Patterns of nystagmus conversion in sudden sensorineural hearing loss with vertigo

The patients with sudden sensorineural hearing loss (SSNHL) may complain of vertigo. Although there have been many reports on SSNHL with vertigo (SSNHL_V), changes in the pattern of nystagmus have not been studied as yet. This study is a retrospective study and aims to investigate the characteristic changes in type of nystagmus and clinical features in patients with SSNHL_V who experienced a change in their nystagmus pattern during follow-up. Among 50 patients with SSNHL_V between January 2012 and December 2015, we identified 15 patients with SSNHL_V whose pattern of nystagmus changed. Initial nystagmus was classified into 5 subgroups: paretic type, irritative type, persistent geotropic direction-changing positional nystagmus (PG-DCPN), persistent apogeotropic direction-changing positional nystagmus (PA-DCPN), and posterior semicircular canal benign paroxysmal positional vertigo. The most common pattern of initial nystagmus was PG-DCPN (n = 7). The change of initial nystagmus pattern occurred on day 2 to 75 from symptom onset, and 2 (of 15) patients showed further conversion. The most common pattern of final nystagmus was PA-DCPN (n = 9). Hearing improvement after treatment was not significantly different (P = .59) between SSNHL_V patients with nystagmus change (25 ± 17 dB, n = 15) and those without nystagmus change (28 ± 18 dB, n = 35). In conclusion, clinician's attention is required in evaluating the vertigo symptom in patients with SSNHL_V because the initial patterns of nystagmus can be converted to another type of nystagmus. The presence of nystagmus change during follow-up may not be a prognosticator for hearing recovery in patients with SSNHL_V.

Benign paroxysmal positional vertigo in patients after mild traumatic brain injury

BACKGROUND

Post-traumatic vertigo, dizziness and balance disorders following head trauma range from 15% to 78% in the general population. Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder in such patients.

OBJECTIVES

The aim of the study was to assess the occurrence of BPPV in patients with mild traumatic brain injury (MTBI) and determine the outcome of treatment.

MATERIAL AND METHODS

A group of 179 patients, with a mean age of 45.2 years, complaining of vertigo/ /dizziness and balance instability after MTBI, was enrolled into the study. All these patients were diagnosed and treated in the Department of Otolaryngology (Medical University of Lodz, Poland) between the years 2012 and 2014. Anamnesis and otoneurological examination were conducted in each patient. The diagnosis was based on the medical history, the Dix-Hallpike test or the rollover test. The treatment comprised the Epley, barbecue and particle repositioning (RM) maneuvers.

RESULTS

Nineteen patients (10.6%) complained about attacks of vertigo elicited by positional changes. The diagnosis of BPPV was confirmed in 9 (47.4%) patients: 8 cases with a positive Dix-Hallpike test and 1 with the roll test. In 10 cases, a high probability of BPPV was diagnosed based on the medical history. Eight patients were treated by a single Epley maneuver and 1 patient by the barbecue roll. In 4 (44.4%) patients, the maneuvers were repeated. On the follow-up examination, the patients were not found to have vertigo.

CONCLUSIONS

Benign paroxysmal positional vertigo should be diagnosed and treated successfully in patients after head trauma.

Pilot cluster randomized controlled trial of a complex intervention to improve management of vertigo in primary care (PRIMA-Vertigo): study protocol

OBJECTIVES

Vertigo and dizziness are highly prevalent symptoms in primary care, frequently misdiagnosed. Based on a thorough need assessment, INDICORE (INform, DIagnose, COmmunicate, REfer), an evidence-based complex intervention has been developed to transfer knowledge of specialized tertiary clinics to primary care providers (PCPs), improve the referral process and, ultimately, improve the functioning and quality of life of patients with vertigo/dizziness. The main objective of the PRIMA-Vertigo pilot study is to examine whether the INDICORE intervention is feasible and sufficiently promising to warrant a larger trial.

METHODS

We plan to perform a single-blind, pragmatic cluster-randomized controlled pilot study with an accompanying process evaluation. PCPs will be the cluster units of randomization. Patients who consult these PCPs because of vertigo/dizziness symptoms will be included consecutively and considered the units of analysis. The intervention will be multi-faceted training on diagnostics targeted at the PCPs, supported by patient education material and a newly developed tool to structure the referral process. To balance the influence of non-specific effects, all clusters will receive generic communication training.

EXPECTED RESULTS

The process evaluation aims to provide results on the acceptability and feasibility of the INDICORE intervention components to PCPs and patients. Additionally, this study will provide a first estimate of the likely effectiveness of the intervention on patients' quality of life, functioning and participation.

CONCLUSIONS

The PRIMA-Vertigo pilot study will allow further tailoring of the INDICORE intervention to stakeholder needs before its effectiveness is evaluated in a large-scale main study.

Update on Vertigo in Autoimmune Disorders, from Diagnosis to Treatment

The prevalence of autoimmune diseases has been increasing over the last 20 years. The clinical presentation of this large and heterogeneous group of disorders depends on whether the involvement is organ-specific or non-organ-specific. Dizziness, vertigo, and disequilibrium are common symptoms reported by patients with vestibulocochlear involvement. The association of vertigo and autoimmune diseases has been largely documented, suggesting that autoimmune disorders could be overrepresented in patients with vertigo in comparison to the general population. The aim of this review is to present the recent literature findings in the field of autoimmune-mediated diseases with cochleovestibular involvement, focusing on the clinical presentation, diagnosis, and treatment of immune-mediated inner ear diseases including autoimmune inner ear disease (AIED), Meniere's disease, and bilateral vestibulopathy, as well as of systemic autoimmune diseases with audiovestibular disorders, namely, Behçet's disease, Cogan's syndrome, sarcoidosis, autoimmune thyroid disease, Vogt-Koyanagi-Harada syndrome, relapsing polychondritis, systemic lupus erythematosus, antiphospholipid syndrome, IgG4-related disease, and ANCA-associated vasculitides.

Standardizing your approach to dizziness and vertigo

First, determine whether the sensation the patient is experiencing is dizziness or true vertigo. Then eliminate ominous causes from the array of benign ones.

Aviation Fuel Exposure Resulting in Otitis Externa with Vertigo

BACKGROUND

Otitis externa secondary to irritant or chemical exposure is well documented; however, specifically secondary to jet fuel exposure and its associated toxicology is not. Over 2 million military and civilian personnel per year are occupationally exposed to aviation fuels.

CASE REPORT

An aircraft maintainer presented with noninfectious acute otitis externa secondary to external ear canal exposure to JP-5 jet fuel. Proper exposure guidelines were followed, but it was not realized that the external ear canal was involved. The first symptoms to emerge were vertigo, dizziness, and disequilibrium; however, on physical exam it appeared that there was no middle ear involvement.

DISCUSSION

Otitis externa normally does not present with vestibular symptoms as the pathology affects the external ear canal dermal tissue. Upon review of JP-5's toxicology profile, dermal absorption is a route of entry and can cause general neurological symptoms, including loss of coordination. This case highlights potential deficiencies in the standardized safety data sheets that are used after exposure. Without mention of possible auricular exposure one may focus on the logical protection of the eyes, mouth, and visible skin. This is concerning due to potential delayed exposure symptoms, dermal absorption, high level of dermal destruction, and the close proximity to the sensory system. The goal of this case report is to improve the knowledge of providers caring for personnel who may be exposed and to suggest possible revisions to the Safety Data Sheets for jet fuel.Long RJ, Charles RA. Aviation fuel exposure resulting in otitis externa with vertigo. Aerosp Med Hum Perform. 2018; 89(7):661-663.

Successive occurrence of vertebrobasilar dolichectasia induced trigeminal neuralgia, vestibular paroxysmia and hemifacial spasm: A case report

RATIONALE

Study reported an extremely rare case of trigeminal neuralgia, vestibular paroxysmia, and hemifacial spasm successively occurring in a patient with vertebrobasilar dolichoectasia (VBD).

PATIENT CONCERNS

A 66-year-old female patient presented with episodic vertigo for 20 days before she was admitted to our hospital. Vertigo suddenly occurred when the patient rotated her head 20 days ago, the symptoms of vertigo were improved after continuous 1 to 3 seconds, and similar symptoms were repeated in sleep and rest, with a frequency of 30 to 40 times per day. The patient had a history of hypertension with poor blood pressure control for more than 20 years.

DIAGNOSES

The final diagnosis was vertebrobasilar dolichectasia, right trigeminal neuralgia, and vestibular paroxysmia.

INTERVENTIONS

Vitamin B1 (10 mg), methylcobalamin (0.5 mg), and carbamazepine (0.1 g) were given orally 3 times a day to relieve the symptoms.

OUTCOMES

On the seventh day of drug treatment, the symptoms of paroxysmal vertigo and trigeminal neuralgia were completely relieved, but occasional episodes occurred during the follow-up period. Five months after discharge, right hemifacial spasm appeared in the patient, which did not affect the quality of life of the patient, so the patient did not choose further treatment. Six months after discharge, the patient was lost to follow-up.

LESSONS

Comprehensive treatment to control VBD risk factors, delay the progression of VBD, and improve clinical symptoms may have a better effect on such patients. However, further research is needed.

Diagnosis of Vertigo and Dizziness Syndromes in a Neurological Outpatient Clinic

BACKGROUND

Dizziness and vertigo are frequent complaints of outpatients in the neurological department. Our objective was to explore the epidemiological category and clinical features of patients with dizziness or vertigo in the neurological outpatient department of a tertiary hospital.

METHODS

We consecutively recruited all patients with dizziness and/or vertigo visiting the neurological outpatient clinic of the First Affiliated Hospital of Chongqing Medical University from January 2016 to June 2017. All patients were interviewed by 4 neurologists and they completed self-administered questionnaires. General physical and standardized neuro-otology bedside examinations were performed in all participants. Instrumental examinations and other related examinations were prescribed as needed.

RESULTS

A total of 392 patients, 272 female and 120 male, were enrolled and the ratio of males to females was 1: 2.27. The mean age was 52.39 ± 13.87 years (range 11-90). Elderly patients (≥60 years) accounted for about one-third of the patients. Peripheral vestibular disorders accounted for 54.6% of patients, central vestibular disorders (including vestibular migraine [VM]) accounted for 22.4% of patients, psychogenic vertigo in 64 (16.3%), other reasons in 9 (2.3%) and unknown in 17 (4.3%). Benign paroxysmal positional vertigo (BPPV; 30.8%), psychiatric dizziness (20.5%), and VM (14.4%) were the 3 major vestibular diseases in patients under 60 years of age; however, BPPV (27.9%), central vertigo (21.7%), and Meniere's disease (11.7%) were more common in patients over 60 years of age.

CONCLUSIONS

This study provided a classification and clinical features of vestibular disorders in a neurological outpatient department of a tertiary hospital in China. The spectrum of vertigo or dizziness is different between different age groups and clinicians should pay attention to this difference in clinical reasoning.

Response to Cervical Medial Branch Blocks In Patients with Cervicogenic Vertigo

BACKGROUND

Among the various causes of vertigo, the so-called cervicogenic vertigo (CV) has been the most controversial. However, perturbations of proprioceptive signals and abnormal activity of the cervical afferents can induce vertigo. Medial branch blocks (MBBs) are a diagnostic tool designed to test whether a patient's neck pain is mediated by one or more of the medial branches of the dorsal rami of the spinal nerve. It is unknown whether MBBs are also suitable for testing symptoms other than pain.

OBJECTIVES

The purpose of this study was to test whether MBBs of the cervical spine can be used as a diagnostic tool to identify patients with CV.

STUDY DESIGN

A retrospective practice audit (clinical observation).

SETTING

An interventional pain management and spine practice.

METHODS

An electronic medical record system was used to identify patients in a single spine center. Included were consecutive patients with neck pain and vertigo, who had received cervical MBBs in a period from July 2001 to April 2016. The patients were tested with a MBB of about 1 mL of bupivacaine (0.25%) and 20 mg triamcinolone. Injections were performed with fluoroscopic visualization using established techniques in 2 or 3 levels on one or both sides. Vertigo was analyzed through the global clinical impression of the patient (i.e., "gone," "better," "the same," or "worse").

RESULTS

One-hundred seventy-eight patients met the inclusion criteria. One-hundred eleven patients (62.4%) experienced a significant improvement of the vertigo. In 47 patients (26.4%), no information about the vertigo was available at follow-up; these patients were assumed to have no improvement (worst-case scenario). Hence, altogether 67 patients (37.6%) had a negative result. The median relief of the vertigo was 2 months. Differences in age, gender, level of treatment, or pain duration between patients with relief of the vertigo and without relief were not found. Nine patients with a whiplash injury in their medical history were also tested. They experienced a lower success rate and had longer duration of pain before the treatment; however, these differences are not statistically significant.

LIMITATIONS

It was the primary intention to treat neck pain; the assessment of vertigo was an additional aim. Therefore, the history taken and the clinical examination were not targeted specifically to vertigo. A placebo effect cannot be excluded. Further studies with the primary focus on CV are necessary to prove the significance of MBBs.

CONCLUSIONS

This is the first study to demonstrate that MBBs of the cervical spine can be a useful tool for the diagnosis of CV, because they temporarily block cervical afferents. In 63.4% of patients with neck pain and suspected CV, the vertigo was significantly improved. Further placebo-controlled studies with the primary intention on CV are necessary to prove the significance of MBBs.

KEY WORDS

Cervicogenic vertigo, medial branch block, facet joint, zygapophysial joint, neck pain, differential diagnosis.

Multicenter data banking in management of dizzy patients: first results from the DizzyNet registry project

PURPOSE

Comprehensive phenotypical data across countries is needed to understand the determinants, prognosis and consequences of vestibular disease. The registry is a data repository for the members of the European DizzyNet. We report results from a pilot study using data from Turkey and Germany.

METHODS

The pilot study included a convenience sample of patients aged 18 or above referred to Ege University Medical School Hospital, Dokuz Eylül University Hospital, Izmir, Turkey, and the German Center for German Center for Vertigo and Balance Disorders, University on Munich, Germany, with symptoms of vertigo or dizziness. Health-related quality of life was assessed with the EQ5-D and the Dizziness Handicap Inventory (DHI). To obtain comparable groups we matched data from the two countries for age, sex and diagnosis by propensity score.

RESULTS

We included 80 adult patients, 40 from each country (60% female, mean age 54.1, SD 12.4). Matching was successful. Vestibular migraine (34%) was the most frequent diagnosis, followed by benign paroxysmal positional vertigo (29%) and Menière's disease (12%). Clinical signs and symptoms were comparable in both countries. Patients from Turkey were more likely to report headaches (65 vs. 32%) and to show gait unsteadiness (51 vs. 5%). Patients from Germany reported significantly higher quality of life and lower values of the DHI score.

CONCLUSIONS

Sharing data facilitates research, enhances translation from basic science into clinical applications, and increases transparency. The DizzyNet registry is a first step to data sharing in vestibular research across Europe.

[Dizziness and vertigo associated with vestibular neuronitis: the approaches to the diagnostics and treatment]

This article is focused on the peculiar features of diagnostics and treatment of dizziness and vertigo in the patients presenting with vestibular neuronitis. The authors present the detailed overview of various theories concerning etiology and pathogenesis of this condition, describe the methods for its clinical and instrumental diagnostics (including its differential diagnostics from other diseases associated with acute dizziness and vertigo). Special attention is given to the methods of pharmacological and physical rehabilitation of the patients suffering from vestibular neuronitis.

[Stroke mimicking acute peripheral vertigo: how to avoid misdiagnosis - importance of alarm symptoms and assessment of eye movements]

Identifying the occurrence of stroke in patients with isolated vertigo is difficult for general practitioners (GPs) as well as for physicians working in the Emergency Department. Three patients with acute vestibular syndrome are presented in this clinical lesson. The importance of an adequate neuro-otological examination is emphasised. However, many GPs lack knowledge of the nystagmus and the head impulse test. Alternative strategies for GPs are discussed.

[Approach to patients with vertigo]

Vertigo is defined as an abnormal sensation of body motion or of its surrounding objects. It is a common chief complaint in emergency departments comprising 2 to 3% of these consultations worldwide. Vertigo is classified as peripheral or central, according to its origin, and can also be occasionally mixed, the most common cause of peripheral involvement being benign paroxysmal positional vertigo. The initial findings on clinical evaluation of patients are the clues for making a correct diagnosis. The differentiation between central and peripheral vertigo can be optimized by analysing nystagmus, by using the skew test and the head impulse test (HINTS), as also by performing the appropriate tests to evaluate the integrity of the vestibular-cerebellar pathway. In addition, tonal threshold audiometry could raise the diagnostic sensibility from 71 to 89% on initial approach. Appropriate diagnosis is the principal key for managing this clinical condition.

Cerebral gray matter changes in persistent postural perceptual dizziness

BACKGROUND

Persistent postural perceptual dizziness (PPPD) is the most common vestibular syndrome in middle-aged patients. Multisensory maladjustment involving alterations of sensory response pattern including vestibular, visual and motion stimuli is thought to be a key pathophysiological correlate of this disorder.

OBJECTIVE

We aimed to identify regional gray matter changes in PPPD patients that might be involved in the underlying pathophysiology of this disorder.

METHODS

42 PPPD patients and healthy age and gender matched controls were investigated using magnetic resonance imaging-based voxel-based morphometry. All patients fulfilled the current diagnostic criteria for PPPD, established by the Bárány-Society based on previous criteria for chronic subjective dizziness and phobic postural vertigo.

RESULTS

PPPD patients showed gray matter volume decrease in the temporal cortex, cingulate cortex, precentral gyrus, hippocampus, dorsolateral prefrontal cortex, caudate nucleus and the cerebellum. A negative correlation of disease duration and gray matter volume was observed in the visual cortex, supplementary motor area and somatosensory processing structures.

CONCLUSIONS

In patients with PPPD areas involved in multisensory vestibular processing show gray matter volume decrease. These brain regions resemble those previously described for other vestibular disorders. Longer duration of disease leads to a more pronounced gray matter alteration, which might represent maladaptive mechanisms within the course of disease.

A case study of Ramsay Hunt Syndrome in conjunction with cranial polyneuritis

RATIONALE

Ramsay Hunt syndrome in conjunction with cranial polyneuritis is not extensively documented, and is very easily misdiagnosed.

PATIENT CONCERNS

A case of a 53-year-old male with Ramsay Hunt syndrome in conjunction with cranial polyneuritis is presented with early symptoms of vertigo, cephalalgia, and facial palsy, followed by zoster oticus 10 days later.

DIAGNOSES

Diagnosis was challenging as this condition presents with multiple neuropathies, and attempting to diagnose based on clinical symptoms was often misleading. Polymerase chain reaction can be used to test for presence of the virus in the cerebrospinal fluid, followed by targeted drug therapy.

INTERVENTIONS

Acupuncture, in conjunction with fire cupping, bloodletting around the afflicted region on the face, as well as oral consumption of herbal medicine and vitamins for nerve nourishment was given to treat this disease.

OUTCOMES

Due to misdiagnosis resulting in delayed treatment, peripheral facial paralysis was left as the main sequelae, while other symptoms responded quickly to treatment. After a 6-month follow-up, facial palsy was still present.

LESSONS

Considering that targeted antiviral therapy can be used to increase the effectiveness of treatment, early diagnosis, and timely use of medication is critical.

Alternobaric vertigo and facial baroparesis caused by scuba diving and relieved by chewing pineapple: a case report

Equalization of middle ear pressure is an important consideration for scuba divers. When middle ear pressure is asymmetric, a diver may experience alternobaric vertigo. Moreover, individuals with an underlying temporal bone dehiscence are predisposed to facial baroparesis. An understanding on behalf of fellow divers and emergency responders to recognize and differentiate facial baroparesis from decompression illness is critical. Misdiagnosis may lead to inappropriate treatment or unwarranted stoppage of diving. There have been a few dozen reported cases of facial baroparesis in the literature, but few have included firsthand accounts. This report describes an incidence of unilateral facial baroparesis preceded by alternobaric vertigo, with commentary from divers who witnessed the individual experiencing the facial paresis. The facial weakness in this case resolved within 15 minutes after the diver chewed on fresh pineapple. This report suggests that alternobaric vertigo may be a harbinger of facial baroparesis. Upon resurfacing divers should consider prophylactic measures that help to dilate the Eustachian tube such as chewing, yawning and swallowing in order to minimize the risk of middle ear pressure-induced vertigo or facial paresis.

Health-related quality of life and disability in patients with acute unilateral peripheral vestibular disorders

Introduction

Health-related quality of life is used to denote that portion of the quality of life that is influenced by the person's health.

Objectives

To compare the health-related quality of life of individuals with vestibular disorders of peripheral origin by analyzing functional, emotional and physical disabilities before and after vestibular treatment.

Methods

A prospective, non randomized case-controlled study was conduced in the ENT Department, between January 2015 and December 2015. All patients were submitted to customize a 36 item of health survey on quality of life, short form 36 health survey questionnaire (SF-36) and the Dizziness Handicap Inventory for assessing the disability. Individuals were diagnosed with acute unilateral vestibular peripheral disorders classified in 5 groups: vestibular neuritis, Ménière Disease, Benign Paroxysmal Positional Vertigo, cochlear-vestibular dysfunction (other than Ménière Disease), or other type of acute peripheral vertigo (as vestibular migraine).

Results

There was a statistical significant difference for each parameter of Dizziness Handicap Inventory score (the emotional, functional and physical) between the baseline and one month both in men and women, but with any statistical significant difference between 7 days and 14 days. It was found a statistical significant difference for all eight parameters of SF-36 score between the baseline and one month later both in men and women; the exception was the men mental health perception. The correlation between the Dizziness Handicap Inventory and the SF-36 scores according to diagnostics type pointed out that the Spearman's correlation coefficient was moderate correlated with the total scores of these instruments.

Conclusion

The Dizziness Handicap Inventory and the SF-36 are useful, proved practical and valid instruments for assessing the impact of dizziness on the quality of life of patients with unilateral peripheral vestibular disorders.

Benign paroxysmal positional vertigo: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society

This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.

Protocol for a prospective interventional trial to develop a diagnostic index test for stroke as a cause of vertigo, dizziness and imbalance in the emergency room (EMVERT study)

INTRODUCTION

Identifying stroke as a cause of acute vertigo, dizziness and imbalance in the emergency room is still a clinical challenge. Many patients are admitted to stroke units, but only a minority will have strokes. This imposes a heavy financial burden on the healthcare system. The aim of this study is to develop a diagnostic index test to identify patients with a high risk of having a stroke as the cause of acute vertigo and imbalance.

METHODS AND ANALYSIS

Patients with acute onset of vertigo, dizziness, postural imbalance or double vision within the last 24 hours lasting for at least 10 min are eligible to be included in the study. Patients with clinically proven peripheral or central aetiology will be excluded. In the emergency room, all enrolled patients will undergo standardised neuro-ophthalmological/physiological testing (including video-oculography, mobile posturography, measurement of subjective visual vertical) (EMVERT block 1). Within 10 days, standardised MRI will be performed as a reference test to identify stroke (EMVERT block 2). Data from EMVERT block 2 will be compared with results from block 1 in order to devise a diagnostic index test with a high specificity and sensitivity to predict the risk of stroke in the emergency room.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of the University of Munich and will be conducted according to the Guideline for Good Clinical Practice, the Federal Data Protecting Act and the Helsinki Declaration of the World Medical Association in its recent version. Study results are expected to be published in international peer-reviewed journals and will be presented at international conferences.

TRIAL REGISTRATION NUMBER

German Clinical Trial Register: DRKS00008992; Universal trial number: U1111-1172-8719); pre-results.

[The video Head Impulse Test in the vertiginous patient]

The video Head Impulse Test (vHIT) is a new diagnostic device which, in clinical practice, can be used to evaluate the vestibular canal function in a fast and objective way by recording the movements of the eyes and the head. The medical literature makes it possible today to define the place of this device in the care of patients with vertigo.

Protective effect of the microcatheter placed at the normal vertebral artery in intracranial stent-assisted angioplasty for vertebral artery stenosis: A case report

RATIONALE

A carefully designed intracranial stent-assisted angioplasty (SAA) is presented here that may prevent subsequent branch artery occlusion.

PATIENT CONCERNS

A 72-year-old man with a 3-month history of progressive and intermittent vertigo without any obvious trigger, accompanied by nausea.

DIAGNOSES

Intracranial atherosclerotic disease.

INTERVENTIONS

the patient underwent intracranial SAA in accordance with the procedure described here.

OUTCOMES

The patient's paroxysmal vertigo completely subsided, with no complications during the short-term follow-up.

LESSONS

This novel intracranial SAA procedure is safe and may reduce the risk of subsequent artery occlusion.

Schnitzler Syndrome With Delirium and Vertigo: The Utility of Neurologic Manifestations in Diagnosis

<p>Schnitzler syndrome (SS) is an autoinflammatory dermatosis that often goes undiagnosed for 5-6 years. Patients typically carry a diagnosis of urticaria; however, their cutaneous symptoms fail to respond to typical urticaria therapies and lack symptoms such as pruritus. Additionally, patients with SS may see multiple providers for nonspecific complaints of fever, lymphadenopathy, arthralgias, and bone pain. A correct diagnosis is paramount, as close to 20% of patients may develop a lymphoproliferative disorder and appropriate treatment may ameliorate all symptoms.1 We report 2 cases of SS misdiagnosed as urticaria for years in order to illuminate diagnostic pearls, histopathological findings, and treatment modalities. Additionally, we highlight the importance of neurologic disturbances in this rare but important differential diagnosis of urticaria.</p> <p><em>J Drugs Dermatol. 2017;16(6):625-627.</em></p>.

Dizziness in the Outpatient Care Setting

PURPOSE OF REVIEW

This article summarizes an approach to evaluating dizziness for the general neurologist and reviews common and important causes of dizziness and vertigo.

RECENT FINDINGS

Improved methods of diagnosing patients with vertigo and dizziness have been evolving, including additional diagnostic criteria and characterization of some common conditions that cause dizziness (eg, vestibular migraine, benign paroxysmal positional vertigo, chronic subjective dizziness). Other uncommon causes of dizziness (eg, superior canal dehiscence syndrome, episodic ataxia type 2) have also been better clarified. Distinguishing between central and peripheral causes of vertigo can be accomplished reliably through history and examination, but imaging techniques have further added to accuracy. What has not changed is the necessity of obtaining a basic history of the patient's symptoms to narrow the list of possible causes.

SUMMARY

Dizziness and vertigo are extremely common symptoms that also affect function at home and at work. Improvements in the diagnosis and management of the syndromes that cause dizziness and vertigo will enhance patient care and cost efficiencies in a health care system with limited resources. Clinicians who evaluate patients with dizziness will serve their patient population well by continuing to manage patients with well-focused workup and attentive care.

Knowledge, Attitudes and Practices Relating to Vertigo among Newly Diagnosed Patients: Findings of a Prospective, Observational Registry in India

OBJECTIVE

Vertigo is a common complaint in clinical practice, with multi-causative etiology, substantially impacting individual's overall lifestyle and behavior. However, so far no much data is available to understand the knowledge, attitude and practices (KAP) about vertigo in newly diagnosed Indian patients. Hence, the objective of this prospective, non-interventional, observational registry was to evaluate KAP towards vertigo and assessment of their awareness through a questionnaire-based survey.

METHODS

Newly diagnosed patients with vertigo (aged ≥18 years), visiting the physicians, were provided with a self-administered validated questionnaire with domains namely knowledge (18 questions), attitude (7 questions), and practices (8 questions). Primary objective was to analyze the percentage of patients with high, average and low level of knowledge; percentage of patients who were little, quiet and extremely concerned about vertigo and its treatment; percentage of patients taking high, moderate and poor level of precaution towards vertigo. All variables were subjected to statistical analysis.

RESULTS

Overall, 1167 (76.8%) patients completed the KAP questionnaire (women: 52.9%; men: 47.1%). A total of 17.3% patients had low level of knowledge, 73.9% had average and 8.74% patients had high level of knowledge regarding vertigo. Attitude domain revealed that majority of the patients (86.20%) had little concerned attitude towards vertigo; 9.85% patients were extremely concerned and 3.94% patients were not concerned regarding vertigo. Practice domain revealed that none of the patients took high level of precautions, 79.8% patients took moderate precautions and 20.2% took less precaution for disease prevention.

CONCLUSIONS

This study revealed that the knowledge, attitude and practice patterns amongst Indian vertigo patients are inadequate, highlighting the need for awareness and scientific education amongst these patients in India. Moreover, health care providers should be trained to provide counseling to these patients effectively.

Role of video-head impulse test in lateralization of vestibulopathy: Comparative study with caloric test

OBJECTIVE

To evaluate the lateralization value of video head-impulse test (vHIT) for the diagnosis of vestibulopathy and to analyze cases showing dissociated results with caloric test.

METHODS

In total, 19 healthy volunteers and 92 dizzy patients who underwent both a caloric test and a vHIT were enrolled. Patients were divided into two groups depending on their fluctuating pattern of vertigo. The vestibulo-ocular reflex (VOR) gain and gain asymmetry (GA) of a vHIT as well as unilateral weakness (UW) and the sum of the slow-phase velocities (SPVs) of warm and cold irrigation of the same side were compared. A cutoff value of VOR gain of a vHIT was also calculated using a receiver-operating characteristic curve.

RESULTS

A VOR gain in an affected ear and GA of a vHIT showed a statistically significant correlation with UW in a caloric test. The cutoff value of a vHIT was determined to be 0.875, derived under the assumption that UW of a caloric test ≤25% is normal. However, the parameters of the two tests were dissociated in 18%.

CONCLUSION

A VOR gain of vHIT is a valuable objective parameter with a lateralization value determining vestibular hypofunction. However, considering substantial dissociation between a vHIT and a caloric test, these tests can be complementary tools for the lateralization of vestibular impairment for the comprehensive evaluation of patients' VOR.

Hearing aid silicone impression material as a foreign body in the middle ear

We report an extremely rare case of hearing aid silicone impression material as a foreign body in the middle ear. Symptoms of the patient were otorrhea and vertigo after taking of a mold impression on his only hearing ear, and the symptoms mimicked chronic otitis media. A temporal bone CT scan revealed foreign body material in the middle ear and Eustachian tube. An intact canal wall mastoidectomy with a facial recess approach and type IV tympanoplasty was performed to remove the silicone impression material. In addition to the case report, we review the literature regarding impression material foreign bodies.

Cognitive impairment and quality of life in patients with migraine-associated vertigo

OBJECTIVE

To study the impact of migraine-associated vertigo (MV) on the cognitive state of patients and their quality of life.

PATIENTS AND METHODS

A total of 120 patients were enrolled in the study, including 40 diagnosed with MV, forty with a simple migraine and 40 healthy volunteers. Cognitive assessments were done using the mini-mental state examination (MMSE), and a battery of tests for cognitive functions in performance, memory, language, space and attention during interictal periods. Also, MRI was used to detect brain white matter lesions and SF-36 for quality of life.

RESULTS

The scores of cognitive tests (MMSE, tracing, memory and VFT scores) in MV cases were significantly lower than those in the simple migraine group. TMT-A and TMT-B scores in the MV group were the highest followed by those in the simple migraine group. The incidence of deep brain, peripheral lateral ventricle and total white matter lesions in the MV group was higher than that in the simple migraine group. Finally, the deep lesion and peripheral lateral ventricle scores in the MV group were significantly higher than those in the simple migraine group. The physical, social, mental and total health scores in the MV group were significantly lower than those in the simple migraine group. All the differences found between groups had statistical significance, and all the variables examined fared best in the healthy control group.

CONCLUSIONS

MV patients show a more pronounced cognitive impairment than patients with a simple migraine or healthy volunteers, the incidence of brain white matter lesions is increased in them, and their quality of life is severely compromised.

[Update on the evaluation and management of dizziness in older people]

This article provides an update on the evaluation and management of dizziness in older people. It is based on a recent literature review. Indeed, it is a frequent reason to consult a general practitioner. Its clinical presentation is not very specific and its treatment is often challenging. Although dizziness is often benign it can have serious physical, functional and psychological consequences. Thanks to a careful medical history and simple clinical examination tools, general practitioners can make a correct diagnosis and provide early multidisciplinary care that can greatly improve the quality of life of elderly people who suffer from dizziness.

Unrecognized Benign Paroxysmal Positional Vertigo in Elderly Patients

Balance disorders in elderly patients are associated with an increased risk of falls but are often difficult to diagnose because of comorbid chronic medical problems. We performed a cross-sectional study to determine the prevalence of unrecognized benign paroxysmal positional vertigo (BPPV) and associated lifestyle sequelae in a public, inner-city geriatric population. Dizziness was found in 61% of patients, whereas balance disorders were found in 77% of patients. Nine percent were found to have unrecognized BPPV. Multivariate analysis demonstrated that the presence of a spinning sensation and the absence of a lightheadedness sensation predicted the presence of unrecognized BPPV. Patients with unrecognized BPPV were more likely to have reduced activities of daily living scores, to have sustained a fall in the previous 3 months, and to have depression. These data indicate that unrecognized BPPV is common within the elderly population and has associated morbidity. Further prospective studies are warranted.

Vestibular evoked myogenic potentials in multiple sclerosis: clinical and imaging correlations

Patients with multiple sclerosis (MS) frequently report symptoms related to vestibular disorders in the course of their disease. At present, the fundamental tests assessing vestibulospinal involvement are posturography and vestibular evoked myogenic potentials (VEMPs). While posturography cannot be performed in every subject requiring minimal stance control, VEMPs do not require any specific skill on the part of the subjects and they may be investigated in all patients able to sit. VEMPs were recorded for 40 patients (17 men, 23 women; mean age 38 years, range 17-71 years) fulfilling diagnostic criteria of clinically defined MS, by means of rarefaction clicks, recording modulation of sterno-cleido-mastoideus tonic contraction saccule-mediated modulation. VEMPs were found to be abnormal in 28 of 40 patients. In 18 of the cases the VEMPs were asymmetric, i.e., had a prolonged latency on one side. In six cases latency was increased on both sides (mean delay 4.1 ms). In four subjects VEMPs were absent on one side. C oncordance with clinical findings of presence/absence of brainstem involvement was found in 55% and with MRI findings in 65% of the cases. A bnormal VEMPs indicated brainstem dysfunction in four patients (10%) with normal MRI and no specific clinical signs.

Bilateral Sudden Profound Hearing Loss and Vertigo as a Unique Manifestation of Bilateral Symmetric Inferior Pontine Infarctions

Objectives:

We present a case of sudden bilateral profound deafness and vertigo, without any accompanying neurologic signs, secondary to bilateral infarctions of the cochlear and vestibular nuclei.

Methods:

Vertigo, vomiting, tinnitus, and bilateral profound deafness suddenly developed in a 65-year-old woman without any accompanying neurologic signs. In particular, she did not present dysarthria, numbness, cranial nerve palsies, or visual or cerebellar signs.

Results:

Magnetic resonance imaging of the brain revealed 2 fresh infarctions of 8 to 10 mm symmetrically localized in the posterolateral bulbopontine junction. Angiography revealed a complete occlusion of the basilar artery, with a well-represented backward flow of its distal portion from the carotid artery via posterior communicating arteries. Excluding a transient ischemic attack that occurred 16 days after the acute episode, the patient had had no other neurologic events at 8 months of follow-up.

Conclusions:

Acute vertigo and sudden deafness in a patient with known cerebrovascular occlusive disease may represent the warning signs of an impending brain stem or cerebellar infarction, even when other neurologic signs are absent. These events are fortunately very rare, but should be considered by clinicians who see patients with vertigo.

Combined Horizontal and Posterior Canal Benign Paroxysmal Positional Vertigo in Three Patients with Head Trauma

We report 3 patients who complained of positional vertigo shortly after head trauma. Positional maneuvers performed in the plane of the posterior canal (PC; Dix-Hallpike maneuver) and the horizontal canal (HC; patients were rolled to either side in a supine position with the head raised 30°) revealed a complex positional nystagmus that could only be interpreted as the result of combined PC and HC benign paroxysmal positional vertigo (BPPV). Two patients had a right PC BPPV and an ageotropic HC BPPV, and 1 patient had a bilateral PC BPPV and a left geotropic HC BPPV. All 3 patients were rapidly free of vertigo after the PC BPPV was cured by the Epley maneuver and the geotropic HC BPPV was cured by the Vannucchi method. The ageotropic HC BPPV resolved spontaneously. Neuroimaging (brain computed tomography and/or magnetic resonance imaging scans) findings were normal in all 3 patients. From a physiopathological viewpoint, it is easy to conceive that head trauma could throw otoconial debris into different canals of each labyrinth and be responsible for these combined forms of BPPV. Consequently, in trauma patients with vertigo, it is mandatory to perform the Dix-Hallpike maneuver, as well as supine lateral head turns, in order to diagnose PC BPPV, HC BPPV, or the association of both. Early diagnosis and treatment of BPPV may help to reduce the postconcussion syndrome.

The application of vestibular-evoked myogenic potentials in otoneurosurgery

Objective

To evaluate the applicability of vestibular-evoked myogenic potentials (VEMPs) in the diagnostics, intraoperative monitoring, and postoperative follow-up of patients in otoneurosurgery.

Study Design

A prospective study of patients who underwent either cochlear implantation (CI, n = 18) or were diagnosed with an acoustic neuroma (AN, n = 9) or with neuro(micro)vascular compression of the VIIIth nerve (NVC, n = 27) in the period 2002 to 2004. The follow-up was 1 year for all patients.

Setting

A tertiary-referral unit.

Results

VEMPs could be recorded in 64% of all patients before CI and in 22% after surgery. The patients with AN had normal VEMPs in 22% of all cases when first diagnosed. Normal VEMPs were found in 37% of those patients with NVC. From the 5 AN patients who had to be operated, only 1 had intact VEMPs after surgery. In contrast, after microvascular decompression all patients (4) had normal VEMPs.

Conclusions

VEMPs are helpful in diagnosing patients with vertigo to better identify saccular defects. They are highly sensitive in the early diagnosis of retrocochlear lesions.

Significance

VEMPs can help to reliably identify patients with a retrocochlerar lesion at an early stage and can be used in intraoperative, neurophysiological monitoring. EBM rating: C-4

Impaired Visual Suppression of Manually Rotated Vestibuloocular Reflex Indicates the Need of Further Evaluation by MRI and MRA in Patients with Vertigo

OBJECTIVE: MRI and MRA are accepted as valuable methods for diagnosing vertigo, although they are costly and time-consuming. Thus, some indicator of the necessity of a detailed evaluation by MRI and MRA is desirable.

STUDY DESIGN AND SETTING: To assess the usefulness of an impairment of the visual suppression (VS) as an indicator, the relation between abnormal findings on MRI and/or MRA and impairment of the VS of manually rotated vestibuloocular reflex (VOR) was retrospectively examined in 40 consecutive patients suffering from vertigo.

RESULTS: 12 of 23 patients with a low VS% were found to have a pathologic condition on MRI and/or MRA, however, no abnormality was found in any of the patients with a normal VS%. The rates of abnormality on MRI and/or MRA significantly differed between the 2 groups ( X2, P = 0.0004).

CONCLUSION: The VS% is thought to be a good indicator of the need for further evaluation by MRI and MRA in vertiginous patients.

Diagnostic, Pathophysiologic, and Therapeutic Aspects of Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo is the most common peripheral vestibular disorder. It can be defined as transient vertigo induced by a rapid head position change, associated with a characteristic paroxysmal positional nystagmus. Canalolithiasis of the posterior semicircular canal is considered the most convincing theory of its pathogenesis and the development of appropriate therapeutic maneuvers resulted in its effective treatment. However, involvement of the horizontal or the anterior canal has been found in a significant rate and the recognition and treatment of these variants completed the clinical picture of the disease. This paper describes the advances in understanding how this disease is generated and discusses the current therapeutic modalities.

Cinnarizine and dimenhydrinate in the treatment of vertigo in medical practice

The efficacy and safety of the fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg in the treatment of vertigo of various origins have been investigated in a prospective, noninterventional study involving private practices throughout Germany. A total of 1275 patients with an average age of 61.2 years participated in the study. The vertigo symptoms, measured by a validated mean vertigo score (primary efficacy endpoint) improved by 61 % in the course of the observational period (median: 6 weeks). Concomitant symptoms frequently associated with vertigo such as nausea, vomiting and tinnitus were also markedly reduced by 84, 85 and 51 %, respectively. Overall efficacy has been rated by the physicians as 'very much improved' or 'much improved' in 95 % of the patients. A total of 47 patients (3.7 %) reported 51 adverse drug reactions (all nonserious). The results indicate a good tolerability and efficacy of the fixed combination of cinnarizine and dimenhydrinate in the treatment of vertigo in daily medical practice, which is in line with previous findings of numerous interventional, randomised, double-blind, controlled clinical trials.

Influence of Age on Caloric Response

In an aging society, the number of patients suffering from vertigo and dizziness is increasing. Vertigo is mostly thought to occur owing to otorhinolaryngologic disease. In contrast, it is difficult to diagnose dizziness, because of its varied causes, and we believe that the number of elderly patients suffering from dizziness is increasing. Here, we evaluated the relationship between canal paralysis and symptoms at the first medical examination and age-related changes in caloric response, and obtained the following 3 main findings: (a) 41.3% of the patients with canal paralysis complained of dizziness at the first medical examination, with an increased tendency in patients aged >70 years; (b) the slow-phase eye velocity (SPEV) of patients aged >70 years was lower than that of patients aged ≤69 years, and the SPEV of patients complaining of vertigo was higher than that of patients who complained of dizziness during a caloric test, and (c) the percentage of patients complaining of dizziness and those not complaining of symptoms during a caloric test increased with age. In conclusion, patients with canal paralysis tend to complain of dizziness at the first medical examination, and the percentage of patients without vertigo during a caloric test increased with age.

Vestibular migraine: the most frequent entity of episodic vertigo

Vestibular migraine (VM) is the most common cause of episodic vertigo in adults as well as in children. The diagnostic criteria of the consensus document of the International Bárány Society for Neuro-Otology and the International Headache Society (2012) combine the typical signs and symptoms of migraine with the vestibular symptoms lasting 5 min to 72 h and exclusion criteria. Although VM accounts for 7% of patients seen in dizziness clinics and 9% of patients seen in headache clinics it is still underdiagnosed. This review provides an actual overview on the pathophysiology, the clinical characteristics to establish the diagnosis, the differential diagnosis, and the treatment of VM.

An approach to vertigo in general practice

BACKGROUND

Dizziness is a common and very distressing presentation in general practice. In more than half of these cases, the dizziness is due to vertigo, which is the illusion of movement of the body or its surroundings. It can have central or peripheral causes, and determining the cause can be difficult.

OBJECTIVE

The aim of this article is to provide a clear framework for approaching patients who present with vertigo. A suggested approach to the assessment of vertigo is outlined.

DISCUSSION

The causes of vertigo may be central (involving the brainstem or cerebellum) or peripheral (involving the inner ear). A careful history and physical examination can distinguish between these causes. The most common causes of vertigo seen in primary care are benign paroxysmal positional vertigo (BPPV), vestibular neuronitis (VN) and Ménière's disease. These peripheral causes of vertigo are benign, and treatment involves reassurance and management of symptoms.

10 years of Vertigo Clinic at National Hospital Abuja, Nigeria: what have we learned?

The clinician's major role in management of the dizzy patient involves determining what dizziness is vertigo, and what vertigo is of central or peripheral origin. These demand attention to details of history, otolaryngological workup including vestibular assessment, and often use of diagnostic and management algorithms. There is paucity of published reports of the management outcomes of peripheral vestibular diseases from Africa. Two tertiary care otologist-led dedicated vertigo clinics are located in Abuja, Nigeria. A prospective, non-randomized study of patients presenting with features of peripheral vestibular diseases attending the National Hospital Abuja Nigeria (between May 2005 and April 2014) and CSR Otologics Specialist Clinics (May 2010 to April 2014) was carried out. Both institutions adopted the same diagnostic and management protocols. Data extracted from anonymized databases created for this study include age, sex, vertigo duration (acute <12 weeks, chronic >12 weeks), dizziness handicap inventory score at presentation and at subsequent visits, otological and vestibular findings, ice-water caloric testing results, other investigation outcomes, treatments offered and outcomes. 561/575 (97.5 %) of the cases recorded had peripheral vestibular disease. The male-to-female ratio was 290:271. The mean age of the subjects was 44.7 years. Duration of vertigo at presentation was acute in 278 subjects and chronic in 283 subjects. Identifiable clinical diagnostic groups include BPPV (n = 200), Meniere's disease (n = 189), cervicogenic vertigo (n = 35), labyrinthitis (n = 32), Migraine-associated vertigo (MAV) (n = 32), cholesteatoma/perilymph Fistula (n = 10), climacteric vertigo (n = 8) and unclassified vertigo (n = 55). Migraine-associated vertigo recorded the highest DHI score (95 % CI 75 ± 4.3), followed by cholesteatoma/perilymph fistula (95 % CI 72 ± 6.1) and labyrinthitis (95 % CI 62 ± 1.9). Pure tone audiometry (95 % CI 67.3 ± 3.43), followed by thyroid function tests (95 % CI 66.7 ± 23.55) and ice-water caloric testing (95 % CI 59.7 ± 2.69) were investigations with the highest yields. 86.5 % of cases were treated by either vestibular suppressant medications alone (n = 285) and/or particle repositioning maneuver (n = 200) with improvement in vertigo control (95 % CI 63.63 to 74.37 % and 62.59 to 75.41 %, respectively). Peripheral vestibular diseases constitute majority of cases of self-reported vertigo seen in our setting. Migraine-associated vertigo seen in our setting all have peripheral vestibular signs. Dedicated vertigo clinics could significantly improve the diagnostic and treatment yield in a resource-constrained setting like ours. Most cases can be managed using non-operative measures.