Vertigo

[Increased report completeness and satisfaction with structured neurotological reporting in the interdisciplinary assessment of vertigo]

BACKGROUND

Results of neurotological function diagnostics in the context of interdisciplinary vertigo assessment are usually formulated as free-text reports (FTR). These are often subject to high variability, which may lead to loss of information. The aim of the present study was to evaluate the completeness of structured reports (SR) and referrer satisfaction in the neurotological assessment of vertigo.

MATERIALS AND METHODS

Neurotological function diagnostics performed as referrals (n = 88) were evaluated retrospectively. On the basis of the available raw data, SRs corresponding to FTRs from clinical routine were created by means of a specific SR template for neurotological function diagnostics. FTRs and SRs were evaluated for completeness and referring physician satisfaction (n = 8) using a visual analog scale (VAS) questionnaire.

RESULTS

Compared to FTRs, SRs showed significantly increased overall completeness (73.7% vs. 51.7%, p < 0.001), especially in terms of patient history (92.5% vs. 66.7%, p < 0.001), description of previous findings (87.5% vs. 38%, p < 0.001), and neurotological (33.5% vs. 26.7%, p < 0.001) and audiometric function diagnostics (58% vs. 32.3%, p < 0.001). In addition, SR showed significantly increased referring physician satisfaction (VAS 8.8 vs. 4.9, p < 0.001).

CONCLUSION

Neurotological SRs enable a significantly increased report completeness with higher referrer satisfaction in the context of interdisciplinary assessment of vertigo. Furthermore, SRs are particularly suitable for scientific data analysis, especially in the context of big data analyses.

Advanced progress of vestibular compensation in vestibular neural networks

Vestibular compensation is the natural process of recovery that occurs with acute peripheral vestibular lesion. Here, we summarize the current understanding of the mechanisms underlying vestibular compensation, focusing on the role of the medial vestibular nucleus (MVN), the central hub of the vestibular system, and its associated neural networks. The disruption of neural activity balance between the bilateral MVNs underlies the vestibular symptoms after unilateral vestibular damage, and this balance disruption can be partially reversed by the mutual inhibitory projections between the bilateral MVNs, and their top-down regulation by other brain regions via different neurotransmitters. However, the detailed mechanism of how MVN is involved in vestibular compensation and regulated remains largely unknown. A deeper understanding of the vestibular neural network and the neurotransmitter systems involved in vestibular compensation holds promise for improving treatment outcomes and developing more effective interventions for vestibular disorders.

Comparative Diagnostic Accuracy of Computed Tomography Scan versus Magnetic Resonance Imaging in the Emergency Department for the Evaluation of Dizziness: A Systematic Review

Introduction  Both computed tomography (CT) and magnetic resonance imaging (MRI) play significant roles in assessing patients with dizziness. However, understanding the comparative capabilities of these imaging methods in detecting pathological causes is crucial for determining the most suitable modality. This review aims to evaluate the diagnostic accuracy and clinical utility of MRI and CT scans in managing patients with acute dizziness in the emergency department. Methods  Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search in various databases (PubMed, Google Scholar, Cochrane library, British Medical Journals, and ScienceDirect) from 2010 to 2023. We used the QUADAS-2 tool to assess bias risk, considering MRI as the reference standard and CT scan as the index test. Results  The final analysis included six studies, with 3,993 patients (48% male, 52% female; average age: 56.7 years). Three studies were of high quality, two of medium quality, and one of low quality. Central ischemia was the predominant diagnosis for dizziness. MRI demonstrated higher diagnostic efficacy for stroke compared with CT scans, while mixed results were observed for other multiple diseases when both MRI and CT scans were used. Conclusion  MRI outperforms CT scans in diagnosing dizziness-related strokes. However, for other causes of dizziness, there is no significant difference between these techniques. Nevertheless, it is crucial to acknowledge the limitations associated with MRI. Consequently, to address these concerns, the selection of an imaging technique should be tailored to the individual based on factors such as their clinical presentation, comorbidities, and socioeconomic circumstances.

Association of Young-Onset Dementia with Pre-Existing Peripheral Vestibular Disorders

Background

The relationship between young-onset dementia and peripheral vestibular disorders remained largely unknown although this association was observed in the older population.

Objective

This case-control study aims to investigate the association of young-onset dementia with a pre-existing diagnosis of peripheral vestibular disorders using a population-based data from Taiwan's Longitudinal Health Insurance Database 2010.

Methods

This study included 989 patients with young-onset dementia and 2967 propensity-score-matching controls. Differences in baseline characteristic between patients with young-onset dementia and controls were investigated using chi-square tests or t-tests. Multiple logistic regression models were employed to assess the association of young-onset dementia (outcome) with pre-existing peripheral vestibular disorders (predictor).

Results

Compared to patients without young-onset dementia, those affected by this condition exhibited a statistically significantly higher rate of peripheral vestibular disorders (18.3% versus 8.2%, p < 0.001). Furthermore, our analysis found notable between-group disparities in the rates of Meniere's Disease (3.5% versus 2.0%, p= 0.015), benign paroxysmal positional vertigo (2.4% versus 1.1%, p= 0.006), and vestibular neuritis (2.4% versus 1.1%, p= 0.003). Multiple logistic regression analysis showed that the presence of prior peripheral vestibular disorders increased the odds of young-onset dementia [2.603 (95% CI = 2.105∼3.220)] after adjusting for age, sex, monthly income, geographic location, urbanization level, hyperlipidemia, diabetes, coronary heart disease, hearing loss, and hypertension.

Conclusions

The study findings demonstrate a notable association between young-onset dementia and pre-existing peripheral vestibular disorders, suggesting that vestibular malfunction could play a role in the development of young-onset dementia.

Vertigo and its burden of disease-Results from a population-based cohort study

Objectives

Vertigo describes symptoms of abnormal movement of the environment or the patient's own body. As such, it affects patients' quality of life, prevents them from following their daily activities, and increases healthcare utilization. The Global Burden of Disease Project aims to quantify morbidity and mortality worldwide. In 2013, a separate disability weight for vertigo was introduced. The aim of this study is to estimate the symptom burden of disease caused by vertigo.

Methods

This study analyzes data from the Gutenberg Health Study (GHS). The GHS is a population-based cohort study representative of the city of Mainz and its district. Participants were asked whether they suffered from vertigo and, if so, how bothered they felt by it, rating their distress on a six-level scale from 1 = little stressful to 6 = extremely stressful.

Results

Eight thousand five hundred and nineteen participants could be included in the study. The overall prevalence of vertigo was 21.6% (95%-confidence interval [CI] [20.7%; 22.5%]). Vertigo prevalence peaked in the age group of 55-64 years. Vertigo annoyance averaged 2.42 (± 1.28). When an annoyance of 3-6 was considered bothersome, the prevalence of bothersome vertigo was 8.1 % (95%-CI [7.5%; 8.7%]). Age-standardized to the European Standard Population 2013, vertigo caused a burden of 2102 years lived with disability per 100,000 population.

Conclusion

In this study, it was found that one in five people suffer at least occasionally from vertigo. This result suggests a significant burden of disease. This burden is reported at the symptom level. Future studies are needed to attribute the burden to specific causes.

Level of Evidence

2.

The effects of continuous administration of diazepam on the recovery of lesion-induced nystagmus in unilaterally labyrinthectomised rats

BACKGROUND

Diazepam, a gamma-aminobutyric acid type A receptor agonist, is classified as a vestibular suppressant and is effective in treating acute vertigo. However, its effects on vestibular compensation (VC) remain unclear.

OBJECTIVES

We examined the effects of continuous administration of diazepam on the frequency of spontaneous nystagmus (SN) after unilateral labyrinthectomy (UL) as an index of the initial process of VC in rats.

MATERIALS AND METHODS

Diazepam was continuously administered at doses of 3.5 and 7.0 mg/kg/day, intraperitoneally, via an osmotic minipump. The frequency of SN beating against the lesion side after UL was measured. Potassium chloride (KCl) solution (1 M) was injected intratympanically to induce SN beating to the injection side.

RESULTS

Continuous administration of diazepam significantly and dose-dependently decreased the frequency of SN after UL, and also reduced the x intercept of the nonlinear regression curve of the decline in UL-induced SN with time in rats. However, the continuous administration of diazepam did not affect the frequency of intratympanic KCl-induced SN in the rats.

CONCLUSION

These findings suggested that continuous administration of diazepam accelerates the initial process of VC; however, it does not suppress the nystagmus-driving mechanisms in rats.

Dizziness Among Population in a Tertiary care Centre in Maduranthagam

Dizziness is a common chief complaint and there is a broad variety of possible underlying diseases for dizziness. Physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. Diagnosis can be a challenge sometimes due to lack of dedicated vestibular lab and injudicious use of vestibular suppressant medications. In total of 100 cases were taken into study in which the most common was found to be benign paroxysmal positional vertigo and the most serious was cerebellar infarct and space occupying lesion. Complete evaluation of the patient should be done to arrive at a diagnosis. Therefore, a modification in the assessment methods of the dizzy patients with emphasis on history and clinical presentation seems essential.

Acupuncture Therapy for Peripheral Vestibular Vertigo (with Suspected Ménière's Disease)

Background

Vertigo occurs in the balance system, both peripherally and centrally. Vertigo that occurs due to abnormalities in the peripheral balance system is called peripheral vestibular vertigo. Pharmacologic therapies, such as vestibular suppressants, antiemetics, and benzodiazepines, are often used for complaints of spinning dizziness, but these drugs are not indicated for long-term daily use. Acupuncture can be a therapeutic choice for treating vertigo.

Case

Mrs. T.R., age 66, had episodic spinning dizziness for 18 months. Her dizziness recurred 3-4 times per month, and lasted ∼30 minutes to 2 hours. The dizziness was accompanied by cold sweating, but no nausea and vomiting. She also felt fullness in her right ear. A Rinne test was positive in both ears and a Weber test showed lateralization to the left. On a balance examination, the Fukuda stepping test showed 90° to the left. Her Vertigo Symptom Scale-Short Form (VSS-SF) score was 22. She was diagnosed with vestibular peripheral vertigo (Meniere's disease). Manual acupuncture therapy was performed 1-2 times per week at GV 20 (Baihui), TE 17 (Yifeng), GB 20 (Fengchi), LI 4 (Hegu), and LR 3 (Taichong).

Results

After 6 sessions of acupuncture therapy, this patient no longer experienced spinning dizziness and her score on the VSS-SF questionnaire was reduced to 4.

Conclusions

This case report shows that acupuncture therapy was very helpful for a patient with peripheral vestibular vertigo. Acupuncture can be used to treat patients who have vertigo and contraindications to pharmacologic therapies, and can to reduce side-effects of pharmacologic therapies. Further investigation of acupuncture therapy for peripheral vertigo is warranted.

Complex benign horizontal canal positional vertigo: new perceptual management

OBJECTIVE

Horizontal semicircular canal site pathology of benign paroxysmal positional vertigo demonstrating three types of nystagmi on positional test were studied. We have attempted to design a protocol for its diagnosis and treatment.

METHODS

320 patients of HSC-BPPV were subjected to two types of positional tests. Of these, patients with bilateral steady apogeotropic nysatgmus were treated with VAV modification of Semont's maneuver. Patients with unsteady or changing apo/geotropic signs were converted into steady geotropic ones by repetitive positional tests; followed by barbecue maneuver with forced prolong positioning.

RESULTS

Overall 88% of patients had a total recovery. 92% of patients with geotropic nystagmus showed no symptoms after second maneuveral sitting. 85% of patients with apogeotropic nystagmus recovered fully after third maneuveral sitting.

CONCLUSIONS

Correct identification of subtypes of HSC-BPPV is based on provoked nystagmus by positional tests. After locating the site and side on the basis of nystagmic pattern, physician can apply the appropriate PRM.

LEVEL OF EVIDENCE

II a.

A Holistic Approach to a Dizzy Patient: A Practical Update

Dizziness is one of the most common symptoms encountered by physicians daily. It is divided into four categories: vertigo, disequilibrium, presyncope, and psychogenic dizziness. It is essential to distinguish these four symptoms because the causes, prognosis, and treatment differ. Vertigo constitutes a disease of the central or peripheral nervous system. Central origin vertigo may be a life-threatening situation and must be detected as soon as possible because it includes diseases such as stroke, hemorrhage, tumors, and multiple sclerosis. Peripheral origin vertigo includes benign diseases, which may be fully treatable such as vestibular migraine, benign paroxysmal positional vertigo, vestibular neuritis, Ménière’s disease, and cervical vertigo. The HINTS (head impulse, nystagmus, test of skew) examination is essential to distinguish central from peripheral causes. A detailed history including the duration of vertigo (episodic or continuous), its trigger, and a clinical examination step by step following the appropriate protocol could help to make a definite and accurate diagnosis and treatment. Due to a lack of expertise in dizziness and inappropriate treatment, many patients are admitted to dizziness clinics with long-standing dizziness. A holistic treatment combining medications, vestibular rehabilitation, physiotherapy, and psychotherapy should be initiated to improve the quality of life of these patients. So, this review aims to recommend a clinical protocol for approaching a dizzy patient with vertigo and to present in detail the epidemiology, pathophysiology, symptoms, diagnosis, and contemporary treatments of all causes of vertigo.

Efficacy of Yokukansan, a traditional Japanese herbal medicine, in patients with dizziness and irritability

OBJECTIVE

Irritability is an emotional stress symptom that causes or exacerbates dizziness. Antidepressants may be helpful for some conditions that are accompanied by irritability; however, they do not completely inhibit irritability. Yokukansan (YKS), a traditional Japanese herbal medicine, has been used for neurosis, insomnia, and children's irritability and night crying. The study investigated the efficacy of YKS in nystagmus in patients with chronic dizziness and irritability.

METHODS

Twenty-two cases with chronic dizziness and irritability were reviewed retrospectively. The patients were divided into two groups: control patients (0-7 days of treatment) and YKS-treated patients (YKS cases; >7 days of treatment). Dizziness before and during (after, in the controls) YKS treatment was evaluated by scoring the nystagmus intensity on a 5-point scale. The average scores were calculated within a maximum of 6 months before and during or after treatment. The normalized scores were also calculated. The optimal treatment regimen was calculated via receiver operating characteristic (ROC) curve analysis.

RESULTS

There were six control cases (1 male, 5 females; mean age: 59.5 years). There were 16 YKS cases (3 males, 13 females; mean age: 61.8 years). While the group mean nystagmus intensity scores significantly decreased from 1.18 to 0.73 in the YKS cases, it did not change in the control cases. The group mean of the normalized nystagmus intensity scores during treatment was 0.73 in the YKS cases. The results of the ROC curve analysis indicated the optimal cut-off period of the YKS treatment was 10 days.

CONCLUSION

The oral administration of YKS for more than 10 days was optimal. The treatments with YKS could be a good option for the treatments of vertigo.

Vestibular rehabilitation in benign paroxysmal positional vertigo: Reality or fiction?

The objective of this article is to systematically review the evidence on the effectiveness of vestibular rehabilitation (VR) in patients with benign paroxysmal positional vertigo (BPPV). Relevant published studies about VR in BPPV were searched in PubMed, Google Scholar and Ovid using various keywords. We included trials that were available in the English language and did not apply publication year or publication status restrictions. Studies based on the VR in other peripheral and/or central balance disorders are excluded. Primary outcome was the effect on vertigo attacks and balance. Of 42 identified trials, only 12 trials fulfilled our inclusion criteria and were included in this review. Three of them investigated the role of VR in patients with BPPV comparing with no treatment, two of them evaluated the efficacy of VR versus medications, seven of them have highlighted the benefits of the VR alone or in combination with canalith repositioning procedure (CRP) compared to CRP alone. The studies differed in type of intervention, type of outcome and follow-up time. VR improves balance control, promoting visual stabilization with head movements, improving vestibular–visual interaction during head movement and expanding static and dynamic posture stability. CRP and VR seem to have a synergic effect in patients with BPPV, especially in elderly patients. VR does not reduce the recurrence rate, but it seems to reduce the unpleasantness. So VR can substitute CRP when spine comorbidities contraindicate CRP and can reduce the uptake of anti-vertigo drugs post CRP. Further studies are needed to confirm these encouraging results.

Spontaneous Intracranial Hypotension: A Rare Cause of Labyrinthine Hydrops

Spontaneous intracranial hypotension should be considered as a possible cause of cochlear hydrops. We report a case of unilateral hearing loss attributed to spontaneous intracranial hypotension on the basis of characteristic abnormalities seen on magnetic resonance imaging. The diagnostic gold standards for intracranial hypotension are lumbar measurement of cerebrospinal fluid pressure and magnetic resonance imaging. The usual treatment is an autologous blood injection into the peridural spaces. The mechanism of hearing loss is thought to involve secondary perilymph depression due to a patent cochlear aqueduct. This perilymph depression would induce a compensatory expansion of the endolymphatic compartment, with a subsequent decrease in basilar or Reissner's membrane compliance. Endolymphatic hydrops can occur in the course of intracranial hypotension, and not only because of abnormal endolymph production or resorption. Hydrops can thus be classified into 1) syndromes of endolymphatic origin and 2) syndromes of perilymphatic origin, in which loss of perilymph induces compensatory expansion of the endolymphatic space.

Decreased risk of stroke in patients receiving traditional Chinese medicine for vertigo: A population-based cohort study

ETHNOPHARMACOLOGICAL RELEVANCE

Patients with vertigo are reported to exhibit a higher risk of subsequent stroke. However, it remains unclear if Traditional Chinese Medicine (TCM), the most common form of complementary and alternative medicine, can help lower the risk of stroke for these patients. So the aim of the study was to investigate the effects of TCM on stroke risk among patients with vertigo.

MATERIALS AND METHODS

This longitudinal cohort study used the Taiwanese National Health Insurance Research Database to identify 112,458 newly diagnosed vertigo patients aged ≥20 years who received treatment between 1998 and 2007. Among these patients, 53,203 (47.31%) received TCM after vertigo onset (TCM users), and the remaining 59,201 patients were designated as a control group (non-TCM users). All enrollees received follow-up until the end of 2012 to measure stroke incidence. Cox proportional hazards regression was used to compute the hazard ratio (HR) of stroke in recipients of TCM services.

RESULTS

During 15-year follow-up, 5532 TCM users and 12,295 non-TCM users developed stroke, representing an incidence rate of 13.10% and 25.71% per 1000 person-years. TCM users had a significantly reduced risk of stroke compared to non-TCM users (adjusted HR=0.64; 95% confidence interval CI=0.59-0.74). The predominant effect was observed for those receiving TCM for more than 180 days (adjusted HR=0.52; 95% CI=0.49-0.56). Commonly used TCM formulae, including Ban-Xia-Bai-Zhu-Tian-Ma-Tang, Ling-Gui-Zhu-Gan-Tang, Bai Zhi (Angelica dahurica (Hoffm.) Benth. & Hook.f. ex Franch. & Sav., root), Ge Gen (Pueraria lobata (Willd.) Ohwi, root) and Hai Piao Xiao (Endoconcha Sepiae, Cuttlefish Bone) were significantly associated with lower risk of stroke.

CONCLUSIONS

Results of this population-based study support the effects of TCM on reducing stroke risk, and may provide a reference for stroke prevention strategies. The study results may also help to integrate TCM into clinical intervention programs that provide a favorable prognosis for vertigo patients.

An overview of vestibular rehabilitation

Data related to the efficacy of vestibular rehabilitation and its evolution as an intervention are provided. Concepts and various treatment strategies are described, with explanations of why people with uncompensated peripheral and central vestibular disorders might improve with rehabilitation. Various tests and measures are described that are commonly used to examine patients and determine their level of ability to participate in their environment. Factors that affect recovery, both positively and negatively, are described in order to better prognosticate recovery. A case utilizing many of the principles discussed is included to provide insight into how to utilize vestibular rehabilitation with a person with an uncompensated peripheral vestibular loss.

Approach to dizziness in the emergency department

Acute dizziness/vertigo is among the most common causes for visiting the emergency department. The traditional approach to dizziness starts with categorizing dizziness into four types: vertigo, presyncope, disequilibrium, and nonspecific dizziness. However, a recently proposed approach begins with classifying dizziness/vertigo as acute prolonged spontaneous dizziness/vertigo, recurrent spontaneous dizziness/vertigo, recurrent positional vertigo, or chronic persistent dizziness and imbalance. Vestibular neuritis and stroke are key disorders causing acute prolonged spontaneous dizziness/vertigo, but the diagnosis of isolated vascular vertigo has increased by virtue of developments in clinical neurotology and neuroimaging. However, a well-organized bedside examination appears more sensitive than brain imaging in diagnosing strokes presenting with acute dizziness/vertigo. A detailed history is vital to diagnose recurrent spontaneous dizziness/vertigo since confirmatory diagnostic tests are usually unavailable. Isolated positional vertigo is usually caused by benign paroxysmal positional vertigo, which can be treated at the bedside. In recent years, marked progress has occurred in the evaluation/management of acute dizziness/vertigo. However, even with developments in imaging technology, the diagnosis of acute dizziness/vertigo largely relies on bedside examination.

[The level of beta-endorphin, chronic stress, and depression associated with vestibular pathology]

The objective of the present study was to evaluate the presence and the severity of manifestations of anxiety and depression in the patients presenting with vestibular dysfunction making use of the psychometric scales and taking into consideration variations in the plasma beta-endorphin level as a biochemical marker before and after medicamental and physical rehabilitative treatment. A total of 8 patients presenting with stage I-III Meniere's disease and 8 patients suffering from dyscirculatory encephalopathy concomitant with vestibular ataxic syndrome were available for the observation. We separately analysed the results of examination of two patients with vestibular neuronitis and two others presenting with vestibular migraine. It was shown that the degree of anxiety and depression correlated with the plasma beta-endorphin level whereas its correlation with the severity of vestibular oculomotor and vestibular motor disorders during the inter-bout periods was not documented. It was demonstrated that the plasma beta-endorphin level was many times higher than the normal value of 20 ng/l in the patients with the well apparent vegetative symptoms accompanied by dizziness and the patients suffering from vegetative migraine.

Clinical assessment of dizzy patients: the necessity and role of diagnostic tests

Over administration of diagnostic tests in health care settings is a critical issue, imposing a great deal of expenditure on health sector. Vertigo and dizziness are common complaints of many patients who seek medical advice, and the vast majority of them undergo several evaluations, including Brain Magnetic Resonance Imaging (MRI), Laboratory tests, Pure Tone Audiometry (PTA), and Electrocardiography (ECG). The aim of this study was to investigate the performing rate of these diagnostic tests, and to evaluate their necessity and medical indications. This study was conducted on 270 dizzy patients referred to Apadana Dizziness and Vertigo Clinic, Ahvaz, Iran, from July 2008 to February 2013. Of these, 71.9% were diagnosed with peripheral lesions while laboratory assessment (58.1%) and brain MRI (38.1%) were the most requested tests. Age was an important factor, affecting the frequency of performing the ECG and Brain MRI. Medications were still administered widely even to those who seemed to respond well enough to vestibular rehabilitation. These findings revealed that many unnecessary and time-consuming diagnostic tests were performed, which had minor contribution to the final diagnosis and treatment of the patients. Therefore, a modification in the assessment methods of the dizzy patients with emphasis on history and clinical presentation seems essential.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

Clinical significance of orthostatic dizziness in the diagnosis of benign paroxysmal positional vertigo and orthostatic intolerance

PURPOSE

Orthostatic dizziness (OD) and positional dizziness (PD) are considerably common conditions in dizziness clinic, whereas those two conditions are not clearly separated. We aimed to evaluate the clinical significance of simple OD and OD combined with PD for the diagnosis of benign paroxysmal positional vertigo (BPPV) and orthostatic intolerance (OI).

PATIENTS AND METHODS

Patients presenting with OD (n=102) were divided into two groups according to their symptoms: group PO, presenting with PD as well as OD; group O, presenting with OD. A thorough medical history, physical examination, and vestibular function tests were performed to identify the etiology of the dizziness. Orthostatic vital sign measurement (OVSM) was used to diagnose OI.

RESULTS

The majority of patients were in group PO (87.3%). BPPV was the most common cause of OD for entire patients (36.3%) and group PO (37.1%), while OI was most common etiology for group O (38.5%). Total of 17 (16.7%) OI patients were identified by OVSM test. Orthostatic hypotension (n=10) was most frequently found, followed by orthostatic hypertension (n=5), and orthostatic tachycardia (n=2). Group O showed significantly higher percentage (38.5%) of OI than group PO (13.5%) (P=0.039).

CONCLUSION

It is suggested that orthostatic testing such as OVSM or head-up tilt table test should be performed as an initial work up for the patients with simple OD. Positional tests for BPPV should be considered as an essential diagnostic test for patients with OD, even though their dizziness is not associated with PD.

[Sudden onset vertigo: imaging work-up]

Vertigo and dysequilibrium are a frequent cause of medical consultation. Clinical evaluation is essential. Some cases of vertigo are diagnosed clinically while others require imaging, sometimes emergently (suspected stroke). MRI is the imaging modality of choice to assess the labyrinth (labyrinthitis? labyrinthine hemorrhage?), internal auditory canal (vestibular schwannoma? other tumor?…) and brain parenchyma including all structures of the auditory pathways: vestibular nuclei, vestibulocerebellar tract, tracts involved with ocular motricity, vestibular cortex… Multiple central etiologies exist: stroke, multiple sclerosis, tumor… However, some etiologies are best depicted with CT, especially lesions of the labyrinth: cholesteatoma, trauma, suspected dehiscence of the superior semicircular canal, suspected labyrinthine fistula… Finally, imaging may be negative (Benign Paroxysmal Positional Vertigo, Meniere's disease, vestibular neuritis, migraine…), merely reducing the differential diagnosis.

Vestibular rehabilitation of older adults with dizziness

The role of rehabilitation for treatment of older adults with dizziness and balance disorders is reviewed. Theories related to functional recovery from peripheral and central vestibular disorders are presented. Suggestions on which older adults might benefit from vestibular rehabilitation therapy are presented. Promising innovative rehabilitation strategies and technologies that might enhance recovery of the older adult with balance dysfunction are discussed.

Emergency department documentation templates: variability in template selection and association with physical examination and test ordering in dizziness presentations

Background

Clinical documentation systems, such as templates, have been associated with process utilization. The T-System emergency department (ED) templates are widely used but lacking are analyses of the templates association with processes. This system is also unique because of the many different template options available, and thus the selection of the template may also be important. We aimed to describe the selection of templates in ED dizziness presentations and to investigate the association between items on templates and process utilization.

Methods

Dizziness visits were captured from a population-based study of EDs that use documentation templates. Two relevant process outcomes were assessed: head computerized tomography (CT) scan and nystagmus examination. Multivariable logistic regression was used to estimate the probability of each outcome for patients who did or did not receive a relevant-item template. Propensity scores were also used to adjust for selection effects.

Results

The final cohort was 1,485 visits. Thirty-one different templates were used. Use of a template with a head CT item was associated with an increase in the adjusted probability of head CT utilization from 12.2% (95% CI, 8.9%-16.6%) to 29.3% (95% CI, 26.0%-32.9%). The adjusted probability of documentation of a nystagmus assessment increased from 12.0% (95%CI, 8.8%-16.2%) when a nystagmus-item template was not used to 95.0% (95% CI, 92.8%-96.6%) when a nystagmus-item template was used. The associations remained significant after propensity score adjustments.

Conclusions

Providers use many different templates in dizziness presentations. Important differences exist in the various templates and the template that is used likely impacts process utilization, even though selection may be arbitrary. The optimal design and selection of templates may offer a feasible and effective opportunity to improve care delivery.

Neuro-otological symptoms in patients with migraine

INTRODUCTION

Neurootological symptoms are common in patients with migraine, and have been reported to be associated with diverse conditions.

PATIENTS AND METHODS

A total of 70 patients with a diagnosis of episodic migraine, with or without aura, attending our Migraine Unit were selected. The specific variables studied were the diagnosis of instability, psycho-physiological dizziness, presyncopal symptoms, benign paroxysmal positional vertigo (BPPV), migraine associated recurrent vertigo (MARV), and Meniere's disease.

RESULTS

A total of 44.3% of cases had orthostatism or syncope, 15.7% with instability (possibly due to bilateral vestibular hypofunction), 14.2% with MARV and 8.6% with BPPV. The presence of BPPV was observed in older patients (40 years), whilst MARV was a condition seen in younger ones (35 years). These findings are of interest and remind us that benign paroxysmal vertigo is a childhood condition and age is a risk for BPPV.

CONCLUSIONS

Migraine patients often present with neuro-otological symptoms that can be classified as inter-episodic and episodic symptoms, and specific and non-specific migraine symptoms. This approach is of obvious pathophysiological interest, given that MARV and the possible vestibular hypofunction of migraine patients are symptoms that share physiological aspects with migraine, while the orthostatism symptoms and BPPV are non-specific and are seen to be associated with other conditions.

Enhanced external counterpulsation and traction therapy ameliorates rotational vertebral artery flow insufficiency resulting from cervical spondylosis

STUDY DESIGN

Clinical trial of patients with rotational vertebrobasilar insufficiency (VBI) resulting from cervical spondylosis.

OBJECTIVE

To investigate the effectiveness of enhanced external counterpulsation (EECP) and traction therapy for these patients.

SUMMARY OF BACKGROUND DATA

EECP would reduce arterial stiffness and vascular resistance, and increase regional blood flow of vertebral arteries, thus may ameliorate symptoms in these patients.

METHODS

One hundred sixty-three patients who were clinically suspected rotational VBI caused by cervical spondylosis were enrolled in this study. They were randomly allocated into 3 groups: EECP + traction, EECP, and traction group. All patients and 50 healthy volunteers received transcranial color Doppler examination of the vertebral artery and basilar artery in both a neutral cervical spine position and a rotational position.

RESULTS

Within 3 days after treatment, 47 (84%) patients in EECP + traction group, 32 (61%) patients in EECP group, and 8 (15%) patients in traction group achieved successful outcomes, while at 3 months' follow-up, 45 (80%) patients in EECP + traction group, 34 (64%) in EECP group, and 3 (6%) in traction group achieved successful outcomes. With head rotation, the percentage of reduction of blood flow velocities of the vertebrobasilar artery (VBA) in patients was much greater than that of the healthy volunteers (P < 0.01). After treatment, rotational blood flow velocity reduction percentage of VBA in each treatment group was much lower than that of each group before treatment. EECP + traction group experienced the greatest decrease of rotational blood flow velocity reduction percentage of VBA, while EECP group experienced second greatest.

CONCLUSION

EECP and traction therapy can relieve the symptoms of rotational VBI, improve the rotational reduction of vertebrobasilar blood flow, and reduce the increased arterial impedance.

[Results evaluation in cervical vertigo kinesitherapy--preliminary report]

INTRODUCTION

The work aimed at analyzing results of kinesitherapeutic procedures in patients with cervical vertigo as well as evaluating a mobility range of the cervical spine.

MATERIAL AND METHODS

The study was conducted on 23 people, including 17 women and 6 men suffering from cervical vertigo, at the age of 23-73 (the average age of 49.5). All the patients had an individually selected cycle of kinesitherapeutic exercises through the period of 2 months. The objective efficiency evaluation of the applied therapy was made on the grounds of the videonystagmographic examination (VNG). Additionally, the range of active mobility of the cervical spine was analyzed and the evaluation of vertigo according to Silvoniemi's criteria was performed.

STUDY RESULTS

After a 2-month therapy 4 patients (17.4%) out of the examined material showed a total lack of vertigo, 15 patients (65.2%) demonstrated a meaningful decrease in the vertigo intensity, also in the frequency of their occurrence in 14 cases (60.8%). Only 3 patients did not show any decrease in vertigo whereas in 1 patient a slight increase in the intensity was indicated. On the basis of a subjective evaluation of the vertigo increase according to the 5-stage Silvoniemi's scale it was proved that a mean point assessment claimed by the patients at the beginning of the therapy amounts to 3.0 points whereas after the therapy it was as follows: 1.43 pt after 2 weeks, 1.17 pt after 1 month and 1.13 pt after 2 months of kinesitherapy.

CONCLUSIONS

It is extremely difficult to fully eliminate the symptoms of cervical vertigo (in the studied material in 4 cases--17.3%) because the causes of their occurrence, which are connected with excessive tension and degeneration in the cervical spine, cannot usually be eradicated. Additionally, as a diagnostic means, the videonystagmographic examination (VNG) accompanied by the positioning tests and the cervical rotation test facilitates precise and objective monitoring of the progress in treatment and rehabilitation of vertigo.

Causes of persistent dizziness in elderly patients in primary care

PURPOSE

Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of dizziness.

METHODS

We performed a cross-sectional diagnostic study among elderly patients in the Netherlands consulting their family physician for persistent dizziness. All patients underwent a comprehensive evaluation according to a set of diagnostic tests that were developed during an international Delphi procedure. Data for each patient were independently reviewed by a panel consisting of a family physician, a geriatrician, and a nursing home physician, which resulted in major and minor contributory causes of dizziness.

RESULTS

From June 2006 to January 2008, we included 417 patients aged 65 to 95 years. Presyncope was the most common dizziness subtype (69%). Forty-four percent of the patients were assigned more than 1 dizziness subtype. Cardiovascular disease was considered to be the most common major contributory cause of dizziness (57%), followed by peripheral vestibular disease (14%), and psychiatric illness (10%). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23%). Sixty-two percent of the patients were assigned more than 1 contributory cause of dizziness.

CONCLUSIONS

Contrary to most previous studies, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care. In one-quarter of all patients an adverse drug effect was considered to be a contributory cause of dizziness, which is much higher than reported in previous studies.

Benign paroxysmal positional vertigo as the cause of dizziness in patients after severe traumatic brain injury: diagnosis and treatment

OBJECTIVES

To identify patients with benign paroxysmal positional vertigo (BPPV) among patients with severe traumatic brain injury (TBI) and to evaluate the effectiveness of the Particle Repositioning Maneouvre (PRM).

DESIGN AND METHODS

Eighteen months prospective study of 150 consecutive patients with severe TBI referred to an in-patients rehabilitation department.

INTERVENTIONS

A structured interview emphasizing the possible presence of vertigo followed by a detailed neuro-otological examination. Patients diagnosed with BPPV were immediately treated with the PRM.

MAIN OUTCOMES AND RESULTS

BPPV diagnosis was based on a positive Dix-Hallpike positional test. PRM efficacy was determined by repeating the positional test 1 or 2 weeks after treatment. Twenty out of 150 (13.3%) patients complained about positional vertigo. The diagnosis of BPPV was confirmed in 10 patients. Signs and symptoms were completely relieved in six patients after a single PRM, while the other four patients needed repeated treatment for complete resolution of BPPV.

CONCLUSIONS

About half of the patients with severe TBI who complain about positional vertigo suffer from BPPV. These patients can be efficiently treated by physical maneouvres improving the rehabilitation outcome.

[Vertigo treatment according to their mechanisms]

Vertigo is an illusion of rotatory or linear movement that demonstrates a functional or lesional disturbance of the vestibular system, from periphery to central connections. According to the ANAES report (1997), benign paroxysmal positional vertical vertigo, vestibular neuronitis and Ménière's disease account for 40-50% of all mixed vertigo etiologies. Central etiologies may account for 20-40% of causes and 10-40% remain more difficult to classify, and are usually classified under the term of "peripheral vestibulopathy." These include vertigo due to neurovascular compression syndrome of the VIIIth nerve. Clinical manifestations, differential diagnosis, and treatment of the main etiologies of vertigo will be developed in this chapter. A specific section will discuss the subject of neurovascular compression syndrome of the VIIIth nerve. Even though some publications should be challenged, it appears that neurovascular compression syndrome of the VIIIth nerve might explain some cases of vertigo or chronic instability, with or without cochlear signs. The diagnosis is difficult and must be established on multiple clinical, electrophysiological and radiological arguments. A therapeutic test with antiepileptic drugs is helpful. The treatment includes these drugs as a first option but may require a neurosurgical approach if medical treatment fails.

Current treatment of nausea and vomiting associated with gastroparesis: antiemetics, prokinetics, tricyclics

Gastroparesis is a symptomatic chronic disorder characterized by delayed gastric emptying without a mechanical obstruction. Gastroparesis is most often associated with diabetes, gastric surgery, and systemic disorders affecting the neuromuscular control of the stomach. However, no underlying etiology can be found in up to 40% of patients, a condition referred to as idiopathic gastroparesis. Due to the numerous potential etiologies and the highly variable clinical manifestations, the management of gastroparesis is particularly challenging. The purpose of this review is to provide an update on the use of antiemetics, prokinetics, and tricyclics for the treatment for nausea and vomiting associated with gastroparesis.

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.