Posterior Semicircular Canal Dehiscence with Vestibulo-Ocular Reflex Reduction for the Affected Canal at the Video-Head Impulse Test: Considerations to Pathomechanisms

Posterior semicircular canal dehiscence (PSCD) has been demonstrated to result in a third mobile window mechanism (TMWM) in the inner ear similar to superior semicircular canal dehiscence (SSCD). Typical clinical and instrumental features of TMWM, including low-frequency conductive hearing loss (CHL), autophony, pulsatile tinnitus, sound/pressure-induced vertigo and enhanced vestibular-evoked myogenic potentials, have been widely described in cases with PSCD. Nevertheless, video-head impulse test (vHIT) results have been poorly investigated. Here, we present six patients with PSCD presenting with a clinical scenario consistent with a TMWM and an impaired vestibulo-ocular reflex (VOR) for the affected canal on vHIT. In two cases, an additional dehiscence between the facial nerve and the horizontal semicircular canal (HSC) was detected, leading to a concurrent VOR impairment for the HSC. While in SSCD, a VOR gain reduction could be ascribed to a spontaneous "auto-plugging" process due to a dural prolapse into the canal, the same pathomechanism is difficult to conceive in PSCD due to a different anatomical position, making a dural herniation less likely. Alternative putative pathomechanisms are discussed, including an endolymphatic flow dissipation during head impulses as already hypothesized in SSCD. The association of symptoms/signs consistent with TMWM and a reduced VOR gain for the posterior canal might address the diagnosis toward PSCD.

Audiovestibular Findings in Patients with Concurrent Superior Canal Dehiscence and Vestibular Schwannoma

OBJECTIVE

To describe the clinical-instrumental findings in case of concurrent superior canal dehiscence (SCD) and ipsilateral vestibular schwannoma (VS), aiming to highlight the importance of an extensive instrumental assessment to achieve a correct diagnosis.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Five patients with concurrent SCD and VS.

INTERVENTION

Clinical-instrumental assessment and imaging.

MAIN OUTCOME MEASURE

Clinical presentation, audiovestibular findings, and imaging.

RESULTS

The chief complaints were hearing loss (HL) and unsteadiness (80%). Other main symptoms included tinnitus (60%) and pressure-induced vertigo (40%). Mixed-HL was identified in three patients and pure sensorineural-HL in 1, including a roll-over curve in speech-audiometry in two cases. Vibration-induced nystagmus was elicited in all cases, whereas vestibular-evoked myogenic potentials showed reduced thresholds and enhanced amplitudes on the affected side in three patients. Ipsilesional weakness on caloric testing was detected in three patients and a bilateral hyporeflexia in one. A global canal impairment was detected by the video-head impulse test in one case, whereas the rest of the cohort exhibited a reduced function for the affected superior canal, together with ipsilateral posterior canal impairment in two cases. All patients performed both temporal bones HRCT scan and brain-MRI showing unilateral SCD and ipsilateral VS, respectively. All patients were submitted to a wait-and-scan approach, requiring VS removal only in one case.

CONCLUSION

Simultaneous SCD and VS might result in subtle clinical presentation with puzzling lesion patterns. When unclear symptoms and signs occur, a complete audiovestibular assessment plays a key role to address imaging and diagnosis.

Skull Vibration-Induced Nystagmus in Superior Semicircular Canal Dehiscence: A New Insight into Vestibular Exploration-A Review

The third window syndrome, often associated with the Tullio phenomenon, is currently most often observed in patients with a superior semicircular-canal dehiscence (SCD) but is not specific to this pathology. Clinical and vestibular tests suggestive of this pathology are not always concomitantly observed and have been recently complemented by the skull-vibration-induced nystagmus test, which constitutes a bone-conducted Tullio phenomenon (BCTP). The aim of this work was to collect from the literature the insights given by this bedside test performed with bone-conducted stimulations in SCD. The PRISMA guidelines were used, and 10 publications were included and analyzed. Skull vibration-induced nystagmus (SVIN), as observed in 55 to 100% of SCD patients, usually signals SCD with greater sensitivity than the air-conducted Tullio phenomenon (ACTP) or the Hennebert sign. The SVIN direction when the test is performed on the vertex location at 100 Hz is most often ipsilaterally beating in 82% of cases for the horizontal and torsional components and down-beating for the vertical component. Vertex stimulations are more efficient than mastoid stimulations at 100 Hz but are equivalent at higher frequencies. SVIN efficiency may depend on stimulus location, order, and duration. In SCD, SVIN frequency sensitivity is extended toward high frequencies, with around 400 Hz being optimal. SVIN direction may depend in 25% on stimulus frequency and in 50% on stimulus location. Mastoid stimulations show frequently diverging results following the side of stimulation. An after-nystagmus observed in 25% of cases can be interpreted in light of recent physiological data showing two modes of activation: (1) cycle-by-cycle phase-locked activation of action potentials in SCC afferents with irregular resting discharge; (2) cupula deflection by fluid streaming caused by the travelling waves of fluid displacement initiated by sound or vibration at the point of the dehiscence. The SVIN direction and intensity may result from these two mechanisms' competition. This instability explains the SVIN variability following stimulus location and frequency observed in some patients but also discrepancies between investigators. SVIN is a recent useful insight among other bedside examination tests for the diagnosis of SCD in clinical practice.

Low-Frequency Air-Bone Gap and Pulsatile Tinnitus Due to a Dural Arteriovenous Fistula: Considerations upon Possible Pathomechanisms and Literature Review

Low-frequency air-bone gap (ABG) associated with pulsatile tinnitus (PT) and normal impedance audiometry represents a common finding in patients with third window syndromes. Other inner disorders, including Meniere's disease (MD), perilymphatic fistula and intralabyrinthine schwannoma, might sometimes result in a similar scenario. On the other hand, PT is frequently associated with dural arteriovenous fistula (DAVF), while conductive hearing loss (CHL) is extremely rare in this clinical setting. A 47-year-old patient was referred to our center with progressive left-sided PT alongside ipsilateral fullness and hearing loss. She also experienced headache and dizziness. Otoscopy and video-oculographic examination were unremarkable. Conversely, a detailed instrumental audio-vestibular assessment revealed low-frequency CHL with normal impedance audiometry, slight left-sided caloric weakness, slightly impaired vestibular-evoked myogenic potentials on the left and normal results on the video-head impulse test, consistent with an MD-like instrumental profile. Gadolinium-enhanced brain MRI revealed an early enhancement of the left transverse sinus, consistent with a left DAVF between the left occipital artery and the transverse sinus, which was then confirmed by angiography. A trans-arterial embolization with Onyx glue was performed, resulting in a complete recession of the symptoms. Post-operatively, the low-frequency ABG disappeared, supporting the possible role of venous intracranial hypertension and abnormal pressure of inner ear fluids in the onset of symptoms and offering new insights into the pathomechanism of inner ear CHL.

Impaired Vestibulo-Ocular Reflex on Video Head Impulse Test in Superior Canal Dehiscence: "Spontaneous Plugging" or Endolymphatic Flow Dissipation?

Surgical plugging of the superior semicircular canal (SSC) represents an effective procedure to treat disabling symptoms in superior canal dehiscence (SCD), despite resulting in an impaired vestibulo-ocular reflex (VOR) gain for the SSC. On the other hand, SSC hypofunction on video head impulse test (vHIT) represents a common finding in patients with SCD exhibiting sound/pressure-induced vertigo, a low-frequency air-bone gap (ABG), and enhanced vestibular-evoked myogenic potentials (VEMPs). "Spontaneous canal plugging" has been assumed as the underlying process. Nevertheless, missing/mitigated symptoms and/or near-normal instrumental findings would be expected. An endolymphatic flow dissipation has been recently proposed as an alternative pathomechanism for SSC VOR gain reduction in SCD. We aimed to shed light on this debate by comparing instrumental findings from 46 ears of 44 patients with SCD exhibiting SSC hypofunction with post-operative data from 10 ears of 10 patients with SCD who underwent surgical plugging. While no difference in SSC VOR gain values was found between the two groups (p = 0.199), operated ears developed a posterior canal hypofunction (p = 0.002). Moreover, both ABG values (p = 0.012) and cervical/ocular VEMP amplitudes (p < 0.001) were significantly higher and VEMP thresholds were significantly lower (p < 0.001) in ears with SCD compared to operated ears. According to our data, canal VOR gain reduction in SCD should be considered as an additional sign of a third window mechanism, likely due to an endolymphatic flow dissipation.

Vestibular assessment in sudden sensorineural hearing loss: Role in the prediction of hearing outcome and in the early detection of vascular and hydropic pathomechanisms

Introduction

Predicting hearing outcome in sudden sensorineural hearing loss (SSNHL) is challenging, as well as detecting the underlying pathomechanisms. SSNHL could be associated with vestibular damage since cochleo-vestibular structures share the same vascularization, along with being in close anatomical proximity. Whereas viral inflammations and autoimmune/vascular disorders most likely represent the involved aetiologies, early-stage Menière's disease (MD) can also present with SSNHL. Since an early treatment could beneficially influence hearing outcome, understanding the possible etiology plays a pivotal role in orienting the most appropriate treatment. We aimed to evaluate the extent of vestibular damage in patients presenting with SSNHL with or without vertigo, investigate the prognostic role of vestibular dysfunctions on hearing recovery and detect specific lesion patterns related to the underlying pathomechanisms.

Methods

We prospectively evaluated 86 patients with SSNHL. Audio-vestibular investigation included pure-tone/speech/impedance audiometry, cervical/ocular-VEMPs, vHIT and video-Frenzel examination. White matter lesions (WML) were evaluated on brain-MRI. Patients were followed-up and divided into "SSNHL-no-vertigo," "SSNHL+vertigo" and "MD" subgroups.

Results

Hearing was more impaired in "SSNHL+vertigo" patients who exhibited either down-sloping or flat-type audiograms, and was less impaired in "MD" where low frequencies were mostly impaired (p < 0.001). Otolith receptors were more frequently involved than semicircular canals (SCs). Although the "SSNHL-no-vertigo" subgroup exhibited the lowest vestibular impairment (p < 0.001), 52% of patients developed otolith dysfunctions and 72% developed nystagmus. Only "MD" subjects showed anterior SC impairment and upbeating spontaneous/positional nystagmus. They more frequently exhibited cervical-VEMPs frequency tuning (p = 0.036) and ipsilesional spontaneous nystagmus (p < 0.001). "SSNHL+vertigo" subjects presented with more frequently impaired cervical-VEMPs and posterior SC and with higher number of impaired receptors (p < 0.001). They mainly exhibited contralesional spontaneous and vibration-induced nystagmus (p < 0.05) and only they showed the highest WML score and "vascular" lesion patterns (p < 0.001). Concerning the outcomes, hearing was better in "MD" and worse in "SSNHL+vertigo" (p < 0.001). Hearing recovery was mostly affected by cervical-VEMPs impairment and the number of involved receptors (p < 0.05). Patients with "vascular" lesion patterns presented with the highest HL degree and WML score (p ≤ 0.001), while none of them exhibited a complete hearing recovery (p = 0.026).

Conclusions

Our data suggest that vestibular evaluation in SSNHL can provide useful information on hearing recovery and underlying aetiologies.

Is it possible to diagnose Posterior Semicircular Canal BPPV from the sitting position? The role of the Head Pitch Test and the upright tests along the RALP and LARP planes

PURPOSE

The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the posterior semicircular canal (PSC) is traditionally entrusted to positioning tests where patients are rapidly brought in the supine position. This prospective study aims to define the role of a diagnostic protocol for PSC-BPPV including only upright tests.

MATERIALS AND METHODS

109 patients with PSC-BPPV were enrolled. The Head Pitch Test (HPT) was carried out first. If uneventful, the patient's head was turned 45° to each side and bent back-and-forth along the plane aligning either with the right anterior-left posterior (RALP) or left anterior-right posterior (LARP) canals, thus performing the upright RALP / upright LARP (uRALP/uLARP) test. Nystagmus observed was used to predict the diagnosis, which was therefore confirmed by Dix-Hallpike tests.

RESULTS

PSC-BPPV could be correctly diagnosed in 75.2% of cases with the sole HPT and in 87.2% of cases by adding the uRALP/uLARP test (Upright Protocol). The time elapsed from symptoms onset was closely related to the protocol sensitivity, as it reached 100% (64/64) in acute patients while decreased to 68.9% (31/45) in cases evaluated after 7 days (p < 0.001).

CONCLUSIONS

Upright maneuvers could correctly diagnose PSC-BPPV in most cases. uRALP/uLARP test demonstrated to improve the sensitivity of the HPT, mainly in recent-onset BPPV.

Ultra-broadband high-resolution microdroplet spectrometers for the near infrared

By stabilizing the evaporation dynamics of a microliter fluorocarbon droplet, we demonstrate a fast-scan optofluidic Fourier transform (FT) spectrometer on the tip of an optical fiber operating in the 1000-2000 nm window with a resolution of 3.5 cm^-1 (i.e., <1 nm at 1560 nm). Compared with other FT near-infrared (NIR) small-scale spectrometers reported in the literature, the fluorocarbon droplet spectrometer shows the largest wavelength span and span/resolution ratio, allowing spectral analysis of broadband or narrowband radiation to be easily performed. Our results open the way for the practical application of droplet spectrometers as advanced optofluidic NIR analyzers with small size and low cost that are capable of operating in harsh environments, even in the absence of electrical power sources.

Spontaneous Upbeat Nystagmus and Selective Anterior Semicircular Canal Hypofunction on Video Head Impulse Test: A New Variant of Canalith Jam?

We describe a rare case of spontaneous upbeat nystagmus (UBN) attributable to a canalith jam involving the anterior semicircular canal (ASC) in a patient in whom comprehensive vestibular assessment was useful to identify the underlying pathomechanism. A 56-year-old woman with unsteadiness following repositioning procedures for left-sided benign paroxysmal positional vertigo (BPPV) presented with spontaneous UBN that showed slight right torsional components. A vestibular test battery detected isolated left ASC hypofunction on a video-head impulse test (Video-HIT). We postulated a persistent utriculopetal deflection of the left ASC cupula, which was attributable to entrapment of debris in a narrow canal tract, with consequent sustained inhibition of the ampullary afferents. Although spontaneous UBN receded after impulsive physical therapy, unsteadiness deteriorated into positional vertigo secondary to canalolithiasis involving the ipsilateral posterior canal. In our view, physical therapy possibly fragmented the canalith jam and released free-floating otoconia that eventually settled into the ipsilateral posterior canal. Video HIT revealed normalization of ASC hypofunction, and left-sided posterior canal canalolithiasis was successfully treated using appropriate repositioning procedures. We propose that a canalith jam involving the ASC should be considered in the differential diagnosis of spontaneous UBN, particularly in patients with a history of BPPV and isolated ASC hypofunction detected on video HIT.

Light pressure in droplet micro-resonators excited by free-space scattering

A droplet optical resonator is a unique environment to investigate light-matter interaction and optomechanics in liquids. Here, we report on light pressure effects derived from whispering gallery modes excited in a liquid-polymer droplet micro-resonator by free-space laser scattering. From the nonlinear resonance spectrum observed in the visible, we provide evidence of photon pressure exerted at the liquid-air boundary and quantify it with a coherent physical model. Our findings pave the way to studies on micro-rheology and nonlinear optofluidics, where droplets serve as miniature liquid laboratories.

Case Report: Could Hennebert's Sign Be Evoked Despite Global Vestibular Impairment on Video Head Impulse Test? Considerations Upon Pathomechanisms Underlying Pressure-Induced Nystagmus due to Labyrinthine Fistula

We describe a case series of labyrinthine fistula, characterized by Hennebert's sign (HS) elicited by tragal compression despite global hypofunction of semicircular canals (SCs) on a video-head impulse test (vHIT), and review the relevant literature. All three patients presented with different amounts of cochleo-vestibular loss, consistent with labyrinthitis likely induced by labyrinthine fistula due to different temporal bone pathologies (squamous cell carcinoma involving the external auditory canal in one case and middle ear cholesteatoma in two cases). Despite global hypofunction on vHIT proving impaired function for each SC for high accelerations, all patients developed pressure-induced nystagmus, presumably through spared and/or recovered activity for low-velocity canal afferents. In particular, two patients with isolated horizontal SC fistula developed HS with ipsilesional horizontal nystagmus due to resulting excitatory ampullopetal endolymphatic flows within horizontal canals. Conversely, the last patient with bony erosion involving all SCs developed mainly torsional nystagmus directed contralaterally due to additional inhibitory ampullopetal flows within vertical canals. Moreover, despite impaired measurements on vHIT, we found simultaneous direction-changing positional nystagmus likely due to a buoyancy mechanism within the affected horizontal canal in a case and benign paroxysmal positional vertigo involving the dehiscent posterior canal in another case. Based on our findings, we might suggest a functional dissociation between high (impaired) and low (spared/recovered) accelerations for SCs. Therefore, it could be hypothesized that HS in labyrinthine fistula might be due to the activation of regular ampullary fibers encoding low-velocity inputs, as pressure-induced nystagmus is perfectly aligned with the planes of dehiscent SCs in accordance with Ewald's laws, despite global vestibular impairment on vHIT. Moreover, we showed how pressure-induced nystagmus could present in a rare case of labyrinthine fistulas involving all canals simultaneously. Nevertheless, definite conclusions on the genesis of pressure-induced nystagmus in our patients are prevented due to the lack of objective measurements of both low-acceleration canal responses and otolith function.

Spontaneous Jamming of Horizontal Semicircular Canal Combined with Canalolithiasis of Contralateral Posterior Semicircular Canal

Spontaneous canalith jam is an uncommon form of benign paroxysmal positional vertigo mimicking acute vestibular neuritis. We described for the first time a spontaneous horizontal semicircular canalith jam associated with a typical canalolithiasis involving contralateral posterior semicircular canal (PSC), illustrating how the latter condition modified direction-fixed nystagmus during head movements. An 81-year-old woman with persistent vertigo referred to our center. Video-Frenzel examination showed horizontal direction-fixed right-beating nystagmus in primary gaze position, inhibited by visual fixation. She exhibited corrective saccades after leftward head impulses. Chin-to-chest positioning at the head-pitch test did not modify spontaneous nystagmus, whereas slight torsional components with the top pole of the eye beating toward the right ear appeared in backward head-bending, resulting in mixed horizontal-torsional nystagmus. At supine positioning tests, direction-fixed nystagmus turned into direction-changing geotropic horizontal nystagmus, which was stronger on the left side, while overlapping upbeat nystagmus with torsional right-beating components appeared on the right. Primary clinical findings were consistent with a left horizontal semicircular canalith jam, inducing a persistent utriculofugal cupular displacement, combined with a typical right-sided PSC-canalolithiasis. Once canalith jam crumbled, resulting in a non-ampullary arm canalolithiasis of the horizontal semicircular canal, both involved canals were freed by debris with appropriate repositioning procedures.

Fluctuating Posterior Canal Function in Benign Paroxysmal Positional Vertigo Depending on How and Where Otoconia Are Disposed

OBJECTIVE

Though fluctuations in vestibular function represent a common finding in Menière's disease, we describe how benign paroxysmal positional vertigo (BPPV) may result in fluctuations of vestibulo-ocular reflex for the involved canal depending on the disposition of otoliths.

PATIENT

A 54-year-old woman suffering from refractory posterior canal (PC)-BPPV resulting in fluctuating PC function.

INTERVENTIONS

Diagnostic evaluation and rehabilitative treatment for BPPV involving the affected PC.

MAIN OUTCOME MEASURES

Video-Frenzel and video-head impulse test (vHIT) findings before and after canalith repositioning procedures for PC-BPPV.

RESULTS

BPPV involving the nonampullary arm of right PC was diagnosed based on presenting positional downbeat nystagmus and selective right PC hypofunction at the vHIT. During physical treatment, nystagmus first became positional paroxysmal upbeat likely due to a shift of debris into the ampullary arm of the canal, then turned to spontaneous downbeat nystagmus consistently with a plug effect exerted by particles entrapped within the nonampullary arm of PC and finally receded proving an otoliths fall within the utriculus. Simultaneously, vHIT documented fluctuations for right PC vestibulo-ocular reflex gain as it first increased to normal values, then severely declined and finally normalized, respectively. High-resolution computed tomography scan detected ipsilateral superior canal dehiscence.

CONCLUSIONS

In accordance with recently reported vHIT findings in different types of BPPV, fluctuation of PC function could be likely explained by the effect of particles on cupular dynamic responses depending on the portion of the canal gradually involved. Superior canal dehiscence may have played a role facilitating otoliths mobilization by reducing labyrinthine impedance.

Case Report: Filling Defect in Posterior Semicircular Canal on MRI With Balanced Steady-State Gradient-Echo Sequences After Labyrinthine Ischemia in the Common Cochlear Artery Territory as an Early Sign of Fibrosis

We describe a rare case of posterior semicircular canal (PSC) fibrosis following acute labyrinthine ischemia in the territory supplied by the common cochlear artery (CCA) and review the relevant literature. A 71-year-old man with multiple vascular risk factors presented 12 days after the onset of acute vertigo and profound left-sided hearing loss. Right-beating spontaneous nystagmus with downbeat components elicited by mastoid vibrations and headshaking was detected. The video head impulse test (vHIT) revealed an isolated hypofunction of the left PSC, whereas vestibular evoked myogenic potentials (VEMPs) showed ipsilateral saccular loss. The clinical presentation and instrumental picture were consistent with acute ischemia in the territory supplied by left CCA. Compared to previous imaging, a new MRI of the brain with 3D-FIESTA sequences highlighted a filling defect in the left PSC, consistent with fibrosis. Hearing function exhibited mild improvement after steroid therapy and hyperbaric oxygen sessions, whereas vHIT abnormalities persisted over time. To the best of our knowledge, this is the only case in the literature reporting a filling defect on MRI, consistent with semicircular canal fibrosis following acute labyrinthine ischemia. Moreover, PSC fibrosis was related with poor functional outcome. We therefore suggest using balanced steady-state gradient-echo sequences a few weeks following an acute lesion of inner ear sensors to detect signal loss within membranous labyrinth consistent with post-ischemic fibrosis. Besides addressing the underlying etiology, signal loss might also offer clues on the functional behavior of the involved sensor over time. In cases of acute loss of inner ear function, a careful bedside examination supplemented by instrumental assessments, including vHIT and VEMPs, of vestibular receptors and afferents may be completed by MRI with balanced steady-state gradient-echo sequences at a later time to confirm the diagnosis and address both etiology and functional outcome.

Upright BPPV Protocol: Feasibility of a New Diagnostic Paradigm for Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo Compared to Standard Diagnostic Maneuvers

Background: The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the lateral semicircular canal (LSC) is traditionally entrusted to the supine head roll test, also known as supine head yaw test (SHYT), which usually allows identification of the pathologic side and BPPV form (geotropic vs. apogeotropic). Nevertheless, SHYT may not always allow easy detection of the affected canal, resulting in similar responses on both sides and intense autonomic symptoms in patients with recent onset of vertigo. The newly introduced upright head roll test (UHRT) represents a diagnostic maneuver for LSC-BPPV, supplementing the already-known head pitch test (HPT) in the sitting position. The combination of these two tests should enable clinicians to determine the precise location of debris within LSC, avoiding disturbing symptoms related to supine positionings. Therefore, we proposed the upright BPPV protocol (UBP), a test battery exclusively performed in the upright position, including the evaluation of pseudo-spontaneous nystagmus (PSN), HPT and UHRT. The purpose of this multicenter study is to determine the feasibility of UBP in the diagnosis of LSC-BPPV.

Methods: We retrospectively reviewed the clinical data of 134 consecutive patients diagnosed with LSC-BPPV. All of them received both UBP and the complete diagnostic protocol (CDP), including the evaluation of PSN and data resulting from HPT, UHRT, seated-supine positioning test (SSPT), and SHYT.

Results: A correct diagnosis for LSC-BPPV was achieved in 95.5% of cases using exclusively the UBP, with a highly significant concordance with the CDP (p < 0.000, Cohen's kappa = 0.94), regardless of the time elapsed from symptom onset to diagnosis. The concordance between UBP and CDP was not impaired even when cases in which HPT and/or UHRT provided incomplete results were included (p < 0.000). Correct diagnosis using the supine diagnostic protocol (SDP, including SSPT + SHYT) or the sole SHYT was achieved in 85.1% of cases, with similar statistical concordance (p < 0.000) and weaker strength of relationship (Cohen's kappa = 0.80).

Conclusion: UBP allows correct diagnosis in LSC-BPPV from the sitting position in most cases, sparing the patient supine positionings and related symptoms. UBP could also allow clinicians to proceed directly with repositioning maneuvers from the upright position.

Feasibility of Using the Video-Head Impulse Test to Detect the Involved Canal in Benign Paroxysmal Positional Vertigo Presenting With Positional Downbeat Nystagmus

Positional downbeat nystagmus (pDBN) represents a relatively frequent finding. Its possible peripheral origin has been widely ascertained. Nevertheless, distinguishing features of peripheral positional nystagmus, including latency, paroxysm and torsional components, may be missing, resulting in challenging differential diagnosis with central pDBN. Moreover, in case of benign paroxysmal positional vertigo (BPPV), detection of the affected canal may be challenging as involvement of the non-ampullary arm of posterior semicircular canal (PSC) results in the same oculomotor responses generated by contralateral anterior canal (ASC)-canalolithiasis. Recent acquisitions suggest that patients with persistent pDBN due to vertical canal-BPPV may exhibit impaired vestibulo-ocular reflex (VOR) for the involved canal on video-head impulse test (vHIT). Since canal hypofunction normalizes following proper canalith repositioning procedures (CRP), an incomplete canalith jam acting as a "low-pass filter" for the affected ampullary receptor has been hypothesized. This study aims to determine the sensitivity of vHIT in detecting canal involvement in patients presenting with pDBN due to vertical canal-BPPV. We retrospectively reviewed the clinical records of 59 consecutive subjects presenting with peripheral pDBN. All patients were tested with video-Frenzel examination and vHIT at presentation and after resolution of symptoms or transformation in typical BPPV-variant. BPPV involving non-ampullary tract of PSC was diagnosed in 78%, ASC-BPPV in 11.9% whereas in 6 cases the involved canal remained unidentified. Presenting VOR-gain values for the affected canal were greatly impaired in cases with persistent pDBN compared to subjects with paroxysmal/transitory nystagmus (p < 0.001). Each patient received CRP for BPPV involving the hypoactive canal or, in case of normal VOR-gain, the assumed affected canal. Each subject exhibiting VOR-gain reduction for the involved canal developed normalization of vHIT data after proper repositioning (p < 0.001), proving a close relationship with otoliths altering high-frequency cupular responses. According to our results, overall vHIT sensitivity in detecting the affected SC was 72.9%, increasing up to 88.6% when considering only cases with persistent pDBN where an incomplete canal plug is more likely to occur. vHIT should be routinely used in patients with pDBN as it may enable to localize otoconia within the labyrinth, providing further insights to the pathophysiology of peripheral pDBN.

Upright head roll test: A new contribution for the diagnosis of lateral semicircular canal benign paroxysmal positional vertigo

Diagnosing the affected side in Benign Paroxysmal Positional Vertigo (BPPV) involving the Lateral Semicircular Canal (LSC) is often challenging and uncomfortable in patients with recent onset of vertigo and intense autonomic symptoms. The Minimum Stimulus Strategy (MSS) aims to diagnose side and canal involved by BPPV causing as little discomfort as possible to the patient. The strategy applied for LSC-BPPV includes the evaluation of pseudo-spontaneous nystagmus and oculomotor responses to the Head Pitch Test (HPT) in upright position, to the seated-supine test and to the Head Yaw Test (HYT) while supine. Matching data obtained by these tests enables clinicians to diagnose the affected side in LSC-BPPV. The purpose of this preliminary study is to propose a new diagnostic test for LSC-BPPV complimentary to the HPT, the Upright Head Roll Test (UHRT), to easily determine the affected ear and the involved arm in the sitting position and to evaluate its efficiency. Our results suggest that the UHRT can increase the sensitivity of the MSS without resorting to the HYT, thus reducing patient's discomfort.

A self-operating broadband spectrometer on a droplet

Small-scale Fourier transform spectrometers are rapidly revolutionizing infrared spectro-chemical analysis, enabling on-site and remote sensing applications that were hardly imaginable just few years ago. While most devices reported to date rely on advanced photonic integration technologies, here we demonstrate a miniaturization strategy which harnesses unforced mechanisms, such as the evaporation of a liquid droplet on a partially reflective substrate. Based on this principle, we describe a self-operating optofluidic spectrometer and the analysis method to retrieve consistent spectral information in spite of the intrinsically non-reproducible droplet formation and evaporation dynamics. We experimentally realize the device on the tip of an optical fiber and demonstrate quantitative measurements of gas absorption with a 2.6 nm resolution, in a 100 s acquisition time, over the 250 nm span allowed by our setup's components. A direct comparison with a commercial optical analyzer clearly points out that a simple evaporating droplet can be an efficient small-scale, inexpensive spectrometer, competitive with the most advanced integrated photonic devices.

Isolated horizontal canal hypofunction differentiating a canalith jam from an acute peripheral vestibular loss

OBJECTIVES

To describe a unique case of acute vertigo presenting with spontaneous horizontal nystagmus (SHN) and a clinical picture consistent with right acute peripheral vestibular loss (APVL) in which an isolated hypofunction of a horizontal semicircular canal (HSC) permitted to detect a spontaneous canalith jam and treat the patient accordingly.

METHODS

Case report and literature review.

RESULTS

A 74-year old woman presented with acute vertigo, left-beating SHN and a clinical picture consistent with right APVL. Nevertheless, vestibular evoked myogenic potentials were normal with symmetrical amplitudes and the video head impulse test (vHIT) revealed an isolated hypofunction of the right HSC. After repeated head shakings, the supine roll test evoked bilaterally a positioning paroxysmal geotropic horizontal nystagmus suggesting benign paroxysmal positional vertigo involving the non-ampullated arm of the right HSC. vHIT and caloric testing confirmed restitution of HSC function after repositioning maneuvers.

CONCLUSIONS

In case of acute vertigo with SHN, a complete functional assessment of vestibular receptors and afferents should always be given in order to avoid misdiagnosis. Canalith jam should be considered in case of spontaneous nystagmus and isolated canal hypofunction.

Metallic skeletons as reinforcement of new composite materials applied in orthopaedics and dentistry

Purpose: The article concerns the development of completely new groups of composite materials that can be used to produce functional replacements for damaged bones or teeth. Design/methodology/approach: A selective laser sintering was used to produce the reinforcement of those materials from titanium and its Ti6Al4V alloy in the form of skeletons with pores with adjustable geometric features. The matrix of those materials is either air or crystallised from the liquid AlSi12 or AlSi7Mg0.3 alloys condition after prior vacuum infiltration or human osteoblast cells from the hFOB 1.19 (Human ATCC - CRL - 11372) culture line. Findings: The porous material may be used for the non-biodegradable scaffold. After implantation into the body in the form of an implant-scaffold one, it allows the natural cells of the patient to grow into the pores of the implant, and it fuses with the bone or the appropriate tissue over time. The essential part of the implant-scaffold is the porous part inseparably connected with the core of solid materials. Into pores can grow living cells. Research limitations/implications: Biological-engineering composite materials in which natural cells were cultured in the pores in the laboratory next are combined as an artificial material with the natural cells of the patient in his/her body. Practical implications: The hybrid technologies of the all group of those materials were obtained and optimised. Numerous structure research was carried out using the most modern research methods of contemporary materials engineering, and mechanical tests and biological research involving the cultivation of natural cells were realised. Originality/value: The results of the research indicate the accuracy of the idea of implementing a new group of biological-engineering materials and the wide possibilities of their application in regenerative medicine.

Opto-mechanical oscillator in a nanoliter droplet

Droplets are very simple physical systems, whereby surface tension shapes liquids into ideal opto-mechanical devices. This has recently enabled low-viscosity liquid samples to serve as miniature acoustic resonators harnessing optical generation of bulk vibrations, capillaries, or surface waves. Uniquely, a simple room-temperature pendant droplet can be activated as a hypersound-laser emitter when illuminated by a free-space, low-power visible laser thanks to stimulated Brillouin scattering of optical and acoustic whispering-gallery modes. Here, we demonstrate continuous operation of a liquid polymer opto-mechanical resonator and characterize its quality factor and long-term frequency stability. Our results point to the feasibility of all-liquid micro-mechanical oscillators working in the 50-100 MHz range. The stimulated generation of high-quality surface waves on nanoliter droplets gives momentum to new optical schemes for characterization of material viscous-elastic properties, laboratory investigation of atmospheric phenomena, and mass sensing for direct analysis of biological fluids based on ultrasound-hypersound coherent generation and detection.

Mode-splitting cloning in birefringent fiber Bragg grating ring resonators

In this Letter, we report the theoretical model and the experimental evidence of a mode-splitting cloning effect due to the resonant coupling between modes having different polarizations in weakly birefringent fiber Bragg grating (FBG) ring resonators. This modal coupling depends on the fiber birefringence and the FBG reflectivity. In the ideal case of the absence of birefringence, a single split-mode resonant structure can be observed in the resonator transmission spectrum due to the degeneracy removal of the two counter-propagating modes. In the presence of FBG birefringence, a secondary split doublet resulting in a clone of the initial one is generated. The described effect can be exploited for spectroscopic-sensing applications based on more complex split-mode dynamics.

Fiber Bragg grating laser sensor with direct radio-frequency readout

A fiber Bragg grating (FBG)-coupled ring laser sensor is demonstrated. In the proposed configuration the interrogating source, the sensing head and the readout instrument are integrated in a single fiber-optic device. An FBG inserted within a bidirectional fiber ring couples the two counterpropagating modes of the cavity, generating a splitting of the resonant wavelengths proportional to the FBG reflectivity. When the cavity gain is brought beyond threshold, the two peaks of the split resonances simultaneously lase, leading to a beat note in the emission spectrum whose frequency tracks any small shift of the FBG reflectivity spectrum. Such a beat note can be simply monitored by a frequency counter, without the need for an optical spectrometer, allowing to significantly reduce size and costs of the sensor setup. The sensing performance compares well to the state-of-the-art thermo-mechanical fiber sensors.

Laser-frequency locking to a whispering-gallery-mode cavity by spatial interference of scattered light

We present a simple and effective method for frequency locking a laser source to a free-space-coupled whispering-gallery-mode cavity. The scheme relies on the interference of spatial modes contained in the light scattered by the cavity, where low- and high-order modes are simultaneously excited. A dispersion-shaped signal proportional to the imaginary component of the resonant optical field is simply generated by spatial filtering of the scattered light. Locking of a diode laser to the equatorial modes of a liquid droplet resonator is demonstrated using this scheme, and its performance is compared to the Pound-Drever-Hall technique. This new approach makes laser-frequency locking straightforward and shows a number of advantages, including robustness, low cost, and no need for sophisticated optical and electronic components.

Enhanced spectral response of π-phase shifted fiber Bragg gratings in closed-loop configuration

The transmission spectrum of a ring resonator enclosing a π-phase shifted fiber Bragg grating (π-FBG) shows a spectral feature at the Bragg wavelength that is much sharper than resonance of the π-FBG alone, and that can be detected with a simple integrated cavity output technique. Hence, the resolution of any sensor based on the fitting of the π-FBG spectral profile can be largely improved by the proposed configuration at no additional fabrication costs and without altering the sensor robustness. A theoretical model shows that the resolution enhancement attainable in the proposed closed-loop geometry depends on the quality factor of the ring resonator. With a commercial grating in a medium-finesse ring, a spectral feature 12 times sharper than the π-FBG resonance is experimentally demonstrated. A larger enhancement is expected in a low-loss, polarization maintaining setup.

Split-mode fiber Bragg grating sensor for high-resolution static strain measurements

We demonstrate a strain sensor with very high sensitivity in the static and low frequency regime based on a fiber ring cavity that includes a π phase-shifted fiber Bragg grating. The grating acts as a partial reflector that couples the two counter-propagating cavity modes, generating a splitting of the resonant frequencies. The presence of a sharp transition within the π phase-shifted fiber Bragg grating's spectral transmittance makes this frequency splitting extremely sensitive to length, temperature, and the refractive index of the fiber in the region where the grating is written. The splitting variations caused by small mechanical deformations of the grating are tracked in real time by interrogating a cavity resonance with a locked-carrier scanning-sideband technique. The measurable strain range and bandwidth are characterized, and a resolution of 320  pϵ/Hz(1/2) at 0 Hz is experimentally demonstrated, the highest achieved to date with a fiber Bragg grating sensor.

High-sensitivity ring-down evanescent-wave sensing in fiber resonators

We report on optical-fiber cavity ring-down spectroscopy (CRDS) in the liquid phase using a laser emitting at telecommunication wavelengths. A fiber-ring cavity, comprising a short evanescent-wave coupler for radiation-matter interaction, is used as a sensor while its resonance modes are frequency locked to the laser. Exploiting the intrinsic sensitivity and noise immunity of the CRDS technique, we show that liquid absorption can be detected down to a level that is nearly a factor of 20 above the shot noise limit. We provide a thorough comparison between the experimental results and various noise contributions and address different expressions that can be used to calculate the shot noise equivalent absorbance. As a proof of principle, polyamine detection in aqueous solutions is carried out demonstrating a minimum detectable absorbance of 1.8×10(-7)  Hz(-1/2), which, to our knowledge, is the best sensitivity limit reported to date for evanescent-wave sensors.

Localized strain sensing with fiber Bragg-grating ring cavities

We report the theoretical description and the experimental demonstration of an optical resonator formed by inserting a Fiber Bragg Grating (FBG) in a closed fiber loop. The spectral characteristics of such a resonator strongly depend on the reflectivity of the FBG. In the wavelength region where the FBG reflectivity R is negligible, the system behaves like a conventional ring resonator. On the other hand, when R is not vanishing, a split-mode structure can be observed, associated to the degeneracy removal of two counterpropagating resonant modes. The magnitude of the mode splitting can be used to sense small variations of the FBG physical parameters, such as length, temperature or group index. An example of strain sensing with this setup is reported, showing that the mode splitting is sensitive to a mechanical strain applied to the FBG, while it is almost insensitive to a strain applied to any other point of the resonator. This peculiar feature allows to perform cavity-enhanced, local strain measurements with a reduced sensitivity to environmental perturbations, which represents an important improvement in the framework of the fiber-optic sensors.

Two-tone frequency-modulation spectroscopy in off-axis cavity

As opposed to a conventional optical resonator, an off-axis-aligned cavity is able to transmit without distortion radiation modulated at a frequency even far above the cavity bandpass. This allows us to implement a simple spectroscopic technique that combines the cavity path-length enhancement of integrated cavity output spectroscopy (ICOS) and the noise reduction associated with radio-frequency modulation (FM). An FM-ICOS spectrometer is demonstrated for the first time using a two-tone modulation technique. The performance is compared to the traditional ICOS by examining the acetylene absorption at 1543.77 nm. A signal-to-noise ratio improvement by a factor 3.5 is found with our proof-of-concept setup. Larger improvements are expected in a more optimized setup.

Surface plasmon resonance optical cavity enhanced refractive index sensing

We report on a method for surface plasmon resonance (SPR) refractive index sensing based on direct time-domain measurements. An optical resonator is built around an SPR sensor, and its photon lifetime is measured as a function of loss induced by refractive index variations. The method does not rely on any spectroscopic analysis or direct intensity measurement. Time-domain measurements are practically immune to light intensity fluctuations and thus lead to high resolution. A proof of concept experiment is carried out in which a sensor response to liquid samples of different refractive indices is measured. A refractive index resolution of the current system, extrapolated from the reproducibility of cavity-decay time determinations over 133 s, is found to be about 10(-5) RIU. The possibility of long-term averaging suggests that measurements with a resolution better than 10(-7) RIU/√Hz are within reach.

Absolute frequency measurement of molecular transitions by a direct link to a comb generated around 3-microm

A 3-microm continuous-wave difference-frequency source is directly referenced to a mid-infrared optical frequency comb synthesizer by measuring their beat-note signal by a fast HgCdTe detector. Absolute frequency metrology of molecular vibration spectra is demonstrated by locking the 3-microm coherent radiation to the nearest comb tooth and tuning the comb mode spacing across the Doppler-broadened absorption profile of a CH(4) ro-vibrational transition.

Non-collinear quasi phase matching and annular profiles in difference frequency generation with focused Gaussian beams

We present and experimentally test a simple model for difference frequency generation (DFG) in periodically-poled crystals with gaussian pumping beams. Focusing of input beams originates several non-collinear quasi-phase-matching configurations of the interacting wavevectors, which contribute to the idler output field. In this picture, we accurately describe a number of effects, such as the occurrence of annular idler intensity profiles and the asymmetric trend of DFG power vs temperature. Finally, we quantitatively test the model by means of an indirect measurement of the crystal poling period.

Combining a difference-frequency source with an off-axis high-finesse cavity for trace-gas monitoring around 3 microm

High-sensitivity spectroscopy of methane around 3 microm was carried out by means of a 5.5-mW cw difference-frequency generator in conjunction with a high finesse cavity in off-axis alignment. By cavity-output integration a minimum detectable absorption coefficient of 5.7*10-9 cm-1Hz-1/2 was achieved, which compares well with results already reported in the literature. Detection of methane in natural abundance was also performed in ambient air, for different values of total pressure, allowing direct concentration measurements via evaluation of the integrated absorbance of the spectra. In particular, at atmospheric pressure, a minimum detectable concentration of 850 parts per trillion by volume (pptv)*Hz-1/2 was demonstrated.

Dynamics of changes in vascular endothelial growth factor (VEGF) expression and angiogenesis in stress-induced gastric ulceration in rats

Angiogenesis and VEGF play a major role in many repair processes such as healing of gastric ulceration. The present study was undertaken to assess the dynamics of changes in VEGF expression and angiogenesis in stress-induced gastric ulcers in rats. Acute gastric ulceration was induced using a water-immersion and restraint stress method. The VEGF expression, angiogenesis, size of area and depth of ulcers in gastric specimens were evaluated. The study shows that as early as one day after the development of ulcers there is a significant increase in both the expression of the VEGF protein and the number of newly formed microvessels, while an abrupt decrease in VEGF expression, observed on the fifth day, results in a decreased intensity of angiogenesis. Moreover, it has been demonstrated that the increase in VEGF expression and angiogenesis is accompanied by a reduction in the size of area and depth of stress-induced ulcers in rats. Six days after ulcer development both VEGF expression and angiogenesis return to normal levels.