Dizziness in aging: the clinical experience

Dizziness and vertigo occur frequently in aging. Inner ear or nervous system pathology (central or peripheral) may be the cause. Other causes may also be cardiovascular disease, medication, leg pathology, psycho-pathologic processes (psychogenic dizziness), etc. In our Dizziness Clinic, 3427 patients 70 years of age or older were evaluated and an accurate diagnosis was possible in 76.25 percent of cases. Dizziness specific to aging was not identified, although at times dizziness was more serious than in younger patients due either to weakness because of aging or to more than one cause of dizziness. Thus dizziness and vertigo in aging have to be investigated carefully and similarly to other age groups. To this effect, the history, the clinical examination, and the follow-up are the most essential tools available to the practicing physician.

[Practical approach to recurrent benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo is the most common vestibular disorder and it has a significant impact on health-related quality of life. The disease is probably caused by the accumulation of lithiasis material from the otolithic membrane of the utricle. Patients experience multiple short vertigo crises lasting seconds when they go to bed or turn over. There are several clinical variants affecting posterior, horizontal or anterior canals and in some cases vestibular lithiasis can occur in two canals simultaneously. Diagnosis is by video-oculographic recording of positional nystagmus during positional tests to identify the canal affected. There are specific treatment manoeuvres for each clinical variant, which a high degree of short-term effectiveness.

Vestibular function in cochlear implant users

Balance alterations in the postoperative of cochlear implant surgeries varies from 31 to 75%.

AIM

to analyze vestibular function in the pre and postoperative periods of cochlear implanted individuals.

MATERIALS AND METHODS

the vestibular function was assessed, through electronystagmography, in 38 patients, in the pre and postoperative of cochlear implant procedures.

RESULTS

The main complaint of unbalance reported by patients was dizziness, followed by postural vertigo and non-postural vertigo. Results: 13% of the patients did not show any balance disorder following cochlear implant surgery and just 5% showed symptoms worsening. 13 % of the patients showed an improvement, and this could be related to the vestibular compensation phenomenon and to electric stimulation. However, it was observed, in the caloric responses, a worsening in the vestibular system function, for both implanted and non-implanted ears. Thus, there is no evidence of more damage to the implanted ear.

CONCLUSION

the study showed that cochlear implant surgeries could injure the vestibular system in both ears. However, the vestibular symptoms take place in a smaller proportion, and can improve after cochlear implant surgery.

Gentamicin injections for Ménière disease: comparison of subjective and objective end points

This retrospective study reports the overall efficacy and comparative results of intratympanic gentamicin injections for disabling vertigo episodes. All patients received weekly injections for diagnosed Ménière disease. In Group 1 (81 patients), treatment end points were determined by subjective complaints of imbalance, with resolution of vertigo. In Group 2 (23 patients), treatment end points were determined when 2 or more values of nystagmus were demonstrated. (Group 2 patients were assessed before initiation of therapy for head-shaking, head-thrust, and spontaneous nystagmus using infrared video goggles.) After the final injection, all patients had audiograms and balance and oculomotor retraining. Gentamicin therapy was determined to be successful based on 3-month post-therapy findings of vertigo resolution, stable hearing, normalized nystagmus, and functional balance.

A case of bilateral parietal cortical laminar necrosis with a loss of vertiginous sensation

BACKGROUND

Animal experiments demonstrated that there are vestibular cortical areas at the parietal cortex. Moreover, in humans, recent functional neuroimaging studies revealed that caloric stimulation activated the parietoinsular vestibular cortex and optokinetic stimulation activated the parieto-occipital cortex. These activations indicate that the parietal vestibular areas play some role in nystagmus generation or in spatial information processing in the eye movement tasks.

AIMS OF THE STUDY

The aim of this communication was to present a patient giving some information about parietal cortical function in nystagmus production and vertigo.

CASE

We report a 51-year-old, heavy alcoholic man with Bálint syndrome, constructional disability, limb-kinetic apraxia and ideo-motor apraxia. Brain magnetic resonance imaging demonstrated bilateral parietal cortical laminar necrosis anterior to the parieto-occipital sulci without any involvement of the primary sensory and parietoinsular cortices. Optokinetic nystagmus (OKN) was not elicited whereas cold caloric stimulation fully evoked nystagmus toward the opposite side with oscillopsia when eyes opened. However, he did not feel vertiginous sensation when the eyes were closed.

CONCLUSIONS

These findings suggest that the parietal cortices are indispensable for OKN production and vertiginous sensation.

Efficacy of a home-based exercise program on benign paroxysmal positional vertigo compared with betahistine

OBJECTIVE

To determine the efficacy of a home-based exercise program by comparing it with betahistine in patients with benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Prospective, randomized, controlled study.

SETTING

Outpatient clinic of a university hospital.

PATIENTS

Thirty-eight patients (10 males, 28 females; mean age 46 +/- 13 years) diagnosed as having BPPV.

INTERVENTIONS

Patients were randomly assigned to either an exercise or a medication group. In the medication group, betahistine was prescribed at 24 mg/d for 1 month. The exercise group was required to perform Cawthorne-Cooksey exercises six times/day for 4 weeks.

MAIN OUTCOME MEASURES

The Vertigo, Dizziness, Imbalance Questionnaire (VDI), which consists of two subscales, the VDI symptom subscale (VDI-ss) and the VDI health-related quality of life (VDI-HRQoL) subscale, and the Vertigo Symptom Scale (VSS) were used for assessment at the beginning of the study and after 2 months.

RESULTS

The mean scores of the two components of the VDI and the VSS decreased in the exercise group by the fourth week. In the medication group, VSI mean scores, VDIss mean scores, and VSS mean scores decreased in the second week and VDI-HRQoL mean scores decreased in the fourth week. However, there were no significant differences between baseline and week 8. There were significant differences between groups regarding the change in the mean scores of the VDI (p = .001) and the VSS (p = .001) at the end of the study in favour of the exercise group.

CONCLUSIONS

Exercise was found to be a better treatment choice than medication and may be preferable for patients with persistent or chronic vertigo.

The DizzyFix: initial results of a new dynamic visual device for the home treatment of benign paroxysmal positional vertigo

OBJECTIVE

To develop and test a completely new dynamic visual device for the home treatment of benign paroxysmal positional vertigo (BPPV).

DESIGN

Randomized, controlled, prospective trial.

SETTING

Tertiary care hospital.

METHODS

We designed and manufactured a new device (the DizzyFix) to assist in the performance of the particle repositioning manoeuvre (PRM). Fifty healthy volunteers were taught the PRM, half using the new device. At 1 week, we compared the PRM performance between the device and nondevice user groups.

MAIN OUTCOME MEASURES

Performance of the PRM as graded on an 11-point scale.

RESULTS

DizzyFix users in phase I scored significantly higher on their PRM performance compared with controls (p = .0001).

CONCLUSIONS

The use of this new device enables volunteers to conduct a correct PRM on their own. This is a significant improvement from written instructions or in-office training.

Alternobaric vertigo--really a hazard?

OBJECTIVE

To determine the prevalence of alternobaric vertigo (AV) in sport divers and to find out whether AV led to dangerous situations underwater. Furthermore, to examine whether objective neurootologic tests are associated with the manifestation of AV.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Sixty-three sport divers with an average diving experience of 10 years and 650 dives were questioned regarding their medical and diving history and the manifestation of vertigo during diving.

METHODS

Microscopic otoscopy, tympanometry, stapedius reflexes, hearing threshold for air and bone conduction, caloric video-oculography including analysis of the slow-phase velocity of the nystagmus, acoustic brain stem responses, and magnetic resonance imaging were performed to find possible differences between divers with and without AV.

RESULTS

We found 17 divers with AV (27%). There was no significant difference in all measured parameters apart from sex and history of middle ear equalization difficulty in divers with AV. Ten (59%) of 17 female divers and 7 (15%) of 46 male divers experienced AV, representing a significant sex difference (p < 0.001). Correlation with our divers' outpatient clinic revealed that female divers had a significantly higher incidence of middle ear equalization disorders which could be an explanation for the predominance of female divers with symptoms of AV. None of the divers reported any dangerous or life-threatening situations following AV. Whether AV leads to dangerous situations underwater remains unclear, but this hypothesis is not supported by our data.

CONCLUSION

Alternobaric vertigo is a common finding in divers. In our study group, female divers had a four-time higher risk to suffer AV. Our data do not support the thesis that AV is a life-threatening condition.

[Evaluation of diagnosing cervical vertigo with computerized static posturography]

OBJECTIVE

To provide a quantitative base for diagnosing cervical vertigo by establishing a biomechanics method.

METHODS

From July 2004 to Nov 2005, the static posturography (SPG) of normal 86 health individuals and 75 patients with cervical vertigo were quantitatively measured and qualitative diagnosis respectively in closed and open eyes. There were 40 male and 46 female in health adults, ranging from 20 to 74 years old (mean 30 years). There were 16 male and 59 female in vertigo patients, ranging from 20 to 74 years old (mean 44.5 years). In contrast to current diagnosis method of patients with cervical vertigo, the clinical value was evaluated.

RESULTS

Under the state of closed eyes, the sensitivity of SPG diagnosing cervical vertigo was 76%; the specificity was 93%; the Youden index was 69%; the coincidence was 85.1%; the positive predictive value was 90.5%; the negative predictive value was 93%; the positive and negative likelihood ratio were 10.893 and 0.258 respectively. Under the state of open eyes, the sensitivity was 49.3%; the specificity was 87.2%; the Youden index was 38.6%; the coincidence was 69.6%; the positive predictive value was 77.1%; the negative predictive value was 87.2%; the positive likelihood ratio was 3.857; the negative one was 0.581. Regardless of closed or open eyes, foreword-backward type shift orbit was the with cervical vertigo.

CONCLUSION

The patients with cervical vertigo and normal individuals can be diagnosed objectively and quantitatively with SPG under the state of closed eyes, which can achieve the basic requirements of diagnosing cervical vertigo with validity, reliability and good clinical application. However, the rate of missed diagnosis with SPG under the state of open eyes is too high to meet the diagnostic needs.

Vestibular evoked myogenic potentials in patients with benign paroxysmal positional vertigo involving each semicircular canal

PURPOSE

We have investigated vestibular evoked myogenic potentials (VEMPs) as a function of age and the involvement of each of the 3 semicircular canals in patients with benign paroxysmal positional vertigo (BPPV).

MATERIALS AND METHODS

We performed prospective assessment from January 2005 to September 2006. Vestibular evoked myogenic potential was measured in 53 patients with BPPV and 84 healthy subjects, with the latter subdivided by patient age.

RESULTS

The subgroup of healthy subjects older than 60 years showed significantly more prolonged p13 and n23 latencies and lower amplitude than the other 2 subgroups. Of the 53 patients with BPPV, 13 (24.5%) showed abnormal VEMP responses on the affected side when compared with their age-related control subgroup. There was no correlation between VEMP findings and the affected semicircular canal.

CONCLUSION

Patients with BPPV may show abnormal VEMP findings, irrespective of the involved semicircular canal, and age was associated with VEMP results suggesting degeneration of the maculae of the saccule.

Bilateral posterior semicircular canal aplasia and atypical paroxysmal positional vertigo: a case report

Isolated congenital malformations of semicircular canals are rare abnormalities. Most inner ear abnormalities occur in syndromes and are associated with hearing loss. Unilateral or bilateral single aplasia of one semicircular canal does not usually result in vertigo, but these become clinically important if there are clinical complaints of vertigo. Computed tomography imaging and high resolution magnetic resonance imaging may reveal inner ear abnormalities. The case is presented here of a 46-year-old male with a 10-year history of recurrent positional vertigo with strong onset when changing position to the left side. Magnetic resonance imaging of the inner ear showed a bilateral posterior semicircular canal aplasia as well as an enlarged vestibule on both sides. Dix-Hallpike positional manoeuvre revealed a positional nystagmus in the left head-hanging position of short duration and latency of a few seconds. When rising, vertigo occurred, but no nystagmus was visible. The fast phase of the nystagmus was mainly vertical down-beating with a slight torsional component to the uppermost ear. Although benign paroxysmal vertigo of the anterior canal was suspected, physical therapy was not effective using a modified liberatory manoeuvre. Brandt-Daroff therapy was effective permanently.

Pseudo-spontaneous nystagmus: a new sign to diagnose the affected side in lateral semicircular canal benign paroxysmal positional vertigo

Early diagnosis of the affected side in Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo is important in effectively applying treatment manoeuvres. This study was performed to examine the frequency of a new clinical sign, pseudo-spontaneous nystagmus, in a large cohort of patients with Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo, comparing its efficacy in the identification of the involved side with that of other diagnostic signs, seated supine positioning nystagmus, and the intensity of the nystagmus evoked by the head yaw test in the supine position. Overall, 293 patients affected by Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo (197 geotropic and 96 apogeotropic forms) were examined. Pseudo-spontaneous nystagmus was observed in 222 patients (76%). After a very slow, repeated horizontal rotation of the head, in the seated position, this percentage increased to 96% (281 patients). The pseudo-spontaneous nystagmus and the seated supine positioning nystagmus always beat in the same direction and both were in accordance in identifying the affected side with the nystagmus evoked by the head yaw test. The differential diagnosis between spontaneous nystagmus and pseudo-spontaneous nystagmus is easily achieved with the head pitch test in the sitting position: the pseudo-spontaneous nystagmus disappears with the head bent forward 30 degrees (neutral position), it reverses its direction with the head bent 60 degrees forward, it returns visible bringing the head in axis with the body and increases its intensity extending the head about 30 degrees backwards. Pseudo-spontaneous nystagmus is an important sign for determining the affected ear in Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo. Early identification of the affected side improves efficacy of treatment and compliance of patients.

[A randomized controlled trial of rotatory reduction manipulation and acupoint massage in the treatment of younger cervical vertigo]

OBJECTIVE

To explore the effects of rotatory reduction manipulation and acupoint massage on blood flow velocity of vertebrobasilar artery (VBA) in younger cervical vertigo of high velocity,and to observe the difference of clinical therapeutic effect between two manipulations.

METHODS

Seventy-six patients who diagnosed as high flow velocity of younger cervical vertigo were randomly divided into rotatory reduction manipulation group (group A, 38 cases)and acupoint massage group (group B, 38 cases). The changes of flow velocity of VBA before and after treatment were observed using transcranial Doppler (TCD) and the therapeutic effects were observed also.

RESULTS

The mean flow velocity in left vertebral artery (LVA)and basilar artery (BA)of group B and in BA of group A were significantly decreased as compared with those before treatment (P < 0.05, P < 0.01) 1 week after treatment,and there was significant difference in the change of mean flow velocity in LVA between two groups (P < 0.01). The mean velocity in LVA, right vertebral artery (RVA) and BA were obviously lower than thosfre before treatment in two groups (P < 0.01) 3 weeks after treatment. There was obvious difference in LVA, RVA between two groups (P < 0.01). The therapeutic effect of group B was superior to that of group A (P < 0.05).

CONCLUSION

The effect of acupoint massage on flow velocity of VBA was superior to that of rotatory reduction manipulation, and the therapeutic effect of acupoint massage might be better than that of rotatory reduction manipulation in treating younger cervical vertigo of high flow velocity.

An effective maneuver of positional test by turning of the head and body together

OBJECTIVE

To find the effective maneuver of a positional test.

METHODS

We performed three different maneuvers of a positional test in 86 vertiginous patients in supine-lying position in the following order: (1) "body-only maneuver": a patient turned only his body to one side while keeping his head still; (2) "head-only maneuver": a patient turned only his head to one side while keeping the body still; (3) "head-and-body maneuver": a patient turned his head and body together to one side. Eye movement during the whole procedure was recorded by two-dimensional electronystagmography.

RESULTS

Nystagmus provocation rates were 9% in "body-only maneuver", 16% in "head-only maneuver", and 33% in "head-and-body maneuver".

CONCLUSION

The positional test in which patient turned his head and body together proved most effective.

Head-tilting stabilometry in patients with benign paroxysmal positional vertigo

OBJECTIVE

One of the pathologic conditions underlying benign paroxysmal positional vertigo (BPPV) is degeneration of the otolith organs. In this study, we examined changes in the parameters of stabilometry under an upright condition and head-tilt conditions in patients with BPPV.

METHODS

We performed stabilometry on 21 patients with right BPPV, on 21 patients with left BPPV and on 21 controls. First, the subject stood barefoot in an upright position with both feet together on the platform with eyes closed. Next, tilting of the head about 30 degrees to the left was added. Then, tilting about 30 degrees to the right was performed.

RESULTS

In right BPPV patients, the total length of velocity vectors in the right or left direction on right or left head-tilt were significantly smaller than those in an upright position. The enveloped area and total length of velocity vectors in the right or left direction were significantly larger than those in controls. In left BPPV patients, there were no parameters that showed any significant difference.

CONCLUSIONS

In this study, lesions of right BPPV patients were coincidentally more severe than those in left BPPV patients, and velocity vectors with head-tilts were significantly smaller than in an upright position. Using the total length of the velocity vectors, head-tilting stabilometry has the potential to become a reliable otolith function examination method.

[Peripheral vertigo classification. Consensus document. Otoneurology committee of the Spanish otorhinolaryngology society (2003-2006)]

There are many different vertigo classifications and different denominations are frequently used for the same clinical processes. The Otoneurology Committee of the Spanish Society for Otorhinolaryngology and Head and Neck Pathology proposes an eminently practical classification of peripheral vertigo to facilitate a common terminology that can be easily used by the general ENT practitioners. The methodology used has been by consensus within our Society and especially among the most outstanding work groups in the area of otoneurology in Spain. Initially vertigo is divided into single-episode vertigo and recurring attacks of vertigo, and these are then sub-divided into 2 groups, depending on whether or not hearing loss is present. Acute vertigo without hearing loss corresponds to vestibular neuritis and if it is associated with hearing loss, it is due to labyrinthitis of different aetiologies and cochleo-vestibular neuritis. Recurrent vertigos without hearing loss are classified as induced, either by posture (BPPV) or pressure (perilymphatic fistula), or as spontaneous, including migraine-associated vertigo, metabolic vertigo, childhood paroxysmal vertigo and vertigo of vascular causes (AITs, vertebral-basilar failure). Finally, recurrent vertigo with hearing loss includes Ménière's disease and others such as vertigo-migraine (with hearing loss), autoimmune pathology of the inner ear, syphilitic infection, and perilymphatic fistula (with hearing loss).

[Diagnostic and expert value of functional tests in detection of latent vestibular dysfunction]

Vestibular dysfunction was studied in 150 patients with paroxysmal states and minimal neurological defect in the past. A series of functional stress tests proved to be highly effective in diagnosis of latent vestibular dysfunction.

Simulation of cupulolithiasis and canalolithiasis by an animal model

The physical mechanisms responsible for cupulolithiasis and canalolithiasis have been investigated by two groups of experiments in isolated posterior semicircular canal (SCC) of frog (Rana esculenta L.). First, clouds of 10-30 isolated otoconia were let to fall (snowfall of otoconia) either through the ampulla onto the cupula, or inside the long arm of the canal, opposite to the cupula. Second, microspheres ranging 30 to 350 microm in diameter were gently moved to and fro inside the long arm of the canal by a micromanipulator. The effects were evaluated by recording the firing rate (Nfr) of the ampullary nerve. Snowfall of otoconia produced detectable changes of Nfr only when otoconia got in contact with the cupula, but not when falling through the endolymph. Movement of the microspheres in the canal long arm induced Nfr changes only if the microsphere diameter exceeded about 50 microm. Although the exact microsphere size needed for receptor stimulation may depend on the experimental conditions, these results strongly suggest that debris moving inside a SCC (canalolithiasis) can produce transcupular pressures able to stimulate ampullar receptors only if they have suitable size, whereas isolated otoconia cannot, except when lying on the cupula (cupulolithiasis).

Surgery of the semicircular canals

INTRODUCTION

Surgery of the semicircular canals is seeing a revival as recently we have witnessed the development of specialized surgeries for each canal.

OBJECTIVES

The aim of this work is through a review of the literature to describe these different surgeries while stressing on certain surgical aspects, their respective indications, results and their risks.

DISCUSSION

1: The surgery of the posterior canal relates to the benign paroxysmal positional vertigo resistant to the medical treatments. The results are very good but the indications have become rarer since the introduction of the repositioning maneuvers. 2: The surgery of the lateral canal is the most frequent and the oldest because of chronic otitis and especially cholesteatomas. It is now well codified and is subject to various factors. Plugging of the lateral canal in Menière's disease has just been described and interesting results on vertiginous crises have been reported. Its interest and its place in the treatment of this disease are still to determine. It can be an alternative to surgical management but also to the gentamycin injection. 3: The dehiscence of the superior semicircular canal must be systematically sought after when confronted with a Menière-like disease, a suspicion of perilymphatic fistula or a conductive deafness evoking an otosclerosis with preserved stapedial reflexes. Very often these dehiscences of the superior canal are asymptomatic. High density scans of the petrous bones provide the diagnosis but it is necessary to obtain a 3D view to ascertain the dehiscence. A radiological classification of the dehiscence in 3 types has been proposed. It appears to be of help during surgery. Videonystagmography with and without vibrator and vestibular myogenic evoked potentials allow the determination of the side responsible for the symptoms in case of bilateral dehiscence. The surgery usually through a middle fossa approach will be proposed only to the symptomatic and incapacitated patients. The results are promising. 4: Finally the authors discuss the cochlear risk of this surgery and the types of material used to occlude or cover the canal.

CONCLUSION

The otologists must generally know these indications as this type of surgery entails very good results with a relatively moderate risk on hearing.

[Positional vertigo. Symptom, clinical sign, or disease?]

INTRODUCTION

We present a prospective study with the aim of assessing the differences found between position-triggered vertiginous syndromes, those diagnosed as benign paroxysmal positional vertigos (BPPV) in primary care and non-specific clinics, and those classified as BPPV at an otoneurology unit.

PATIENTS AND METHOD

Over a 17 month period, 432 consecutive patients were included after evaluation at a otoneurology unit receiving all referrals for vestibular pathologies. The existence of trigger factors was investigated, as was the distribution of the diagnoses associated with a positional trigger. The characteristics of the patients with a final diagnosis of BPPV were also studied.

RESULTS

Of this population, 217 patients (50.23%) reported a positional change as the trigger for their symptoms, 106 (24.53%) were referred from their initial care centres with a diagnosis of BPPV, and 128 (29.62%) were classified as truly BPPV. The coincidence between the preliminary diagnosis and the definitive one was 52.8%. A history of positional paroxysmal vertigo during seconds was linked to BPPV in 78% of cases. Only in 4.7% of the BPPV cases diagnosed at the otoneurology unit had provoking manoeuvres been performed.

CONCLUSIONS

We have found that an adequate anamnesis is capable of providing accurate guidance for diagnostic purposes in most cases of BPPV, but the performance of provoking manoeuvres and the correct specific treatment for this pathology is of paramount importance when classifying a patient with suspected BPPV.

Benign paroxysmal positional vertigo: an overview

This study consists of a general review of benign paroxysmal positional vertigo and nystagmus. The main etiopathogenesis, diagnosis, and treatments are evoked. The author describes his experience on the subject.

Familial clustering of migraine, episodic vertigo, and Ménière's disease

OBJECTIVE

To evaluate the association between migraine, episodic vertigo, and Ménière's disease in families.

STUDY DESIGN

Clinical report.

SETTING

University Neurotology Clinic.

PATIENTS

Index patients identified with Ménière's disease and migraine and their family members.

INTERVENTION

Structured interview to assess a diagnosis of migraine, episodic vertigo, and Ménière's disease in 6 families. Genotyping was performed on 3 sets of twins to analyze monozygosity or dizygosity.

MAIN OUTCOME MEASURES

Clinical history of migraine, episodic vertigo, and Ménière's disease.

RESULTS

Six index patients and 57 family members were interviewed either by a senior neurologist in person or over the phone by a trained study coordinator. An additional 6 family members completed questionnaires by mail. All 6 index patients had Ménière's disease and migraine. Twenty-six (41%) of the 63 relatives met International Classification of Headache Disorders II criteria for migraine headaches. Thirteen (50%) of these 26 experienced migraine with aura. Three others experienced typical aura without headache. Seventeen (27%) of 63 family members experienced recurrent spells of spontaneous episodic vertigo. There was one twin pair in each of 3 families; 2 pairs were monozygotic and one was dizygotic. In each twin pair, one twin had migraine and Ménière's disease, whereas the other experienced migraine and episodic vertigo without auditory symptoms.

CONCLUSION

The frequent association of episodic vertigo, migraine, and Ménière's disease in closely related individuals, including identical twins supports the heritability of a migraine-Ménière's syndrome, with variable expression of the individual features of hearing loss, episodic vertigo, and migraine headaches.

Digital craniocorpography and peripheral vestibular diseases

Peripheral vestibular diseases (PVDs) often produce many symptoms but few or no measurable signs. Tests that capture and measure signs permit the comparison between normal and vertiginous populations. The aim of our research was to find movement patterns that could identify PVD patients, using a motion analysis laboratory. The results from 21 asymptomatic volunteers who underwent the Unterberger-Fukuda stepping test were compared to those of 38 PVD patients. We established diagnosis after a complete otoneurological workup prior to the stepping test. The VICON 370 (Oxford Metrics Ltd, Oxford, UK) was used for digital capture and analysis of the stepping tests. Lateral sway, linear and total displacement, shoulder height oscillation, and torticollis angle were the same for individuals in both groups, but stepping time, body spin, and angular deviation were statistically greater in those in the patient group and might help in the diagnosis of PVDs.

[The changes in vestibular function in patients with diabetes mellitus and its clinical significance]

OBJECTIVE

To study the changes of vestibular function in patients with diabetes mellitus and its clinical significance.

METHOD

Electronystagmography (ENG) was used to examine 76 patients with diabetes mellitus and 60 healthy adults subjects. After clinical detection of vestibular function including spontaneous nystagmus, positional test, head shaking nystagmus, neck torsion test, caloric test, and sensory organization tests which consist of gaze, saccade and smooth pursuit test, the results of these two groups were recorded for qualitative and quantitative statistical analysis.

RESULT

The rate of vestibular dysfunction in patients with diabetes mellitus were 68.4%. and that of the controls were 8.3%. There was significant difference between these two groups (chi2 = 15.472, P < 0.01).

CONCLUSION

Vertigo or dizziness occurred in patients with diabetes mellitus might be related to vestibular dysfunction. ENG test could be used as one of the objective clinical examinations in patients with diabetes mellitus.

Changes in slow phase eye velocity and time constant of positional nystagmus at transform from cupulolithiasis to canalolithiasis

Changes in slow phase eye velocity (SPEV) and time constant (TC) of benign paroxysmal positional nystagmus in horizontal canal type were examined at transitional period from cupulolithiasis (apogeotropic nystagmus) into canalolithiasis (geotropic nystagmus) in two patients. SPEV and TC of positional nystagmus were tri-dimensionally analyzed. The first patient showed an apogeotropic nystagmus. Head rotation to the left in supine position induced a right-beating nystagmus with an initial SPEVof 15.3 degrees/s and a TC of 133 s. The nystagmus then gradually declined with a TC of 31.3 s after reaching a maximum SPEV of 28.8 degrees/s. After the nystagmus disappeared, he showed a geotropic nystagmus. The second patient showed a left-beating nystagmus with an initial SPEV of 2.5 degrees/s and a TC of 141 s when his head was rotated to the right in supine position. The nystagmus then gradually declined with a TC of 8.05 s after reaching a maximum SPEV of 16.7 degrees/s. After the nystagmus disappeared, he showed a geotropic nystagmus. The present findings suggested that in both patients, at the period of an increase of SPEV of the positional nystagmus with the shortening of its TC, cupulolithiasis transformed into canalolithiasis.

Office management of benign paroxysmal positional vertigo with Epley's maneuver

BACKGROUND

The underlying cause of benign paroxysmal positional vertigo is free floating endolymph particles (otoconia displaced from the otolithic membrane of the utricle) in the posterior semicircular canal. Particle repositioning techniques are one of the effective method of treatment. The purpose of the study was to determine the effectiveness of Epley's maneuver against expectant treatment and to find out if this treatment should be used more frequently than watchful waiting for the treatment of BPPV.

METHODS

This study was carried out at outpatient clinic, departments of ENT, Combined Military hospital Rawalpindi and PNS Shifa hospital Karachi over a three years period from Jan, 2002 to Jan, 2005. Based upon history and Dix-hallpike testing 44 patients diagnosed as benign paroxysmal positional vertigo were collected by convenient sampling from these hospital's outpatient departments and divided by non probability convenience into two groups of 22 each. The control group (group A) was given placebo and the test group (group B) received single treatment by Epley's maneuver in the OPD. The results were analyzed at the end of one and two weeks by history taking and Dix-hallpike testing. Computer software SPSS version 10 was used.

RESULTS

At the end of week one 14 (63.63%) patients of group B were symptom free and 2 (9.1%) patients was much better as compared to the control group where only 1 (4.5%) patient reported as symptom free and another 5 (22.7%) reported as much better. At the end of second week out of those treated by Epley's maneuver 16 (72.7%) reported as symptom free and another 2 (9.1%) as much better whereas 4 (18.2%) patients reported no improvement at all. In the control group only 4 (18.2%) patients reported as symptom free, 3 (13.6%) as much better, 6 (27.3%) as better and 9 (40.9%) reported no change in the symptoms. Chi square test was applied and the value of p came out to be 0.001 and 0.002 at week one and week two respectively.

CONCLUSION

It was concluded that Epley's maneuver is a much better form of management for benign paroxysmal positional vertigo.

Dynamics of canal response to head-shaking test in benign paroxysmal positional vertigo

CONCLUSIONS

Time constant and maximum slow phase velocity (SPV) of head-shaking nystagmus (HSN) demonstrated a differential canal response to head shaking in 24% of patients with posterior canal benign paroxysmal positional vertigo (BPPV). We suggest that vestibular lithiasis has a limited contribution to the mechanism that generates HSN.

OBJECTIVE

To determine the canal response to head shaking in BPPV.

PATIENTS AND METHODS

This was a case-control study including 104 individuals with BPPV. The diagnosis was based on the presence of vertigo and nystagmus during the positional test. Subjects were examined by the horizontal and vertical head-shaking test. Eye movements were recorded on a video camera to analyze the nystagmus. The head was shaken passively in the horizontal and sagittal planes, respectively, for horizontal and vertical HSN at a frequency of 2 Hz. HSN was considered when six consecutive beats of nystagmus with an SPV of at least 2 degrees/s were detected. Main outcome measures were the presence of horizontal and vertical HSN, maximum SPV of HSN, time constant of HSN, and canal paresis.

RESULTS

Maximum SPV of vertical HSN was higher in BPPV patients with posterior canal BPPV (n = 10) than in controls (p = 0.04). Moreover, the time constant of vertical HSN was significantly lower for posterior canal BPPV when compared with controls (p < 0.02).

Cochlear modiolus and lateral semicircular canal in sudden deafness

CONCLUSION

This study demonstrated that precise analysis shows that the inner ear shape in sudden deafness (SD) is different from that in controls in that the fluid-filled area of SD labyrinths is significantly larger than that of controls. Reduced cochlear modiolus area and inner area of the lateral semicircular canal (LSCC) may be associated with insufficient maturation of the inner ear.

OBJECTIVE

The aim of this study was to quantify the morphologies of the cochlea and LSCC using magnetic resonance imaging (MRI) and to evaluate their relationships with clinical symptoms in SD.

SUBJECTS AND METHODS

Twenty-six unilateral SD patients with vertigo, 26 unilateral SD patients without vertigo and a matched control group without hearing loss were studied. The areas of cochlear modioli and LSCCs were traced on the MRI console and compared between SD patients with or without vertigo and control subjects. The ratio of the LSCC fluid-filled area to the total LSCC area was used to index the degree of dysplasia.

RESULTS

The cochlear modiolus area was significantly less in SD ears (4.1+/-0.2 mm2) than in controls (4.3+/-0.4 mm2). The LSCC inner area was significantly less in SD ears (6.9+/-1.7 mm2) than in controls (9.1+/-1.8 mm2). These results suggest that the fluid-filled area of SD labyrinths is significantly larger than controls. Morphology did not differ between affected and contralateral sides or between ears with or without vertigo in SD patients.

Clinical significance of vertical component of caloric response including its second phase in vertiginous patients

CONCLUSIONS

Up-beating vertical component recorded in the caloric first phase was attributed mainly to the inhibitory endolymph flow in the anterior canal. Down-beating vertical component recorded in the caloric second phase provoked by a positional change could be explained by a reversed endolymph flow in vertical canal(s).

OBJECTIVE

To investigate the origin of a vertical component in caloric response.

MATERIALS AND METHODS

We analyzed electronystagmography (ENG) of caloric responses, which had measurable horizontal component in the caloric first phase in both ears in 200 ears of 100 vertiginous patients. A caloric first phase was provoked by cold water in the supine position with the lateral semicircular canal earth-vertical. A caloric second phase was provoked by re-orienting the lateral canal from the earth-vertical to earth-horizontal after the cessation of the first phase (provoked second phase). The nystagmus of the whole procedure was recorded by two-dimensional ENG.

RESULTS

We recorded the vertical component in 103/200 ears in the caloric first phase, which was directed mostly upward (92/103 ears). We also recorded the vertical component in 91/200 ears in the provoked second phase, which was directed almost exclusively downward (90/91 ears).

Body balance in patients with systemic vertigo after rehabilitation exercise

The aim of this paper was to characterize structural balance of the body in people with systemic vertigo after applying rehabilitation exercise, such as motor-visual coordination on a posturographic platform and balance exercise. Physiotherapeutic procedures were carried out in a group of 12 people, aged 25-60 years suffering from vertigo. The evaluation of body balance in the standing position was performed by means of recording of postural sways based on force-plate posturography. The examination was performed before and after the rehabilitation program. Standard tests were done, with eyes open, eyes closed, and with conscious visual control-biofeedback. Patients with vertigo underwent a month-long therapy, which included: exercise of motor-visual coordination on a posturographic platform and balance exercise, which consisted of repeated visual, vestibular, and somatosensory stimulation for conscious postural control. The rehabilitation program resulted in a decrease of the range of sways, improved visuomotor coordination and thus also improved balance.

[Characterization of bilateral superior canal dehiscence]

In the superior canal dehiscence syndrome, patients can have sound- or pressure-induced vertigo and oscillopsia. They may also present conductive hearing loss or higher than normal bone conduction thresholds. Clinical manifestations are due to the effect of a third mobile window in the inner ear created by the dehiscence. Diagnosis is based on clinical manifestations, vertical and rotatory nystagmus induced by sound and pressure reflecting SSC stimulation, reduced threshold and increased amplitude of vestibular evoked myogenic potentials (VEMP) and temporal bone CT scan images showing the SSC dehiscence. Characteristic eye movements can be recorded with the scleral search coil technique.

Clinical and diagnostic characterization of canal dehiscence syndrome: a great otologic mimicker

OBJECTIVE

To identify otologic and audiologic characteristics of superior (and posterior) semicircular canal dehiscence (SCD).

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Sixty-five adult patients were evaluated for SCD; 26 of 65 (35 ears) had dehiscence.

INTERVENTION(S)

Otologic examination, high-resolution computerized tomography (CT), air and bone audiometry, tympanometry, acoustic reflex, and vestibular evoked myogenic potential (VEMP).

MAIN OUTCOME MEASURE(S)

Imaging demonstrating canal dehiscence, preferentially including Poschel and Stenvers reconstructions. Audiologic findings of pseudoconductive loss, intact ipsilateral stapedial reflex, and abnormally low VEMP thresholds.

RESULTS

The most common presenting complaints were autophony of voice and a "blocked ear" (94%), mimicking patulous eustachian tube, including relief with Valsalva or supine position (50%), but without autophony of nasal breathing. Pseudoconductive loss was found in 86% of dehiscence ears, and 60% (21 of 35) of these ears had better than 0-dB-hearing-loss bone conduction thresholds at 250 and/or 500 Hz. Acoustic reflex was present in 89%. Assuming CT as the criterion standard, VEMP resulted in 91.4% sensitivity and 95.8% specificity. One false-positive CT, with abnormal VEMP, resulted in surgical explorations negative for superior SCD but positive for posterior SCD.

CONCLUSION

Semicircular canal dehiscence may present with various symptoms such as autophony, ear blockage, and dizziness/vertigo. A combination of high-resolution CT and audiologic testing is recommended for diagnosis. Low-frequency conductive loss with better than 0 dB hearing level (HL) bone conduction threshold and normal tympanometry, with intact acoustic reflexes, are audiologic signs of SCD. Vestibular evoked myogenic potential is highly sensitive and specific for SCD, possibly better than CT.

A case of acute disseminated encephalomyelitis presenting with vertigo

We report a 37-year-old woman with acute disseminated encephalomyelitis (ADEM) who presented with progressive vertigo. A central nervous system disorder was initially suspected because gaze-evoked torsional nystagmus was observed and electrical nystagmography (ENG) revealed abnormal eye movements with saccadic ocular pursuit and pathological optokinetic nystagmus. Finally ADEM was diagnosed by the clinical symptoms and the characteristic patterns of brain MRI. It is rare for otolaryngologists to examine patients with ADEM. ADEM takes an acute course and can present a grave state and therefore needs early diagnosis, early treatment. We have to keep ADEM in mind in the diagnosis of vertigo.

Should patients with benign positional vertigo be imaged?

Unexpected intra-cranial pathology is unusually encountered in patients with BPV in the presence of a classically positive Hallpike's response and in the absence of any other neurological signs or symptoms. We carried out a retrospective review to assess the incidence of unexpected intra-cranial pathology in patients with a clinical diagnosis of benign positional vertigo (BPV) and to review the role of radiological imaging in these patients. 145 consecutive patients seen by the senior author with a diagnosis of posterior semi-circular canal BPV over a five-year period were reviewed. In the series of 63 patients who underwent MRI, two cases (3.2%) had cerebral aneurysms, one patient had an epidermoid cyst (1.58%) and one patient had a large right parietal arterio-venous malformation. We would conclude that possible warning signs exist that may alert the clinician to the possibility of unexpected intracranial pathology including failed response to the initial Epley manoeuvre or any asymmetry in hearing. Thus, we would advocate imaging be performed on this sub-group of patients with BPV.

Horizontal and anterior canal benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is suspected when the patient complains of brief episodes of vertigo induced by changes in the head position. The direction of the positional nystagmus during the positional maneuvers is essential to affirm the canal involved. There is a consensus for the diagnosis of a PC-BPPV and HC-BPPV (geotropic and ageotropic form) as well as for the treatment of a PC-BPPV and a geotropic HC-BPPC. However, there is still a debate for the diagnosis of an AC-BPPV and the treatment of an ageotropic HC-BPPV and an AC-BPPV.

Analytic view to concordance between electrocochleography and caloric test in Meniere’s disease

We aimed to investigate if there is a concordance between summation potential (SP)/action potential (AP) ratio and unilateral weakness in patients with definite-Meniere's disease. There were two groups, a group of unilateral definite-Meniere patients who received no treatment and another group of control subjects. Twenty-six patients were identified as complying with the defined criteria. Fifteen healthy subjects with no hearing and balance disorders were assigned to the control group. Arithmetic mean of the four-tone average of thresholds at 0.5, 1, 2, and 3 or 4 kHz, SP/AP ratio and degree of unilateral weakness were calculated. The number of patients was tabulated based on the presence of abnormal SP/AP ratio and unilateral weakness. Co-occurrence of unilateral weakness and elevated-SP/AP ratio was investigated with reference to the stage of the disease. A correlation was sought among pure-tone average, SP/AP ratio and degree of unilateral weakness in a pair-wise manner. Unilateral weakness and abnormal SP/AP ratio were identified in 53.8% and 38.4% of the patients, respectively. Co-occurrence of unilateral weakness and abnormal SP/AP ratio was observed in 34.6% of the patients. However, it was noticed that this co-occurrence gradually increased when the disease progressed. Mean SP/AP ratio also gradually increased as the stage progressed. Of pair-wise correlations among pure-tone average, SP/AP ratio and degree of unilateral weakness, a weak correlation (r = 0.383) was found only between SP/AP ratio and degree of unilateral weakness with marginal significance (P = 0.053). We concluded that co-occurrence of unilateral weakness and elevated SP/AP ratio increases when the disease progresses. This co-occurrence is less encountered in earlier stages. This difference might be resulted from a difference in distension capability of the endolymphatic space of the cochlea and the vestibule. Albeit weak, there was a correlation between mean SP/AP ratio and degree of unilateral weakness, which suggests that the disease parallelly disturbs the lateral semicircular or cochlear functions especially in advanced stages.

[Benign paroxysmal vertigo of childhood: categorization and comparison with benign positional paroxysmal vertigo in adult]

INTRODUCTION

The differential diagnosis of vertigo in children is extensive. This implies an additional difficulty in diagnosing dizziness in paediatric population.

PATIENTS AND METHOD

Twenty-three children consecutively examined for paroxysmal attacks of dizziness and/or vertigo attacks entered our study, and were compared to a 15 adults group with benign positional paroxysmal vertigo. Fifteen healthy paediatric subjects and 18 adults were selected as control groups. The clinical characteristics of vertigo, presence of triggering factors, family history of migraine, presence of motion sickness, migraine, and other accompanying symptoms were considered. Neurological, vestibular, and auditory functions were assessed including the performance of a posturography in every group of patients.

RESULTS

The presence of migraine, physical activity prior to vertigo, and positional trigger of vertigo were the clinical elements which differentiated both populations of patients with vertigo. There were significant differences in adult posturography between vertigo and control groups. In paediatric population, there were no differences between vertigo and control group in the posturography study.

CONCLUSIONS

The benign paroxysmal vertigo of childhood complex is the most frequent aetiology of paediatric dizziness. The duration and triggers of vertigo in children are quite similar to those found in VPPB adults. The instability posterior to vertigo, measured by posturography, were less intense in children than in adult population.

Vestibular Rehabilitation Exercises in Acute Vertigo

OBJECTIVES/HYPOTHESIS

To evaluate the effect of vestibular rehabilitation exercises in the early stages of peripheral vestibular disorders.

STUDY DESIGN

Prospective, randomized trial. Patients were blinded to assignment groups.

METHODS

The study group (45 patients) performed exercises for adaptation of the vestibulo-ocular reflex; the control group (42 patients) performed placebo exercises. Both groups were instructed to use dimenhydrinate (up to 150 mg/d) if symptomatic, irrespective of exercises. Patients were evaluated by visual analogue scale, physical examination, and need to use the medication. All patients were adults and symptomatic for less than 5 days.

RESULTS

The study and control groups were comparable in terms of demographics data and duration and intensity of symptoms. Study group patients recovered faster than controls and used less medication. By 10 to 14 days after the intervention, 43% of study group and 5% of control group patients had no significant symptoms (P < .001), and 67% of study group and 3% of control group patients needed no medication (P < .001). Although both groups had no significant symptoms by the end of the follow-up period (21 days), 14% of the study group patients were still using medication, compared with 83% of the placebo group patients (P < .001).

CONCLUSIONS

Vestibular exercises are effective in reducing the duration of symptoms and the need of medication of patients in the early stages of peripheral vestibular disorders.

Alternobaric vertigo: prevalence in Portuguese Air Force pilots

CONCLUSION

Having found a prevalence rate of alternobaric vertigo in Portuguese Air Force pilots that is somewhat higher than previously reported, we underline the importance of implementing education on the management of this condition as part of routine Air Force pilot training programs.

OBJECTIVES

Alternobaric vertigo is a condition in which transient vertigo with spatial disorientation occurs suddenly during flying or diving activities, caused by bilateral asymmetrical changes in middle ear pressure. Its prevalence is very likely underestimated and under-reported, with the 10-17% prevalence rate mentioned in early literature not being challenged by recent data.

SUBJECTS AND METHODS

To assess its actual prevalence, the authors requested all high performance aircraft pilots presently on active duty in the Portuguese Air Force to anonymously answer a questionnaire on alternobaric vertigo symptoms, after a short briefing on the subject.

RESULTS

A 29% prevalence rate of in-flight episodes consistent with alternobaric vertigo was obtained.

[Vestibulo-oculomotor reflex recording using the scleral search coil technique. Review of peripheral vestibular disorders]

Our goal is to review vestibulo-oculomotor reflex (VOR) studies on several peripheral vestibular disorders (Ménière's disease, vestibular neuritis, benign paroxysmal positional vertigo, superior canal dehiscence syndrome, and vestibular neuroma), using the scleral search coil (SSC) technique. Head movements are detected by vestibular receptors and the elicited VOR is responsible for compensatory 3 dimensional eye movements. Therefore, to study the VOR it is necessary to assess the direction and velocity of 3 dimensional head and eye movements. This can be achieved using the SCC technique. Interaction between a scleral search coil and an alternating magnetic field generates an electrical signal that is proportional to eye position. Ideally, eye rotation axis is aligned with head rotation axis and VOR gain (eye velocity/head velocity) for horizontal and vertical head rotations is almost 1. The VOR gain, however, for torsional head rotations is smaller and about 0.7.

Subjective visual horizontal in patients with posterior canal benign paroxysmal positional vertigo

CONCLUSION

Patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) could have mild excitation in the vestibular system on the affected side.

OBJECTIVE

p-BPPV is considered to be caused by small particles dislodged from the utricular macula. While subjective visual horizontal (SVH) mainly reflects utricular function, there is less documentation on SVH in patients with p-BPPV. The purpose of this study was to clarify whether p-BPPV could affect SVH.

PATIENTS AND METHODS

Twenty-eight patients with unilateral idiopathic p-BPPV were enrolled. For comparison, 17 patients with vestibular neuritis and 45 patients with cerebello-pontine angle (CPA) tumor were also examined. For measurement of SVH, we used a device that has a red bar of light-emitting diodes (LEDs) in front of the patient. Subjects were asked to rotate the bar to the position that they felt was horizontal in a completely dark room.

RESULTS

Deviation of SVH toward the unaffected side down was seen in 82.1% (23/28) of patients with p-BPPV. Mean+/-SD deviation of SVH from the true horizontal to the unaffected side down was 0.49+/-1.21 degrees. Conversely, deviation of SVH was toward the affected side down in 88.2% of patients with vestibular neuritis and in 75.6% of patients with CPA tumor.