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We report a novel type of idiopathic bilateral vestibulopathy with acute simultaneous involvement of the vestibulo-ocular reflex limited to the low-frequency range. A 64-year-old female presented with dizziness, oscillopsia, and difficulty walking. She did not experience rotatory vertigo and did not show any nystagmus. Vestibular function tests showed absent caloric responses in both ears, while vestibulo-ocular reflex (VOR) gains in the video head impulse test (vHIT) were preserved in all six semicircular canals. Cervical and ocular vestibular evoked myogenic potentials in response to air-conducted sound were absent on both sides. Since the caloric test and vHIT measures low-frequency and high-frequency VOR, respectively, we diagnosed the patient as having a bilateral VOR deficit limited to the low-frequency range. During a 1-year follow-up with vestibular rehabilitation, the subjective symptom of dizziness gradually recovered while recovery of vestibular function was minimal.

Exploding head syndrome is a rare sleep disorder, characterized by an explosive feeling in the head, that occurs during the sleep-wake transition. Usually the attacks are painless, but the fear caused by the attack can result in awakening and insomnia when it is generated frequently. It has been suspected that exploding head syndrome is related to emotional stress, because most patients report stressful life situations in periods when attacks are intense and frequent. The benign character and good prognosis of exploding head syndrome are the most likely reasons why it has not become a subject of more extensive neurologic research. Moreover, most of the articles reported symptomatic episodes but a lack of objective physiologic examinations, such as polysomnography, and effective treatment. Here, we report two cases of exploding head syndrome with the attacks documented by polysomnography and our trial treatment. CITATION: Nakayama M, Nakano N, Mihara T, et al. Two cases of exploding head syndrome documented by polysomnography that improved after treatment. J Clin Sleep Med. 2021;17(1):103–106.

Background: Chronic subjective dizziness (CSD), which was superseded by persistent postural-perceptual dizziness as of 2017, has a great impact on patients’ quality of life. Cognitive-behavioural t...

Objective Tinnitus is an auditory sensation that can cause discomfort or even pain. Because patients with tinnitus frequently have psychological problems, self-reporting of the severity of tinnitus is unreliable. We developed a new grading system and practical protocol for the systematic treatment of tinnitus that accounts for its severity, patients’ psychological problems, and the frequency of catastrophic episodes. The aim of this study is to employ and validate the new system in patients with tinnitus. Methods This study comprised two parts: (i) We identified 113 patients, who were then analyzed in terms of severity of tinnitus, psychological problems, and catastrophic episodes. They were then classified into 5 grades, and the records of their previous treatments were scrutinized. From these records, we designed a practical treatment protocol suitable for each of the 5 grades. (ii) We then identified 82 new patients, and graded and treated them according to the system developed in part (i). Patients were followed-up for at least 6 months; treatment efficacy was evaluated using the pre- and post-treatment scores on the Tinnitus Handicap Inventory (THI) and Hospital Anxiety and Depression Scale (HADS). Psychological status was also assessed with the DSM-IV. Results (i) The overall patient group was categorized as follows: Grade I, 38 patients, average THI = 37.6 points, average HADS = 10.9 points, catastrophic episodes = 0 points; Grade II, 24 patients, THI = 70.6, HADS = 13.1, catastrophic episodes = 0; Grade III, 5 patients, THI = 73.2, HADS = 28.4, catastrophic episodes = 0; Grade IV, 33 patients, THI = 63.5, HADS = 18.8, catastrophic episodes = 1.0; Grade V, 13 patients, THI = 73.2, HADS = 22.4, catastrophic episodes = 2.2. The treatment records revealed treatment via psychotropic drugs for 40% of Grade III, 45.5% of Grade IV, and 84.6% of Grade V patients; psychiatric consultation was provided for 20% of Grade III, 12.5% of Grade IV, and 53.8% of Grade V patients. (ii) THI scores improved significantly in Grades II, IV, and V after treatment using the new protocol; HADS scores improved significantly in Grades IV and V. Catastrophic episode scores improved significantly in Grades IV and V. Conclusion We found large enough differences in THI and HADS scores to successfully classify patients with tinnitus into 5 distinct grades that accounted for tinnitus severity, psychological problems, and catastrophic episodes. We found significant improvements in tinnitus severity and psychological problems in the higher (more severe) grades when this system was used to guide treatment. This system not only provided a reasonably reliable categorization system, it simplified treatment without sacrificing efficacy.

This study investigated the feasibility of acceptance and commitment therapy for persistent postural-perceptual dizziness and preliminarily verified the long-term effectiveness of the therapy.This study implemented the within-group pre-post comparison design. We enrolled 27 adult patients who met the criteria of persistent postural-perceptual dizziness. They underwent a treatment program including acceptance and commitment therapy combined with vestibular rehabilitation once a week for a total of six sessions. The primary outcome was changes in the Dizziness Handicap Inventory score 6 months posttreatment.All 27 patients completed the acceptance and commitment therapy + vestibular rehabilitation program, and 25 patients (92.6%) could be followed for 6 months posttreatment. For 27 participants, the scores from pretreatment to 6 months posttreatment significantly declined (P .001), and the Dizziness Handicap Inventory effect size was 1.11 (95% confidence interval = 0.80-1.42). At 6 months posttreatment, 11 patients (40.7%) achieved remission (the score ≤ 14), 16 (59.3%) achieved treatment response (reduction in the score ≥ 18), and 20 (74.1%) achieved remission and/or treatment response.Acceptance and commitment therapy is feasible for persistent postural-perceptual dizziness and might have long-term effectiveness. However, a randomized controlled trial is warranted.

Objective Dizziness is one of the most common symptoms in the general population. Patients with dizziness experience balance problems and anxiety, which can lead to decreased physical activity levels and participation in their daily activities. Moreover, recovery of vestibular function from vestibular injury requires physical activity. Although there are reports that decreased physical activity is associated with handicap, anxiety, postural instability and reduced recovery of vestibular function in patients with chronic dizziness, these data were collected by self-report questionnaires. Therefore, the objective data of physical activity and the relationships between physical activity, handicap, anxiety and postural stability in patients with chronic dizziness are not clear. The purpose of this research was to objectively measure the physical activity of patients with chronic dizziness in daily living as well as handicap, anxiety and postural stability compared to healthy adults. Additionally, we aimed to investigate the relationships between physical activity, handicap, anxiety and postural stability in patients with chronic dizziness. Methods Twenty-eight patients with chronic dizziness of more than 3 months caused by unilateral vestibular hypofunction (patient group) and twenty-eight age-matched community dwelling healthy adults (healthy group) participated in this study. The amount of physical activity including time of sedentary behavior, light physical activity, moderate to vigorous physical activity and total physical activity using tri-axial accelerometer, self-perceived handicap and anxiety using questionnaires, and postural stability were measured using computerized dynamic posturography. Results The results showed worse handicap, anxiety and postural stability in the patient group compared to the healthy group. Objective measures of physical activity revealed that the patient group had significantly longer time of sedentary behavior, shorter time of light physical activity, and shorter time of total physical activity compared to the healthy group; however, time of moderate to vigorous physical activity was not significantly different between groups. Moreover, there were correlations between physical activity and postural stability in the patient group, while there were no correlations between physical activity, handicap or anxiety in the patient group. Conclusion These results suggest that objectively measured physical activity of the patients with chronic unilateral vestibular hypofunction is lower compared to the healthy adults, and less active patients showed decreased postural stability. However, the details of physical activity and causal effect between physical activity and postural stability were not clear and further investigation is needed.

Background Induction chemotherapy for patients with head and neck cancer is widely performed, and several advantages of induction chemotherapy have been reported. However, there is currently insufficient evidence to strongly recommend induction chemotherapy. In this study, we analyzed the outcomes for patients treated with induction chemotherapy and subsequent definitive treatments. Methods Operable patients with untreated oropharyngeal, hypopharyngeal and laryngeal squamous cell carcinoma treated with induction chemotherapy were included in this retrospective study. We conducted induction chemotherapy using docetaxel, cisplatin and 5-fluorouracil and performed subsequent surgical treatment or radiotherapy according to the response to induction chemotherapy. Results A total of 65 patients were included in this study, and 50 patients (76.9%) had Stage IV tumors. The response to induction chemotherapy was CR in two patients, PR in 55 patients, and SD in eight patients. The subsequent definitive treatment was radiotherapy in 60 patients, and surgery in five patients. The 3-year overall survival rates for patients who received radiotherapy and surgery were 88.4% and 75.0%, respectively (P = 0.30). The 3-year disease-free survival rates for patients who received radiotherapy and surgery were 68.0% and 0%, respectively (P = 0.01). The 3-year laryngeal dysfunction free survival rates for patients who received RT and surgery were 77.8% and 0%, respectively (P < 0.01). Conclusions We achieved favorable survival outcomes and high larynx preservation rates. Our results suggest that induction chemotherapy using TPF regimen is one of the optimal treatment strategies when treating head and neck cancers. Further prospective studies with a larger cohort are required to confirm our findings.

Purpose of review Several recent reports have described the relation between sleep disorders and inner ear function. There are also many reports that insomnia is observed in Meniere's patients. However, the possibility that obstructive sleep apnea syndrome (OSAS) might affect Meniere's disease or other neurotological consequences was not noticed, until studies using polysomnography for these patients. Recent findings OSAS may cause not only vestibular but also auditory dysfunction. Several reports suggest that insufficient supply of blood via the vertebral basilar artery, which supplies the inner ear, may cause hydropic distension of the endolymphatic system and lead to Meniere's disease. However, few people noticed that in OSAS this insufficient supply might be exacerbated in the night while patients are sleeping. Even more, we should note that Meniere's patients may not only suffer from insomnia, but also that the impaired sleep might be caused by OSAS. Summary Physicians routinely prescribe benzodiazepines or other drugs that have hypnotic, muscle relaxing, antianxiety, and anticonvulsant properties for insomnia, but these properties may have the effect of aggravating OSAS symptoms. Continuous positive airway pressure (CPAP) is an effective therapy used worldwide for the treatment of OSAS. CPAP or surgeries for OSAS may also be useful as one aspect of treatment for Meniere's disease patients with OSAS.

急性低音障害型感音難聴は再発, 反復する例や, メニエール病へ移行する例があり, 必ずしも予後良好な疾患ではないという認識が広まってきた。これまでに予後を予測する因子として, 発症年齢, 発症から初診までの期間, 初診時の1000Hzの聴力レベル, 重症度等が検討されているが, 重症度に関しては予後との相関が明らかではないという報告もある。今回, 当院を受診した急性低音障害型感音難聴症例361例にて, 背景と予後を検討し, 1年以上の長期経過観察例に関しては重症度と予後との関連を詳細に検討した。初診時の重症度は予後との関連が見られないものの, 1ヶ月後の重症度は予後と相関することが判明した。受診から1ヶ月後までは聴力変動が大きいため, 慎重に経過観察することが必要だと考えられた。

Many studies have shown that optokinetic stimulation induces postural sway and that vision, in addition to vestibular and somatosensory inputs, plays an important role in postural control. In the present study, we examined individual differences in the postural sway induced by movement of visual images back and forth and the effect of the response to the projected image. Three kinds of visual images were used: "normal direction" (image moving backward), "reverse direction" (image moving forward), and "static" images. Subjects received visual stimulation via a head-mounted display while standing on a stabilometer with their feet aligned in the Romberg position, and the postural sway was measured. The subjects initially maintained the standing position at rest for one minute (a static image was presented) and were then given visual stimulation for two minutes, followed by a 2-minute presentation of the static image. The period of visual stimulation is referred to as "during stimulation" and the 2-minute period of presentation of the static image is referred to as "after stimulation". The postural sway was measured over time. In Experiment 1, the measurement was conducted 5 times under each stimulation condition. In many subjects, postural sway was induced in the direction of visual stimulation "during stimulation" and in the opposite direction "after stimulation" (normal type); however, some subjects showed the opposite postural sway (reverse type) or showed no induced postural sway at all (poor response type). Most subjects showed similar changes for each of the five stimulations. Individual differences in postural sway were considered to be induced by the effect of vision on the postural control system. In Experiment 2, the measurement was conducted using the same visual stimulation under two kinds of mental states: a sub-conscious condition, in which the subjects were instructed to watch the image without any assumption regarding their own motion, and a conscious condition, in which the subjects were instructed to assume that that they were moving in response to the projected image (although no actual walking motion occurred). Many subjects showed postural sway in the opposite direction when the state was changed, despite the image remaining the same. These results suggest that posture is smoothly controlled using visual information to allow adaptation to various environments.

ObjectivesTo evaluate the effect of continuous positive airway pressure (CPAP) therapy on Ménière's disease patients with concomitant obstructive sleep apnea syndrome (OSAS), since recent reports suggest OSAS may cause dysfunction of the vestibular system.Study designProspective study using CPAP administered to patients diagnosed with "Definite Ménière's disease" according to the guidelines of the American Academy of Otolaryngology--Head and Neck Surgery and combined with OSAS.SettingUniversity hospital.MethodsTwenty consecutive patients, 14 male and 6 female with active, unilateral, cochleovestibular Ménière's disease refractory to medical management who also had concurrent OSAS as defined by International Classification of Sleep Disorders, Second Edition were selected to undergo solitary CPAP therapy. Audiometric testing, caloric testing, and DHI survey were conducted before and after CPAP therapy and compared to assess effectiveness of CPAP therapy as utilized for treatment of Ménière's disease.ResultsAlthough caloric testing did not show significant difference, audiometric testing and results of dizziness handicap inventory were significantly improved (p < 0.05) after CPAP therapy only, without standard treatment for Ménière's disease.ConclusionRecent reports have suggested that OSAS may cause dysfunction of the vestibular system. We investigated whether standard therapy for OSAS would be of benefit in the management of vertigo and hearing loss in Ménière's disease patients. Our study cohort demonstrated significant improvement in both DHI and audiometric testing following solitary CPAP therapy for OSAS. Solitary CPAP therapy may become a new effective treatment strategy for Ménière's disease patients with OSAS, not just only for control of dizziness and vertigo but also for potential benefit of hearing.

Our herpes simplex virus (HSV) labyrinthitis mouse model suggests that HSV infection induces vestibular neuritis and sudden deafness.Viral labyrinthitis has been postulated to play a role in vestibular neuritis and sudden deafness. We established a mouse model to investigate the pathogenesis of HSV-induced labyrinthitis. The relationship between HSV infection and apoptosis in the labyrinth was assessed.HSV types 1 and 2 were inoculated into the middle ear of mice, and the function of the cochlear and vestibular nerves was assessed. Histopathological changes were examined with hematoxylin and eosin staining. Anti-HSV immunohistochemistry staining and TUNEL staining were done to investigate the relationship between HSV-infected cells and apoptotic cells.Hearing loss and vestibular dysfunction were observed in all mice after inoculation of HSV type 1 or 2. In the cochlear duct, columnar epithelial cells in the stria vascularis were infected with HSV, but only a portion of the infected cells underwent apoptosis. In contrast, many uninfected cells in the spiral organ of Corti were apoptotic. Vestibular dysfunction was observed when vestibular ganglion cells were largely infected, but not apoptotic. These findings recapitulate sudden deafness and vestibular neuritis described in patients.