and those having a diagnosis of vestibular neuritis were eligible for inclusion in the study. Sixty-eight patients (43 men and 25 women; mean age, 54.9 years) met this criterion, and 53 of them (77.9%) completed the study.

Main Outcome Measures: Spontaneous head-shaking and vibration-induced nystagmus elicited with a battery-powered device were tested wearing Frenzel goggles. The head-impulse and head-heave tests were performed manually. Caloric irrigation was administered with hot, cold, and ice water.

Results: At baseline, more than half of the patients exhibited positive signs with all 4 tests and all had caloric paralysis or paresis. Signs with the head-impulse and head-heave tests correlated highly (odds ratio, 24.9; P < .001), as did those with the head-shake and vibration tests (odds ratio, 22.8; P < .001). Patients with a positive sign with the head-impulse or vibration test were 70% less likely to recover than were those with a negative sign. Head-impulse (hazard ratio, 0.08; P = .002) and head-shake (hazard ratio, 0.23; P = .01) test results were associated with the outcome of the caloric test.

Conclusion: Careful bedside examination of patients with vestibular neuritis has both diagnostic value in the short term and prognostic value in the long term.
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http://dx.doi.org/10.1001/archoto.2007.35DOI Listing
February 2008

A child with vestibular neuritis. is adenovirus implicated?

Brain Dev 2006 Jul 28;28(6):410-2. Epub 2006 Feb 28.

Department of Pediatrics, Section of Pediatric Neurology, Policlinico Le Scotte, University of Siena, Siena, Italy.

Vertigo in children is relatively under examined in the literature. Among its causes, vestibular neuritis (VN) represents only 2% of cases, with its etiology remaining unknown. We report for the first time a 4-year-old boy with vestibular neuritis and serological results compatible with adenoviral infection. Serological diagnosis was performed on the basis of a rise and consequent normalization of complement fixation (CF) titers of the plasma antibodies. Although we were not able to detect exactly when the infection started, we were able to detect an increased level of adenovirus antibodies by CF titers, followed by a decrease (i.e. 1/16, then 1/8, then <1/4) during the recovery. This is typical of a resolving infection. Furthermore, that this increase in antibodies was specific to an adenovirus infection was suggested by the observation that we did not detect increases in antibodies to other common viruses (i.e. herpes simplex and zoster viruses, Epstein-Barr virus, cytomegalovirus, influenza and parainfluenza viruses). This allows us to exclude the chance of nonspecific antibody activation. We concluded that, although our data do not formally demonstrate an involvement of adenovirus in VN, they suggest such an involvement. This may be of interest, given that a viral etiology for VN has been proposed but not definitively proven.
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http://dx.doi.org/10.1016/j.braindev.2005.12.001DOI Listing
July 2006

Transtympanic gentamicin and fibrin tissue adhesive for treatment of unilateral Menière's disease: effects on vestibular function.

Otolaryngol Head Neck Surg 2005 Dec;133(6):929-35

Department of Otorhinolaryngology, University of Pisa, Italy.

Objective: To determine the effects of transtympanic injections, with a mixture composed of gentamicin and fibrin tissue adhesive (FTA), on vestibular function of patients with intractable unilateral Menière's disease.

Study Design: This was an open, prospective study.

Setting And Patients: The study was performed at 2 tertiary referral centers. Twenty-six patients affected by "definite" unilateral Menière's disease, unresponsive to medical therapy for at least 6 months, were enrolled.

Intervention: A buffered gentamicin solution mixed with FTA was injected in the middle ear until the development of bedside vestibular hypofunction signs and/or caloric weakness in the treated ear.

Main Outcome Measure: Vestibular function was evaluated by 3 bedside vestibular tests (observation of spontaneous nystagmus, head shaking test, and head thrust test) and by a caloric test. Tests were performed on days 10 and 30 after completion of treatment. Tests were also performed 3, 6, and 12 months from completion of the gentamicin-FTA protocol. The effects of treatment were also assessed in terms of hearing levels, control of vertigo, and disability status.

Results: In 22 of the 26 patients, only 1 gentamicin-FTA injection was necessary to obtain 1 or more signs indicating a reduction of the vestibular function in the treated ear. Four patients needed another treatment because of the persistence of their incapacitating symptoms during the follow-up. Four patients needed more than 1 injection to obtain a vestibular hypofunction. None of the patients who received 1 or 2 injections presented hearing loss in direct temporal relationship to the treatment.

Conclusions: A mixture of gentamicin and fibrin glue makes it possible to considerably reduce the number of administrations in patients with intractable unilateral Menière's disease. Spontaneous nystagmus, post head shaking nystagmus, and a head thrust sign are the clinical signs that indicate onset or progression of unilateral vestibular hypofunction. These signs were obtained with only 1 injection in 81% of patients.
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http://dx.doi.org/10.1016/j.otohns.2005.07.033DOI Listing
December 2005

Sarcoidosis with upper respiratory tract involvement.

Respir Med 2006 Feb 1;100(2):253-7. Epub 2005 Jun 1.

Respiratory Diseases Section, Department of Immunology and Clinical Medicine, Siena University, Siena, Italy.

The aim of the study was to investigate the upper respiratory tract as a site of extrapulmonary sarcoidosis. Diagnosis of sarcoidosis with upper respiratory tract involvement was performed on the basis of clinical, laboratory, radiographic and histological evidence and by excluding other granulomatous diseases in eight patients followed by the Sarcoidosis Regional Reference Centre pneumologists in collaboration with an experienced ENT specialist at Siena University. In five cases, sarcoidosis was localized in the parotid glands, in the other three subjects larynx, nasopharynx and nose were involved. In four patients parotid gland, nasopharynx and upper respiratory tract mucous membrane involvement was the only clinical manifestation at onset of the disease. Upper respiratory tract involvement should be suspected in all patients with systemic sarcoidosis and in patients with persistent upper respiratory tract symptoms of unknown cause. What a general practitioner should do as not to miss SURT is underlined. Interdisciplinary management and collaboration are of paramount importance for rapid diagnosis and to avoid the possible complications of this form.
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http://dx.doi.org/10.1016/j.rmed.2005.04.018DOI Listing
February 2006