Association between Anterior Cervical Osteophytes and Parasympathetic Dysfunction in Tinnitus Patients

Context: Pathological changes secondary to degeneration of the cervical intervertebral disc may cause irritation of sympathetic nerve fibers, leading to sympathetic symptoms and tinnitus. Objectives: The aim of this study was to relate the effect of percutaneous radiofrequency treatment of superior cervical sympathetic ganglion in patients with tinnitus to cervical pathology. Method: A retrospective study of 74 consecutive patients who underwent treatment of the superior cervical sympathetic ganglion for tinnitus that persisted for 1 month or longer from October 2016 to January 2018. The work-up of a patient with tinnitus consisted of a standardized clinical history, a bilateral audiogram and a cervical spine radiograph. Results: All patients had a test blockade of superior cervical sympathetic ganglion first, and 54% of these patients (n=40) responded with a reduction of their tinnitus. These patients underwent a radiofrequency lesion and 53% (n=21) responded with a reduction of their tinnitus at 7 weeks following treatment. The size of anterior osteophyte at the fifth cervical vertebrae was related to a positive response at 7 weeks following this treatment. Patients with tinnitus and an anterior osteophyte at vertebrae C5 more than 17% of the width of those vertebrae had a success rate of 52% following treatment of the superior cervical sympathetic ganglion, compared to 13%, when the anterior osteophyte at C5 was 17% or less. Conclusions: The size of anterior cervical osteophytes is associated with a higher success rate of radiofrequency lesions of the superior sympathetic ganglion for tinnitus. The current results imply a role for cervical sympathetic nervous system irritation in the development of tinnitus in a subgroup of patients.

ObjectivesTo objectively assess pupillary involvement according to various etiologies of acquired isolated third nerve palsy using automated pupillometry, and evaluate the efficacy of digital pupillometry in discriminating compressive lesions from microvascular ischemic third nerve palsy.DesignRetrospective, observational case seriesMethodsA total of 171 subjects were included in this study, consisting of 60 subjects with presumed microvascular ischemic third nerve palsy, 51 with non-ischemic third nerve palsy, and 60 controls whose pupillary light responses were measured using a dynamic automated pupillometer. Subjects with non-ischemic third nerve palsy were divided into subgroups according to their etiology; inflammatory and compressive groups including tumor and aneurysm. Pupillometry parameters including minimum and maximum pupil diameters, constriction latency and ratio, maximum and average constriction velocities and dilation velocity were noted. The diagnostic ability of pupillometry parameters for discriminating compressive vs microvascular ischemic third nerve palsy was evaluated. The inter-eye difference of the involved eye and the uninvolved fellow eye was calculated to adjust for individual variability.ResultsAmong all parameters, reduced pupillary constriction ratio was the most specific parameter for detecting non-ischemic third nerve palsy, as a large inter-eye difference beyond the normative range of controls was found in 0% of ischemic, 20% of inflammatory and 60% of compressive third nerve palsy. With the diagnostic criteria using inter-eye differences of 1) minimum pupil diameter > 0.45 mm, or 2) pupillary constriction ratio < -7.5% compared to the fellow eye, the sensitivity and specificity for diagnosing compressive third nerve palsy were 95% and 88%, respectively. In the compressive group, positive correlations were found between the degree of external ophthalmoplegia and constriction ratio (r = 0.615, p<0.001), average constriction velocity (r = 0.591, p = 0.001) and maximum constriction velocity (r = 0.582, p = 0.001).ConclusionsAbnormal pupillary constriction ratio was highly specific for detecting compressive third nerve palsy, although the sensitivity was not high. Digital pupillometry demonstrated relatively good performance for discriminating compressive lesions from microvascular ischemic third nerve palsy.

BackgroundHere we report the first autopsied case involving pathological examination after two resections of symptomatic ossification of the anterior longitudinal ligament with anterior osteophytes and etidronate treatment with more than 8 years of follow-up.Case presentationA 51-year-old Japanese man complained of severe dysphagia due to esophageal compression by ossification of his anterior longitudinal ligament with anterior cervical osteophytes. Although surgical removal of the anterior cervical osteophytes was performed following etidronate treatment (800 mg/day for 6 months), dysphagia occurred secondary to recurrent ossification of his anterior longitudinal ligament with anterior osteophytes 7 years after the initial resection. A second resection of the anterior cervical osteophytes was performed, and cyclic administration of etidronate disodium (1000 mg/day, 3-month administration and 3-month cessation) did not result in re-outgrowth of ossification of his anterior longitudinal ligament with anterior osteophytes. At 1 year and 6 months after the second surgery, he suddenly died. The pathological findings associated with the ossification of his anterior longitudinal ligament during etidronate therapy showed no recurrence of ossification of the anterior longitudinal ligament with anterior osteophytes.ConclusionA recurrence of ossification of the anterior longitudinal ligament with anterior osteophytes formation, which caused dysphagia, was not observed with the cyclic administration of etidronate disodium at a dose of 1000 mg/day every 3 months for a period of 1 year and 5 months in the present case.

Anterior cervical osteophytes are common and usually asymptomatic in elderly people. Due to mechanical compressions, inflammations, and tissues swelling of osteophytes, patients may be presented with multiple complications, such as dysphagia, dysphonia, dyspnea, and pulmonary aspiration. Paradoxical vocal cord motion is an uncommon disease characterized by vocal cord adductions during inspiration and/or expiration. This condition can create shortness of breath, wheezing, respiratory stridor or breathy dysphonia. We report a rare case demonstrating combined symptoms of dyspnea, dysphonia as well as dysphagia at the same time in a patient with asymptomatic anterior cervical osteophytes. Moreover, this is the first report demonstrating that anterior osteophytes can be a possible etiological factor for paradoxical vocal cord motion that induces serious respiratory symptoms.

Background: Visual deficits and autonomic dysfunction have been well recognized following pediatric concussion. Testing of the pupillary light reflex (PLR) is a simple, non-invasive, and objective approach to examine the autonomic nervous system by accessing the brain pathways. The aim of this study was to objectively evaluate adolescent pupillary responses to a light stimulus after a physician-diagnosed concussion and compare them to baseline responses. Methods: In this prospective cohort study, PLR was assessed in 135 adolescent athletes (ages 14-18) during their sport pre-season. All of the athletes were not recovering from a concussion at the time of their baseline assessment. Within this cohort, seven athletes (ages 14-17) sustained a concussion during their sport season and had longitudinal post-injury assessments of PLR through their recovery. The PLR was obtained in response to a brief step-input (0.8 seconds) white light stimulus using a hand-held pupillometer (stimulus recording duration= 5 seconds, light intensity= 150 lux). Pre-set and automated device-generated parameters used for analysis include the minimum and maximum pupil diameter, response amplitude and latency, mean constriction and dilation velocities and the maximum constriction velocity of the eye in response to a light stimulus. During each assessment, three monocular trials were performed in each eye alternatively, and the responses for each eye were subsequently averaged. Results: Six out of the seven concussed adolescents showed response enhancement of about 20% (IQR 11-33%). Enhancement was noted in the steady state diameter with a mean of 24% (median 18%), minimum pupil diameter mean of 17% (median 11%) and maximum constriction velocity mean of 28% (median 33%) following concussion, which decreased during the recovery process (days to weeks post-injury) to pre-injury or below initial pre-injury baseline measurements. Pupillary responsivity was found to be significantly enhanced after concussion compared to baseline measurements, waning over time. Maximum constriction velocity better highlighted the enhancement compared to the baseline pupil diameter. Conclusions/Significance: Pupil responsivity was found to be significantly enhanced after concussion compared to baseline measurements which waned over time during recovery. Assessment of dynamic PLR responses has potential utility as an objective biomarker to aid in concussion diagnosis on the sidelines or in the office, allowing physicians to quantify function (and dysfunction) of the autonomic nervous system under parasympathetic and sympathetic control after concussion.

ContextAlthough the pupil light reflex has been widely used as a clinical diagnostic tool for autonomic nervous system dysfunction, there is no systematic review available to summarize the evidence that the pupil light reflex is a sensitive method to detect parasympathetic dysfunction. Meanwhile, the relationship between parasympathetic functioning and hearing impairment is relatively unknown.ObjectivesTo 1) review the evidence for the pupil light reflex being a sensitive method to evaluate parasympathetic dysfunction, 2) review the evidence relating hearing impairment and parasympathetic activity and 3) seek evidence of possible connections between hearing impairment and the pupil light reflex.MethodsLiterature searches were performed in five electronic databases. All selected articles were categorized into three sections: pupil light reflex and parasympathetic dysfunction, hearing impairment and parasympathetic activity, pupil light reflex and hearing impairment.ResultsThirty-eight articles were included in this review. Among them, 36 articles addressed the pupil light reflex and parasympathetic dysfunction. We summarized the information in these data according to different types of parasympathetic-related diseases. Most of the studies showed a difference on at least one pupil light reflex parameter between patients and healthy controls. Two articles discussed the relationship between hearing impairment and parasympathetic activity. Both studies reported a reduced parasympathetic activity in the hearing impaired groups. The searches identified no results for pupil light reflex and hearing impairment.Discussion and ConclusionsAs the first systematic review of the evidence, our findings suggest that the pupil light reflex is a sensitive tool to assess the presence of parasympathetic dysfunction. Maximum constriction velocity and relative constriction amplitude appear to be the most sensitive parameters. There are only two studies investigating the relationship between parasympathetic activity and hearing impairment, hence further research is needed. The pupil light reflex could be a candidate measurement tool to achieve this goal.

Pupillary light reflex (PLR), i.e. pupil constriction in response to light stimulus, offers a sensitive index of parasympathetic nervous regulation. Yet, the studies on PLR in acute mental stress are rare. We aimed to study potential changes of PLR to acute mental stress in healthy young people with respect to sex. Thirty-eight participants (24 women, age: 22.95+/-0.19 yrs) were examined in a cross-sectional study under standard conditions. PLR parameters were measured separately for both eyes using PLR-2000 (NeurOptics, USA) before arithmetic test (baseline), immediately after arithmetic test, and after recovery period. Evaluated PLR parasympathetically-mediated parameters: pupil diameter (mm) before (initial value, INIT) and after illumination (peak of constriction, END), maximum constriction velocity (MCV), relative constriction amplitude (RCA). INIT and END diameters were significantly reduced immediately after mental stress and after recovery compared to baseline (left eye: INIT: p=0.044, p=0.035, respectively; END: p=0.004, p<0.001, respectively; right eye: INIT: p<0.001, p=0.002, respectively; END: p<0.001 for both comparisons). No significant differences were found in MCV and RCA. Moreover, the study established no significant changes in the assessed PLR parameters between sex throughout the stress protocol. Our study revealed that acute mental stress is associated with greater PLR-parasympathetic response resulting in prolonged pupil constriction. This finding could represent the first step for understanding the effect of cognitive processing on PLR under physiological conditions, before its clinical application. Key words Pupillary light reflex " Acute mental stress " Cognitive processing " Parasympathetic nervous system " Psychophysiology.

Cervical osteophytosis, a common manifestation of degenerative spondylosis, can rarely exert mass effect to compromise adjacent airway structures. Acquired tracheomalacia secondary to anterior cervical osteophytes is exceptionally uncommon and results from dynamic airway collapse due to weakened tracheal cartilaginous support. Tracheomalacia may present with nonspecific respiratory symptoms such as dyspnea, cough, and orthopnea, and diagnosis is best established with direct visualization on bronchoscopy. We report a rare case of localized upper tracheal tracheomalacia caused by cervical diffuse idiopathic skeletal hyperostosis (DISH) with severe anterior osteophyte formation, resulting in clinically significant airway obstruction. A 74-year-old male with a history of coal worker's pneumoconiosis, osteoarthritis, DISH, and prior lumbar spine surgery presented with a six-year history of progressive dyspnea, recently complicated by audible resting stridor. He denied dysphagia or orthopnea. Bronchoscopy demonstrated dynamic upper tracheal collapse consistent with localized tracheomalacia. MRI and X-ray imaging revealed extensive anterior cervical osteophytes from C5-C7 producing marked posterior compression of the trachea and esophagus, accompanied by cervical spinal stenosis extending from C1-C6. Given progressive airway compromise, the patient underwent anterior cervical microsurgical osteophyte excision with posterior decompressive laminectomy and foraminotomies. Resection was confirmed intraoperatively with microscopy and fluoroscopy. Postoperatively, the patient exhibited resolution of stridor, improved respiratory function, and no new neurological deficits, and he remained symptom-free at follow-up. This case highlights a rare but clinically significant cause of acquired tracheomalacia due to compressive cervical osteophytosis associated with DISH. Progressive dyspnea and stridor in patients with extensive anterior cervical osteophytes should prompt thorough airway evaluation, including bronchoscopy and cross-sectional imaging. Surgical decompression can provide durable symptomatic relief and restoration of airway patency in appropriately selected patients.

Background: Dysphagia due to diffuse idiopathic skeletal hyperostosis (DISH)-related anterior cervical osteophytes is not uncommon. However, this rarely leads to dysphonia and/or dysphagia along with life- threatening airway obstruction requiring emergency tracheotomy.Case Description: A 56-year-old male presented with progressive dysphagia and dysphonia secondary to DISH-related anterior osteophytes at the C3–C4 and C4–C5 levels. The barium swallow, X-ray, magnetic resonance imaging, and computed tomography scans confirmed the presence of DISH. Utilizing an anterior cervical approach, a large beak-like osteophyte was successfully removed, while preserving the anterior annulus. After clinic-radiological improvement, the patient was discharged with a soft cervical collar and nonsteroidal anti-inflammatory drug (NSAID).Conclusion: Large anterior osteophytes in Forestier disease/DISH may cause dysphagia and dysphonia. Direct anterior resection of these lesions yields excellent results as long as other etiologies for such symptoms have been ruled out.

The prevalence of anterior cervical osteophyte among elderly patients is high due to many causes such as trauma, degenerative changes, and diffuse idiopathic skeletal hyperostosis. Severe dysphagia is one of the main presenting symptoms for anterior cervical osteophytes. We describe a case of a patient with anterior cervical osteophyte with severe dysphagia and quadriparesis. The 83-year-old man presented to the emergency department following the incident of falling on his face. CT and X-ray were done in the emergency department, which showed huge anterior osteophytes at the level of C3-4 compressing the esophagus. The patient's consent was taken and shifted to the operation room and surgery was done. Anterior cervical osteophyte was removed, a discectomy was performed, and a peek cage and screws were inserted for fusion. In many cases of anterior cervical osteophyte, surgery is considered the ultimate treatment for patients to relieve symptoms, improve quality of life, and decrease mortality.

This study aims to investigate whether pupillary light reflex (PLR) parameters in dynamic pupillometry can effectively predict postoperative nausea and vomiting (PONV). In this prospective observational study, patients scheduled to undergo elective lobectomy under general anesthesia were enrolled from 1 August 2023 to 7 October 2023 at Yantai Yuhuangding Hospital, a large regional tertiary hospital in Yantai City, Shandong Province, China. Preoperative pupillary parameters were measured using a portable infrared pupillometer, and the patients were followed up within 24 hours postoperatively to assess postoperative nausea and vomiting (PONV) and recovery quality. Logistic regression analysis and receiver operating characteristics (ROC) curves were used to evaluate the predictive efficacy of pupillary parameters, and mediation analysis was conducted to explore the mediating role of PONV between pupillary parameters and recovery quality. Forty-six patients (29.9%) who experienced PONV had smaller maximum pupil diameter, average constriction velocity (ACV), maximum constriction velocity (MCV), and percentage pupil change. MCV was identified as an independent predictor of PONV, with each 1-unit increase in MCV reducing the risk of PONV by 87%. Gender was a protective factor, with males having a 65% lower risk of PONV compared to females. The ROC analysis showed that the area under the curve (AUC) value of MCV was 0.831 (95% confidence interval (CI): 0.760-0.902), indicating that the model has strong classification ability when using MCV as a predictor. Thus, PONV plays a full mediating role in the relationship between MCV and postoperative recovery quality. MCV is a reliable predictor of PONV, which plays a full mediating role in the relationship between MCV and postoperative recovery quality. Thus, with a capability in predicting PONV occurrence, preoperative MCV measurement can be employed for the purpose of improving patient recovery outcomes. Chinese Clinical Trial Registry (ChiCTR2300073869).

Effects of stimulus size, eccentricity, luminance, and attention on pupillary light response examined by concentric stimulus

The reliability of dynamic pupillometry parameters varies from one pupillometer to another, making it difficult to standardize the values for any particular device. Hence, further studies are required to evaluate the agreement of various pupillometer devices and explore their utility in routine clinical settings. This study sought to evaluate the agreement between smartphone and commercial pupillometer measurements in routine clinical settings. The study included pupillary measurements obtained by a single investigator from 100 healthy participants (200 eyes) with each pupillometer. Pupillary measurements taken by a smartphone pupillometry application (reflex pupillary light reflex analyzer by Brightlamp [Indianapolis, IN, USA]) were compared with a commercial pupillometer (neurological pupil index-200, NeurOptics Inc., Irvine, USA). The comparison of descriptive statistics revealed a statistically significant difference between the smartphone and commercial pupillometers for various parameters, including maximum diameter, minimum diameter, constriction velocity (CV), maximum CV, and dilatation velocity (P < 0.05), except for latency (P = 0.36). The intraclass correlation coefficient revealed poor agreement between the two devices (<0.50). The measurements by smartphone pupillometry application were found to be unreliable, indicating that they may not be an ideal substitute for commercial pupillometers in their present form in the Indian population. Further studies with larger sample size as well as improvements in the processing and interpretation of the measurements by the software, are needed to determine its utility in routine clinical settings.

To assess the light reflex of the pupil after Implantable Collamer Lens (ICL) (KS-aquaPORT; STAAR Surgical, Nidau, Switzerland) implantation to determine whether the ICL implantation might affect the pupil dynamics. This study examined 28 eyes of 28 consecutive patients who underwent implantation of the posterior phakic ICL for the correction of myopia and astigmatism. Patient age at the time of surgery was 31.1 ± 6.8 years (range: 25 to 42 years). Preoperative refraction was -7.38 ± 2.26 diopters (D) (range: -3.25 to -11.80 D). Light reflex was evaluated using the infrared pupillometer Iriscorder C7364 (Hamamatsu Photonics, Hamamatsu, Japan). Measured parameters included pupil diameter (D1), constriction ratio, maximum constriction velocity, maximum dilation velocity, and the time required to recover 63% of the pupil diameter (T5). At 6 months postoperatively, the authors also investigated the relationship with the amount of vault using the Pentacam (Oculus Optikgeräte, Wetzlar, Germany). Evaluations with the instrument were performed before and at 1, 3, and 6 months after surgery. There was no significant association found between any of the parameters (analysis of variance, D1: P = .99, constriction ratio: P = .59, maximum constriction velocity: P = .87, maximum dilation velocity: P = .13, T5: P =.57). The vault of the ICL at 6 months postoperatively was 382.1 ± 176.5 μm. There were no significant associations between the maximum constriction velocity, maximum dilation velocity, and amount of vaulting (Spearman correlation coefficient maximum constriction velocity: r = 0.07, P = .71, maximum dilation velocity: r = 0.26, P = .28). The light reflex of the pupillary dynamics continued to be maintained at 6 months after ICL implantation. Current findings also verified that ICL implantation had little influence on the postoperative function of the iris. [J Refract Surg. 2017;33(10):704-707.].

Cholinergic deficiency in Alzheimer's and Parkinson's disease: Evaluation with pupillometry