Introdução: Os papilomas invertidos nasossinusais (PIN) constituem neoplasias benignas raras ca... more Introdução: Os papilomas invertidos nasossinusais (PIN) constituem neoplasias benignas raras caracterizadas pelo seu comportamento localmente agressivo, crescimento expansivo, elevada taxa de recorrência e potencial para transformação maligna. A cirurgia endoscópica endonasal é considerada actualmente a abordagem gold-standard para seu o tratamento. Objectivos: Analisar a experiência de um centro terciário universitário no diagnóstico e tratamento ci-rúrgico do PIN e identificar potenciais factores de risco para a sua recidiva. Material e Métodos: Estudo observacional, retrospectivo e descritivo; revisão da literatura. Resultados: Foram incluídos 14 doentes com uma idade média de 51,1±17,5 anos e um ligeiro predomínio do sexo masculino (64,3%). De acordo com a classificação de Krouse, 10 tumores foram classificados em estadio II (71,4%) e 4 em estadio III (28,6%). Realizou-se um total de 18 procedimentos (14 primários e 4 de revisão), dos quais 11 abordagens exclusivamente endoscópicas (61,1%) e 7 abordagens combinadas (38,9%). A taxa de recidiva global foi de 28,6%, com um tempo médio para ocorrência de 65±22 meses. A análise bivariada dos potenciais factores de risco para recidiva não encontrou nenhuma associação da mesma com o género (p=0,095), idade (p=0,066), estadio de Krouse (0,520) ou abordagem cirúrgica (p=1,000). Conclusão: A cirurgia endoscópica endonasal permite ressecções cirúrgicas eficazes em tumores seleccionados, com mínima morbilidade e respeito dos princípios de segurança oncológica. A nossa experiência reforça a importância da vigilância endoscópica e imagiológica ad eternum durante o período de seguimento pós-operatório destes tumores, com vista a diagnosticar e tratar precocemente as recidivas ou eventuais transformações malignas. Palavras-chave: papiloma invertido; tumor nasosinusal benigno; neoplasias nasais; cirurgia endoscópica endonasal.
The cerebellar flocculus is a critical structure involved in the control of eye movements. Both s... more The cerebellar flocculus is a critical structure involved in the control of eye movements. Both static and dynamic abnormalities of the vestibulo-ocular reflex (VOR) have been described in animals with experimental lesions of the flocculus/paraflocculus complex. In humans, lesions restricted to the flocculus are rare so they can become an exceptional model to contrast with the clinical features in experimental animals or in patients with more generalized cerebellar diseases. Here, we examined a 67-year-old patient with an acute vestibular syndrome due to an isolated infarct of the right flocculus. We evaluated him multiple times over 6 months-to follow the changes in eye movements and vestibular function-with caloric testing, video-oculography and head-impulse testing, and the anatomical changes on imaging. Acutely, he had an ipsilateral-beating spontaneous nystagmus, bilateral gaze-evoked nystagmus, borderline impaired smooth pursuit, and a complete contraversive ocular tilt reaction. The VOR gain was reduced for head impulses directed contralateral to the lesion, and there was also an ipsilesional caloric weakness. All abnormalities progressively improved at follow-up visits but with a considerable reduction in volume of the affected flocculus on imaging. The vestibular and ocular motor findings, qualitatively similar to a previously reported patient, further clarify the Bacute floccular syndrome^in humans. We also add new information about the pattern of recovery from such a lesion with corresponding changes in the size of the affected flocculus on imaging.
Witsch et al. 1 described a patient with acute vestibular syndrome, left-beating spontaneous nyst... more Witsch et al. 1 described a patient with acute vestibular syndrome, left-beating spontaneous nystagmus, and an abnormal head-impulse test (HIT) to the right who was found to have an acute left cerebellar hemisphere stroke. The authors attributed the findings to the lesion and concluded that this case "…illustrates the limited specificity…" of the HIT. 1 We have 2 concerns about this conclusion. First, the lesion shown is not in the flocculonodular lobe, as suggested by the authors, 1 but within the left cerebellar hemisphere, most likely in the superior cerebellar artery (SCA) territory. 2 Among 41 SCA strokes reported by Drs. Lee and Kim, 3 none had an abnormal HIT, only 11 had nystagmus, and those with nystagmus almost all had more ventrally located lesions. Thus, the clinical findings as described by Witsch et al. cannot readily be explained by the lesion shown. Other possibilities include missed brainstem stroke in the vestibular nucleus, labyrinthine
BACKGROUND: Differentiating central from peripheral origins of spontaneous nystagmus (SN) is chal... more BACKGROUND: Differentiating central from peripheral origins of spontaneous nystagmus (SN) is challenging. Looking for a simple sign of peripheral disease with the video Head Impulsive Test we noticed anti-compensatory eye movements (AQEM) in patients with peripheral etiologies of spontaneous nystagmus (SN). Here we assess the diagnostic accuracy of AQEM in differentiating peripheral from central vestibular disorders. METHODS: We recorded the eye movements in response to horizontal head impulses in a group of 43 consecutive patients with acute vestibular syndrome (12 with central, 31 with peripheral disorders), 5 patients after acute vestibular neurectomy (positive controls) and 39 healthy subjects (negative controls). AQEM were defined as quick eye movements (peak velocity above 50 • /s) in the direction of the head movement. RESULTS: All patients with peripheral disorders and positive controls had AQEM (latency 231 ± 53 ms, amplitude 3.4 ± 1.4 • , velocity 166 ± 55 • /s) when their head was moved to the opposite side of the lesion. Central patients did not have AQEM. AQEM occurrence rate was higher in peripheral patients with contralesional (74 ± 4%, mean ± SD) in comparison to ipsilesional (1 ± 4%) impulses (p < 0.001). Overall diagnostic accuracy for differentiating central from peripheral patients was 96% (95% CI for AUC ROC curve: 0.90 to 1.0) for VOR gain and 100% (95% CI: 1.0 to 1.0) for AQEM occurrence rate. CONCLUSIONS: These results suggest that AQEM are a sign of vestibular imbalance in a peripheral deficit. In addition to VOR gain they should be added to the evaluation of the head impulse test.
Journal of vestibular research : equilibrium & orientation, Jan 28, 2016
Differentiating central from peripheral origins of spontaneous nystagmus (SN) is challenging. Loo... more Differentiating central from peripheral origins of spontaneous nystagmus (SN) is challenging. Looking for a simple sign of peripheral disease with the video Head Impulsive Test we noticed anti-compensatory eye movements (AQEM) in patients with peripheral etiologies of spontaneous nystagmus (SN). Here we assess the diagnostic accuracy of AQEM in differentiating peripheral from central vestibular disorders. We recorded the eye movements in response to horizontal head impulses in a group of 43 consecutive patients with acute vestibular syndrome (12 with central, 31 with peripheral disorders), 5 patients after acute vestibular neurectomy (positive controls) and 39 healthy subjects (negative controls). AQEM were defined as quick eye movements (peak velocity above 50°/s) in the direction of the head movement. All patients with peripheral disorders and positive controls had AQEM (latency 231 ± 53 ms, amplitude 3.4 ± 1.4°, velocity 166 ± 55°/s) when their head was moved to the opposite side...
Journal of Neurology, Neurosurgery & Psychiatry, 2014
Background Angular vestibular ocular reflex (VOR) can be non-invasively and easily assessed with ... more Background Angular vestibular ocular reflex (VOR) can be non-invasively and easily assessed with the video head-impulse test (vHIT), allowing the quantification of VOR dynamic parameters (latency and gain) at a physiological frequency domain, as well as the characterisation of quick eye movements (QEM) triggered with head impulses. Here we characterise these findings in HD patients. Methods We explored 18 genetically confirmed HD patients (44.7 ± 8.1 years; male=9), classified as Shoulson and Fahn severity stages 1 (n = 5; pre-symptomatic), 2 (n = 4), 3 (n = 8) and 4 (n = 1) based on their Total Functional Capacity (TFC) scores, and 40 healthy controls (39.9 ± 16.5 years; male=20). We calculated the VOR latency and gain and determined the latency, peak-velocity and occurrence rate of the QEM triggered during and after head impulses. All patients had an oculomotor evaluation (spontaneous nystagmus, smooth pursuit, gaze fixation and saccades) before vHIT testing. Results VOR latency and VOR gain were not different from controls (p > 0.29 for both comparisons). No differences were found between presymptomatic and symptomatic patients. QEM were present in 11 patients and 18 controls, always after the head impulse and compensatory (overt saccades). QEM latency (174.5 ± 41.2 ms), peak velocity (71.58 ± 34.48 º/s) and occurrence rate (0.45 ± 0.29) were not different from controls (p > 0.11 for all comparisons). Though not realising it, 5 of the symptomatic patients majorly failed to direct gaze in darkness, both horizontal as vertically, this correlating with TFC scores (Spearman r = 0.65, p = 0.005). Conclusions VOR seems to be preserved at physiological frequency domains in HD patients, even in more advanced stages of the disease. Although both voluntary saccades and quick phases of nystagmus are known to be slower in HD, quick eye movements triggered with impulses showed no differences in comparison to controls. Gaze failure in darkness may prove beneficial as a biological marker for HD.
A rinosseptoplastia constitui um procedimento cirúrgico complexo que tem como objectivo primário ... more A rinosseptoplastia constitui um procedimento cirúrgico complexo que tem como objectivo primário a obtenção de um nariz funcional e esteticamente atractivo. O sucesso dos seus resultados é significativamente determinado pela realização sistemática de uma análise estética e funcional pré-operatória completa e meticulosa por parte do cirurgião, complementada por um registo operatório minucioso e reprodutível. Os autores apresentam detalhadamente uma proposta de protocolo de análise pré-operatória e registo cirúrgico em doentes candidatos a rinosseptoplastia passível de documentação em formato papel e/ou electrónico, adaptável a cada plano de tratamento individualizado.
Ménière's disease (MD) is a clinical syndrome characterized by recurrent episodes of spontaneous ... more Ménière's disease (MD) is a clinical syndrome characterized by recurrent episodes of spontaneous vertigo, unilateral fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and more recently by magnetic resonance imaging (MRI). The current criteria of the disease, however, remain symptom based and do not include the demonstration of endolymphatic hydrops. The authors review MRI techniques and diagnostic criteria of endolymphatic hydrops and the role of MRI in MD is discussed.
Journal of vestibular research : equilibrium & orientation, Jul 2, 2016
Although the diagnosis of inherited ataxias is ultimately genetic, this usually means an extensiv... more Although the diagnosis of inherited ataxias is ultimately genetic, this usually means an extensive and expensive process. This justifies the search for distinct clinical signs that may potentially help orient molecular diagnosis. We explored the vestibulo-ocular reflex (VOR) with the video Head Impulse Test in patients diagnosed with spinocerebellar ataxia (SCA) type 3 (n = 15), type 1 (n = 4) and type 2 (n = 4), Friedreich's ataxia (FA) (n = 9) and healthy controls (n = 40). We estimated the latency, regression (VORr) and instantaneous VOR gain at 40, 60 and 80 ms (VOR40, VOR60 and VOR80), and determined the latency, peak-velocity and occurrence rate of catch-up saccades triggered with head-impulses. VOR latency was higher in FA (p < 0.001) and SCA3 (p = 0.02) as compared to controls, discriminating FA from other ataxic patients with an overall diagnostic accuracy of 88%. VORr, VOR40 and VOR60 were significantly lower in FA and SCA3 (p < 0.01). VOR80 was only significantl...
Objective: To evaluate the clinical pathophysiology of oculo-motor changes in a patient presentin... more Objective: To evaluate the clinical pathophysiology of oculo-motor changes in a patient presenting with a spontaneous semi-circular horizontal canal plug. Patient: A 42-year-old man with acute spontaneous vertigo with spinning and persistent left-horizontal nystagmus, intensity but not direction dependent on head orientation with respect to gravity, indicating a benign paroxysmal positional vertigo due to otoconia causing a plug in the horizontal semicircular canal. Intervention: Electrophysiological and video-oculographic test-ing; vestibular rehabilitation. Main OutcomeMeasures: Cervical and ocular vestibular evoked myogenic potentials (VEMPs); video head impulse testing. Results: The video head-impulse test revealed an eye velocity cutoff at 80-/s in the time interval from 40 to 90 ms after ini-tiation of head impulses to the right. This normalized within
Background: Menière's disease (MD) is an inner ear disorder characterized by recurrent episod... more Background: Menière's disease (MD) is an inner ear disorder characterized by recurrent episodes of spontaneous vertigo, unilateral low-frequency sensorineural hearing loss, tinnitus, and aural fullness. Current diagnosis still often has to rely on subjective and audiometric criteria only, although endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and by magnetic resonance (MRI). The modiolus has a close functional and anatomical relationship with the cochlear nerve and membranous labyrinth and can be evaluated with MRI but no data exist on the modiolar size in MD. Purpose: Our purpose is to examine the following hypothesis. Is cochlear modiolus smaller in symptomatic ears in MD? Methods: We used a retrospective 3 Tesla MR study (heavily T2-weighted 3D fast asymmetric spin-echo images and 0.5 mm slice thickness) comparing the mean modiolar area (MMA) in the index and best ears of eig...
Objectives: Review the main indications and intraoperative findings in patients undergoing explor... more Objectives: Review the main indications and intraoperative findings in patients undergoing exploratory tympanotomy. Study design: Observational, retrospective, longitudinal study Material and methods: All patients who underwent exploratory tympanotomy, in our institution, from 2015 to 2019 were included. Patients with pathologic findings at otoscopy were excluded. Results: A total of 45 patients underwent unilateral exploratory tympanotomy. Of these, 19 were excluded due to pathologic findings in otoscopy. The mean age was 38,26 years (range 5-77 years). The main indication was conductive hearing loss (88%). Intraoperatively, the ossicular chain was fixed by adhesions (23%), followed by ossicular chain discontinuity (19%), otosclerosis (15%) and cholesteatoma (15%). There were no intra or postoperative complications. Conclusions: Exploratory tympanotomy is a safe diagnostic technique, with added value, since it allows us to directly view the middle ear, obtain the correct diagnosis,...
We read with interest the report “Teaching Video NeuroImages: Vestibulo-ocular reflex defect in c... more We read with interest the report “Teaching Video NeuroImages: Vestibulo-ocular reflex defect in cerebellar stroke” by Witsch et al.1 Although this is a well-written case report with a good-quality video, we have an alternative interpretation of the MRI findings. The flocculus is located posterior to the facial and vestibulocochlear nerves and the internal auditory canal at the cerebellopontine level, and the nodulus is located just posterior to the fourth ventricle at the facial colliculus level. Lesions involving the flocculus can cause gaze-evoked nystagmus, impaired smooth pursuit, contraversive ocular tilt reaction, and reduced vestibulo-ocular reflex gain for head impulses directed contralateral to the lesion.2 However, the lesion found by the authors, indicated by the arrow in the diffusion-weighted MRI scan,1 has a more posterolateral location compared with the floccular area on MRIs of previous reports2 and on anatomic templates (figure).
Objectives: To determine the positive predictive value (PPV) for malignancy and distribution of h... more Objectives: To determine the positive predictive value (PPV) for malignancy and distribution of head and neck cancer diagnosed by biopsy in the outpatient clinic of a tertiary hospital. To identify the presence of Epstein-Barr virus (EBV) and human papilloma virus (HPV) in nasopharyngeal and oropharyngeal carcinoma, respectively. Materials and Methods: Observational, retrospective, transversal study of the pathologic anatomy results of 365 biopsies performed on the Otorhinolaryngology outpatient clinic for clinical/imagological suspected malignancy in a 2 year period (2018-2019). The PPV for malignancy was calculated for each anatomical region. Results: We identified 111 malignant results (PPV 30,4%), of which 81% were squamous cell carcinoma (SCC). Immunohistochemistry stained positive for EBV in 75% of nonkeratinizing SCC of the nasopharynx and for p16 (HPV) in 9,7% of the SCC of the oropharynx. Conclusion: The most common diagnosis in the malignant results was SCC. There was a lo...
The cerebellar flocculus is a critical structure involved in the control of eye movements. Both s... more The cerebellar flocculus is a critical structure involved in the control of eye movements. Both static and dynamic abnormalities of the vestibulo-ocular reflex (VOR) have been described in animals with experimental lesions of the flocculus/paraflocculus complex. In humans, lesions restricted to the flocculus are rare so they can become an exceptional model to contrast with the clinical features in experimental animals or in patients with more generalized cerebellar diseases. Here, we examined a 67-year-old patient with an acute vestibular syndrome due to an isolated infarct of the right flocculus. We evaluated him multiple times over 6 months-to follow the changes in eye movements and vestibular function-with caloric testing, video-oculography and head-impulse testing, and the anatomical changes on imaging. Acutely, he had an ipsilateral-beating spontaneous nystagmus, bilateral gaze-evoked nystagmus, borderline impaired smooth pursuit, and a complete contraversive ocular tilt reacti...
Introdução: Os papilomas invertidos nasossinusais (PIN) constituem neoplasias benignas raras ca... more Introdução: Os papilomas invertidos nasossinusais (PIN) constituem neoplasias benignas raras caracterizadas pelo seu comportamento localmente agressivo, crescimento expansivo, elevada taxa de recorrência e potencial para transformação maligna. A cirurgia endoscópica endonasal é considerada actualmente a abordagem gold-standard para seu o tratamento. Objectivos: Analisar a experiência de um centro terciário universitário no diagnóstico e tratamento ci-rúrgico do PIN e identificar potenciais factores de risco para a sua recidiva. Material e Métodos: Estudo observacional, retrospectivo e descritivo; revisão da literatura. Resultados: Foram incluídos 14 doentes com uma idade média de 51,1±17,5 anos e um ligeiro predomínio do sexo masculino (64,3%). De acordo com a classificação de Krouse, 10 tumores foram classificados em estadio II (71,4%) e 4 em estadio III (28,6%). Realizou-se um total de 18 procedimentos (14 primários e 4 de revisão), dos quais 11 abordagens exclusivamente endoscópicas (61,1%) e 7 abordagens combinadas (38,9%). A taxa de recidiva global foi de 28,6%, com um tempo médio para ocorrência de 65±22 meses. A análise bivariada dos potenciais factores de risco para recidiva não encontrou nenhuma associação da mesma com o género (p=0,095), idade (p=0,066), estadio de Krouse (0,520) ou abordagem cirúrgica (p=1,000). Conclusão: A cirurgia endoscópica endonasal permite ressecções cirúrgicas eficazes em tumores seleccionados, com mínima morbilidade e respeito dos princípios de segurança oncológica. A nossa experiência reforça a importância da vigilância endoscópica e imagiológica ad eternum durante o período de seguimento pós-operatório destes tumores, com vista a diagnosticar e tratar precocemente as recidivas ou eventuais transformações malignas. Palavras-chave: papiloma invertido; tumor nasosinusal benigno; neoplasias nasais; cirurgia endoscópica endonasal.
The cerebellar flocculus is a critical structure involved in the control of eye movements. Both s... more The cerebellar flocculus is a critical structure involved in the control of eye movements. Both static and dynamic abnormalities of the vestibulo-ocular reflex (VOR) have been described in animals with experimental lesions of the flocculus/paraflocculus complex. In humans, lesions restricted to the flocculus are rare so they can become an exceptional model to contrast with the clinical features in experimental animals or in patients with more generalized cerebellar diseases. Here, we examined a 67-year-old patient with an acute vestibular syndrome due to an isolated infarct of the right flocculus. We evaluated him multiple times over 6 months-to follow the changes in eye movements and vestibular function-with caloric testing, video-oculography and head-impulse testing, and the anatomical changes on imaging. Acutely, he had an ipsilateral-beating spontaneous nystagmus, bilateral gaze-evoked nystagmus, borderline impaired smooth pursuit, and a complete contraversive ocular tilt reaction. The VOR gain was reduced for head impulses directed contralateral to the lesion, and there was also an ipsilesional caloric weakness. All abnormalities progressively improved at follow-up visits but with a considerable reduction in volume of the affected flocculus on imaging. The vestibular and ocular motor findings, qualitatively similar to a previously reported patient, further clarify the Bacute floccular syndrome^in humans. We also add new information about the pattern of recovery from such a lesion with corresponding changes in the size of the affected flocculus on imaging.
Witsch et al. 1 described a patient with acute vestibular syndrome, left-beating spontaneous nyst... more Witsch et al. 1 described a patient with acute vestibular syndrome, left-beating spontaneous nystagmus, and an abnormal head-impulse test (HIT) to the right who was found to have an acute left cerebellar hemisphere stroke. The authors attributed the findings to the lesion and concluded that this case "…illustrates the limited specificity…" of the HIT. 1 We have 2 concerns about this conclusion. First, the lesion shown is not in the flocculonodular lobe, as suggested by the authors, 1 but within the left cerebellar hemisphere, most likely in the superior cerebellar artery (SCA) territory. 2 Among 41 SCA strokes reported by Drs. Lee and Kim, 3 none had an abnormal HIT, only 11 had nystagmus, and those with nystagmus almost all had more ventrally located lesions. Thus, the clinical findings as described by Witsch et al. cannot readily be explained by the lesion shown. Other possibilities include missed brainstem stroke in the vestibular nucleus, labyrinthine
BACKGROUND: Differentiating central from peripheral origins of spontaneous nystagmus (SN) is chal... more BACKGROUND: Differentiating central from peripheral origins of spontaneous nystagmus (SN) is challenging. Looking for a simple sign of peripheral disease with the video Head Impulsive Test we noticed anti-compensatory eye movements (AQEM) in patients with peripheral etiologies of spontaneous nystagmus (SN). Here we assess the diagnostic accuracy of AQEM in differentiating peripheral from central vestibular disorders. METHODS: We recorded the eye movements in response to horizontal head impulses in a group of 43 consecutive patients with acute vestibular syndrome (12 with central, 31 with peripheral disorders), 5 patients after acute vestibular neurectomy (positive controls) and 39 healthy subjects (negative controls). AQEM were defined as quick eye movements (peak velocity above 50 • /s) in the direction of the head movement. RESULTS: All patients with peripheral disorders and positive controls had AQEM (latency 231 ± 53 ms, amplitude 3.4 ± 1.4 • , velocity 166 ± 55 • /s) when their head was moved to the opposite side of the lesion. Central patients did not have AQEM. AQEM occurrence rate was higher in peripheral patients with contralesional (74 ± 4%, mean ± SD) in comparison to ipsilesional (1 ± 4%) impulses (p < 0.001). Overall diagnostic accuracy for differentiating central from peripheral patients was 96% (95% CI for AUC ROC curve: 0.90 to 1.0) for VOR gain and 100% (95% CI: 1.0 to 1.0) for AQEM occurrence rate. CONCLUSIONS: These results suggest that AQEM are a sign of vestibular imbalance in a peripheral deficit. In addition to VOR gain they should be added to the evaluation of the head impulse test.
Journal of vestibular research : equilibrium & orientation, Jan 28, 2016
Differentiating central from peripheral origins of spontaneous nystagmus (SN) is challenging. Loo... more Differentiating central from peripheral origins of spontaneous nystagmus (SN) is challenging. Looking for a simple sign of peripheral disease with the video Head Impulsive Test we noticed anti-compensatory eye movements (AQEM) in patients with peripheral etiologies of spontaneous nystagmus (SN). Here we assess the diagnostic accuracy of AQEM in differentiating peripheral from central vestibular disorders. We recorded the eye movements in response to horizontal head impulses in a group of 43 consecutive patients with acute vestibular syndrome (12 with central, 31 with peripheral disorders), 5 patients after acute vestibular neurectomy (positive controls) and 39 healthy subjects (negative controls). AQEM were defined as quick eye movements (peak velocity above 50°/s) in the direction of the head movement. All patients with peripheral disorders and positive controls had AQEM (latency 231 ± 53 ms, amplitude 3.4 ± 1.4°, velocity 166 ± 55°/s) when their head was moved to the opposite side...
Journal of Neurology, Neurosurgery & Psychiatry, 2014
Background Angular vestibular ocular reflex (VOR) can be non-invasively and easily assessed with ... more Background Angular vestibular ocular reflex (VOR) can be non-invasively and easily assessed with the video head-impulse test (vHIT), allowing the quantification of VOR dynamic parameters (latency and gain) at a physiological frequency domain, as well as the characterisation of quick eye movements (QEM) triggered with head impulses. Here we characterise these findings in HD patients. Methods We explored 18 genetically confirmed HD patients (44.7 ± 8.1 years; male=9), classified as Shoulson and Fahn severity stages 1 (n = 5; pre-symptomatic), 2 (n = 4), 3 (n = 8) and 4 (n = 1) based on their Total Functional Capacity (TFC) scores, and 40 healthy controls (39.9 ± 16.5 years; male=20). We calculated the VOR latency and gain and determined the latency, peak-velocity and occurrence rate of the QEM triggered during and after head impulses. All patients had an oculomotor evaluation (spontaneous nystagmus, smooth pursuit, gaze fixation and saccades) before vHIT testing. Results VOR latency and VOR gain were not different from controls (p > 0.29 for both comparisons). No differences were found between presymptomatic and symptomatic patients. QEM were present in 11 patients and 18 controls, always after the head impulse and compensatory (overt saccades). QEM latency (174.5 ± 41.2 ms), peak velocity (71.58 ± 34.48 º/s) and occurrence rate (0.45 ± 0.29) were not different from controls (p > 0.11 for all comparisons). Though not realising it, 5 of the symptomatic patients majorly failed to direct gaze in darkness, both horizontal as vertically, this correlating with TFC scores (Spearman r = 0.65, p = 0.005). Conclusions VOR seems to be preserved at physiological frequency domains in HD patients, even in more advanced stages of the disease. Although both voluntary saccades and quick phases of nystagmus are known to be slower in HD, quick eye movements triggered with impulses showed no differences in comparison to controls. Gaze failure in darkness may prove beneficial as a biological marker for HD.
A rinosseptoplastia constitui um procedimento cirúrgico complexo que tem como objectivo primário ... more A rinosseptoplastia constitui um procedimento cirúrgico complexo que tem como objectivo primário a obtenção de um nariz funcional e esteticamente atractivo. O sucesso dos seus resultados é significativamente determinado pela realização sistemática de uma análise estética e funcional pré-operatória completa e meticulosa por parte do cirurgião, complementada por um registo operatório minucioso e reprodutível. Os autores apresentam detalhadamente uma proposta de protocolo de análise pré-operatória e registo cirúrgico em doentes candidatos a rinosseptoplastia passível de documentação em formato papel e/ou electrónico, adaptável a cada plano de tratamento individualizado.
Ménière's disease (MD) is a clinical syndrome characterized by recurrent episodes of spontaneous ... more Ménière's disease (MD) is a clinical syndrome characterized by recurrent episodes of spontaneous vertigo, unilateral fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and more recently by magnetic resonance imaging (MRI). The current criteria of the disease, however, remain symptom based and do not include the demonstration of endolymphatic hydrops. The authors review MRI techniques and diagnostic criteria of endolymphatic hydrops and the role of MRI in MD is discussed.
Journal of vestibular research : equilibrium & orientation, Jul 2, 2016
Although the diagnosis of inherited ataxias is ultimately genetic, this usually means an extensiv... more Although the diagnosis of inherited ataxias is ultimately genetic, this usually means an extensive and expensive process. This justifies the search for distinct clinical signs that may potentially help orient molecular diagnosis. We explored the vestibulo-ocular reflex (VOR) with the video Head Impulse Test in patients diagnosed with spinocerebellar ataxia (SCA) type 3 (n = 15), type 1 (n = 4) and type 2 (n = 4), Friedreich's ataxia (FA) (n = 9) and healthy controls (n = 40). We estimated the latency, regression (VORr) and instantaneous VOR gain at 40, 60 and 80 ms (VOR40, VOR60 and VOR80), and determined the latency, peak-velocity and occurrence rate of catch-up saccades triggered with head-impulses. VOR latency was higher in FA (p < 0.001) and SCA3 (p = 0.02) as compared to controls, discriminating FA from other ataxic patients with an overall diagnostic accuracy of 88%. VORr, VOR40 and VOR60 were significantly lower in FA and SCA3 (p < 0.01). VOR80 was only significantl...
Objective: To evaluate the clinical pathophysiology of oculo-motor changes in a patient presentin... more Objective: To evaluate the clinical pathophysiology of oculo-motor changes in a patient presenting with a spontaneous semi-circular horizontal canal plug. Patient: A 42-year-old man with acute spontaneous vertigo with spinning and persistent left-horizontal nystagmus, intensity but not direction dependent on head orientation with respect to gravity, indicating a benign paroxysmal positional vertigo due to otoconia causing a plug in the horizontal semicircular canal. Intervention: Electrophysiological and video-oculographic test-ing; vestibular rehabilitation. Main OutcomeMeasures: Cervical and ocular vestibular evoked myogenic potentials (VEMPs); video head impulse testing. Results: The video head-impulse test revealed an eye velocity cutoff at 80-/s in the time interval from 40 to 90 ms after ini-tiation of head impulses to the right. This normalized within
Background: Menière's disease (MD) is an inner ear disorder characterized by recurrent episod... more Background: Menière's disease (MD) is an inner ear disorder characterized by recurrent episodes of spontaneous vertigo, unilateral low-frequency sensorineural hearing loss, tinnitus, and aural fullness. Current diagnosis still often has to rely on subjective and audiometric criteria only, although endolymphatic hydrops is recognized as the pathophysiological substrate of the disease, having been demonstrated in anatomical pathological studies and by magnetic resonance (MRI). The modiolus has a close functional and anatomical relationship with the cochlear nerve and membranous labyrinth and can be evaluated with MRI but no data exist on the modiolar size in MD. Purpose: Our purpose is to examine the following hypothesis. Is cochlear modiolus smaller in symptomatic ears in MD? Methods: We used a retrospective 3 Tesla MR study (heavily T2-weighted 3D fast asymmetric spin-echo images and 0.5 mm slice thickness) comparing the mean modiolar area (MMA) in the index and best ears of eig...
Objectives: Review the main indications and intraoperative findings in patients undergoing explor... more Objectives: Review the main indications and intraoperative findings in patients undergoing exploratory tympanotomy. Study design: Observational, retrospective, longitudinal study Material and methods: All patients who underwent exploratory tympanotomy, in our institution, from 2015 to 2019 were included. Patients with pathologic findings at otoscopy were excluded. Results: A total of 45 patients underwent unilateral exploratory tympanotomy. Of these, 19 were excluded due to pathologic findings in otoscopy. The mean age was 38,26 years (range 5-77 years). The main indication was conductive hearing loss (88%). Intraoperatively, the ossicular chain was fixed by adhesions (23%), followed by ossicular chain discontinuity (19%), otosclerosis (15%) and cholesteatoma (15%). There were no intra or postoperative complications. Conclusions: Exploratory tympanotomy is a safe diagnostic technique, with added value, since it allows us to directly view the middle ear, obtain the correct diagnosis,...
We read with interest the report “Teaching Video NeuroImages: Vestibulo-ocular reflex defect in c... more We read with interest the report “Teaching Video NeuroImages: Vestibulo-ocular reflex defect in cerebellar stroke” by Witsch et al.1 Although this is a well-written case report with a good-quality video, we have an alternative interpretation of the MRI findings. The flocculus is located posterior to the facial and vestibulocochlear nerves and the internal auditory canal at the cerebellopontine level, and the nodulus is located just posterior to the fourth ventricle at the facial colliculus level. Lesions involving the flocculus can cause gaze-evoked nystagmus, impaired smooth pursuit, contraversive ocular tilt reaction, and reduced vestibulo-ocular reflex gain for head impulses directed contralateral to the lesion.2 However, the lesion found by the authors, indicated by the arrow in the diffusion-weighted MRI scan,1 has a more posterolateral location compared with the floccular area on MRIs of previous reports2 and on anatomic templates (figure).
Objectives: To determine the positive predictive value (PPV) for malignancy and distribution of h... more Objectives: To determine the positive predictive value (PPV) for malignancy and distribution of head and neck cancer diagnosed by biopsy in the outpatient clinic of a tertiary hospital. To identify the presence of Epstein-Barr virus (EBV) and human papilloma virus (HPV) in nasopharyngeal and oropharyngeal carcinoma, respectively. Materials and Methods: Observational, retrospective, transversal study of the pathologic anatomy results of 365 biopsies performed on the Otorhinolaryngology outpatient clinic for clinical/imagological suspected malignancy in a 2 year period (2018-2019). The PPV for malignancy was calculated for each anatomical region. Results: We identified 111 malignant results (PPV 30,4%), of which 81% were squamous cell carcinoma (SCC). Immunohistochemistry stained positive for EBV in 75% of nonkeratinizing SCC of the nasopharynx and for p16 (HPV) in 9,7% of the SCC of the oropharynx. Conclusion: The most common diagnosis in the malignant results was SCC. There was a lo...
The cerebellar flocculus is a critical structure involved in the control of eye movements. Both s... more The cerebellar flocculus is a critical structure involved in the control of eye movements. Both static and dynamic abnormalities of the vestibulo-ocular reflex (VOR) have been described in animals with experimental lesions of the flocculus/paraflocculus complex. In humans, lesions restricted to the flocculus are rare so they can become an exceptional model to contrast with the clinical features in experimental animals or in patients with more generalized cerebellar diseases. Here, we examined a 67-year-old patient with an acute vestibular syndrome due to an isolated infarct of the right flocculus. We evaluated him multiple times over 6 months-to follow the changes in eye movements and vestibular function-with caloric testing, video-oculography and head-impulse testing, and the anatomical changes on imaging. Acutely, he had an ipsilateral-beating spontaneous nystagmus, bilateral gaze-evoked nystagmus, borderline impaired smooth pursuit, and a complete contraversive ocular tilt reacti...
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Papers by Leonel Luis