Benign paroxysmal positional vertigo in older women may be related to osteoporosis and osteopenia

Immunogold TEM of otoconin 90 and otolin - relevance to mineralization of otoconia, and pathogenesis of benign positional vertigo

Implementation of the deep-etch technique enabled unprecedented definition of substructural elements of otoconia, including the fibrillar meshwork of the inner core with its globular attachments. Subsequently the effects of the principal soluble otoconial protein, otoconin 90, upon calcite crystal growth in vitro were determined, including an increased rate of nucleation, inhibition of growth kinetics and significant morphologic changes. The logical next step, ultrastructural localization of otoconin 90, by means of immunogold TEM in young mature mice, demonstrated a high density of gold particles in the inner core in spite of a relatively low level of mineralization. Here gold particles are typically arranged in oval patterns implying that otoconin 90 is attached to a scaffold consisting of the hexagonal fibrillar meshwork, characteristic of otolin. The level of mineralization is much higher in the outer cortex where mineralized fiber bundles are arranged parallel to the surface. Following decalcification, gold particles, as well as matrix fibrils, presumed to consist of a linear structural phenotype of otolin, are aligned in identical direction, suggesting that they serve as scaffold to guide mineralization mediated by otoconin 90. In the faceted tips, the level of mineralization is highest, even though the density of gold particles is relatively low, conceivably due to the displacement by the dense mineral phase. TEM shows that individual crystallites assemble into iso-oriented columns. Columns are arranged in parallel lamellae which convert into mineralized blocks for hierarchical assembly into the complex otoconial mosaic. Another set of experiments based on immunogold TEM in young mice demonstrates that the fibrils interconnecting otoconia consist of the short chain collagen otolin. By two years of age the superficial layer of mouse otoconia (corresponding to mid-life human) has become demineralized resulting in weakening or loss of anchoring of the fibrils interconnecting otoconia. Consequently, otoconia detached from each other may be released into the endolymphatic space by minor mechanical disturbances. In humans, benign positional vertigo (BPV) is believed to result from translocation of otoconia from the endolymphatic space into the semi-circular canals rendering their receptors susceptible to stimulation by gravity causing severe attacks of vertigo. The combinations of these observations in humans, together with the presented animal experiments, provide a tentative pathogenetic basis of the early stage of BPV.

Benign paroxysmal positional vertigo is a common cause of dizziness and unsteadiness in a large population of 75-year-olds

BACKGROUND AND AIMS

Studies have shown that 65% of people with dizziness may have a vestibular etiologic diagnosis, possibly benign paroxysmal positional vertigo (BPPV). The diagnosis of BPPV is based on medical history and findings after the Dix-Hallpike test. It is sometimes difficult to perform the Dix-Hallpike test in elderly persons, due to the limited range of motion when extending the neck. In this study, we used a side-lying test to stimulate the posterior semicircular canal, while the head and neck were fully supported on the examination table. The aims of this study were to investigate the prevalence of dizziness and/or impaired balance and BPPV in a population of 75-year-olds by means of a questionnaire and clinical tests, and to compare elderly persons with and without BPPV.

METHODS

A representative population sample of 675 persons completed a questionnaire about dizziness and 571 persons underwent side-lying, static balance and dynamic walking tests.

RESULTS

Subjective dizziness and/or impaired balance were found in 36% of subjects, especially when walking outdoors. A significant gender difference was found, with a higher prevalence in women (40%) compared with men (30%) (p<0.01). BPPV was found in 11% and was significantly more common in women (p<0.01). Elderly individuals with BPPV also displayed significantly impaired balance in static and dynamic balance tests compared with persons without BPPV (p<0.01). Persons with BPPV reported significantly more sub- jective problems with dizziness and balance compared with persons without BPPV (p<0.001).

CONCLUSIONS

Subjective and objective unsteadiness, dizziness and BP- PV are common in the elderly.

Inner ear disease and benign paroxysmal positional vertigo: a critical review of incidence, clinical characteristics, and management

Background. This study is a review of the incidence, clinical characteristics, and management of secondary BPPV. The different subtypes of secondary BPPV are compared to each other, as well as idiopathic BPPV. Furthermore, the study highlights the coexistence of BPPV with other inner ear pathologies. Methods. A comprehensive search for articles including in the abstract information on incidence, clinical characteristics, and management of secondary BPPV was conducted within the PubMed library. Results. Different referral patterns, different diagnostic criteria used for inner ear diseases, and different patient populations have led to greatly variable incidence results. The differences regarding clinical characteristics and treatment outcomes may support the hypothesis that idiopathic BPPV and the various subtypes of secondary BPPV do not share the exact same pathophysiological mechanisms. Conclusions. Secondary BPPV is often under-diagnosed, because dizziness may be atypical and attributed to the primary inner ear pathology. Reversely, a limited number of BPPV patients may not be subjected to a full examination and characterized as idiopathic, while other inner ear diseases are underdiagnosed. A higher suspicion index for the coexistence of BPPV with other inner ear pathologies, may lead to a more integrated diagnosis and consequently to a more efficient treatment of these patients.

Benign Paroxysmal Positional Vertigo (BPPV): History, Pathophysiology, Office Treatment and Future Directions

BPPV is the most common cause of vertigo. It most often occurs spontaneously in the 50 to 70 year age group. In younger individuals it is the commonest cause of vertigo following head injury. There is a wide spectrum of severity from inconsistent positional vertigo to continuous vertigo provoked by any head movement. It is likely to be a cause of falls and other morbidity in the elderly. Misdiagnosis can result in unnecessary tests. The cardinal features and a diagnostic test were clarified in 1952 by Dix and Hallpike. Subsequently, it has been established that the symptoms are attributable to detached otoconia in any of the semicircular canals. BPPV symptoms can resolve spontaneously but can last for days, weeks, months, and years. Unusual patterns of nystagmus and nonrepsonse to treatment may suggest central pathology. Diagnostic strategies and the simplest "office" treatment techniques are described. Future directions for research are discussed.

Association between type 1 diabetes mellitus and deposits in the semicircular canals

OBJECTIVE

To compare the prevalence of cupular and free-floating deposits in the semicircular canals between temporal bones of type 1 diabetes mellitus patients and normal controls.

STUDY DESIGN

Case-control histopathologic human temporal bone study.

SETTING

Otopathology laboratory in a tertiary academic medical center.

SUBJECTS AND METHODS

Twenty-eight temporal bones from 14 patients with type 1 diabetes mellitus and 56 normal temporal bones from 28 age-matched individuals were histopathologically examined. The cupula and lumina of the semicircular canals were examined for evidence of deposits.

RESULTS

The prevalence of cupular and free-floating deposits in the lateral and posterior semicircular canals was significantly higher in type 1 diabetes mellitus patients compared with normal temporal bones (lateral, cupular deposits, odds ratio [OR], 5.47; 95% confidence interval [CI], 1.43 to 21.02; free-floating deposits, OR, 8.25; 95% CI, 2.42 to 27.85; posterior, cupular deposits, OR, 41.73; 95% CI, 5.96 to 275.50; free-floating deposits, OR, 7.44; 95% CI, 1.91 to 28.53). The prevalence of these deposits was associated with the duration of disease rather than with aging.

CONCLUSION

The findings suggest that type 1 diabetes mellitus is associated with cupular and free-floating deposits in the semicircular canals. The patients with type 1 diabetes mellitus with a longer duration of disease have an increased probability of suffering from benign paroxysmal positional vertigo.

The facial skeleton in patients with osteoporosis: a field for disease signs and treatment complications

Osteoporosis affects all bones, including those of the facial skeleton. To date the facial bones have not drawn much attention due to the minimal probability of morbid fractures. Hearing and dentition loss due to osteoporosis has been reported. New research findings suggest that radiologic examination of the facial skeleton can be a cost-effective adjunct to complement the early diagnosis and the follow up of osteoporosis patients. Bone-mass preservation treatments have been associated with osteomyelitis of the jawbones, a condition commonly described as osteonecrosis of the jaws (ONJ). The facial skeleton, where alimentary tract mucosa attaches directly to periosteum and teeth which lie in their sockets of alveolar bone, is an area unique for the early detection of osteoporosis but also for the prevention of treatment-associated complications. We review facial bone involvement in patients with osteoporosis and we present data that make the multidisciplinary approach of these patients more appealing for both practitioners and dentists. With regard to ONJ, a tabular summary with currently available evidence is provided to facilitate multidisciplinary practice coordination for the treatment of patients receiving bisphosphonates.

Meniere's disease in the elderly

Menière disease usually begins in adults from 20 to 60 years old, and occurs in more than 10% of patients older than 65. The treatment of Menière disease in the elderly represents a challenge because of polymedication. Antivertiginous drugs such as betahistine and cinnarizin give good results with minor secondary effects. In contrast, major vestibular suppressor drugs such as thiethylperazin must be avoided as long-term treatment because of their side effects. Definitive vestibular surgical deafferentations such as labyrinthectomy and selective vestibular neurectomy represent optional procedures but must be carefully evaluated from case to case. Ablative procedures remain the efficient treatment of drop attacks, which represent a high potential risk of severe injuries by older patients sometimes with important social consequences.

Clinical study of vertigo in the outpatient clinic of Kyoto University Hospital

CONCLUSION

The epidemiology of vertigo remains unclear. This study might contribute to an understanding of the mechanisms underlying vestibular disease.

OBJECTIVE

To investigate the epidemiological features of patients with vertigo.

METHODS

A retrospective study on 612 patients with vertigo who visited Kyoto University Hospital.

RESULTS

Elderly individuals comprised > 30% of patients presenting with vertigo, with more female patients than male patients.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is characterized by brief recurrent episodes of vertigo triggered by changes in head position. BPPV is the most common etiology of recurrent vertigo and is caused by abnormal stimulation of the cupula by free-floating otoliths (canalolithiasis) or otoliths that have adhered to the cupula (cupulolithiasis) within any of the three semicircular canals. Typical symptoms and signs of BPPV are evoked when the head is positioned so that the plane of the affected semicircular canal is spatially vertical and thus aligned with gravity. Paroxysm of vertigo and nystagmus develops after a brief latency during the Dix-Hallpike maneuver in posterior-canal BPPV, and during the supine roll test in horizontal-canal BPPV. Positioning the head in the opposite direction usually reverses the direction of the nystagmus. The duration, frequency, and symptom intensity of BPPV vary depending on the involved canals and the location of otolithic debris. Spontaneous recovery may be expected even with conservative treatments. However, canalithrepositioning maneuvers usually provide an immediate resolution of symptoms by clearing the canaliths from the semicircular canal into the vestibule.

Does vertigo disappear only by rolling over? Rehabilitation for benign paroxysmal positional vertigo

CONCLUSION

We propose that the rolling-over maneuver (ROM) is as effective as the canalith repositioning maneuver (CRP) for the treatment of benign paroxysmal positional vertigo (BPPV). ROM involves easy movements, with only a small load. This therapy is suitable for most BPPV patients, even for those without an indication for CRP.

OBJECTIVES

BPPV is a common vestibular disorder. CRP is known to be an effective therapy for the treatment of BPPV. Because of its various movements of the head and body, it is impossible to perform CRP in BPPV patients with orthopedic impairments or in the elderly. For these patients, we perform a maneuver called ROM, which involves easy movements. In this study, we compared the efficacy of ROM with that of CRP in patients with posterior semicircular canal-type BPPV.

PATIENTS AND METHODS

The study included 22 patients with BPPV who were randomized and divided into the following 2 groups: 1) those treated by the modified Epley maneuver as CRP; and 2) those treated by ROM.

RESULTS

We found no significant difference between the two groups in the number of days from onset to remission of both nystagmus and vertigo.

Negative association between treated osteoporosis and benign paroxysmal positional vertigo in women

OBJECTIVE

To determine the degree of association, if any, between benign paroxysmal positional vertigo and osteoporosis, both of which are disorders of impaired calcium carbonate homeostasis.

METHODS

A retrospective chart review was undertaken in two otology clinics to assess the prevalence of treated osteoporosis in 260 women with and without benign paroxysmal positional vertigo, between the ages of 51 and 80 years.

RESULTS

There was a statistically significant, negative association between benign paroxysmal positional vertigo and treated osteoporosis in women aged 51 to 60 years. We also observed a trend towards a negative association for women in their 60s, and for the group as a whole.

CONCLUSION

Osteoporosis, or the medication used to treat it, may provide protection against benign paroxysmal positional vertigo.

Loss of otolith function with age is associated with increased postural sway measures

Loss of balance and increased fall risk is a common problem associated with aging. Changes in vestibular function occur with aging but the contribution of reduced vestibular otolith function to fall risk remains unknown. We examined a population of 151 healthy individuals (aged 21-93) for both balance (sway measures) and ocular counter-rolling (OCR) function. We assessed balance function with eyes open and closed on a firm surface, eyes open and closed on a foam surface and OCR during +/-20 degree roll tilt at 0.005 Hz. Subjects demonstrated a significant age-related reduction in OCR and increase in postural sway. The effect of age on OCR was greater in females than males. The reduction in OCR was strongly correlated with the mediolateral measures of sway with eyes closed. This correlation was also present in the elderly group alone, suggesting that aging alone does not account for this effect. OCR decreased linearly with age and at a greater rate in females than males. This loss of vestibular otolith-ocular function is associated with increased mediolateral measures of sway which have been shown to be related to increased risk of falls. These data suggest a role for loss of otolith function in contributing to fall risk in the elderly. Further prospective, longitudinal studies are necessary to confirm these findings.

Daily exercise does not prevent recurrence of benign paroxysmal positional vertigo

OBJECTIVE

The purpose of this study was to analyze if a daily routine of self-canalith repositioning procedure (CRP) will increase the time to recurrence and reduce the rate of recurrence of benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Prospective study, nonrandomized control group.

SETTING

Outpatient clinic.

PATIENTS

Thirty-nine patients diagnosed with posterior canal BPPV successfully treated with the CRP. Based on a convenience sample, 17 (44%) patients were assigned to the treatment group, whereas 22 (56%) were assigned to the no-treatment group. The number of subjects lost at the time of follow-up were 5 (29.4%) of the treatment group and 2 (9%) of the no-treatment group.

INTERVENTIONS

Patients assigned to the treatment group performed the self-CRP daily, whereas those assigned to the no-treatment group performed no exercises. Patients were followed for up to 2 years.

MAIN OUTCOME MEASURES

The main outcome measures were the rate of recurrence of BPPV and the time for BPPV to recur.

RESULTS

Of the 39 subjects, symptoms recurred in 16 (41%) of the total population, 6 (35%) of 17 of the treatment group, and 10 (46%) of 22 of the no-treatment group. There was no difference in the frequency of recurrence (Pearson chi; p = 0.522) or the time to recurrence (survival analysis; log-rank test; p = 0.242).

CONCLUSION

Our results suggest that a daily routine of the self-CRP does not affect the time to recurrence and the rate of recurrence of posterior canal-BPPV.

Relationship between bone mineral density and clinical features in women with idiopathic benign paroxysmal positional vertigo

OBJECTIVE

To evaluate the relationship between bone mineral density (BMD) and clinical features in women with idiopathic benign paroxysmal positional vertigo (IBPPV).

STUDY DESIGN

Prospective study.

SETTING

Tertiary referral center.

PATIENTS

Patients with BMD measurements made after a diagnosis of IBPPV were included. The IBPPV (n = 78) and control groups (n = 177) were divided into ordinal age categories of similar size. Group A (n = 20) patients were aged 20 to 39 years, Group B (n = 21) patients were aged 40 to 49 years, Group C (n = 18) patients were aged 50 to 59 years, and Group D (n = 19) patients were aged 60 to 69 years.

INTERVENTIONS

In each age range, the BMD values were compared according to the number of canalith repositioning maneuvers (CRMs) or the presence of recurrence. We divided all patients into 2 groups with the normal and abnormal BMD values and compared both groups based on the number of CRMs or the frequency of recurrence.

MAIN OUTCOME MEASURES

The BMD value, the number of CRMs, and the presence of recurrence.

RESULTS

In Groups A, B, and C, there was a significant difference in the BMD values between the control, 1-visit, and 2-or-more-visits subgroups. In Group D, the 2-or-more-visits subgroup had a lower BMD value than other subgroups. The difference in the number of CRMs between the normal and abnormal BMD groups was significant. In Groups A and B, there was a significant difference in the BMD values between the control, first-attack, and recurrent-attacks subgroups. In Groups C and D, the recurrent-attacks subgroup had lower BMD values than other subgroups. The difference in the frequency of recurrence between the normal and abnormal BMD groups was significant.

CONCLUSION

Patients with IBPPV had lower BMD values compared with control subjects, and patients with low BMD values showed a significant increase in the number of CRMs required and the recurrence rate.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

Objectives:

This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV.

Purpose:

The primary purposes of this guideline are to improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology–head and neck surgery, physical therapy, and physical medicine and rehabilitation.

Results

The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. ® 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

[Vertigo and falls in the elderly. Part 1: epidemiology, pathophysiology, vestibular diagnostics and risk of falling]

Disorders of the equilibrium function in the elderly will increase in the coming years due to demographic changes in Germany. In addition to a reduction in the quality of life of affected patients, the risk of suffering from a fall increases with age. At the morphological level age-specific changes of the peripheral vestibular structures, somatosensory pathways and vision can be found, such as degenerative alterations, reduced number of cells and receptors and an accumulation of lipofuscin. Disorders of the equilibrium function in old age are individual-specific, complex procedures which develop from age-related physiological, degenerative alterations in the components of the sensomotor system which maintain equilibrium and can come into being together with vestibular and non-vestibular accompanying diseases as well as psychological factors.

Ultrastructural changes in otoconia of osteoporotic rats

The etiology of benign paroxysmal positional vertigo (BPPV) remains obscure in many cases and women are affected more often than men. A recent prospective study, performed in women >50 years of age suffering from recurrent BPPV, showed associated osteopenia or osteoporosis in a large percentage of these patients. These results suggested the possible relationship between recurrent BPPV and a decreased fixation of calcium in bone in women >50 years. To test this hypothesis, an experimental study was performed in adult female rats. Utricular otoconia of female rats in which osteopenia/osteoporosis was induced by bilateral ovariectomy (OVX) were compared to those of sham-operated adult females rats (SHAM), as control group. FIRST STUDY: The morphology of theutricles of OVX and SHAM rats was analyzed with scanning electron microscopy. In osteopenic/osteoporotic rats, the density of otoconia (i.e. the number of otoconia per unit area) was decreased (p = 0.036)and their size was increased (p = 0.036) compared to the control group. SECOND STUDY: To test the role of calcium turnover in such morphological changes, utricular otoconia of 2 other groups of OVX and SHAM rats, previously injected with calcein subcutaneously, were examined by conventional and epifluorescence microscopy. In epifluorescence microscopy, labeling with calcein showed no significant fluorescence in either group. This finding was interpreted as a lack of external calcium turnover into otoconia of adult female rats. The ultrastructural modifications of otoconia in osteopenic/osteoporotic female adult rats as well as the role of estrogenic receptors in the inner ear are discussed. The possible pathophysiological mechanisms which support the relationship between recurrent BPPV in women and the disturbance of the calcium metabolism of osteopenia/osteoporosis are debated.

Recovery of otolith function in patients with benign paroxysmal positional vertigo evaluated by sinusoidal off-vertical axis rotation

The vestibulo-ocular reflex (VOR) was studied via sinusoidal off-vertical axis rotation (OVAR) to evaluate otolith function in patients with benign paroxysmal positional vertigo (BPPV). Subjects were sinusoidally rotated with eyes open in complete darkness at frequencies of 0.4 and 0.8 Hz with a maximum angular velocity of 60 degrees /s in earth vertical axis rotation (EVAR) and OVAR. Ten patients with BPPV patients were investigated. We performed OVAR tests for all patients for the following different points and compared otolith function: (1) The point at which patients had typical nystagmus; we call this state 'Before', that is, before recovery. (2) The point when their nystagmus disappeared; we call this state 'After' that is, after nystagmus disappear. Results showed that VOR gain during OVAR at 0.8 Hz in a 30 degrees nose-up position in BPPV patients was significantly less than the gain during EVAR at the point Before. On the other hand, gain was not significantly different between EVAR and OVAR at the point After. VOR gain itself at 0.8 Hz nose-up OVAR showed a significant increase at the point After compared to Before. This increase of VOR gain might be caused by the recovery of the otolith function in patients with BPPV.

Positional Vertigo and Cochlear Implantation

OBJECTIVE

To identify patients developing positional vertigo after cochlear implantation.

STUDY DESIGN

Prospective study on a cohort of patients undergoing cochlear implantation.

SETTING

Academic tertiary referral center.

PATIENTS

The study included 70 consecutive patients who underwent vestibular evaluation before and after cochlear implantation.

INTERVENTION

Medical record review.

MAIN OUTCOME MEASURE

Recorded vestibular symptoms after cochlear implantation. Patients with positional vertigo were considered case subjects, whereas those without vestibular symptoms were considered case controls.

RESULTS

Benign paroxysmal positional vertigo (BPPV) occurred in 8 patients (on the cochlear implant [CI] side in 7 patients, and in the other ear in 1). One patient had BPPV of the lateral semicircular canal on the implanted side, and 7 patients had BPPV of the posterior semicircular canal (on the same CI side in 6 patients, and on the opposite side in 1), which were detected and presented during the last examination. In 5 patients, the onset of symptoms varied from 7 to 130 days after implant activation; in 2 patients, the onset occurred before activation.

CONCLUSION

Three different mechanisms are proposed for the occurrence of BPPV in patients with CI. The first focuses on the fall of bone dust particles into the cochlea during cochleostomy. In the second, the vibration caused by drilling the cochlea would be sufficient to dislodge otoconia into the labyrinth. The third hypothesis suggests dislodging of an otolith because of the electric stimulation. In our patients, conservative approaches have been used with a minimal invasive cochleostomy and without perilymph suction. Thus, the vibratory trauma affecting the cochlea during cochleostomy seems to play a fundamental role in the development of paroxysmal vertigo in patients with implant.

Epidemiology of benign paroxysmal positional vertigo: a population based study

OBJECTIVES

To examine the prevalence and incidence, clinical presentation, societal impact and comorbid conditions of benign paroxysmal positional vertigo (BPPV) in the general population.

METHODS

Cross-sectional, nationally representative neurotological survey of the general adult population in Germany with a two stage sampling design: screening of 4869 participants from the German National Telephone Health Interview Survey 2003 (response rate 52%) for moderate or severe dizziness or vertigo, followed by validated neurotological interviews (n = 1003; response rate 87%). Diagnostic criteria for BPPV were at least five attacks of vestibular vertigo lasting <1 min without concomitant neurological symptoms and invariably provoked by typical changes in head position. In a concurrent validation study (n = 61) conducted in two specialised dizziness clinics, BPPV was detected by our telephone interview with a specificity of 92% and a sensitivity of 88% (positive predictive value 88%, negative predictive value 92%).

RESULTS

BPPV accounted for 8% of individuals with moderate or severe dizziness/vertigo. The lifetime prevalence of BPPV was 2.4%, the 1 year prevalence was 1.6% and the 1 year incidence was 0.6%. The median duration of an episode was 2 weeks. In 86% of affected individuals, BPPV led to medical consultation, interruption of daily activities or sick leave. In total, only 8% of affected participants received effective treatment. On multivariate analysis, age, migraine, hypertension, hyperlipidaemia and stroke were independently associated with BPPV.

CONCLUSION

BPPV is a common vestibular disorder leading to significant morbidity, psychosocial impact and medical costs.

Epidemiology of vertigo

PURPOSE OF REVIEW

Epidemiological findings on the distribution, determinants and outcome of vertigo can be used for clinical decision making and can help understand the underlying causes of vestibular diseases. This article gives an overview of the epidemiology of the vestibular symptom vertigo and of four specific vestibular disorders: benign paroxysmal positional vertigo, migrainous vertigo, Menière's disease and vestibular neuritis.

RECENT FINDINGS

Based on a neurotologic survey of the general population, 1-year prevalence estimates for vertigo were 4.9%, for migrainous vertigo 0.89% and for benign paroxysmal positional vertigo 1.6%. Diagnostic positional manoeuvres and treatments for benign paroxysmal positional vertigo, however, are still not being done by most doctors. The female preponderance among patients with benign paroxysmal positional vertigo and migrainous vertigo may be linked to migraine but is not fully understood. A recently reported prevalence of Menière's disease of 0.51% is much higher than previous estimates. Follow-up studies have shown benign paroxysmal positional vertigo recurrence rates of 50% at 5 years and a persistence of dizziness related to anxiety in almost a third of patients 1 year after vestibular neuritis.

SUMMARY

The epidemiology of vertigo and vestibular disorders is still an underdeveloped field. Recent studies have underscored the impact of vertigo at the population level, but its determinants and outcome are not well known yet.

Age-related changes on the morphology of the otoconia

OBJECTIVES/HYPOTHESIS

Although there are numerous reports on otoconial morphology using field-emission scanning electron microscopy (FESEM), there are few reports regarding the changes of otoconial morphology with aging. The aim of the current study was to investigate changes in otoconial morphology in rats according to age, using FESEM.

STUDY DESIGN

Laboratory study using experimental animals.

METHODS

We investigated age-related changes in otoconial morphology using FESEM in three groups of rats: young (1 wk old), middle-aged (6 mo old), and aged (23 mo old).

RESULTS

There was great size variation in utricular otoconia in the young and aged rats, but we found no clear regional separation of saccular otoconia in all groups based on size. In the oldest rats, the bodies of many otoconia in both maculae were pitted, fissured, penetrated, and eventually broken into several fragments. However, the terminal facets were smooth and the lines of intersection of facets were sharp, despite the degenerated bodies of the otoconia in this group. Giant otoconia were discovered frequently on the outer margin of the utricular maculae in aged rats. We directly observed weakened or broken linking filaments and otoconial fragments in the aged group.

CONCLUSION

The oldest rats showed the most degeneration of otoconia and linking filaments with otoconial fragments. This study of age-related morphologic changes in otoconia might help us understand the origin of idiopathic benign paroxysmal positional vertigo.

Mixing model systems: using zebrafish and mouse inner ear mutants and other organ systems to unravel the mystery of otoconial development

Human vestibular dysfunction is an increasing clinical problem. Degeneration or displacement of otoconia is a significant etiology of age-related balance disorders and Benign Positional Vertigo (BPV). In addition, commonly used antibiotics, such as aminoglycoside antibiotics, can lead to disruption of otoconial structure and function. Despite such clinical significance, relatively little information has been compiled about the development and maintenance of otoconia in humans. Recent studies in model organisms and other mammalian organ systems have revealed some of the proteins and processes required for the normal biomineralization of otoconia and otoliths in the inner ear of vertebrates. Orchestration of extracellular biomineralization requires bringing together ionic and proteinaceous components in time and space. Coordination of these events requires the normal formation of the otocyst and sensory maculae, specific secretion and localization of extracellular matrix proteins, as well as tight regulation of the endolymph ionic environment. Disruption of any of these processes can lead to the formation of abnormally shaped, or ectopic, otoconia, or otoconial agenesis. We propose that normal generation of otoconia requires a complex temporal and spatial control of developmental and biochemical events. In this review, we suggest a new hypothetical model for normal otoconial and otolith formation based on matrix vesicle mineralization in bone which we believe to be supported by information from existing mutants, morphants, and biochemical studies.

Episodic vertigo

PURPOSE OF REVIEW

This review focuses on three neuro-otological syndromes, which are all marked by rapid scientific progress on the one hand but under-recognition or undertreatment on the other: benign paroxysmal positional vertigo and its variants, superior semicircular canal dehiscence syndrome, and migrainous vertigo.

RECENT FINDINGS

The efficacy of Epley's maneuver for treatment of benign paroxysmal positional vertigo has been convincingly demonstrated by a meta-analysis of nine randomized controlled trials. Head vibration during Epley's procedure and keeping upright for 48 h after effective treatment do not improve the outcome. Superior canal dehiscence syndrome presents not only with sound and pressure-induced vertigo but also with conductive hearing loss at low frequencies. Migrainous vertigo may present not only with spontaneous attacks but also with positional vertigo or with chronic dizziness and imbalance. Vestibular rehabilitation has been proven to relieve chronic dizziness and visual vertigo.

SUMMARY

Recent studies have eliminated several white spots on the neuro-otological map. However, many areas are still unexplored, particularly with regard to treatment of specific vestibular syndromes where randomized controlled trials are just at their beginning.