International consensus (ICON) on assessment of oropharyngeal dysphagia

OBJECTIVE

To present international recommendations regarding the proper evaluation of oropharyngeal dysphagia (OD), both objectively and subjectively (self-evaluation).

METHODS

Following a thorough review of the literature, 5 experts in the field from 4 different continents answered separately a questionnaire regarding the work-up of OD. Individual answers were presented and discussed during the world ENT conference that was held in Paris in June 2017. This article will present the recommendations issued from that meeting.

RESULTS

For the initial objective assessment of OD, it is recommended to perform either a functional endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallowing study (VFSS). FEES is the more popular investigation given its increased ease of use and accessibility. When evaluating for the presence of aspiration during the objective evaluation of OD, it is recommended to perform either a FEES or a VFSS. In this case, FEES is the favored investigation given its likely increased sensitivity. In order to highlight the presence of oropharyngeal food residue following the deglutition process, it is recommended to perform either a FEES or a VFSS; FEES likely being the more sensitive investigation while VFSS allows a better quantification of the amount of pharyngeal residue. Is it also recommended to objectify the quality of the deglutition process by means of a score during the objective evaluation of OD. Finally, it is recommended to utilize a self-evaluation questionnaire during research studies exploring the deglutition process.

Plasma biomarker discovery for early chronic kidney disease diagnosis based on chemometric approaches using LC-QTOF targeted metabolomics data

Chronic kidney disease (CKD) is a progressive pathological condition in which renal function deteriorates in time. The first diagnosis of CKD is often carried out in general care attention by general practitioners by means of serum creatinine (CNN) levels. However, it lacks sensitivity and thus, there is a need for new robust biomarkers to allow the detection of kidney damage particularly in early stages. Multivariate data analysis of plasma concentrations obtained from LC-QTOF targeted metabolomics method may reveal metabolites suspicious of being either up-regulated or down-regulated from urea cycle, arginine methylation and arginine-creatine metabolic pathways in CKD pediatrics and controls. The results show that citrulline (CIT), symmetric dimethylarginine (SDMA) and S-adenosylmethionine (SAM) are interesting biomarkers to support diagnosis by CNN: early CKD samples and controls were classified with an increase in classification accuracy of 18% when using these 4 metabolites compared to CNN alone. These metabolites together allow classification of the samples into a definite stage of the disease with an accuracy of 74%, being the 90% of the misclassifications one level above or below the CKD stage set by the nephrologists. Finally, sex-related, age-related and treatment-related effects were studied, to evaluate whether changes in metabolite concentration could be attributable to these factors, and to correct them in case a new equation is developed with these potential biomarkers for the diagnosis and monitoring of pediatric CKD.

The value of electrophysiology results in patients with epilepsy and vigabatrin associated visual field loss

PURPOSE

To determine the value of electrophysiological findings in patients with temporal lobe epilepsy and to relate these findings to the amount of concentric contraction of the visual field and the use of vigabatrin.

METHODS

Electro-retinograms and electro-oculograms were done on 30 patients, operated for temporal lobe epilepsy. The patients were divided into three groups: (A) concentric contraction of the visual field associated with a history of vigabatrin medication (15 patients), (B) normal visual field with vigabatrin use (11 patients) and (C) normal visual field without vigabatrin medication (4 patients).

RESULTS

Electrophysiological abnormalities were found in 50% of the patients in group A. The Arden ratio of the EOG was lowered in 57%. Abnormalities in the ERG were found: b-wave implicit time photopic F was prolonged (50%), b-wave amplitudes scotopic B (53%), C (73%) and G (50%) and photopic H (50%) were diminished. The amount of visual field loss and the total dose of vigabatrin used, showed only slight correlation with the ERG and EOG. The use of vigabatrin during the ERG and EOG recording in group A, gave a higher b-wave amplitude scotopic G in 64% of cases. The a-wave implicit times scotopic G (73%) and photopic G (59%) and H (73%) were shortened in group B.

CONCLUSION

EOG was abnormal in 57% in group A. ERG abnormalities could only be found in 50% of group A, mainly in the inner retina. Since also the total dose of vigabatrin and the amount of visual field loss did not really show a correlation with the electrophysiological findings and results of literature are not unanimous, electrophysiology does not appear at present to be a good method to detect patients with, or at risk of, vigabatrin associated visual field loss. Regularly performed visual field examination remains the cornerstone in screening.

Long term changes in the visual fields of patients with temporal lobe epilepsy using vigabatrin

AIM

To study the long term changes in the concentric contraction of the visual field in patients with temporal lobe epilepsy on vigabatrin medication.

METHODS

Repeated Goldmann visual field examinations were compared in 27 patients with drug resistant temporal lobe epilepsy and concentric contraction of the visual field. Two groups were studied: 16 patients who had already stopped vigabatrin medication before surgery and 11 patients who continued vigabatrin medication.

RESULTS

Concentric contraction of the visual field did not change in 16 patients who stopped vigabatrin before the first examination; there was slight but significant progress in visual field loss in 11 patients who continued the use of vigabatrin.

CONCLUSION

Long term follow up of concentric contraction in this selected group of patients indicates that vigabatrin associated visual field loss is not reversible and that progression is possible when vigabatrin is continued.

Concentric contraction of the visual field in patients with temporal lobe epilepsy and its association with the use of vigabatrin medication

PURPOSE

To describe concentric visual field loss found in the presurgical evaluation of patients with drug-resistant temporal lobe epilepsy and relate the findings to potential causative factors.

METHODS

A series of 157 consecutive patients with drug-resistant temporal lobe epilepsy, who had been selected for neurosurgical treatment, was examined in a study set up as a prospective investigation of their visual fields, to document the loss of visual field resulting from surgery. Pre-as well as postoperative visual field examinations were performed following a standard protocol using static and kinetic perimetry. As a number of patients appeared to have an unexplained concentric visual field contraction in the presurgical examination, a relation with potentially causative factors was analyzed in a cross-sectional study of all these patients. Correlations were sought with duration and severity of the seizure disorder, underlying pathology as indicated by magnetic resonance imaging (MRI) and demonstrated by pathology, any type of antiepileptic drug (AED) ever prescribed, and gender.

RESULTS

In this cross-sectional analysis of 157 consecutive patients who were candidates for surgery for temporal lobe epilepsy, absolute concentric contraction of the visual field of 10 to 30 degrees was found in the presurgical examination in 20 (17%) of 118 patients who had ever used vigabatrin (VGB) and in none of 39 who had not had this medication. This difference was significant (p = 0.004). In addition, men [15 (21%) of 72] were significantly more often affected (p = 0.007) than women [five (6%) of 85]. The degree of visual field loss, as indicated by the Esterman grid, showed a positive correlation with the duration of VGB medication. There was no correlation of visual field contraction with a history of meningitis as potential cause of the epilepsy, duration of the epilepsy, status epilepticus in the medical history, or histologic abnormality of the brain tissue removed. Ophthalmologic examination of the patients with concentric contraction revealed no abnormalities. None of the patients with concentric contraction complained spontaneously of their visual field loss.

CONCLUSIONS

VGB medication is a causative factor in concentric visual field loss. Visual field examination of patients using VGB should be seriously considered.

Evaluation of airway obstruction using virtual endoscopy

OBJECTIVES

This study examines the use of virtual endoscopy (VE) in the evaluation of patients with upper airway obstruction. The utility of VE compared with actual endoscopy was investigated with respect to accuracy of diagnosis and reproduction of endoscopic images.

STUDY DESIGN

A random cohort of 30 patients with various causes of airway obstruction was examined.

METHODS

The computed tomography (CT) data were reconstructed using a proprietary VE software program, FreeFlight, blind to the actual endoscopic findings. The cause of obstruction was identified and compared with actual endoscopic findings. This included 21 patients with airway stenoses, 8 patients with laryngotracheomalacia, 3 tracheal tumors, 2 glottic webs, 5 patients with innominate artery compression, 2 tracheal granulomas, and 7 patients with impaired true vocal cord mobility.

RESULTS

Virtual endoscopic evaluation was accurate in assessing stenosis width and length of fixed airway lesions. Correlation of stenosis shape and contour between actual endoscopy and VE was excellent. The stenosis-to-lumen ratios were compared between VE and actual endoscopy and were found to be within 10% (SD = 8). However, virtual endoscopic evaluation could not illustrate one of the glottic webs, half of the cases of tracheomalacia, or any of the cases of impaired true vocal cord mobility.

CONCLUSIONS

Virtual endoscopy was not as sensitive as actual endoscopy in detecting the cause of airway obstruction that was based on dynamic movement. However, VE was excellent for the measurement and definition of fixed airway lesions.

MR features of pachymeningitis presenting with sixth-nerve palsy secondary to sphenoid sinusitis

Pachymeningitis manifested by localized enhancing dural thickening adjacent to the clivus on MR images of two patients with sphenoid sinusitis and sixth-nerve palsy is presented. This is an unusual complication of sphenoid sinusitis. Prompt diagnosis and therapy may avoid significant intracranial complications.