Acute vertigo following cervical manipulation

OBJECTIVE/HYPOTHESIS

Either licensed American chiropractors or traditional Chinese herbalists may produce vertiginous attack in a patient after cervical manipulation. The purpose of the study was to present our experience in treating these patients to determine the risk of this procedure.

STUDY DESIGN

A retrospective study from May 1999 to April 2002.

METHODS

Nine patients (one man and eight women) with acute vertigo after cervical manipulation were admitted and underwent a battery of audiometric and vestibular tests, accompanied by magnetic resonance imaging and magnetic resonance angiography examination.

RESULTS

The mean interval for the onset of acute vertigo after cervical manipulation was within 1 day (17 h). Electronystagmography revealed multiple central signs. Magnetic resonance angiography scan also disclosed abnormality in the vertebral artery such as occlusion, stenosis, or slow blood flow in three patients. After treatment with dextran, relief of vertigo without neurological deficits was experienced in all nine patients.

CONCLUSIONS

When there are multiple central signs in electronystagmography results or slow blood flow of the vertebral artery is displayed in neck on Doppler sonography or magnetic resonance angiography scan, the therapeutic benefits of cervical manipulation cannot be expected to outweigh its potential risk for the morbidity of cervical vessels.

Benign positional paroxysmal vertigo: videonystagmographic study using rotatory test

Benign Peripheral Paroxysmal Vertigo is a disease of the posterior labyrinth caused by endolymphatic debris, provoking vertigo with some movements of the head. Diagnosis is usually made by finding the positional nystagmus with appropriate manoeuvres. Spontaneous resolution is frequent and in these cases diagnosis is only probable and suspected from anamnesis. Aim of the present investigation was to establish more evaluation parameters in the study of Benign Peripheral Paroxysmal Vertigo. A series of 97 selected patients presenting Benign Peripheral Paroxysmal Vertigo, have been submitted to sinusoidal kinetic test. Patients have been studied during the acute phase of the condition and after recovery. Vestibulo-oculomotor reflex has been sought by stimulating the horizontal and vertical canals. Kinetic stimulus consisted in sinusoidal rotation at 0.12 Hz and 0.05 Hz. Evaluation parameters comprised preponderance, gain and phase of provoked nystagmus, recorded by means of an Ulmer videonystagmograph. Using this same technique of stimulation, 20 normal volunteers were studied in order to establish normal values for reference. Values obtained in the patient population of patients have been compared, by Student t test, with values obtained in the same cured patients and with those in normal subjects. In the patients with Benign Peripheral Paroxysmal Vertigo of the lateral canal a nystagmus preponderance toward the healthy side was observed, as well as an increase in the phase lead, also in the canals not affected by the condition. In cured patients, disappearance of the preponderance and persistence of the phase abnormalities are observed. These results suggest a multicanal pathogenesis of Benign Peripheral Paroxysmal Vertigo.

[A statistical analysis of 1300 patients with dizziness-vertigo. Its most frequent causes]

PATIENTS AND METHODS

We analysed the records of the individuals who were attended because of dizziness or vertigo in the vestibular sector, with the aim of describing the epidemiological clinical profile of a group of patients with such symptoms. 1300 patients were systematically evaluated according to our neuro otological examination protocol. Diagnoses were ordered, according to the international classification reported by Drachman and later modified by Bahlo, in four categories: 1. Vertigo, 2. Instability, 3. Pre syncope and 4. Miscellaneous. Each of these classes was organised according to the topography of the lesion and these were in turn grouped by aetiologies (viral, vascular, tumoural, demyelinating, post traumatic, idiopathic, autoimmune, etc.). The data were stored and analysed in a computer database, Epi info 6.02 (OMS 1994), which was especially adapted by the researchers for the purpose.

RESULTS

63.1% were women. The average age was 55.5 years old (SD: 17.5, interval: 4 93). Vertigo was diagnosed in 68.9%, instability was found in 12.4%, 1.8% presented syncope and miscellaneous disorders occurred in 16.9% (of these, 64.1% had disorders of the central integrator and 16.4% were of a psychogenic origin). Of the 1300 patients, 896 presented vertigo; the positional type was seen in 54%, sustained in 6.5%, recurrent in 27.7% and 11.8% were found to have the otolithic type.

CONCLUSIONS

The relevance of the epidemiological work based on clinical evaluation and the thorough neuro otological examination in our medium must be highlighted. These findings were similar to those reported in the international literature in more delimited series.

Vestibular reflexes and positional manoeuvres

Dizziness and vertigo are some of the more frequently encountered symptoms in neurology clinics. In turn, one of the most common causes of vertigo is benign paroxysmal positional vertigo (BPPV), accounting for a quarter of all patients with dizziness and vertigo. Reviewing the value of the positional manoeuvres available is relevant, particularly in the light of the efficient treatments available for BPPV. In this article I will deal with positional manoeuvres first, and then with how vestibulo-ocular reflexes (VOR) can be tested in the clinic. I will not discuss VOR suppression assessment.

Vestibular dysfunction after cochlear implantation

OBJECTIVE

To determine the prevalence, symptom characteristics, and potential risk factors for vestibular symptoms after cochlear implantation.

STUDY DESIGN

Case-control study design embedded within an ongoing cohort of patients undergoing implantation.

SETTING

Academic medical center cochlear implant research program funded by the National Institutes of Health.

PATIENTS

Seventy five eligible consecutive patients undergoing cochlear implantation.

INTERVENTION

Medical record review.

MAIN OUTCOME MEASURE

Recorded symptoms of vestibular symptoms after cochlear implantation. Subjects with vestibular symptoms were considered case subjects; those without vestibular symptoms were considered control subjects.

RESULTS

Twenty-nine of 75 (39%) patients experienced dizziness postoperatively. Four patients experienced a single, transient acute vertigo attack occurring less than 24 hours after surgery. The majority, 25 patients, experienced delayed, episodic onset of vertigo. The median (interquartile range) time of delayed onset was 74 (26-377) days after implantation. Delayed dizziness manifested as spontaneous episodic or positional vertigo. Preoperative dizziness, age at implantation, and age at onset of hearing loss were significantly greater in the dizzy group. Preoperative electronystagmography did not differentiate between groups.

CONCLUSIONS

Thirty-nine percent (29/75) of subjects with implants were dizzy after implantation. The majority of subjects experienced dizziness in a delayed episodic fashion. Dizziness was not related to implant activation. It seemed that delayed dizziness was not related to immediate surgical intervention but could result from chronic changes occurring in the inner ear; there was some suggestion this could take the form of endolymphatic hydrops.

[Summary of the Dutch College of General Practitioners' practice guideline 'Dizziness']

In the Dutch College of General Practitioners' practice guideline entitled 'Dizziness', a distinction is made between two types of dizziness. The first is vertigo which is characterised by a sense of spinning or movement and which is caused by problems with the vestibular organ. The second is lightheadedness or the feeling that one is going to faint; the cause of this problem is found outside the vestibular organ. In making the diagnosis, history-taking and a limited physical examination is usually sufficient. Providing the patient with information plays an important role in the treatment. Medication for dizziness is not advised. In case of nausea and vomiting, specific medication can be prescribed to treat these symptoms. Referral to secondary care is indicated if there are signs of a serious condition or if additional investigations are required.

[The Dutch College of General Practitioners' practice guideline "Dizziness"; reaction from a neurologic perspective]

When a patient complains of dizziness, the term may cover several types of sensations. When the physician carefully takes the history, he or she will most often be able to differentiate between vertigo and other types of dizziness, including a feeling of lightness or fainting. Based on this differentiation, the Dutch College of General Practitioners (NHG) designed a practice guideline for its members. The most important causes of vertigo are paroxysmal benign positional vertigo, vestibular neuritis, Ménière's disease and TIA or stroke in the vertebrobasilar system. Differentiation between vestibular neuritis and stroke may be difficult, in particular at the onset of the complaints and therefore consultation of a neurologist will often be necessary. Fortunately, special drugs for dizziness are not recommended, as their effectiveness has not been proven. Among the causes of non-vertigo dizziness complaints, hyperventilation, often in the context of anxiety disorder, is a major cause. In general, the NHG succeeded in compiling a practical guideline.

Betahistine dihydrochloride in the treatment of peripheral vestibular vertigo

The present study compares the efficacy and safety of betahistine dihydrochloride to that of a placebo in recurrent vertigo resulting from Meniere's disease (MD) or in paroxysmal positional vertigo (PPV) of probable vascular origin. The design was double-blind, multicentre and parallel-group randomised. Eleven Italian centres enrolled 144 patients: 75 of the patients were treated with betahistine (41 MD/34 PPV) and 69 with placebos (40 MD/29 PPV). The betahistine dosage was 16 mg twice per day for 3 months. Compared to the placebo, betahistine had a significant effect on the frequency, intensity and duration of vertigo attacks. Associated symptoms and the quality of life also were significantly improved by betahistine. Both the physician's judgement and the patient's opinion on the efficacy and acceptability of the treatment were in agreement as to the superiority of betahistine. The effective and safe profile of betahistine in the treatment of vertigo due to peripheral vestibular disorders was confirmed.

[A study of factors influencing intensity and annoyance in vertigo or dizziness]

For 74 men and 123 women averaging 52.5 years of age with vertigo and dizziness, we recorded the age, gender, vertigo type, duration of illness, concomitant symptoms, and vestibular and psychological test results and used a 100 mm horizontal visual analog scale (VAS) to quantitatively assess sensation intensity and annoyance in vertigo or dizziness. Factors influencing these 2 quantitative assessment parameters were analyzed by stepwise multiple regression analysis. Factors influencing sensation intensity were nausea or vomiting as a concomitant symptom, duration of vertigo or dizziness (within a day), and first episode onset. Intensity of sensation to vertigo or dizziness, self-rating depression score (SDS), and gender (female) were selected as significantly influencing annoyance. These results suggest that rational care of significant factors that involve the intensity and annoyance in vertigo is essential to treating patients with vertigo or dizziness.

[Audimont--a scientific research expedition to Mount Cho Oyu in the Himalayas]

Even though hearing and vestibular disorders at high altitude have been reported since 1938, their reasons are still unknown. During the Audimont Research Expedition the risk for cochlear and vestibular sensory cells has been quantified by otoacoustic emissions and videonystagmography. Vestibular disorders could not be observed up to 7050 meters. However, the outer hair cells in the inner ear showed a reduction of emissions at increasing height. The pattern of the inner ear reply, depending on the altitude, complies with an increase of the perilymphatic pressure. As the perilymphatic space corresponds directly to the subarachnoid space, the limitation of hearing thus appears to be a direct consequence of raised intracranial pressure.

Psychological manifestations of vertigo: a pilot prospective observational study in a Portuguese population

We sought to ascertain the importance of psychological manifestations of vertigo and psychogenic vertigo among a Portuguese population. Sixty patients complaining of vertigo and imbalance were studied over a 2-year period. At each assessment, the patients underwent a general examination, a neurootological evaluation, psychiatric interviews, and psychopathological assessments conducted by a multidisciplinary team. Overall, 38 patients (63.4%) were given diagnoses of some form of psychopathological complaint. A more detailed analysis revealed panic disorder in 9, moderate depressive episode in 42, and mixed anxiety and depressive disorder in 7, whereas the remaining patients (2) suffered from subclinical symptoms of anxiety or depression. Patients with vertigo demonstrate a high incidence of psychopathological complaints, the most common being anxiety disorders. Somatization, obsessive-compulsive behaviors, and depression tend to lessen over time, whereas few changes are seen in anxiety.

Benign paroxysmal positional vertigo: a comparative prospective study on the efficacy of Semont's maneuver and no treatment strategy

PURPOSE

The present study investigates the efficacy of Semont's repositioning liberatory maneuver by comparing it with no-treatment in a population of patients with benign paroxysmal positional vertigo (BPPV).

MATERIALS AND METHODS

In this randomised, controlled, 6-month efficacy trial, 40 patients affected by BPPV were treated with Semont's maneuver. Outcomes were measured subjectively by patients about their Activities of Daily Living (ADL) and quality of life, based on the "Vestibular Disorders Activities of Daily Living Scale". Results were compared to those obtained in 40 non-treated BPPV patients.

RESULTS

During the first month of the study, 92.5% of patients of Semont's group resolved their symptoms. Cure rates with Semont's maneuver were significantly higher than those obtained with no-therapy (92.5% versus 37.5%). Within a six month follow-up, relapse rates were lower among patients treated with Semont's maneuver than among the no-treated ones (5% versus 60%). All patients with a resolution of symptoms and a negative Dix-Hallpike's test presented a great improvement in daily activities and quality of life.

CONCLUSIONS

BPPV is easy to solve with a successful repositioning maneuver. Since BPPV is a very common cause of vertigo and can represent a medical emergency, we believe that it is of interest for every general practitioner to be able to promptly recognize this frequent balance disorder and to be able to treat a patient affected by BPPV with a safe repositioning maneuver.

Vértigo posicional paroxístico no benigno

Positional vertigo is a frequent clinical manifestation of vertigo of very different etiologies, being the benign paroxystic positional vertigo (BPPV) the most frequent one of them, representing in some series even the most found etiology of peripheral vertigo. Usually of severe entities, positional vertigo may appear in the context of severe entities and of difficult diagnosis. In these cases, the bearing of the symptoms in spite of the repositioning manoeuvers, the association with otological or neurological symptoms, and the atypical nystagmus evoked by Dix-Hallpike manoeuver, must take the otolaryngologist to suspect of a feasible non benign pathology. We report a case of positional paroxysmal vertigo caused by an intracranial tumour and we review the clinical signs that shoved help us to suspect of non benign pathologies that can mimic a positional vertigo.

Increased independence and decreased vertigo after vestibular rehabilitation

OBJECTIVE

We sought to determine the effectiveness in decreasing some symptoms, such as vertigo, and increasing performance of daily life skills after vestibular rehabilitation.

STUDY DESIGN AND SETTING

Patients who had chronic vertigo due to peripheral vestibular impairments were seen at a tertiary care center. They were referred for vestibular rehabilitation and were assessed on vertigo intensity and frequency with the use of the Vertigo Symptom Scale, the Vertigo Handicap Questionnaire, the Vestibular Disorders Activities of Daily Living Scale, and the Dizziness Handicap Inventory. They were then randomly assigned to 1 of 3 home program treatment groups.

RESULTS

Vertigo decreased and independence in activities of daily living improved significantly. Improvement was not affected by age, gender, or history of vertigo.

CONCLUSION

For many patients a simple home program of vestibular habituation head movement exercises is related to reduction in symptoms and increasing independence in activities of daily living.

Electronystagmographic and caloric investigation data about vascular-vestibular dysfunction among patients with vertebrobasilar insufficiency

Audiovestibular symptoms are the first and often the only clinical signs of vertebrobasilar insufficiency. The aim of our investigation was to analyze the results of caloric and electronystagmographic investigation of vascular-vestibular disorders among patients with vertebrobasilar insufficiency. We examined a total of 55 men (mean age, 51.8 +/- 8.2 years)--a primary group of 35 men with proven vascular-vestibular dysfunction and vertebrobasilar insufficiency and a control group of 20 clinically healthy men. Standard and electronystagmographic ("Tönnies" type) caloric tests were used to evaluate the human vestibular analyzer. Our data from this investigation show that in both rotatory and caloric tests, the slow-phase speed is the most important index about function of the vestibular analyzer.

Audiological evaluation of twenty patients receiving pentoxifylline and prednisone after sudden deafness: prospective study

Idiopathic sudden deafness is defined as sudden sensorineural hearing loss of undetermined etiology. As a consequence, various treatments have been developed for this disorder. Our study evaluated the effectiveness of pentoxifylline and prednisone in such treatment. We analyzed this treatment's results in our patients through conventional audiograms, and speech audiometry was performed in the acute stage and during the treatment. We diagnosed idiopathic sudden hearing loss in 20 patients (8 female and 12 male). The left ear was involved in 9 patients and the right in 11. All patients had been examined by us within 15 days from the onset of hearing loss. We compared the hearing threshold results in the different periods in this prospective study.

Electro-otolithography: new insight into benign paroxysmal positioning vertigo

Early vestibular evoked potentials were recorded with an extratympanic electrode. The recording principle was adding responses that were phase-locked to a recording frequency. The recording frequency was empirically determined to match harmonically an individual response frequency, thus allowing averaging. This new technique was evaluated in benign paroxysmal positioning vertigo. Normal data were obtained from 12 patients without vestibulocochlear symptoms and were compared with data from 18 symptomatic patients with diagnoses of benign paroxysmal positioning vertigo. All symptomatic patients were treated with a canalith repositioning maneuver, and all responded, in that they no longer had attacks of vertigo. Of the five patients who could be reassessed, all five no longer had attacks of vertigo, but three complained of persisting postural imbalance. Repeat electro-otolithography results continued to be abnormal in these patients, whereas in the remaining two patients responses were normal, consistent with the treatment outcome. The results suggest that electro-otolithography is a valuable addition to the otoneurological test battery. Successful canalith repositioning can abolish attacks of vertigo, although not necessarily a persisting imbalance, which patients frequently describe as a temporary and momentary instability. This is most likely related to a remaining otolithic deficit.

[Multifactorial dizziness]

We report about a patient with recurrent dizziness, looked upon for about 8 years as Menière's disease.He suffered from benign positional vertigo, which led to an additional psychogenic dizziness, connected to early live events. The different parts of complex dizziness, diagnosis and treatment will be described.

Diagnóstico y tratamiento de un caso de vértigo posicional paroxístico benigno del canal horizontal

Ahorizontal canal positional vertigo with apogeotropic and persistent directional changing nystagmus is reported. A new procedure consisting in cervical hiperflexion was used to determine the affected side in order to perform a particle repositioning manoeuvre.

[Simultaneous posterior and horizontal canal benign paroxysmal positional vertigo]

OBJECTIVE

To explore effective methods for the diagnosis and treatment of simultaneous posterior and horizontal canal benign paroxysmal positional vertigo (combined BPPV, C-BPPV).

METHOD

Epley's maneuver and Barbecue rotation were applied to four cases of C-BPPV separately with an interval of one day.

RESULTS

Positional vertigo in all subjects disappeared completely after treatment and yielded excellent resolution of symptoms during period of follow-up.

CONCLUSION

Clinical features in C-BPPV are combinations of both posterior and horizontal canal BPPV. Combined particle repositioning procedures of Epley's maneuver and Barbecue rotation is a successful method for treating the disorder.

A practical assessment algorithm for diagnosis of dizziness

OBJECTIVE

We sought to test a 3-parameter model for diagnosis of dizziness based on the type and temporal characteristics of the dizziness and on hearing status.

STUDY DESIGN AND SETTING

We conducted a prospective blinded study at a tertiary referral neurotology practice. Before examination, patients completed a questionnaire reporting type and timing of dizziness symptoms and hearing status. Clinical diagnoses were compared with questionnaire results.

RESULTS

Fifty-seven patients completed the questionnaire. We were able to correctly classify 21 (60%) of the 35 subjects who had a common otogenic cause of vertigo by the diagnostic algorithm.

CONCLUSION

A simple classification of dizziness by type, timing, and hearing status can be self-reported by patients using a brief questionnaire. This classification scheme is as good as others of much greater complexity.

SIGNIFICANCE

The simple classification scheme reported here is based on history alone and facilitates triage of dizzy patients into diagnostic groups for work-up and management.

[Diagnostic evaluation of "acute" vertigo]

Numerous studies of outpatients have been effected with the object of evaluating the role of the different causes of vertigo, and these have clearly evidenced the importance of the individual disciplinary sectors and, consequently, of the clinicoinstrumental exams necessary in order to reach the correct etiopathogenetic interpretation of the dizzy syndrome. We report the experience of a retrospective study carried out in 310 patients suffering from dizziness who were sent to us from the Emergency Room with a generic diagnosis of "acute vertigo". A detailed medical history was taken in every case, after which the patients underwent a series of otoneurological examinations which enabled us to situate each in the ambit of a vestibular pathology (central and/or peripheral) or to schedule him for a series of specialized exams, the indication of which was drawn directly from the characteristics of the clinical examination and medical history associated with the vertigo symptomatology. Of the 157 cases (50.6%) with otoneurological signs compatible with a vestibular involvement, 77 presented positional paroxysmal vertigo, 34 had an acute peripheral vestibulopathy, and 32 manifested sufferance of the central vestibular structures. In 137 patients, the otoneurological exam was negative and further investigations led to the identification of a psychogenic form in 54 cases, a cardiovascular disease in 31 cases, and a neurological disorder in 24 cases. Our data highlights the fundamental role of the anamnestic approach and the objective examination with particular reference to the search for nystagmic evidence that enabled us to make a definitive diagnosis in an elevated number of cases. In the remainder, we proceeded to perform various instrumental examinations, at times upon the request of the other specialists involved in the management of the vertigo patient. By means of a structured and detailed medical interview, it was possible to obtain useful information that directed our investigation towards a clear distinction between extravestibular and vestibular forms. In this way, furthermore, the same information was able to supply a whole series of clinical indicators of fundamental importance in identifying the most suitable specialist for the clinical picture under examination. A detailed knowledge of the different pathologies (vestibular and extravestibular) capable of causing acute vertigo appears to us to be of fundamental importance if the patients sent from the Emergency Room is to be properly evaluated. From the above, one may see how fundamental a multidisciplinary approach is in appraising the vertigo patients, enabling the correct diagnosis to be reached rapidly and economically, as demonstrated by the results obtained by our group, in which we failed to reach a precise diagnostic conclusion in only 5% of the cases.