BACKGROUND:  As indications for surgical Eustachian tube (ET) procedures have been expanded, it is essential to understand the anatomy of ET surroundings for safe ET interventions.
METHODS:  We evaluated the peritubal region using oblique planes of temporal computed tomography (CT) with the Valsalva maneuver and classified the peritubal region between the osseous ET and the internal carotid artery (ICA) into 5 types: 1. bony prominence; 2. air cell; 3. absence of peritubal structures (3a. thick canal [>0.5 mm], 3b. thin canal [<0.5 mm], 3c. dehiscence).
RESULTS:  Bony prominence and air cell types were observed in 41.0% (50/122 ears) and 13.1% (16/122 ears), respectively. The ICA was located directly medial to the osseous ET in 39.4% (48/114 ears), of which thick and thin canal types were found in 23.8% and 15.6%, respectively. Internal carotid artery canal wall dehiscence was observed in 8 ears (6.6%). The shortest perpendicular distance between the osseous ET and ICA was 1.6 (range: 0.4-4.9) mm and 2.7 (range: 1.3-5.8) mm in the bony prominence and air cell types, respectively. Osseous ET-ICA distances were 1.2 (range: 0.6-3.6) mm and 0.4 (range: 0.1-0.5) mm in thick and thin canal types, respectively.
CONCLUSIONS:  Distinct peritubal structure types were observed on oblique CT planes with Vasalva maneuver. Bony prominence and air cell types provide a protective layer between the osseous ET and ICA. Imaging information on peritubal structures may help to better understand the anatomy of the ET pathway, leading to safe and accurate surgical approaches to the osseous ET.

OBJECTIVE: This study aims to evaluate the application value of contrast-enhanced transthoracic echocardiography (cTEE) in the diagnosis of patent foramen ovale (PFO) under different states of stimulation, with the goal of enhancing the accuracy and efficiency of PFO diagnosis.
METHODS: This research consecutively enrolled patients suspected of having PFO from October 2022 to February 2024, presenting primary clinical symptoms such as unexplained syncope, headache, dizziness, and stroke. Patients underwent standard transthoracic echocardiography (TTE) and cTEE under three different states of stimulation (resting state, coughing, and Valsalva maneuver). Based on the presence of microbubbles in the left heart and their initial appearance time, patients were classified into PFO and control groups, with further diagnostic confirmation via transesophageal echocardiography (TEE) or foramen ovale closure procedures.
RESULTS: The study results revealed significant differences between the PFO and control groups regarding age (p = 0.034) and headache symptoms (p = 0.001). In the PFO group, TTE showed a higher positivity rate both at rest and during coughing, highlighting the association between PFO and specific clinical symptoms. The number of microbubbles observed during TTE increased significantly under various stimulation states, particularly during the Valsalva maneuver (p < 0.05). This increase became more pronounced as the duration of the maneuver was extended, underscoring the differential response of PFO patients under varied physiological testing conditions, especially during prolonged Valsalva maneuvers.
CONCLUSIONS: The study confirms the significant value of cTEE in diagnosing PFO under different stimulation states, particularly emphasizing the application of the Valsalva maneuver to significantly improve the sensitivity and specificity of PFO detection. Thus, incorporating cTEE examinations under various stimulation states holds significant clinical importance for enhancing the accuracy and efficiency of PFO diagnosis.

This review explores standardized clinical assessments for evaluating autonomic nervous system function. Here, we emphasize components of the autonomic medical history as the first pivotal test of the autonomic assessment. We further focus on standard noninvasive cardiovascular autonomic tests including heart rate responses to deep breathing, Valsalva maneuvers, and orthostatic challenges, along with insights from neurochemical tests and quantitative sudomotor axon reflex testing. The article also covers practical aspects of cardiovascular autonomic monitoring, including patient set-up using beat-to-beat blood pressure and ECG, specific assessment protocols, and their respective clinical interpretations that provide insight into adrenergic, cardiovagal, and sudomotor function.

UNASSIGNED: To use the three-dimensional (3D) ultrasound for assessment of pelvic floor muscle function in non-diabetic females with insulin resistance (IR), and to evaluate its functional relationship with insulin levels.
UNASSIGNED: From October 2022 to November 2023, 216 non-diabetic females with insulin-resistant (IR group) and 118 normal females (control group) were sequentially recruited from our hospital for our study. The 3D ultrasound was used to assess the levator hiatus in resting state for all females regarding diameter lines, perimeters and areas; as well as the Valsalva manoeuvre (VM). The t-test and linear regression model were used to analyse the collected data.
UNASSIGNED: The analysis indicates that there were significant differences in the resting state of the levator hiatus between the IR and the control groups (14.8 ± 5.8 cm2 and 11.6 ± 2.7 cm2, p < 0.05); and in the VM (18.2 ± 6.3 cm2 and 13.4 ± 3. 4 cm2, p < 0.05). In addition, the anterior-posterior (AP) diameters of the hiatus on VM were significantly increased in the IR group (40.0 ± 4.7 mm and 33.0 ± 4.4 mm, p < 0.05). With insulin levels as the dependent variable, multivariate regression analysis shows that insulin levels were significantly correlated with the levator hiatus area on VM (p < 0.05) and waist circumference (p < 0.05). The pelvic organ descent on VM in the IR group was significant (p < 0.05).
UNASSIGNED: The areas of resting state levator hiatus and on VM were significantly larger in the IR than that in the control groups. In addition, the position of the pelvic organ on VM in the IR group was significantly descended. The insulin levels were correlated with the pelvic floor muscle function.
With regard to insulin resistance and pelvic floor function, previous studies focused on the role of polycystic ovaries, metabolic syndrome, and pelvic prolapse. The use of ultrasound can improve understanding of the static, dynamic and organ prolapse conditions. This study aimed to assess pelvic floor muscle function in non-diabetic women with insulin resistance, a condition where the body uses insulin less effectively. A total of 216 women with insulin resistance and 118 without it were examined using 3D ultrasound during rest and while performing the Valsalva manoeuvre. Our results show that the pelvic floor muscles had extra space between them and moved differently in women with insulin resistance than in those without the condition. This suggests that insulin resistance may affect function of pelvic floor muscles to cause adverse consequences.

暂无摘要。

OBJECTIVE: This study aimed to assess the efficacy and safety of ballon dilation of the eustachian tube (BDET) in adult population suffering from Eustachian tube dysfunction (ETD).
METHODS: Following PRISMA criteria, a systematic review was conducted by searching PubMed, Cochrane, and Embase databases from January 2015 to March 2024. The primary outcomes included Eustachian Tube Score (ETS), tympanometry, and Valsalva maneuver. The quality of studies was assessed using the Quality in Prognostic Studies (QUIPS) instrument.
RESULTS: Overall, 11 studies were incorporated into the systematic review: two RCTs, three prospective investigations, and six retrospective studies. The balloon dilation in all investigations was performed using either Spiggle & Theis or Acclarent catheters for balloon dilation. There was heterogeneity across studies examining the effect of BDET on persistent ETD in terms of patient selection, period of follow-up, administration of conservative or surgical therapies, and use of assessment methods. Overall, the treatment yielded alleviation of symptoms, which either exhibited stability over time or demonstrated further improvement after an average duration of follow-up. Moreover, the incidence of complications was categorized as low and resolving spontaneously. The majority of the studies exhibited a high risk of bias related to confounding variables, and consequently, the overall risk of bias across most studies was considered high.
CONCLUSIONS: The findings suggest BDET holds promise for ETD treatment, reducing symptom severity with minimal complications. Nonetheless, there is a need for improved studies that adhere to established indications, methodologies, and outcomes to establish a more robust body of evidence.

Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous autonomic disorder. All patients have exaggerated tachycardia upon standing, but the pathophysiology may be diverse. We present a young adult Thai male with a chief complaint of palpitations while in an upright posture since childhood. The patient underwent a modified Ewing test battery which included standing test, deep breathing, and Valsalva maneuver. His heart rate increased more than 30 beats per minute (bpm) during repeated active stand tests (65 to 110 bpm and 77 to 108 bpm), while upright diastolic blood pressure increased more than 10 mmHg. Normal Valsalva ratio (2.01 and 1.86) and baseline heart rate variability (HFRRI = 4030.24 ms2 and 643.92 ms2) indicated intact vagal function. High low-frequency systolic blood pressure variability (LFSBP = 20.93 mmHg2), increased systolic blood pressure overshoot in phase IV of Valsalva (42 mmHg), and increased upright diastolic blood pressure indicated a hyperadrenergic state. In conclusion, the overall autonomic profile was compatible with hyperadrenergic POTS. Thus, we confirmed the first male POTS case reported in Thailand. We demonstrated the importance of autonomic function testing with continuous measurements to confirm POTS. There is a need for further research in POTS in Thailand.

OBJECTIVE: This work\'s purpose was to quantify rapid sympathetic activation in individuals with spinal cord injury (SCI), and to identify associated correlations with symptoms of orthostatic hypotension and common autonomically mediated secondary medical complications.
METHODS: This work was a cross-sectional study of individuals with SCI and uninjured individuals. Symptoms of orthostatic hypotension were recorded using the Composite Autonomic Symptom Score (COMPASS)-31 and Autonomic Dysfunction following SCI (ADFSCI) survey. Histories of secondary complications of SCI were gathered. Rapid sympathetic activation was assessed using pressure recovery time of Valsalva maneuver. Stepwise multiple linear regression models identified contributions to secondary medical complication burden.
RESULTS: In total, 48 individuals (24 with SCI, 24 uninjured) underwent testing, with symptoms of orthostatic hypotension higher in those with SCI (COMPASS-31, 3.3 versus 0.6, p < 0.01; ADFSCI, 21.2 versus. 3.2, p < 0.01). Pressure recovery time was prolonged after SCI (7.0 s versus. 1.7 s, p < 0.01), though poorly correlated with orthostatic symptom severity. Neurological level of injury after SCI influenced pressure recovery time, with higher injury levels associated with more prolonged time. Stepwise multiple linear regression models identified pressure recovery time as the primary explanation for variance in number of urinary tract infections (34%), histories of hospitalizations (12%), and cumulative secondary medical complication burden (24%). In all conditions except time for bowel program, pressure recovery time outperformed current clinical tools for assessing such risk.
CONCLUSIONS: SCI is associated with impaired rapid sympathetic activation, demonstrated here by prolonged pressure recovery time. Prolonged pressure recovery time after SCI predicts higher risk for autonomically mediated secondary complications, serving as a viable index for more \"autonomically complete\" injury.

OBJECTIVE: To investigate the differences in the visibility and size of abdominal wall hernias in computed tomography (CT) with and without Valsalva maneuver.
METHODS: This single-center retrospective study included consecutive patients who underwent abdominal CTs with Valsalva maneuver between January 2018 and January 2022. Inclusion criteria was availability of an additional non-Valsalva CT within 6 months. A combined reference standard including clinical and surgical findings was used. Two independent, blinded radiologists measured the hernia sac size and rated hernia visibility on CTs with and without Valsalva. Differences were tested with a Wilcoxon signed rank test and McNemar\'s test.
RESULTS: The final population included 95 patients (16 women; mean age 46 ± 11.6 years) with 205 hernias. Median hernia sac size on Valsalva CT was 31 mm compared with 24 mm on non-Valsalva CT (p < 0.001). In 73 and 82% of cases, the hernias were better visible on CT with Valsalva as compared to that without. 14 and 17% of hernias were only visible on the Valsalva CT. Hernia visibility on non-Valsalva CT varied according to subtype, with only 0 and 3% of umbilical hernias not being visible compared with 43% of femoral hernias.
CONCLUSIONS: Abdominal wall hernias are larger and better visible on Valsalva CT compared with non-Valsalva CT in a significant proportion of patients and some hernias are only visible on the Valsalva CT. Therefore, this method should be preferred for the evaluation of abdominal wall hernias.

We report a compressed air worker who had diffuse cutaneous decompression sickness with pain in his left shoulder and visual disturbance characteristic of migraine aura after only his third hyperbaric exposure. The maximum pressure was 253 kPa gauge with oxygen decompression using the Swanscombe Oxygen Decompression Table. He was found to have a very large right-to-left shunt across a 9 mm atrial septal defect. He had transcatheter closure of the defect but had some residual shunting with release of a Valsalva manoeuvre. Thirty-two other tunnel workers undertook the same pressure profile and activities in the same working conditions during the maintenance of a tunnel boring machine for a total of 233 similar exposures and were unaffected. As far as we are aware this is the first report of shunt-mediated decompression sickness in a hyperbaric tunnel worker in the United Kingdom and the second case reported worldwide. These cases suggest that shunt-mediated decompression sickness should be considered to be an occupational risk in modern compressed air working. A right-to-left shunt in a compressed air worker should be managed in accordance with established clinical guidance for divers.