The direction of apparent movement during transient pressure vertigo

Pressure vertigo or alternobaric vertigo is the type of vertigo normally associated with relative overpressure in the middle ear. As with other types of vertigo, it should occur only if there is unequal stimulation of the left and right vestibular systems: there should be a lawful relation between the orientation of the head, the side of the overpressured ear, and the direction of apparent movement. Few published accounts give information on all these aspects. This paper reports some old and new cases which suggests that, when the head is upright during the ascent, overpressure in the right ear causes apparent bodily and visual movement to the right (clockwise), while overpressure in the left ear has the opposite effect. Horizontal orientation of the head probably reduces the vertigo. There are no detailed and unequivocal reports of pressure vertigo during descent, or with the head inverted. Some reports exist of tumbling sensations and of tilting of the visual scene, but the exact circumstances are unclear.

Acute flexion-extension injury of the neck. Electronystagmographic study of 309 patients

Three hundred and nine patients, whose chief complaint was dizziness following a flexion-extension type of acceleration neck injury, were examined in the Neurosensory Laboratory of Temple University Health Sciences Center between 1965 and 1972. Specific attention was devoted to vestibular tests, including a search for latent and positional nystagmus, bithermal calorics, and rotatory tests. All tests were performed with the aid of electronystagmography; latent nystagmus was present in 29 percent of the patients, caloric tests were abnormal in 57 percent, and rotatory tests were abnormal in 51 percent. These findings suggest that many of these patients have a verfiable objective vestibular disturbance as a cause of dizziness, even though the neurologic examination may be normal. Furthermore, in order to detect this objective vestibular dysfunction, the patient should be tested with aid of electronystagmography since nystagmus may be inhibited by visual fixation.

[Diabetes and diseases of the internal ear]

The authors present a series of 30 cases of vertigo where diabetes and hyperlipidemia were found. The literature on the subject is reviewed, and evidence points to a diabetic lesion of the inner ear. Our cases illustrate that lesion and its clinical presentation.

The problem of dizziness and syncope in old age: transient ischemic attacks versus hypersensitive carotid sinus reflex

In the elderly, a transient ischemic attack (TIA) and a hypersensitive carotid sinus reflex (HCSR) often co-exist and can pose a diagnostic challenge. Seven cases are presented. HCSR is a relative condition; besides increased irritability of the receptor or target organs, susceptibility of the nerve center to ischemia probably is induced by a slow heart rate or low blood pressure in any patient with pre-existing occlusive cerebrovascular disease. Dizziness and syncope of this type represent hemodynamic TIA in contrast to thromboembolic TIA. The carotid sinus massage test is recommended for differentiating the two types of TIA; the treatments differ. At present there is no uniform management that can be applied to either TIA or HCSR routinely. Therefore, treatment should be approached on an individual basis, keeping in mind the different pathophysiologic factors operating in the specific patient.

Vertigo and rocking sensation. A clinical analysis

A vertigo perceived as a spinning sensation outside the head indicates a somatic vestibular disturbance including a Ménièr's disease. A turning sensation inside the head indicates a functional or vascular disorder while a sensation of unsteadiness often as if being slowly rocked indicates a functional disorder.

The influence of atherosclerosis and ectasia on cerebral blood flow

Of 65 patients with neurological disorders examined with rapid serial angiography of the carotid artery, 24 had normal cerebral arteries, 17 atherosclerosis, 11 arterial ectasia and 13 both kinds of vascular changes. These patients were examined for hemispherical rCBF determination on the same occasion, using the 133Xenon clearance method. Primarily, the patients were examined without general anaesthesia, and they did not have acute illness, trauma, or angiographic evidence of a focal intracranial lesion. In addition, other parameters such as arterial size, ventricular size, cerebral circulation time, age, and sex were determined. All these data were studied statistically in a series of multiple regression analyses with a computer. No significant differences in rCBF could be found between cases with ectasia, atherosclerosis and without any kind of vascular changes. However, the mean value of rCBF in patients with atherosclerosis and in patients with intracranial ectasia was below the normal mean value, although it did not differ significantly from this value. Nor was any influence on the rCBF found in patients with marked stenosis of the internal carotid artery and those with slight stenosis.

Symposium. ENT for nonspecialists. The dizzy patient

Dizziness or vertigo may be a perplexing situation to both the patient and the physician, The most important diagnostic factor is a careful history; a dizziness questionaire may be helpful. An otorhinolaryngologic and neurologic evaluation is necessary, and additional consultations may be in order, including vestibular testing and other laboratory studies, The etiology still may not be apparent, and the patient may need to be treated symptomatically and reevaluated periodically.

Neurotological studies on the role of the sympathetic nervous system in the formation of traumatic vertigo of cervical origin

To test the validity of the hypothesis that irritation of the cervical sympathetic nerves is a cause of hypertonicity of the cervical soft supporting tissues, especially the deep nuchal muscles, and that this hypertonicity is a cause of traumatic vertigo of cervical origin, we examined 44 vertigo cases with whiplash injury by testing equilibrium function and EMG discharges from the neck before and after administration of drugs affecting the sympathetic receptors. The results obtained were as follows: 1. Administration of iso-proterenol (beta-receptor stimulant) caused a significant increase in the EMG's from the injured neck muscles, in parallel with increased impairment of the righting reflex. The blindfolded vertical writing test showed the appearance or intensification of ataxia or deviation in writing when this drug was given. In contrast, administration of propranolol (beta-receptor depressor) had the opposite effects on the EMG's, the righting reflex and blindfolded vertical writing. Furthermore, the resulting changes in the EMG's and equilibrium functions were parallel with alterations in subjects' complaints, i.e., increase or decrease in neck pain and vertigo. 2. Administration of drugs affecting the alpha receptors, such as noradrenaline (alpha-receptor stimulant) and phentolamine (alpha-receptor depressor) had no appreciable effect on the EMG's, equilibrium function or the subjects' complaints. These results show that in vertigo due to whiplash injury hypertonicity of the cervical erector muscles can be induced sympathetically, and that this hypertonicity is based on over-excitement of beta receptors in the injured neck muscles, which results in vertigo of cervical origin.

Lumbomuscular proprioceptive reflexes in body equilibrium

To evaluate the role of reflexes related to the lumbar proprioceptors in maintenance of body equilibrium, changes in equilibrium function of the eyes and body were observed after unilateral procainization of the lumbar erector muscles. Observations were made on normal subjects and vertigo cases with lumbar pain after whiplash injury using various equilibrium tests. The results obtained were as follows: (1) On unilateral procainization of the lumbar erector muscles of normal subjects, eye nystagmus and disturbances of the righting reflex developed. Simultaneously, changes in drift reactions of the lower limbs were detected by the stepping test. Namely, in many of the subjects examined the direction of stepping deviation became quite different from that before procainization, and stepping after procainization tended to show slight or moderate ataxic features, associated with a sensation of unsteadiness. (2) When procaine was injected unilaterally into tender spots in the lumbar erector muscles of traumatic vertigo cases, spontaneous eye nystagmus and disturbances of the righting reflex decreased. Simultaneously, significant changes in the drift reactions of the lower limbs were observed in many of the cases examined. Namely, the direction of deviation became the opposite of that before procainization and ataxia in walking almost disappeared with reduction in vertigo. The following conclusions were drawn from these findings: (1) The effects of procaine on equilibrium of normal subjects are in sharp contrast to its effects on equilibrium of traumatic vertigo cases. Findings in the former might be due to increased imbalance between the activities of the right and left lumbar proprioceptors, while those in the latter might be due to decreased imbalance between the two. (2) These findings support the view that from the standpoint of body equilibrium, there are two phases of the proprioceptive reflex, and that Fukuda's concept of "two phases of the labyrinthine reflex, i.e., a stage of disturbance and a stage of coordination", can be applied to interpretation of the proprioceptive reflex of lumbar origin.