What proportion of patients referred to an otolaryngology vertigo clinic have an otological cause for their symptoms?

Dizziness and Imbalance Across the Lifespan: Findings of a Pediatric and Adult Vestibular Clinic

OBJECTIVE

To evaluate diagnostic trends in pediatric and adult patients presenting for multidisciplinary subspecialty evaluation of dizziness and imbalance across the lifespan.

STUDY DESIGN

Retrospective chart review.

SETTING

Single pediatric and single adult academic tertiary care hospital.

METHODS

Retrospective review of electronic health record for patients presenting to an adult or pediatric multidisciplinary vestibular clinic from 2017 to 2020, including clinical data, physical therapy evaluation, and audiovestibular testing.

RESULTS

A total of 1934 patients aged 1 to 95 were evaluated. Most patients were female (n = 1188, 61%); the largest cohort was in the fifth decade of life (n = 321, 17%). Seventy-six percent of patients (n = 1470) were assigned a pathologic diagnosis. Central causes of dizziness were most common in children and young adults, comprising 38% to 54% of all diagnoses in ages 1 to 30. The proportion of peripheral vestibular disorders increased with age, peaking at 32% in ages 61 to 70. Vestibular migraine was the most common pathologic diagnosis in ages 6 to 20 (n = 110, 39%) and 31 and 50 (n = 69, 17%) regardless of gender, but was more prevalent in females (21% vs 14%; P < .0001). The prevalence of benign paroxysmal positional vertigo (BPPV) increased throughout the lifespan, peaking at age 71 to 80. Meniere's disease (MD) did not occur within the first decade of life, but increased thereafter, peaking at ages 51 to 60.

CONCLUSION

Multidisciplinary vestibular evaluation resulted in a diagnosis for the majority of patients. Vestibular diagnoses vary across the lifespan however among most age groups, central disorders, including migraine disorders, outnumber peripheral vestibulopathies. The prevalence of peripheral vestibular disorders such as BPPV and MD increased with age.

LEVEL OF EVIDENCE

Level IV.

Overview of Dizziness in Practice

The evaluation of dizziness as a chief complaint can be exceptionally challenging to otolaryngologists. The critical piece in evaluating dizzy patients is to have a plan for how to screen and schedule, how to gather data, and to develop a workflow for testing that allows clinical efficiency. This article provides an overview of evidence-based practices on how to screen dizzy patients before being scheduled, how to efficiently move patients through the otolaryngologist's clinic, and strategies for managing a dizzy practice.

Virtual and augmented reality in the vestibular rehabilitation of peripheral vestibular disorders: systematic review and meta-analysis

Vestibular rehabilitation therapy is an established treatment for patients with vestibular dysfunction. Virtual reality (VR) and augmented reality (AR) can be utilised in vestibular rehabilitation. Evidence of the efficacy of VR and AR delivered rehabilitation in patients with peripheral vestibular disorders is reviewed. MEDLINE, EMBASE, CENTRAL, CINAHL, PsychInfo, PsychBITE, OTSeeker, Ei Compendex, IEE, Clinical trials.gov and WebofScience databases were searched. Reduction in vestibular dysfunction symptoms 0-3 months post-intervention was the primary outcome. Secondary outcomes included long-term symptom improvement and side effects. Risk of bias assessment and meta analyses were planned. Five studies meeting eligibility criteria were included. Dizziness Handicap Inventory (DHI) scores 0-3 months post-intervention were reported by four studies. Meta-analysis identified a 1.13 (95% CI, - 1.74, - 0.52) standardized mean difference reduction in DHI in VR and AR treated patients compared to controls. Side effects reported by two studies were reduced by week four of VR intervention. Bias assessment identified DHI scores and side effects to be at high risk or of some concern. Adjunct VR interventions reduced patient DHI significantly more than vestibular rehabilitation alone 0-3 months post-intervention in adult patients diagnosed with unilateral vestibular disease. High quality studies are needed.

The Interrelations Between Different Causes of Dizziness: A Conceptual Framework for Understanding Vestibular Disorders

Background:

According to population-based studies that estimate disease prevalence, the majority of patients evaluated at dizziness clinics receive a single vestibular diagnosis. However, accumulating literature supports the notion that different vestibular disorders are interrelated and often underdiagnosed.

Objective:

Given the complexity and richness of these interrelations, we propose that a more inclusive conceptual framework to vestibular diagnostics that explicitly acknowledges this web of association will better inform vestibular differential diagnosis.

Methods:

A narrative review was performed using PubMed database. Articles were included if they defined a cohort of patients, who were given specific vestibular diagnosis. The interrelations among vestibular disorders were analyzed and placed within a conceptual framework.

Results:

The frequency of patients currently receiving multiple vestibular diagnoses in dizziness clinic is approximately 3.7% (1263/33 968 patients). The most common vestibular diagnoses encountered in the dizziness clinic include benign paroxysmal positional vertigo (BPPV), vestibular migraine, vestibular neuritis, and Ménière’s disease.

Conclusions:

A review of the literature demonstrates an intricate web of interconnections among different vestibular disorders such as BPPV, vestibular migraine, Ménière’s disease, vestibular neuritis, bilateral vestibulopathy, superior canal dehiscence syndrome, persistent postural perceptual dizziness, anxiety, head trauma, and aging, among others.

Sleep apnea, daytime somnolence, and idiopathic dizziness--a novel association

OBJECTIVES/HYPOTHESIS

To determine if an association exists between sleep apnea, daytime somnolence, and chronic idiopathic dizziness.

STUDY DESIGN

Case-control study of new patients presenting to a tertiary neuro-otologic practice. A total of 46 subjects with idiopathic dizziness (ID), 20 positive controls with dizziness (benign paroxysmal positional vertigo [BPV]), and 69 negative controls with hearing loss (HL) but no dizziness were enrolled.

METHODS

Participants who were patients diagnosed with the above conditions and who met all other inclusion criteria completed a sleep questionnaire and had a complete physical exam and investigations to establish or exclude a neuro-otologic diagnosis. They were subsequently evaluated for risk of symptomatic sleep disturbance based on the Epworth Sleepiness Scale (ESS), the Berlin Questionnaire, and the Multivariable Apnea Risk Index (MAP). Statistical analysis was carried out using SPSS (SPSS Inc., Chicago, IL).

RESULTS

There was no significant demographic difference among the groups in terms of age, sex, body mass index, neck size, alcohol consumption, or smoking. Using a cutoff of both 10 and 12 on the ESS, the ID were more likely to have significant daytime somnolence than the HL group, with a likelihood ratio (LR) of 7.8 for the ESS 12 score (P = .021) and 7.1 for the ESS 10 score (P = .029). Using the MAP score, a statistically significant difference between the ID group and both the BPV group (LR 3.99, P = .046) and the HL group (LR 5.46, P = .019) was found.

CONCLUSIONS

This study suggests that a previously undescribed link between idiopathic dizziness, daytime somnolence, and sleep apnea might exist. Prospective investigation is warranted to determine whether treatment of any sleep issues resolves symptoms of idiopathic dizziness.

An Unusual Presentation of Vertigo: Is Head Titubation the Key to Diagnosis?

Objective. Discuss complex interplay of pathophysiological effects of cerebellar space occupying lesions on the vestibular pathway. Discuss challenges of diagnosis and referral along with differential and final diagnosis of unusual presentation. Case Report. We describe the case of a patient with vertiginous symptoms complicated by neurological features, namely, head titubation and tremor. The patient also had signs of oscillopsia and possible impairment of the vestibulo-ocular reflex. The resulting symptom and sign complex made for a difficult diagnosis, as the interplay of the pathophysiology of these signs, were unusual. Conclusion. The discussion has revealed that the cerebellar lesions themselves may have simultaneously caused head tremor and an inability for the vestibulo-ocular reflex to compensate, resulting in vertigo. However, whether the vertigo was a result of an oscillopsia, nystagmus, or central cause, the referral route should initially be via a general physician to rule out such a life threatening cause as a tumour.