[Anesthesia problem cards-indispensable yet problematic : Nationwide survey on experiences from clinical practice]

BACKGROUND

Anesthetic procedures may lead to severe and potentially life-threatening complications (e. g. difficult airway, allergic reactions, malignant hyperthermia). Most complications can be avoided in future anesthetic procedures with adequate preparation (e. g. awake intubation, trigger-free anesthesia). In Germany, anesthesia problem cards were introduced two decades ago to identify patients at risk and to increase patient safety by creating a standardized documentation system for anesthesia-related complications. The purpose of our study was to evaluate the utility and problems of anesthesia problem cards in clinical practice.

MATERIAL AND METHODS

All registered members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Professional Association of German Anesthesiologists (BDA) (n = 19,042) were invited to participate in an online survey on patient safety. A subsection of the survey focused specifically on anesthesia problem cards and their utility in clinical practice (e. g. field of application, issuing procedures, benefits and problems).

RESULTS

The survey subsection on anesthesia problem cards was completed by 1783 participants. Most agreed that anesthesia problem cards are a useful tool to increase patient safety (n = 1502; 84.2%) and that they are routinely issued after the occurrence of anesthesia-related complications (n = 1664, 93.4%). One of the major problems noted was that patients frequently forget to bring their anesthesia problem cards when presenting for the preanesthetic assessment. This was observed by 1457 participants (81.7%). Furthermore, the information provided on anesthesia problem cards may be inadequately phrased (n = 874; 49.0%) or illegible (n = 833; 46.7%). In addition, the space for individual comments or problem solutions is insufficient (n = 811; 45.5%). Replacements for lost anesthesia problem cards with identical informational content can be issued in only 41.9% (n = 747) of the participants' departments.

CONCLUSION

Anesthesia problem cards are considered a useful tool to increase patient safety and are frequently issued in clinical practice; however, in the document's current form its full potential for risk minimization cannot be exploited. Structural changes are required to increase documentation quality and reproducibility. Concerning its informational content, the spectrum of included complications and their individual solutions need to be expanded to meet the requirements of modern anesthetic practice.

Caloric and search-coil head-impulse testing in patients after vestibular neuritis

The objective of this study was to compare results of quantitative head-impulse testing using search coils with eye-movement responses to caloric irrigation in patients with unilateral vestibular hypofunction after vestibular neuritis. The study population consisted of an acute group (<3 days; N = 10; 5 male, 5 female; 26-89 years old) and a chronic group (>2 months; N = 14; 8 male, 6 female; 26-78 years old) of patients with unilateral vestibular hypofunction after vestibular neuritis. The testing battery included: (1) simultaneous measurement of eye and head rotations with search coils in a magnetic coil frame during passive Halmagyi-Curthoys head-impulse testing and (2) electronystagmography during bilateral monaural 44 degrees C-warm and 30 degrees C-cold caloric irrigation. The main outcome measures were (1) the gain of the horizontal vestibulo-ocular reflex during search-coil head-impulse testing and (2) the amount of canal paresis during caloric irrigation. All acute and chronic patients had a unilateral gain reduction during search-coil head-impulse testing. A pathological canal paresis factor was present in 100% of the acute patients but in only 64% of the chronic patients. The clinically suspected unilateral vestibular hypofunction resulting from vestibular neuritis was validated in all acute patients by both search-coil head-impulse and caloric testing. Hence, either of these tests is sufficient for diagnosis in the acute phase of vestibular neuritis. Chronic patients, however, were reliably identified only by search-coil head-impulse testing, which suggests that the low-frequency function of the labyrinths often becomes symmetrical, leading to a normal canal paresis factor.

Auditory threshold and inner ear pressure: measurements in experimental endolymphatic hydrops

HYPOTHESIS

Experimental endolymphatic hydrops leads to an endolymph-perilymph pressure imbalance that is responsible for the loss of auditory sensitivity in the ear.

BACKGROUND

This study investigates whether intralabyrinthine pressure is a factor in the auditory dysfunction of experimental endolymphatic hydrops.

METHODS

Auditory function was investigated in 10 guinea pigs 90 to 120 days after endolymphatic sac ablation by measuring compound action potentials in response to acoustic stimuli including alternating clicks and tone bursts of 0.5, 1, 2, 4, and 8 kHz. After auditory thresholds to the various stimuli were established, endolymphatic and perilymphatic pressures were measured with a no-flow micropressure measuring system. The cause of the hearing loss in Meniere's disease, especially in the early phases of this condition, remains an enigma. Histologic temporal bone preparations show a disproportion in the volume of endolymph to perilymph with an expanded and distorted membranous labyrinth. Speculation as to whether an endolymph-perilymph fluid pressure imbalance is responsible for these morphologic changes were raised by Hallpike and Cairns (1) in their initial report of the histopathology of Meniere's disease. Further speculation has questioned whether this pressure imbalance may be responsible for the symptoms and physical finding of this condition, including hearing loss. The ability to produce experimental endolymphatic hydrops in the guinea pig secondary to surgical occlusion of the endolymphatic sac and duct has been useful in studying various aspects of Meniere's disease (2). Investigators have been able to demonstrate auditory threshold shifts with hydrops. Elevated endolymph-perilymph pressure gradients have also been demonstrated (3). This

RESULTS

Increased auditory thresholds were noted in the hydrops ears at all tested parameters (p < 0.03). A relative increase in endolymph over perilymph pressure was found in hydrops ears as previously reported. The increase in endolymph-perilymph pressure of hydrops could not be correlated directly to the elevated auditory threshold shift.

CONCLUSION

Endolymphatic hydrops is a complex pathologic state with multiple inner ear alterations including abnormal intralabyrinthine pressure. Factors other than or in addition to pressure contribute to the auditory threshold shift of hydrops.

Vestibulo-ocular responses during static head roll and three-dimensional head impulses after vestibular neuritis

This study aimed to investigate whether unilateral vestibular neuritis (VN) causes the same deficits of ocular counter-roll during static head roll (OCR(S)) and dynamic vestibulo-ocular reflex gains during head impulses (VOR(HI)) as unilateral vestibular deafferentation (VD). Ten patients with acute and 14 patients with chronic vestibular paralysis after VN were examined. The testing battery included fundus photography of both eyes with the head upright (binocular cyclorotation) and dual search coil recordings in a three-field magnetic frame. With one dual search coil on the right eye and the other on the forehead, the following stimuli were given: i) Halmagyi-Curthoys head impulses about the vertical, horizontal and torsional axes. ii) Static roll positions of the head up to 20 degrees right- and left-ear-down by movement of the neck. The comparison group consisted of 19 healthy subjects. Compared with the VD-patients, as reported in the literature, acute VN-patients showed the same pattern of OCR(S) gain reduction and binocular cyclorotation (CRb). The main feature that distinguished chronic VN-patients from chronic VD-patients was the normalization of the torsional VOR(HI) gain to the affected side, whereas the VOR(HI) gains in the horizontal and vertical directions did not show recovery (as in the patients with chronic VD). Chronic VN-patients differed from acute VN-patients by: i) symmetrical OCR(S) gains, ii) a less pronounced CRb toward the affected side, and iii) a normal torsional VOR(HI) gain toward the affected side. Since the ipsilesional torsional VOR(HI) gain did not recover in VD-patients, the normalization of this gain in our VN-patients can only be explained by a (partial) recovery of otolith function on the side of the lesion after the neuritis.

Chronic unilateral loss of otolith function revealed by the subjective visual vertical during off center yaw rotation

Assessing the subjective visual vertical, SVV, in a static upright position is an easy clinical test in which a deviation of some 10 degrees from true vertical indicates an acute loss of unilateral (otolithic) vestibular function on the side to which the SVV is tilted. Because this deviation of the SVV is compensated during the following months, patients with chronic unilateral vestibular loss do no longer differ from normal subjects. This study presents an experimental set-up that allows for clear detection of compensated chronic loss of unilateral otolithic function by testing the SVV. 21 normals and 17 unilaterally vestibular deafferentiated (UVD) patients (vestibular neurectomies) were first rotated on a human centrifuge about an earth vertical yaw axis through the midsagittal plane of the head (240 degrees/s). This induced tilts of the gravito-inertial force (GIF) vectors, which differed at the two inner ears by 8 degrees. During constant velocity rotation, the subjects were moved in pseudo-randomized steps laterally up to 16 cm apart from the rotation axis, inducing roll tilts of the GIF vectors up to 16 degrees. Normal subjects set their SVV to pre-centrifugation values at positions with the midsagittal plane of their head close to the rotation axis, while chronic UVD patients indicated pre-centrifugation values during positions with the rotation axis 5.9 +/- 2.5 cm paramedian on the side of the intact ear. Tilts of the GIF vectors shifted the SVV with a gain of 0.70 in normals and only 0.32 in UVD patients. Roll gains for laterally directed GIF vectors relative to the intact inner ear did not differ from medially directed roll gains in the UVD patients. The roll gains observed in this experimental set-up were lower than those observed with static body tilts or during eccentric rotation with a larger radius, which might be at least partially due to conflicting stimulation between otolithic and extra-vestibular cues.

Assessing otolith function by the subjective visual vertical

The effects of peripheral vestibular diseases on the subjective visual vertical (SVV) are resumed and provide the basis for some insights into the otolith pathophysiology. With a normal range of 0 +/- 2 deg (when measured in an upright body position), the SVV was shifted by 11 +/- 6 deg toward the ipsilateral ear in 40 patients following an acute unilateral vestibular deafferentiation (UVD), but in the opposite direction in 9 of 52 patients after stapes surgery. These opposite effects suggest a push-pull mechanism of the pairs of otolith organs with respect to the SVV. The dissociation between the SVV and the perception of body position indicates influences by unconscious reflexive mechanisms such as ocular cyclotorsion on the SVV. In chronic UVD patients, lateral shifts of the subjects during constant angular velocity rotation into various eccentric positions (+/- 16 cm) revealed a shift of the "center of graviception" close to the remaining intact contralateral inner ear. To date, this seems to be the most consistent test for clinical identification of a chronic compensated unilateral loss of otolith function. The findings regarding asymmetries in otolithic sensitivity to medially and laterally directed roll-tilts remain controversial, probably mainly because of influences of extravestibular cues.

Persistent bilateral hearing loss after shunt placement for hydrocephalus. Case report

Transient hearing decrease following loss of cerebrospinal fluid (CSF) has been reported in patients undergoing lumbar puncture, spinal anesthesia, myelography, and/or different neurosurgical interventions. The authors present the first well-documented case of a patient with persistent bilateral low-frequency sensorineural hearing loss after shunt placement for hydrocephalus and discuss the possible pathophysiological mechanisms including the role of the cochlear aqueduct. These findings challenge the opinion that hearing decreases after loss of CSF are always transient. The authors provide a suggestion for treatment.

Pathomechanism of mammalian downbeat nystagmus due to cerebellar lesion: a simple hypothesis

Most of the various hypotheses on the pathomechanism of the slight ocular upward drift in normal mammals and on the prominent downbeat nystagmus following cerebellar lesions assume an inherent vertical asymmetry in the central vestibulo-ocular pathways. In this paper we propose that this vertical asymmetry is simply based on the anatomical orientation of the six semicircular canals in the head which is right-left symmetrical but lacks symmetry in the cranio-caudal direction. Presuming that each semicircular canal elicits eye movements in a direction roughly in its anatomical plane, vectorial addition of the tonic resting activity of all six canals leads to a cancellation of horizontal and torsional eye movement components but leaves an important vertical (slow phase) upward component. This peripheral vestibular bias is centrally cancelled by floccular and parafloccular inhibitory pathways which are related to the smooth pursuit system, but becomes disinhibited in the presence of posterior cerebellar lesions.

[Evaluating otolith function with subjective visual vertical discrimination]

This report summarizes our experiences with the subjective visual vertical (SVV) as a clinical neuro-otological tool. In the SVV test, patients have to orient a dim light bar in an otherwise dark surrounding earth-vertical, using a remote-control. Normal subjects in an upright position did not deviate more than 2 degrees from true vertical. After vestibular neurectomy, the SVV was consistently tilted by some 12 degrees toward the affected ear. Smaller tilts (approximately 7 degrees) of the SVV occurred in patients with spontaneous peripheral vestibular diseases. This shift in SVV disappeared within weeks to months, similar to the spontaneous nystagmus. After stapes surgery slight deviations of the SVV towards the unoperated ear were seen in about 20% of the patients, indicating a slight irritation of the otolith organs. Assessed in an upright position, the SVV thus may be regarded as reflecting tonic otolithic input differences between the two ears. Asymmetries in the shifts of the SVV induced by roll tilts of the gravito-inertial vector by eccentric rotations of the subject have been proposed as a test for otolithic sensitivity. In our studies such asymmetries in the shifts of the SVV could not be induced by 26 degrees or 90 degrees roll tilts of subjects towards the affected or healthy ears. A simple clinical test to reveal unilateral otolithic sensitivity (comparable to an otolithic "caloric test") thus still has to be found.

Three-dimensional analysis of spontaneous nystagmus in peripheral vestibular lesions

The direction of spontaneous nystagmus was recorded in three dimensions with scleral dual search coils in three patients after vestibular neurectomy and in seven patients with vestibular neuritis. The rotation vectors of the spontaneous nystagmus clustered along the sensitivity vector of the lateral semicircular canal (SCC). The direction of the spontaneous nystagmus after resection of the whole eighth nerve was not different from that after resection of only the superior branch of the vestibular nerve. Deviations from this direction were observed only after resection of the inferior vestibular nerve and in one patient with vestibular neuritis. The absence of nystagmus components in direction of the vertical SCC reflects an anisotropy of oculomotor efferents of the vestibulo-ocular reflex are rather than a lesion limited to the lateral SCC afferents. Therefore, the three-dimensional analysis of spontaneous nystagmus does not permit accurate localization of a peripheral vestibular lesion.

[Sudden vertigo--differential diagnosis and therapy in peripheral vestibular (inner ear-induced) forms]

The most important forms of inner ear disorders manifesting as sudden vertigo may be distinguished by the duration of the vertiginous spells: sudden vertigo, diminishing during days = acute peripheral vestibulopathy, recurrent spells lasting for hours = Ménière's disease, recurrent vertigo lasting for minutes = "vascular', recurrent positioning-induced vertigo lasting for seconds = benign paroxysmal positioning vertigo (BPPV). In the last years, major progress was made in the treatment of BPPV. Based on new ideas on the underlying pathomechanism, this most common form of vestibular vertigo now can be treated definitively in most patients within a few minutes by a simple maneuver (canalith reposition maneuver by Epley/Parnes). This procedure is presented in this paper.

Contributions of single semicircular canals to caloric nystagmus as revealed by canal plugging in rhesus monkeys

We demonstrated specific responses from the anterior and the posterior semicircular canal to irrigation of the outer ear canal with cold water in the Rhesus monkey. This required i) three-dimensional analysis of the evoked eye movements in the planes of the semicircular canals (canal plane vectors, CPV); ii) assessing these CPV responses in eight different head positions relative to gravity; iii) comparing the responses in 6 normal animals (12 ears) with responses after selective plugging of pairs of semicircular canals (all, both lateral, and right anterior + left posterior). The results showed: i) Irrigation of the outer ear canal with cold water induces thermoconvection also in the posterior and anterior semicircular canals. This can be inferred from the sinusoidal modulation of eye movement components with changes in position of the corresponding semicircular canal plane relative to gravity; ii) Specific vertical canal responses occur exclusively in the direction of the corresponding semicircular canal, though they are superimposed with response components of other origin, one probably related to endolymph shift in the lateral semicircular canal; iii) before possible clinical application, these different response components of vertical canals will need to be determined in humans.

Candida maltosa NADPH-cytochrome P450 reductase: cloning of a full-length cDNA, heterologous expression in Saccharomyces cerevisiae and function of the N-terminal region for membrane anchoring and proliferation of the endoplasmic reticulum

A full-length cDNA for NADPH-cytochrome P450 reductase from Candida maltosa was cloned and sequenced. The derived amino acid sequence showed a high similarity to the reductases from other eukaryotes. Expression in Saccharomyces cerevisiae under control of the GAL10 promoter resulted in an approximately 70-fold increase in NADPH-cytochrome c reductase activity in the microsomal fraction. The functional integrity of the heterologously expressed reductase as an electron transfer component for alkane hydroxylating cytochrome P450 from C. maltosa was shown in a reconstituted system containing both enzymes in a highly purified state. The signal-anchor sequence of the reductase was identified within the N-terminal region of the protein by means of constructing and expressing fusion proteins with the cytosolic form of yeast invertase. The first 33 amino acids turned out to be sufficient for stable membrane insertion, wild-type membrane orientation and retention in the endoplasmic reticulum. As shown by immunoelectron microscopy, the heterologously expressed reductase was integrated into the endoplasmic reticulum of the host organism. It triggered a strong proliferation of the membrane system. This membrane-inducing property of the reductase was transferable to the cytosolic reporter protein with the same N-terminal sequences that confer membrane insertion.

Can a unilateral loss of otolithic function be clinically detected by assessment of the subjective visual vertical?

Asymmetries in the settings of the subjective visual vertical after unilateral vestibular neurectomy during eccentric centrifugation [3] might provide a clinical test for unilateral otolithic function. This study investigates whether these asymmetries can also be revealed by a technically much easier practicable roll tilt of the subject relative to gravity instead of a roll tilt of the gravitational force on a human centrifuge. Twenty-seven normal subjects and 13 patients before surgery indicated verticality very accurately in the upright position. In 26 degrees roll positions (subjects seated on a slanted chair), they were only slightly more variable with no asymmetries larger than 5.3 and 7.8 degrees in normals and preoperative patients, respectively, between the roll positions toward the healthy and toward the affected ear. One week after surgical unilateral vestibular deafferentation, there was a consistent shift (mean 11.9 degrees) of the subjective vertical toward the affected ear in all patients and in all body positions. When the settings in the two roll tilt positions were referred to the setting in upright position, the group means of the patients were symmetrical although single subjects revealed asymmetries up to 22.4 degrees. Only one of four patients who were tested also during eccentric rotation revealed an important asymmetry with decreased sensitivity for tilts of the gravitational vector toward the affected ear. Measuring the subjective visual vertical assesses only asymmetrical tonic otolithic input, while a simple clinical test for unilateral otolithic sensitivity still has to be found.

Correlation of MRI, clinical, and electroneuronographic findings in acute facial nerve palsy

Intratemporal enhancement of (Gd-DTPA) was investigated by an interleaved-overlapping magnetic resonance imaging (MRI) technique in 35 cases of acute facial palsy. In a reference group (normal facial function), enhancement was localized from the ganglion geniculi to the stylomastoid foramen. In cases of acute palsy, the facial nerve enhanced in the meatal fundus independent of etiology (idiopathic, herpetic, or traumatic). In 70% of those with Ramsay-Hunt syndrome, the vestibular and cochlear nerves, the labyrinth, and the sheets of the internal and external auditory canal additionally enhanced. No correlation was found between intensity, extension, and duration of the enhancement and the clinical, intraoperative, or electroneuronographic degree of the facial palsy. The pathogenesis of the Gd-DTPA enhancement of the facial nerve appears to be closely connected with the vascular supply of the fallopian canal and the permeability of the neural sheets.

Are papillary adenomas endolymphatic sac tumors?

Papillary adenomas of the temporal bone have been considered as originating from the endolymphatic sac. The radiologic, surgical, and pathologic findings in a patient suffering from von Hippel-Lindau disease with bilateral papillary adenomas of the temporal bone cast some doubt on this site of origin. Radiologically, the center of tumor growth was at the top of the jugular bulb. Intraoperatively, the tumor was found to have reached the lateral wall of the endolymphatic sac, but the lumen was tumor-free. Both ciliated and nonciliated tumor cells were found in the resected tumor, resembling the ultrastructure of normal epithelial lining in the human mastoid. A strong positive immunohistochemical reaction for keratin and negative reactions for vimentin, glial fibrillary acidic protein, and S-100 protein in the tumor tissue of this patient are typical for middle ear mucosa. Therefore, the described papillary adenoma originated from the mucosa of the pneumatic spaces surrounding the jugular bulb, and the theory that the endolymphatic sac is the origin of all papillary-cystic tumors (adenocarcinomas) should be questioned.

[The value of clinical examination methods in diagnosis of acoustic neuroma]

The diagnostic value of routine clinical tests for predicting the presence of an acoustic neuroma (AN) was assessed retrospectively in a group of 391 patients having magnetic resonance imaging (MRI) scans because of a suspected retrolabyrinthine lesion. An AN was found by MRI only in 9% of these patients. The positive predictive value of unilateral sensorineural hearing loss in a pure-tone audiogram (PTA) and unilaterally impaired caloric response was 9% and 12%, respectively. In contrast, AN was found in 36% of patients with pathological brainstem evoked response audiometry (BE-RA). A normal PTA or normal caloric response did not exclude the presence of AN (specificity 90% and 71%, respectively). A normal BERA was found in less than 5% of the patients with AN. According to these results, the following guidelines should be followed for the diagnosis of AN: (1) patients with a high suspicion for AN from history, PTA and caloric responses should be sent directly for MRI; (2) patients with low suspicion for AN from screening tests should have BERA performed to exclude a retrolabyrinthine lesion.

Use of selective tyrosine kinase blockers to monitor growth factor receptor dephosphorylation in intact cells

A novel assay was developed which allows measuring the activity of protein tyrosine phosphatases (PTPases) downregulating the signaling activity of the receptors for platelet-derived growth factor (PDGF) or epidermal growth factor (EGF) in intact Swiss 3T3 cells and nerve growth factor (TrkA) in TrkA-overexpressing PC12 cells. The assay is based on the inhibition of the receptor tyrosine kinases by specific inhibitors which enter the cells rapidly and do not affect the activity of PTPases. Thereafter, the decay of phosphotyrosine in the autophosphorylated receptors is monitored by immunoblotting with anti-phosphotyrosine antibodies. The dephosphorylation kinetics of EGF receptors and PDGF receptors in Swiss 3T3 cells as measured with this assay were found to be strikingly different. EGF receptors are almost completely dephosphorylated after 2 min at room temperature, whereas PDGF receptors are dephosphorylated only by 50% after 5 min. These data agree with previous findings about receptor dephosphorylation kinetics in isolated Swiss 3T3 cell membranes employing conventional dephosphorylation assays. The novel assay will facilitate characterization of the hitherto not identified receptor-directed PTPases for PDGF receptors, EGF receptors, and TrkA. The assay principle is general and should be applicable to any PTPases and their substrates, provided specific inhibitors for the respective kinases are available. Furthermore, it can be applied to screen for regulator molecules of specific PTPases in their physiological environment.

Characterization of vestibular potentials evoked by linear acceleration pulses in the chinchilla

The objective of this study was to improve vestibular evoked potentials as a qualitative parameter for vestibular function in small laboratory animals. Linear upward acceleration pulses (up to 8 g within 1 ms) were applied to the head of anesthetized chinchillas. Electrophysiologic responses recorded by a chronically implanted electrode within the facial nerve canal consisted of an initial negative potential, labeled N1, within the first millisecond following the onset of acceleration. This potential was followed by a series of positive and negative potentials found to be highly labile to acoustic masking. The initial negative potential was only minimally sensitive to acoustic masking and persisted following surgical cochlear ablation, but completely disappeared following administration of potassium chloride into the inner ear. Recorded from the contralateral ear, N1 was unaffected by these procedures. Amplitudes of N1 decreased with attenuating stimulus intensity (1.45 microV/dB), whereby N1 latencies slightly increased (-0.015 ms/dB). These data, when coupled with the ability to completely abolish N1 with potassium intoxication while the contralateral ear remained intact, indicate that this potential represents electrophysiologic activity resulting from activation of the ipsilateral vestibular labyrinth.

Short latency vestibular evoked responses to linear acceleration stimuli in small mammals: masking effects and experimental applications

Different potential were recorded from a site close to the 8th nerve in chinchillas in response to linear acceleration pulses. Acoustic masking allowed us to distinguish between an early response (within 1 ms after initiation of the acceleration) of probable vestibular origin and later responses of probable cochlear origin. The latter were abolished by intense acoustic masking and by surgical ablation of the cochlea. The early potential was slightly reduced by simultaneous acoustic masking with white noise above 65 dB SPL and was most sensitive to 1 kHz narrow band masking. Vestibular neurons seem to be stimulated by high frequency movements of their hair cell cilia, and vestibular compound action potentials can be recorded as soon as a sufficient number of neurons are brought to a synchronized response. These vestibular evoked potentials may provide a tool for experimental studies on vestibular function in laboratory animals.

The subjective visual vertical as a clinical parameter of vestibular function in peripheral vestibular diseases

The subjective visual vertical, SV, was measured in the upright and side positions in 25 normal subjects and in 73 patients with various peripheral vestibular disorders. Significant deviations of SV (toward the affected ear) were found in 100% of the patients with vestibular nerve section and with Ramsay Hunt syndrome, in 89% of the patients with vestibular neuritis, and in 0% of the patients with benign paroxysmal positional vertigo. The deviation of SV gradually disappeared within a few weeks of the onset of the disease in all patients except in those with total VIIth nerve resection. SV is a parameter of tonic afferent differences between the two labyrinths similar to vestibular spontaneous nystagmus but is mediated by other parts of the inner ear (probably the otolith organs) and thus provides additional information on the labyrinthine function. SV measured in 90 degrees side positions, however, did not reveal asymmetric vestibular sensitivity, which is in contrast to SV tested during eccentric rotation in patients after vestibular neurectomy.

Clinical pathophysiology of vestibular neurectomy

This study attempts to characterize the residual vestibular function remaining after incomplete supralabyrinthine vestibular neurectomy performed for disabling vertigo. Patients with bilateral vestibular neurectomy had preserved horizontal vestibulo-ocular reflexes in response to high angular accelerations with gain enhancement over time. A torsional down-beating spontaneous nystagmus and an important tilt of the subjective vertical were observed when the remaining eighth nerve was sectioned after homolateral incomplete supralabyrinthine vestibular neurectomy. These findings suggest that a reorganization of vestibular reflexes may occur after incomplete supralabyrinthine vestibular neurectomy if afferents of the inferior vestibular branch are partially spared. The vestibular function after incomplete supralabyrinthine vestibular neurectomy does not affect the postoperative control of vertiginous attacks and may have positive effects in case of deterioration of the contralateral inner ear.

Effects of semicircular canal plugging on caloric nystagmus recorded in three dimensions

In Rhesus monkeys, distinct eye movement response components in the planes of the semicircular canals (canal plane vectors, CPV) were identified by 3-dimensional recordings of caloric nystagmus elicited in different head positions relative to gravity. Surgical plugging of single semicircular canals (SCC) was used to identify the generators of these response components. The lateral CPV is a sinusoidal function of head position, compatible with a thermovective mechanisms in this canal. Surgical plugging of the lateral SCC leaves only a small head position independent, lateral CPV, probably due to direct temperature effects on lateral SCC afferents. The posterior and anterior CPVs are complex responses composed of various components of which the present plugging experiments identified two generators: i) effects of thermovection in the lateral SCC, demonstrated by modifications of posterior and anterior CPVs after occlusion of the lateral SCC; and ii) thermovection in the vertical SCCs, demonstrated by effects of plugging a single vertical SCC exclusively on the corresponding CPV. This is the first definite identification of the vertical SCCs as contributors to the generation of nystagmus induced by caloric irrigation of the outer ear canal. It may provide a basis for the development of a modified caloric test measuring more than only lateral canal function in human patients.

Selective platelet-derived growth factor receptor kinase blockers reverse sis-transformation

A novel class of tyrosine kinase blockers represented by the tyrphostins AG1295 and AG1296 is described. These compounds inhibit selectively the platelet-derived growth factor (PDGF) receptor kinase and the PDGF-dependent DNA synthesis in Swiss 3T3 cells and in porcine aorta endothelial cells with 50% inhibitory concentrations below 5 and 1 microM, respectively. The PDGF receptor blockers have not effect on epidermal growth factor receptor autophosphorylation; weak effects on DNA synthesis stimulated by insulin, by epidermal growth factor, or by a combination of both; and over an order of magnitude weaker blocking effect on fibroblast growth factor-dependent DNA synthesis. AG1296 potently inhibits signaling of human PDGF alpha- and beta-receptors as well as of the related stem cell factor receptor (c-Kit) but has no effect on autophosphorylation of the vascular endothelial growth factor receptor KDR or on DNA synthesis induced by vascular endothelial growth factor in porcine aortic endothelial cells. Treatment by AG1296 reverses the transformed phenotype of sis-transfected NIH 3T3 cells but has no effect on src-transformed NIH 3T3 cells or on the activity of the kinase p60c-src(F527) immunoprecipitated from these cells. These potent and selective compounds represent leads for the development of novel agents to combat tumors driven by PDGF or to inhibit PDGF action in other diseases in which PDGF plays a key role, such as restenosis.

[Stapotomy with ultrasound? Animal experiment study of possible side effects]

Stapedectomy by ultrasound has been proposed as an alternative method for perforating the stapes footplate in surgery for otosclerosis. Possible functional adverse effects of ultrasound perforation of the otic capsule in guinea pigs were investigated in the present study by means of vestibular evoked potentials (VsEP). VsEP were elicited by pulsed linear accelerations applied to the animal's head following surgical removal of the middle ear, following intense ultrasound drilling around the otic capsule and after drilling a small hole in the anterior bony wall of the vestibule. All manipulations did not affect amplitudes and latencies of the early potential N1 (less than 1 msec after onset of acceleration). Significant alterations of N1 occurred following direct mechanical damage of the otolithic organs, indicating that VsEP can be used to detect lesions of these receptors and therefore may be used as a parameter of vestibular function in experimental animals. Findings indicate that perforation of the otic capsule by ultrasound is possible without inducing functional lesions of the otolithic organs.

Bilateral vestibular neurectomy for treatment of vertigo

The effects of bilateral vestibular neurectomy on equilibrium and vestibular function were clinically evaluated in two patients more than 15 years after surgery. Both patients had bilateral Menière's disease and their vertiginous spells were permanently resolved after the second vestibular neurectomy. Symptoms of disequilibrium were absent in one patient and mild in the other. Reflexive horizontal eye movements on whole body rotation in darkness were absent on low angular accelerations (2 degrees/s2), but could be elicited with angular accelerations of 20 degrees/s2 or higher. Extravestibular cues generating these eye movements seemed to be unlikely because a "control" patient with complete peripheral vestibular ablation after bilateral subtotal petrosectomy did not present reflexive eye movements under the same stimulus paradigms. An incomplete deafferentiation of the vestibular end organ (rather than regeneration of vestibular nerve fibers) and a consecutive impairment of the central velocity storage mechanism may explain the good functional outcome in our bilateral neurectomized patients.

Otoneuroscience and space vestibulo-neuroscience in the new century

From a clinically oriented point of view, efforts of otoneuroscience should be directed toward an improvement of the management of dizzy and vertiginous patients. At present, the main obstacles in this field are: (1) the lack of specific therapies for many of the clinical diagnoses. This reduces the necessity of clinical vestibular diagnosis to a pragmatic exclusion of the few diseases with therapeutic consequences; (2) the lack of feedback to confirm or disprove clinical diagnoses; (3) poor knowledge of the pathophysiology of many of the otoneurological diseases; experiments in animal models may be helpful in this respect; (4) most progress in medicine originates from the results of numerous, poorly controlled 'unscientific' trial and error experiments obtained during treatment of patients; training clinicians in more scientific, critical thinking would help to increase the profits that can be realized from this important source of information; and (5) to date, information obtained during zero-gravity experiments in space have not yet led to important consequences in treatment of patients under 1-g conditions, but are important for a possible evolutionary step of mammals adapting to a new environment.

Three-dimensional analysis of caloric nystagmus in the rhesus monkey

The aim of this study was to investigate whether caloric nystagmus contains response components that can be attributed to a stimulation of the vertical semicircular canals. Three dimensional eye movement recordings with a dual search coil technique revealed important horizontal, vertical and torsional nystagmus components following irrigation of the external ear canal with cold water in various head positions relative to gravity. Horizontal nystagmus components, i.e. lateral semicircular canal vectors, followed a cosine function of both the pitch and yaw angle of the head relative to gravity, confirming a mainly thermovective mechanism for stimulation of the horizontal canals. Vertical and torsional nystagmus components behaved differently following left and right ear irrigations. Right-left symmetrical vectors emerged only when the vertical and torsional components were transposed into vectors of single semicircular canal directions. The intensity of these vertical semicircular canal vectors as a function of the position of the corresponding canal relative to gravity, however, excludes important thermovective mechanisms acting at the vertical canals. It remains an open question whether these vertical canal vectors represent a non-thermovective caloric stimulation of vertical canal afferents.

On the pathomechanism of cochlear dysfunction in experimental perilymph fistulas

The mechanism leading to hearing impairment in perilymph fistulas was investigated in guinea pigs with perforated round window membranes (RWM) by analyzing alterations of inner ear fluid pressure, changes of auditory function following manipulations to get presumed air bubbles out of the cochlea ("positional audiometry"), and temporal bone sections. The instantaneous loss of normal positive inner ear fluid pressure after RWM perforation had no immediate effect on auditory function. Inner ear pressure was restored 4 days following RWM perforation. "Positional audiometry" was negative in guinea pigs with perforated RWM. All ears in which auditory thresholds had increased had additional iatrogenic lesions at the spiral lamina. Fistulas in the RWM per se do not affect auditory thresholds. The question of the surgical repair of fistulas was not directly addressed; it only can be concluded that there are no direct sequelae of an isolated fistula which induce auditory impairment and which could be prevented by surgical repair of the fistula.

The measurement and manipulation of intralabyrinthine pressure in experimental endolymphatic hydrops

Three to four months after unilateral surgical ablation of the endolymphatic duct and sac, endolymphatic and perilymphatic pressures were measured in both the normal and hydropic ears of 11 guinea pigs. In normal ears, endolymphatic pressure always approximated perilymphatic pressure. Endolymphatic pressure exceeded perilymphatic pressure in all ears with hydrops, except one in which these pressures were equal. The effect of postural inversion on inner ear pressures were studied in both normal and hydropic inner ears. Normal ears showed endolymphatic and perilymphatic pressure to rise equally during this maneuver. In hydropic ears, the difference between endolymphatic and perilymphatic pressure was notably reduced from measurements obtained in the prone position. This study indicates that an alteration in pressure regulation within the inner ear may be important in the pathogenesis and manifestation of experimental endolymphatic hydrops in the guinea pig. Physiologic mechanisms and clinical implications of these results are described.

Vertical Optokinetic Nystagmus and Optokinetic Afternystagmus in Humans

Vertical optokinetic nystagmus (OKN) and optokinetic afternystagmus (OKAN) were recorded in 6 normal subjects using the magnetic scleral search coil technique in order to reevaluate the up-down symmetry of these responses. The effects of body position relative to gravity were investigated by comparing OKN and OKAN elicited with the subjects in an erect and in a lateral side position. No consistent up-down asymmetry in vertical OKN was found but OKAN was asymmetric (up slow phase velocity > down slow phase velocity). Most subjects had an immediate reversal in OKAN slow phase velocity after downward stimuli. No significant effects of static head position (upright versus lateral position) on vertical OKN and OKAN were found. These features of human OKAN can be explained by the summation of two oppositely directed velocity storage mechanisms.

Experimental endolymphatic hydrops: are cochlear and vestibular symptoms caused by increased endolymphatic pressure?

The correlation between inner ear pressure and cochlear function was investigated in guinea pigs with unilaterally obliterated endolymphatic sacs and ducts. In 11 animals that developed endolymphatic hydrops, auditory thresholds as monitored by auditory evoked action potentials had increased with recruitment. Most of these animals also experienced episodes of spontaneous nystagmus. In control ears endolymphatic pressure did not differ more than 0.5 cm H2O from perilymphatic pressure. In six of 11 hydropic ears, endolymphatic pressure was more than 0.5 cm H2O higher than perilympathic pressure; auditory thresholds in all these ears had deteriorated within 2 weeks before pressure recording. No further hearing deterioration within this period was noted in five hydropic ears with endolymphatic pressure equal to or lower than perilymphatic pressure. Endolympathic-perilymphatic pressure gradients may contribute to auditory threshold increase in endolymphatic hydrops, but are not its only cause.

Endoneurial fluid pressure in the facial nerve of guinea pigs and rabbits

Endoneurial fluid pressure (EFP) was measured in the facial nerve in rabbits and guinea pigs using a servo-controlled micropipette system. EFP in the tympanic segment was 5.3 +/- 1.2 cm H2O in rabbits and 4.1 +/- 0.9 and 4.2 +/- 0.9 cm H2O in the tympanic and mastoid segment respectively in guinea pigs, while EFP in the sciatic nerve was around 2 cm H2O. The higher pressure in the facial nerve may be related to the proximo-distal flow of the endoneurial fluid in peripheral nerves.

Early alterations of cochlear function in experimental perilymph fistulas

Alterations of cochlear function secondary to perforation of the round window membrane in guinea pigs were expected to reveal sensitive and/or specific audiometric parameters in perilymph fistulas. A perforation of the round window membrane either did not affect acoustic compound action potential thresholds, or induced a delayed, possibly conductive, inner ear hearing loss. Also, evoked suprathreshold responses deteriorated progressively and independently of the increase of compound action potential thresholds. A sudden (conductive) hearing loss and a poor response to suprathreshold stimulation might indicate inner ear damage secondary to a perilymphatic fistula.

[Sudden unilateral deafness and geotropic positional nystagmus--a special form of acute cochleo-vestibular disorders?]

Three patients with complete sudden unilateral hearing loss suffered from delayed vertigo and presented a strong geotropic positional nystagmus during the evolution of their disease. Significant direction-fixed spontaneous nystagmus was absent, although two of the three patients had markedly decreased caloric responses on the diseased side. These findings are considered as a special form of peripheral cochleovestibular disorder restricted mainly to the cochlea and the otolith organs.

A novel L-glutamate oxidase from Streptomyces endus. Purification and properties

A new flavoenzyme using molecular oxygen to oxidize L-glutamic acid has been purified to homogeneity, as judged by polyacrylamide gel electrophoresis, from the culture medium of Streptomyces endus. Hydrogen peroxide, 2-oxoglutaric acid and ammonia are formed as products. Among 25 amino acids tested including D-glutamic acid, L-glutamine and L-aspartic acid, only L-glutamic acid is converted. The molecular mass of the enzyme was estimated to be about 90 kDa by gel chromatography and 50 kDa by SDS/PAGE. The subunit contains 1 molecule noncovalently bound FAD. The absorption spectrum shows maxima at 273, 355 and 457 nm and the isoelectric point is at pH 6.2. The Km value for L-glutamic acid in air-saturated phosphate pH 7.0 was estimated to be 1.1 mM, the Km for oxygen was calculated to be 1.86 mM at saturating concentration of L-glutamic acid. The enzymic reaction is inhibited by Ag+ and Hg2+ ions. The enzyme described here distinctly differs from two microbial L-glutamate oxidases purified hitherto, with regard to extremely high substrate specificity and to the subunit structure.

Maintenance of hydrostatic pressure gradients in the membranous labyrinth

In normal guinea pig ears, hydrostatic perilymphatic pressure is equal to endolymphatic pressure. Alterations of perilymphatic pressure induced, for example, by laceration of the round window membrane are transmitted immediately to the endolymphatic compartment, probably via Reissner's membrane. In guinea pigs with experimental endolymphatic hydrops, however, pressure gradients between the endolymph and perilymph remained preserved after rupture of the round window membrane. This is considered as further evidence that after long-standing distention of Reissner's membrane the membranous labyrinth loses its ability to equalize endolymphatic and perilymphatic pressure.

The surgical approach to the endolymphatic sac and the cochlear aqueduct in the guinea pig

The endolymphatic sac and cochlear aqueduct are primary passages of the endolymphatic and perilymphatic fluid compartments in the labyrinth. Closure of the endolymphatic sac and duct in the guinea pig will result in the development of endolymphatic hydrops. Although obstruction of the cochlear aqueduct in this species does not seem to result in any dysfunction, this structure may serve in the dynamics of inner ear fluid physiology. The anatomy of the guinea pig temporal bone is described with special emphasis on the endolymphatic sac and cochlear aqueduct. Surgical techniques to gain access to these structures through both a middle and posterior cranial fossa approach are described.

The Preyer reflex--an easy estimate of hearing function in guinea pigs

Preyer reflex thresholds elicited monaurally by tone bursts from 0.25 to 8 kHz were determined in more than 150 guinea pig ears. Normal reflex thresholds were between 85 and 95 dB SPL in the low and middle frequencies, decreasing to 75 dB in the higher frequencies. The range of measurements at single frequencies usually did not exceed 10 dB. In unselected populations of adult guinea pigs, about half of the animals had increased reflex thresholds--at least unilaterally, in most cases due to middle ear infections. The Preyer reflex showed parallel threshold increase with compound action potential thresholds in conductive loss and recruitment in cochlear hearing loss. Normal Preyer reflex thresholds do not necessarily mean normal hearing, but increased thresholds do indicate hearing impairment. This technique is valuable in the selection and monitoring of animals for otologic experiments.

[Histological study of the binding of Polycel and Ceravital implants to the stapes footplate in rabbits]

Five Polycel and five Ceravital implants were interposed between the stapedial footplate and the tympanic membrane in 10 rabbits. Four to 7 months later the connection of the prostheses to the stapes was histologically examined by temporal bone sections. The union of both types of prostheses to the stapedial footplate was achieved by remnants of crura, middle ear mucosa and connective tissue. Histology revealed a more stable connection of the Polycel prosthesis to the stapedial footplate.

Vestibulo-ocular reflexes after selective plugging of the semicircular canals in the monkey--response plane determinations

The contribution from different pairs of semicircular canals to the generation of horizontal vestibular nystagmus was examined in monkeys. Animals with different pairs of semicircular canals surgically plugged were accelerated sinusoidally at 1 Hz (a predictive stimulus) or with steps of angular velocity (a non-predictive stimulus) about an earth vertical axis while the head was placed in various static pitch positions. In normal animals, and in animals with only the lateral canals intact, horizontal nystagmus elicited with angular velocity steps is maximal at a static pitch angle of 15 degrees nose-down (relative to the horizontal stereotaxic plane). The response follows a cosine function of the pitch angle, approaches zero at an angle of 90 degrees to the optimal orientation, and finally reverses. In animals with only the vertical canals operating, direction specific horizontal nystagmus can still be elicited. Using velocity steps, a null plane at which nystagmus reverses can be determined. It is found at about 32 degrees nose-down and thus is different from the optimal plane of the lateral canals. Consequently, it is not possible to stimulate the lateral canals maximally without stimulating the vertical canals simultaneously. Using sinusoidal rotation, nystagmus is attenuated at the static pitch position of 32 degrees nose-down, but does not reverse direction with further pitching.

Horizontal and vertical vestibulo-ocular and cervico-ocular reflexes in the monkey during high frequency rotation

In the alert monkey the horizontal vestibulo-ocular reflex (VOR) is basically compensatory over the range of 0.5 to 6 Hz with a gain near unity, and with the phase of the compensatory eye position having a minimal lag with respect to head position. Typical frequency-dependent eye movement patterns were observed. Vertical VOR is also compensatory having the same phase relations but with a reduced gain (-2.5 to -3.7 dB). In this range, vestibular input appears to be the predominant sensory influence on reflex eye movements. Additional optokinetic reflexes do not improve the VOR above 0.5 Hz. The horizontal cervico-ocular reflex (COR) is minimal or absent in normal monkeys.