Stress as a Trigger of Attacks in Menière's Disease. A Case-Crossover Study

The clinical manifestation and treatment of Meniere's Disease from the viewpoint of the water homeostasis of the inner ear

Endolymphatic hydrops, a pathological feature of Ménière's disease, has been experimentally and clinically confirmed to be influenced by the blood circulation of vasopressin (VP). VP is a well-known hormonal regulator of water homeostasis. In addition, VP is influenced by various environmental changes, dehydration, fluctuation of atmospheric pressure, pregnancy, and other factors. Furthermore, VP is a key regulator of the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is a major neuroendocrine system that controls reactions to emotional and physical stresses, as well as the sleep/wake cycle (circadian rhythm). Therefore, VP is susceptible to change via the HPA axis. This review considers possible mechanisms of the formation of endolymphatic hydrops from the perspective of the vasopressin-aquaporin 2 system.

Course of Duration and Trigger Factors of Vertigo Attacks in Patients with Benign Recurrent Vertigo, Menière's Disease, or Vestibular Migraine

INTRODUCTION

Benign recurrent vertigo (BRV), Menière's disease (MD), and vestibular migraine (VM) show many similarities with regard to the course of vertigo attacks and clinical features. In this paper, we elaborate on the decreasing frequency of vertigo attacks observed in a previous study from our group by exploring changes in the duration and trigger factors of vertigo attacks in patients with BRV, MD, or VM.

METHODS

For this 3-year prospective cohort study in our tertiary referral center we recruited patients with a confirmed diagnosis of BRV, MD, or VM by a neurologist and otorhinolaryngologist in our center in 2015-2016. A study-specific questionnaire was used to assess the usual duration of vertigo attacks and their potential triggers every 6 months. Main outcome measures were changes in duration and trigger factors of vertigo attacks in the subgroups of patients with persisting attacks, which were analyzed using repeated measures logistic regression models.

RESULTS

121 patients were included (BRV: n = 44; MD: n = 43; VM: n = 34) of whom 117 completed the 3-year follow-up period and 57 (48.7%) kept reporting vertigo attacks at one more follow-up measurements. None of the diagnosis groups showed statistically significant shortening of attack duration at the subsequent annual follow-up measurements compared to baseline. At baseline, stress and fatigue being reported as triggers for attacks differed significantly between the three groups (stress: BRV 40.9%, MD 62.8%, VM 76.5%, p = 0.005; fatigue: BRV 31.0%, MD 48.8%, VM 68.8%, p = 0.003). In the VM group, a consistent reduction of stress and fatigue as triggers was observed up until the 24- and the 30-month follow-up measurements, respectively, with odds ratios (ORs) ranging from 0.15 to 0.33 (all p < 0.05). In the MD group, a consistent reduction of head movements as trigger was observed from the 24-month measurement onward (ORs ranging from 0.07 to 0.11, all p < 0.05).

CONCLUSION

Our study showed no reduction in vertigo attack duration over time in patients with BRV, MD, and VM who remain to have vertigo attacks. In VM and MD patients with persisting vertigo attacks stress, fatigue and head movements became less predominant triggers for vertigo attacks.

Risk factors for Meniere disease: a systematic review and meta-analysis

PURPOSE

To summarized the latest evidence of risk factors for developing MD.

METHODS

We searched Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, CBM, VIP, WanFANG, and CNKI, and ClinicalTrials.gov. till June 2021 for cohort and case-control studies investigating risk factors for MD. The exposure group was participants with a clinical diagnosis of MD which was made according to the diagnostic scale of the Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), the control group was participants without MD. The outcome was determined by incidence or prognostic of MD. Paired reviewers independently screened citations, assessed bias risk of included studies using the Newcastle-Ottawa Scale. Odds ratios (OR), hazard ratios(HR), relative risk(RR) and 95% confidence interval (CI) were calculated for dichotomous data. The statistical analyses were carried out with the use of Review Manager 5.3. The level of statistical heterogeneity for pooled data were assessed by using I² statistics and Q-test.

RESULTS

768 abstracts and articles were identified by our search, of which 25 studies (n = 1, 471, 944) were included. There were 18 cohort studies, 7 case-control studies. Three distinct subgroups (age, sex, sleep) were identified. There were a total of two studies involving age, two studies involving gender and two studies involving sleep disorder. High to moderate methodological quality established that age [hazard ratios (HR) 2.21, 95% CI 1.85-2.65, I² = 0%] and sleep disorder[HR 1.68, 95% CI 1.47-1.93, I² = 0%] were risk factors for MD. While there was little evidence showing that sex was not a risk factor for MD [HR 1.61, 95% CI 0.91-2.84, I² = 74%].

CONCLUSION

The current evidence supports the suggestion that age and sleep disorder are risk factors for MD. Sex, gene, and hypothyroidism are tentative risk factors but conflicting/inconclusive results.

FUNDING

No external funding.

REGISTRATION

CRD42021248199 (Prospero).

A Drosophila model for Meniere's disease: Dystrobrevin is required for support cell function in hearing and proprioception

Meniere's disease (MD) is an inner ear disorder characterised by recurrent vertigo attacks associated with sensorineural hearing loss and tinnitus. Evidence from epidemiology and Whole Exome Sequencing (WES) suggests a genetic susceptibility involving multiple genes, including α-Dystrobrevin (DTNA). Here we investigate a Drosophila model. We show that mutation, or knockdown, of the DTNA orthologue in Drosophila, Dystrobrevin (Dyb), results in defective proprioception and impaired function of Johnston's Organ (JO), the fly's equivalent of the inner ear. Dyb and another component of the dystrophin-glycoprotein complex (DGC), Dystrophin (Dys), are expressed in support cells within JO. Their specific locations suggest that they form part of support cell contacts, thereby helping to maintain the integrity of the hemolymph-neuron diffusion barrier, which is equivalent to a blood-brain barrier. These results have important implications for the human condition, and notably, we note that DTNA is expressed in equivalent cells of the mammalian inner ear.

Relationship Between the Onset of Ménière's Disease and Sympathetic Hyperactivity

Objective

The pathogenesis of Ménière's disease is still largely unknown; however, it is known to be strongly associated with stress. Excessive stress can cause hyperactivity of the sympathetic autonomic nervous system. With the aim of understanding changes in sympathetic hyperactivity before and after Ménière's disease, we compared autonomic nervous function in patients in a stable phase of Ménière's disease and that in healthy adults. We also gathered data over about 10 years on autonomic nervous function immediately before a Ménière's attack.

Study Design

Prospective study.

Patients

Autonomic nervous function was analyzed in 129 patients in a stable phase of Ménière's disease 31 healthy adult volunteers. In nine patients, autonomic nervous function was also measured immediately before and after treatment of a vertigo attack.

Main Outcome Measure

Power spectrum analysis of heart rate variability (HRV) of EEG/ECG and an infrared electronic pupillometer were used. Sympathetic and parasympathetic nervous function was measured.

Results

There were no statistically significant differences in autonomic nervous function determined by HRV and electronic pupillometry between patients in a stable phase of Ménière's disease and healthy adults. Sympathetic function as measured by electronic pupillometry parameters VD and T5 showed no difference between the affected and unaffected sides in the baseline data measured in the stable phase (VD: affected side is 31.02 ± 6.16 mm/sec, unaffected side is 29.25 ± 5.73 mm/sec; T5: affected side is 3.37 ± 0.43 msec, unaffected side is 3.25 ± 0.39 msec). In contrast, all nine patients whose HRV data had been obtained just before an attack showed marked suppression of the parasympathetic nervous system and activation of the sympathetic nervous system. Electronic pupillometry also revealed an overactivation of the sympathetic nervous system on the affected side, just before the attacks. Analysis of sequential changes after the onset of an attack revealed that overactivation on the affected side was reduced after treatment, and no difference between affected and unaffected sides was observed 3 days after treatment.

Conclusion

Detailed analysis of autonomic nervous function showed that immediately before an attack of Ménière's disease, the sympathetic nervous system on the affected side was strongly overactivated.

Expression of circadian clock genes in leukocytes of patients with Meniere's disease

Objectives

The underlying etiology of Meniere's disease (MD) is not completely clear, but the precipitated triggers may alter the circadian clock in patients with MD. This study aims to survey the expression of circadian clock genes in peripheral blood (PB) leukocytes of MD patients.

Methods

We investigated the expression of nine circadian clock genes in the PB leukocytes of patients with MD and normal controls using real‐time quantitative reverse transcriptase‐polymerase chain reaction (qRT‐PCR).

Results

We observed significantly lower expression of PER1 gene and higher expression of CLOCK gene in MD patients than those in normal controls (p < 0.05). PER1 did not associate with the degree of dizziness handicap in the patients with MD, but a lower expression of PER1 was significantly correlated with higher pure tone average (PTA) and speech reception threshold of the affected ear (p < 0.05). Patients with PTA > 30 dB had significantly lower PER1 expression than those with PTA ≤30 dB in the affected ear (p < 0.05). Our qRT‐PCR result was validated by fewer positively stained leukocytes for PER1 protein in the MD patients using the immunocytochemical study.

Conclusion

Our study implies the alteration of the circadian clock in patients with MD. In particular, the downregulation of PER1 correlated with the degree of hearing loss in the affected ear. PER1 in PB leukocytes may be a potential marker for the progression of hearing loss in MD.

Personality and psychopathology in Ménière's disease

INTRODUCTION AND OBJECTIVES

Psychological factors in vertigo patients have been extensively studied but the role of anxiety and personality traits in the clinical course of Ménière's disease (MD) is unknown. The objectives of this study are to identify and characterize psychopathology in MD and to find risk factors for an increased rate and intensity of crisis and chronic symptoms.

MATERIALS AND METHODS

We performed a transversal study in all patients diagnosed with definite MD in our department during a 5-year period. Sample subjects were interviewed in 3 steps: first, an otorhinolaryngologist collected information about clinical and pharmacological background of MD; second, a psychiatrist screened for mood, anxiety and personality disorders; in a third stage, the patient completed the DHI (Dizziness Handicap Inventory), STAI-Y (State Trait Anxiety Inventory), NEO-PI-R (Neo Personality Inventory Reviewed) and VAS (Visual Analogue Scale) for vertigo and dizziness. Statistical analysis was performed to search for risk factors for multiple and intense crisis and chronic symptoms.

RESULTS

Thirty-four patients completed all 3 phases of the study. A predominant dysfunctional personality trait was identified in 80% of patients (predominantly cluster C type), 35% were being treated with psychiatric medication and 34.4% had a considerable mood or anxiety disorder. All patients scored high (>7) in VAS during crisis. There was a statistically significant positive correlation between crisis rate and STAI, anxiety-subscale (N1) in NEO-PI-R, VAS and DHI scores (p<.044). Crises were more common in bilateral MD (p=.041). DHI scores were higher with higher STAI and N1 (p=.001). Disease duration and pure tone average were found to have a positive moderate correlation (p=.017).

CONCLUSIONS

The positive correlations between crisis rate, chronic dizziness and anxiety-related personality traits reveal a bidirectional and intimate relationship between personality, anxiety and MD, affecting these patients' quality of life. These results support the relevance of prospecting adjuvant psychological and psychiatric approaches to these patients.

Association Between Asthma and Meniere's Disease: A Nested Case-Control Study

OBJECTIVES/HYPOTHESIS

This study aimed to investigate the association between Meniere's disease and prior history of asthma.

STUDY DESIGN

A nested case-control study.

METHODS

Among the patients aged ≥40 years from the Korean National Health Insurance Service-Health Screening Cohort 2002-2015, 7,734 diagnosed with Meniere's disease between 2004 and 2015 were enrolled in this study. From the 505,834 participants without a prior history of Meniere's disease, 30,936 control participants were selected based on age, sex, income, and region of residence. The presence of a prior history of asthma before the diagnosis of Meniere's disease was compared between the Meniere's disease group and control group using conditional logistic regression with odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Prior history of asthma was associated with 1.30 (1.21-1.39) times higher odds of Meniere's disease (E-value = 1.92 [1.71]). Both allergic asthma and nonallergic asthma patients demonstrated higher odds of Meniere's disease than the control group (adjusted OR = 1.21 [1.08-1.36] and E-value = 1.72 [1.37] for allergic asthma; adjusted OR = 1.26 [1.17-1.36] and E-value = 1.83 [1.60] for nonallergic asthma).

CONCLUSIONS

This study is the first to demonstrate a positive relationship between Meniere's disease and prior asthma history in adults. The association between prior asthma history and Meniere's disease was noted in both allergic and nonallergic asthma cases. The potential development of Meniere's disease should be considered when managing the asthma patients with dizziness or vertigo.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Association between Meniere's disease and air pollution in South Korea

Meniere's disease is thought to be a disorder of the inner ear function, affected by genetic and environmental factors. Several recent studies have shown that air pollution could affect middle and inner ear diseases. The purpose of this study was to investigate the relationship between the Meniere's disease occurrence and air pollution status in Korea. This study used a time-stratified case-crossover design. Hospital visit data by Meniere's disease were collected from the Korea National Health Insurance Service-National Sample Cohort (NHIS-NSC) database. Daily air pollution data for sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), ozone (O3), and particulate matter (PM10: ≤ 10 μm in diameter, and PM2.5: ≤ 2.5 μm in diameter) were collected from the National Ambient air quality Monitoring Information System (NAMIS) database. We used two-stage analysis to assess the association between degree of air pollution and the occurrence of Meniere's disease. In the first stage, region-specific analysis was conducted to estimate the odds ratios (ORs) of Meniere's disease risk associated with each air pollutant exposure by using conditional logistic regression for matched case-control sets in 16 regions. In the second stage, region-specific ORs from the first stage were combined and the pooled effect estimates were derived through fixed and random effect meta-analysis. Subgroup analysis was conducted for age, sex, seasonality, and urbanization of residence. In total, 29,646 (32.1% males and 67.9% females) Meniere's disease cases were identified from Korea NHIS-NSC database between 2008 and 2015. Overall, SO2, NO2, CO, and PM10 showed significant correlation with Meniere's disease risk at immediate lags, and weaker correlation at delayed lags, whereas O3 showed slightly negative correlation at the immediate lag (lag0) and PM2.5 did not show strong correlation (SO2: 1.04 [95% confidence interval: 1.01, 1.06]; NO2: 1.08 [1.06, 1.11]; CO: 1.04 [1.02, 1.06]; O3: 0.96 [0.93, 0.99]: statistically significant ORs at lag0 are listed). These positive and negative associations between Meniere's disease and each air pollutant were generally stronger in the age of 40-64, female, summer (June-August) season, and urban subgroups. Our results showed that hospital visits for Meniere's disease were associated with the measured concentrations of ambient air pollutants SO2, NO2, CO, and PM10. Further studies are required to confirm these associations and find their mechanisms.

Concomitant Obstructive Sleep Apnoea in Patients with Meniere's Disease: A Case Report and Literature Review

Meniere's disease (MD) is a condition characterised by fluctuating and progressive hearing loss, aural fullness, tinnitus, and intermittent attacks of vertigo. The disabling vertigo symptoms can be controlled in most patients by lifestyle changes and medications such as diuretics. Should standard medical therapy fail, the patient may require surgery in order to control the disease, but such surgical procedures can be functionally destructive. Obstructive sleep apnoea syndrome (OSAS) is common, especially in people who are grossly overweight. Up to 15% of patients with MD may have concomitant OSA. Unless the OSA is well controlled, such patients may continue to experience MD symptoms despite receiving adequate standard medical therapy for MD. Moreover, MD patients may experience insomnia as a result of vertigo and/or tinnitus where sedatives are indicated. The use of sedatives with muscle relaxant properties may inadvertently further aggravate OSA resulting in a vicious cycle of symptoms. Symptoms suggestive of concomitant OSA must be proactively sought as these patients do not necessarily exhibit the obvious phenotypic features of OSA. This is especially so in Asians where OSAS is commonly observed in people who are not overly obese. We report a case of a female patient who presented with recalcitrant MD disease and was later found to have concomitant OSA. The relevant literature will be reviewed, and learning points will be discussed from the perspective of the otologist/neurotologist. The clinician must always be mindful of the existence of concomitant “silent” OSAS as this impacts the management of patients with MD.

Personality and psychopathology in Ménière's disease

INTRODUCTION AND OBJECTIVES

Psychological factors in vertigo patients have been extensively studied but the role of anxiety and personality traits in the clinical course of Ménière's disease (MD) is unknown. The objectives of this study are to identify and characterize psychopathology in MD and to find risk factors for an increased rate and intensity of crisis and chronic symptoms.

MATERIALS AND METHODS

We performed a transversal study in all patients diagnosed with definite MD in our department during a 5-year period. Sample subjects were interviewed in 3 steps: first, an otorhinolaryngologist collected information about clinical and pharmacological background of MD; second, a psychiatrist screened for mood, anxiety and personality disorders; in a third stage, the patient completed the DHI (Dizziness Handicap Inventory), STAI-Y (State Trait Anxiety Inventory), NEO-PI-R (Neo Personality Inventory Reviewed) and VAS (Visual Analogue Scale) for vertigo and dizziness. Statistical analysis was performed to search for risk factors for multiple and intense crisis and chronic symptoms.

RESULTS

Thirty-four patients completed all 3 phases of the study. A predominant dysfunctional personality trait was identified in 80% of patients (predominantly cluster C type), 35% were being treated with psychiatric medication and 34.4% had a considerable mood or anxiety disorder. All patients scored high (>7) in VAS during crisis. There was a statistically significant positive correlation between crisis rate and STAI, anxiety-subscale (N1) in NEO-PI-R, VAS and DHI scores (p<.044). Crises were more common in bilateral MD (p=.041). DHI scores were higher with higher STAI and N1 (p=.001). Disease duration and pure tone average were found to have a positive moderate correlation (p=.017).

CONCLUSIONS

The positive correlations between crisis rate, chronic dizziness and anxiety-related personality traits reveal a bidirectional and intimate relationship between personality, anxiety and MD, affecting these patients' quality of life. These results support the relevance of prospecting adjuvant psychological and psychiatric approaches to these patients.

Review of Temporal Bone Microanatomy : Aqueducts, Canals, Clefts and Nerves

Temporal bone microanatomy is a common source of consternation for radiologists. Serpentine foramina, branching cranial nerves, and bony canals containing often clinically relevant but often miniscule arterial branches may all cause confusion, even among radiologists familiar with temporal bone imaging. In some cases, the tiniest structures may be occult or poorly visualized, even on thin-slice computed tomography (CT) images. Consequently, such structures are often either ignored or mistaken for pathologic entities. Yet even the smallest temporal bone structures have significant anatomic and pathologic importance. This paper reviews the anatomy and function of the temporal bone aqueducts, canals, clefts, and nerves, as well as the relevant developmental, inflammatory, and neoplastic processes that affect each structure.

Disability perceived by primary care patients with posterior canal benign paroxysmal positional vertigo

Background

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Little is known on how posterior canal BPPV affects health-related quality of life in patients diagnosed and treated at primary care facilities or on whether patients with subjective and objective disease perceive the effects differently. This study was designed to describe how patients diagnosed with posterior canal BPPV in primary care perceive disability.

Methods

Cross-sectional descriptive study performed at two urban primary care centers. Participants were patients aged 18 years or older with suspected posterior canal BPPV recruited for baseline evaluation in a clinical trial on the effectiveness of the Epley maneuver in primary care. The recruitment period was from November 2012 to January 2015. Perceived disability was evaluated using the Dizziness Handicap Inventory – Screening version (DHI-S). Other variables collected were age and sex, a history or diagnosis of anxiety or depression, treatment with antidepressants and/or anxiolytics, and results of the Dix-Hallpike (DH) test, which was considered positive when it triggered vertigo with or without nystagmus and negative when it triggered neither.

Results

The DH test was positive in 134 patients, 40.30% of whom had objective BPPV (vertigo with nystagmus). The median age of the patients was 52 years (interquartile range [IQR], 39.00–68.50 years) and 76.1% were women. The median total score on the DHI-S was 16 out of 40 (IQR, 8.00–22.00). Scores were higher (greater perceived disability) in women (p < 0.001) and patients with subjective BPPV (vertigo without nystagmus) (p = 0.033). The items perceived as causing the greatest disability were feeling depressed (67.1%) and worsening of the condition on turning over in bed (88%).

Conclusions

Patients diagnosed with posterior canal BPPV in primary care perceive their condition as a disability according to DHI-S scores, with higher levels of disability reported by women and patients with subjective BPPV. Feelings of depression and turning over in bed were associated with the greatest perceived difficulties.

Trial registration

ClinicalTrials.gov Identifier: NCT01969513. Retrospectively registered. First Posted: October 25, 2013. https://clinicaltrials.gov/ct2/show/NCT01969513

The Reliability and Validity of "Dokuz Eylül University Meniere's Disease Disability Scale"

OBJECTIVE

Ménière's Disease (MD) is a chronic, non-life threatening inner ear disease, with attacks of disabling vertigo, progressive hearing loss, and tinnitus as the major symptoms. All three symptoms, separately or in combination, cause great distress and have a considerable impact on the quality of life of the patients. The aims of this study were to develop a disease-specific quality of life survey for patients with MD and to analyze the relationships between the audiovestibular findings and the survey.

MATERIALS AND METHODS

Following Ear-Nose-Throat examination and audiovestibular tests, the Dokuz Eylül University Meniere's Disease Disability Scale (DEU-MDDS) and Turkish version of the Dizziness Handicap Inventory (DHI-T) were administered to 93 patients with definite MD. Reliability and validity analyses of the scale were performed.

RESULTS

There were 45 (48.4%) male and 48 (51.6%) female patients and the mean age was 48.9±12.1 years. Cronbach's alpha was 0.92 and intraclass correlation coefficients of the DEU-MMDS were significant (p<0.001). Results of the Goodness of Fit Statistics showed that the expression levels of the items were high and the correlation coefficients of each item with the scale were sufficient. There was a statistically significant correlation between DHI-T scores and MDDS. DEU-MDDS was not related to the vestibular tests, age or gender (p>0.05).

CONCLUSION

The MDDS is a valid and reliable scale as a disease-specific quality of life questionnaire for patients with MD.

A hypothetical proposal for association between migraine and Meniere's disease

Meniere's disease (MD) is a chronic condition affecting the inner ear whose precise etiology is currently unknown. We propose the hypothesis that MD is a migraine-related phenomenon which may have implications for future treatment options for both diseases. The association between MD and migraine is both an epidemiological and a mechanistic one, with up to 51% of individuals with MD experiencing migraine compared to 12% in the general population. The presence of endolymphatic hydrops in those with MD may be the factor that unites the two conditions, as hydropic inner ears have an impaired ability to maintain homeostasis. Migraine headaches are theorized to cause aura and symptoms via spreading cortical depression that ultimately results in substance P release, alterations in blood flow, and neurogenic inflammation. Chronically hydropic inner ears are less able to auto-regulate against the changes induced by active migraine attacks and may ultimately manifest as MD. This same vulnerability to derangements in homeostasis may also explain the common triggering factors of both MD attacks and migraine headaches, including stress, weather, and diet. Similarly, it may explain the efficacy of common treatments for both diseases: current migraine treatments such as anti-hypertensives and anti-convulsants have shown promise in managing MD. Though the etiology of both MD and migraine is likely multifactorial, further exploration of the association between the two conditions may illuminate how to best manage them in the future. MD is likely a manifestation of cochleovestibular migraine, which occurs as a result of migraine related changes in both the cochlea and vestibule.

Risk of benign paroxysmal positional vertigo in patients with depressive disorders: a nationwide population-based cohort study

OBJECTIVE

The association between depression and benign paroxysmal positional vertigo (BPPV) remains debated. This study aimed to investigate the risk of BPPV in patients with depressive disorders.

DESIGN

Longitudinal nationwide cohort study.

SETTING

National health insurance research database in Taiwan.

PARTICIPANTS

We enrolled 10 297 patients diagnosed with depressive disorders between 2000 and 2009 and compared them to 41 188 selected control patients who had never been diagnosed with depressive disorders (at a 1:4 ratio matched by age, sex and index date) in relation to the risk of developing BPPV.

METHODS

The follow-up period was defined as the time from the initial diagnosis of depressive disorders to the date of BPPV, censoring or 31 December 2009. Cox proportional hazard regression analysis was used to investigate the risk of BPPV by sex, age and comorbidities, with HRs and 95% CIs.

RESULTS

During the 9-year follow-up period, 44 (0.59 per 1000 person-years) patients with depressive disorders and 99 (0.33 per 1000 person-years) control patients were diagnosed with BPPV. The incidence rate ratio of BPPV among both cohorts calculating from events of BPPV per 1000 person-years of observation time was 1.79 (95% CI 1.23 to 2.58, p=0.002). Following adjustments for age, sex and comorbidities, patients with depressive disorders were 1.55 times more likely to develop BPPV (95% CI 1.08 to 2.23, p=0.019) as compared with control patients. In addition, hyperthyroidism (HR=3.75, 95% CI 1.67-8.42, p=0.001) and systemic lupus erythematosus (SLE) (HR=3.47, 95% CI 1.07 to 11.22, p=0.038) were potential risk factors for developing BPPV in patients with depressive disorders.

CONCLUSIONS

Patients with depressive disorders may have an increased risk of developing BPPV, especially those who have hyperthyroidism and SLE.

Vertigo Induced During Coitus

Objectives: The aim of this study was to describe the clinical features of vertigo developed during sexual intercourse. Methods: We retrospectively reviewed the clinical and laboratory findings of seven patients who reported recurrent vertigo during sexual intercourse. Results: All the patients reported spinning sensation for a few minutes to 1 h, which developed during the coitus. Most patients (6/7, 86%) reported associated auditory symptoms including tinnitus (n = 4), ear fullness (n = 2), autophony (n = 1), hearing impairment (n = 1), or hyperacusis (n = 1). Four patients reported the vertigo to occur exclusively during sexual intercourse or masturbation while the other three patients also experienced vertigo during other physical activities. Underlying disorders included Meniere's disease (n = 3), superior canal dehiscence (n = 1), and high jugular bulb anomaly (n = 1) while the remaining two patients had no identifiable causes. Conclusions: Various disorders may cause coital vertigo probably due to disruption of the mechanism that normally refrains the increased intracranial pressure from being directly transferred to the peripheral vestibular organs.

Stress and Unusual Events Exacerbate Symptoms in Menière's Disease: A Longitudinal Study

HYPOTHESIS

Stress and unusual events are associated with a higher likelihood of attacks and increased symptom severity in Menière's disease (MD).

BACKGROUND

MD is an unpredictable condition which severely impacts the quality of life of those affected. It is thought that unusual activity and stress may act as an attack trigger in MD, but research in this area has been limited to date.

METHODS

This was a longitudinal study conducted over two phases. A mobile phone application was used to collect daily data on Menière's attacks and individual symptoms (aural fullness, dizziness, hearing loss, and tinnitus), as well as prevalence of unusual events (phase I), and stress levels (phase II). There were 1,031 participants (730 women, mean age 46.0 yr) in phase I and 695 participants (484 women, mean age 47.7 yr) in phase II. Panel data regression analyses were employed to examine for associations between unusual events/stress and attacks/symptoms, including the study of 24 hours lead and lag effects.

RESULTS

Unusual events and higher stress levels were associated with higher odds of Menière's attacks and more severe symptoms. The odds of experiencing an attack were 2.94 (95% confidence interval [CI] 2.37, 3.65) with reporting of unusual events and increased by 1.24 (95% CI 1.20, 1.28) per unit increase in stress level. Twenty-four hour lead (OR 1.10 [95% CI 1.07, 1.14]) and lag (OR 1.10 [95% CI 1.06, 1.13]) effects on attacks were also found with increases in stress.

CONCLUSION

This study provides the strongest evidence to date that stress and unusual events are associated with attacks and symptom exacerbation in MD. Improving our understanding of stress and unusual events as triggers in Menière's may reduce the uncertainty associated with this condition and lead to improved quality of life for affected individuals.

Clinical Characteristics of Benign Recurrent Vestibulopathy: Clearly Distinctive From Vestibular Migraine and Menière's Disease?

OBJECTIVE

We aimed to systematically investigate the clinical characteristics of benign recurrent vestibulopathy (BRV), vestibular migraine (VM), and Menière's disease (MD) and to assess whether clinical symptoms exist that are unique to BRV.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral center.

METHODS

Between January 2015 and November 2016, patients were prospectively recruited at a specialized dizziness clinic. Patients were included if they met the diagnostic criteria for BRV, VM, or MD which was evaluated by simultaneous consultation of an otorhinolaryngologist and neurologist. All patients received a comprehensive clinical examination that included vestibular tests and pure-tone audiometry. A questionnaire was designed to systematically document symptoms of the three vestibular disorders.

RESULTS

A total of 122 patients were included in our study, 65 (53%) were females in whom 29 (24%) were postmenopausal. The mean age was 55.5 ± 13.7 years and the mean age of onset of vertigo attacks was 49.2 ± 14.8 years (n = 119). Forty-five (37%) patients had a clinical diagnosis of BRV, 34 (28%) of VM, and 43 (35%) of MD. No symptom could be identified which was specifically linked to BRV. In patients with BRV, similar to those with VM, we found a female preponderance (p = 0.05 in BRV, p = 0.001 in VM). Patients with VM reported significantly more often a positive history of motion sickness (p = 0.01). In addition, canal paresis was most profound in patients with MD (p = 0.001).

CONCLUSION

We found no clinical characteristics that were distinctive for BRV. However, we did find several distinctive clinical features for VM and MD which may assist the physician in their history taking.

Mal de Debarquement Syndrome: a survey on subtypes, misdiagnoses, onset and associated psychological features

Introduction

Mal de Debarquement Syndrome (MdDS) is a neurological condition typically characterized by a sensation of motion, that persists longer than a month following exposure to passive motion (e.g., cruise, flight, etc.). The most common form of MdDS is motion triggered (MT). However, recently it has been acknowledged that some patients develop typical MdDS symptoms without an apparent motion trigger. These cases are identified here as spontaneous or other onset (SO) MdDS. This study aimed to address similarities and differences between the MdDS subtypes. Diagnostic procedures were compared and extensive diagnostic guidelines were proposed. Second, potential triggers and associated psychological components of MdDS were revealed.

Methods

This was a retrospective online survey study for MT and SO MdDS patients. Participants were required to respond to a set of comprehensive questions regarding epidemiological details, as well as the diagnostic procedures and onset triggers.

Results

There were 370 patients who participated in the surveys. It is indicated that MdDS is often misdiagnosed; more so for the SO group. In addition to the apparent self-motion, both groups reported associated levels of stress, anxiety and depression.

Discussion

It appears at present that both MdDS subtypes are still poorly recognised. This was the first attempt to evaluate the diagnostic differences between MdDS subtypes and to propose a set of comprehensive diagnostic guidelines for both MdDS subtypes. In addition, the current research addressed that associated symptoms such as stress, anxiety and depression should also be considered when treating patients. We hope this study will help the medical community to broaden their awareness and diagnostic knowledge of this condition.

Electronic supplementary material

The online version of this article (10.1007/s00415-017-8725-3) contains supplementary material, which is available to authorized users.

Association between ambient particulate matter and disorders of vestibular function

BACKGROUND

Exposure to environmental chemicals has been suggested to alter the physiologic state of the inner and middle ear. However, it is unknown if particulate matter exposure is associated with acute vestibular dysfunction.

OBJECTIVES

To estimate the effects of particulate matter exposure on the number of hospital visits related to three major diseases of vestibular dysfunction, Meniere's disease (MD), benign paroxysmal positional vertigo (BPPV), and vestibular neuronitis (VN).

METHODS

Our study subject is from Korean National Health Insurance Service-National Sample Cohort, which is dynamic cohort consist of 1 million participants representing the Korean population. Among total cohort participants, we used the hospital visit data of 210,000 individuals who resided in Seoul from 2007 to 2010. Time series analysis using the Poisson generalized additive model and case-crossover analysis using conditional logistic regression were used to investigate the association between daily particulate matter levels (PM_2.5, particulate matter <2.5μg/m³; PM₁₀, particulate matter <10μg/m³; PM_10-2.5, PM₁₀- PM_2.5) and number of MD, BPPV, and VN hospital visits.

RESULTS

Time series analysis showed that an interquartile range (IQR) increase in PM₁₀ and PM_10-2.5 on lag day 1 was associated with an increased risk of MD hospital visits [relative risk (RR), 95% confidence interval (CI), PM₁₀: 1.09 (1.02-1.15); PM_10-2.5: 1.06 (1.02-1.10)]. In addition, elderly individuals (≥60 years old) showed an increased risk of MD hospital visits after particulate matter exposure when compared to younger individuals. An IQR increase in particulate matter on lag day 1 was associated with a marginally significant increase in VN hospital visits [RR (95%CI), PM_2.5: 1.11 (0.98-1.25); PM₁₀: 1.07 (0.99-1.15); PM_10-2.5: 1.04 (0.99-1.09)]. However, no association between particulate matter exposure and BPPV hospital visits was noted. Case-crossover analyses showed similar results to the time-series analysis across all three diseases.

CONCLUSION

MD hospital visits were associated with ambient particulate matter exposure. Elderly individuals, in particular, were more susceptible to particulate matter exposure than younger individuals.

Comparative Study of the Daily Lifestyle of Patients with Meniere's Disease and Controls

Objectives:

This study was performed to investigate the possibility that daily lifestyle may have a causal relationship with Meniere's disease.

Methods:

We conducted a questionnaire study of daily lifestyles among groups of patients with Meniere's disease and those with low-frequency hearing loss, and compared the results with those of control groups of local residents matched individually by gender and age.

Results:

The Meniere's disease group diverged most widely from the control groups in their behavior patterns. Significant divergence was especially indicated in their engrossed, self-inhibiting, and time-constrained behaviors. Although the low-frequency hearing loss group also exhibited similar tendencies toward engrossment and in their feeling pressed for time, their self-inhibiting behavior was less pronounced. There was no major difference between the endolymphatic hydrops patient groups and the control groups on other items in the study such as daily lifestyle, environmental stress, and means of relaxation.

Conclusions:

The results of the present study strongly suggest that there may be a link between an individual's specific behavior patterns and the onset of Meniere's disease.

Obstructive sleep apnea syndrome as a novel cause for Ménière's disease

PURPOSE OF REVIEW

Several recent reports have described the relation between sleep disorders and inner ear function. There are also many reports that insomnia is observed in Ménière's patients. However, the possibility that obstructive sleep apnea syndrome (OSAS) might affect Ménière's disease or other neurotological consequences was not noticed, until studies using polysomnography for these patients.

RECENT FINDINGS

OSAS may cause not only vestibular but also auditory dysfunction. Several reports suggest that insufficient supply of blood via the vertebral basilar artery, which supplies the inner ear, may cause hydropic distension of the endolymphatic system and lead to Ménière's disease. However, few people noticed that in OSAS this insufficient supply might be exacerbated in the night while patients are sleeping. Even more, we should note that Ménière's patients may not only suffer from insomnia, but also that the impaired sleep might be caused by OSAS.

SUMMARY

Physicians routinely prescribe benzodiazepines or other drugs that have hypnotic, muscle relaxing, antianxiety, and anticonvulsant properties for insomnia, but these properties may have the effect of aggravating OSAS symptoms. Continuous positive airway pressure (CPAP) is an effective therapy used worldwide for the treatment of OSAS. CPAP or surgeries for OSAS may also be useful as one aspect of treatment for Ménière's disease patients with OSAS.

The relationship between vasomotor symptoms and menopause-associated dizziness

CONCLUSION

Vasomotor symptoms (VMS) and especially hot flushes are negatively associated with recovery from menopause-related dizziness. A further study is justified to determine whether hormone replacement therapy (HRT) can shorten this recovery time.

OBJECTIVES

This study aimed to compare the rate of recovery from dizziness between patients who had VMS and those who did not. We also evaluated the effect of HRT on recovery from dizziness.

METHODS

The medical records of 85 women aged between 40 and 59 years were analyzed retrospectively. The patients were asked detailed questions about their menopausal symptoms as well as any episodes of dizziness, which were diagnosed on the basis of neuro-otological examinations and were treated appropriately. All patients were followed up until dizziness improved.

RESULTS

Over a 2-month period, the rate of recovery from vertigo was significantly higher in patients without VMS (no-VMS group, n = 38) than in those with VMS (VMS group, n = 29). In the VMS group, patients treated with HRT (n = 7) recovered from dizziness more quickly than those who were not treated with HRT (n = 22), although this difference was not statistically significant.

Stress as a Trigger for Relapses in IBD: A Case-Crossover Study

Background

It is important to identify factors that influence the risk of relapses in inflammatory bowel disease. Few studies have been conducted and with limited methodology. This prospective case-crossover study, aims to examine whether perceived stress has a short-term acute effect, namely whether it acts as a trigger, on the risk of relapse in inflammatory bowel disease.

Methods

Sixty patients with inflammatory bowel disease and in remission were included. The case-crossover design was employed, which is an epidemiological design developed to study triggers for acute events and diseases. To collect information regarding symptoms and potential trigger factors, such as perceived stress, a structured diary was constructed. The participants were instructed to fill in the diary daily during six months. Fifty patients completed the study.

Results

The analysis showed an effect for high level of perceived stress. Being exposed to “quite a lot” of stress, yield an increase in risk for relapse during the forthcoming day (OR = 4.8, 95% CI 1.09 - 21.10). No statistically increased risk for lower levels of perceived stress was found, although elevated effect estimates were found for “some” stress.

Conclusion

This study supports earlier findings regarding perceived stress as an important factor in triggering relapses in IBD. However, this is the first case-crossover study performed to explore the trigger risk of stress in this population. Further investigations with larger patient samples are needed to confirm the findings.

Gluten sensitivity in Meniere's disease

OBJECTIVES/HYPOTHESIS

Wheat is one of the most common food allergens found in patients with Meniere's disease (MD). Gluten from wheat has been identified to have a etiopathogenetic role in celiac disease, IgE hypersensitivity to wheat disease, and recently to gluten sensitivity. The aim of this study was to verify the incidence of gliadin prick test response in patients affected by MD.

STUDY DESIGN

Prospective individual case-control study.

METHODS

There were 58 adult patients with definite MD, 25 healthy volunteers, and 25 patients with grass pollen rhinoconjunctivitis tested with skin prick test to gliadin.

RESULTS

A total of 33 MD patients (56.9%) proved to be sensitive to gliadin, eight of whom were positive to prick test after 20 minutes, 13 after 6 hours, 11 after 12 hours, and one after 24 hours.

CONCLUSIONS

This is the first report of gliadin skin test response in MD. Further studies are needed to define the relationship between immune response to wheat proteins and MD symptoms.

Psychological assessment of patients with Menière's disease

The objective of this study was to evaluate daily stressors, coping, personality, physical and mental health, and quality of life in Menière patients. 110 consecutive patients with definite Menière's disease were assessed using the Dutch Daily Hassles List, Coping Inventory for Stressful Situations (CISS), Symptoms Checklist 90 (SCL-90), NEO Five Factor Inventory (NEO-FFI), General Health Questionnaire (GHQ-12), and the Short Form Health Survey 36 (SF-36). Duration and subjective severity of symptoms were scored using a self-report questionnaire. It was shown that Menière patients had more daily stressors, used certain coping strategies less often, and had more psychopathology (e.g. anxiety and depression), and a worse quality of life compared to healthy reference groups. No abnormalities in personality were found. Patients with more severe symptoms had more psychopathology and a worse quality of life than patients with mild symptoms. The psychological profile of Menière patients seems comparable to patients with other chronic diseases. The outcomes should be used to intensify psychological support in patients with this disabling disease.

Symptoms experienced by patients with peripheral vestibular disorders: evaluation of the Vertigo Symptom Scale for clinical application

OBJECTIVES

To describe symptoms during an episode of dizziness in a sample of patients suffering from peripheral vestibular disorders and to compare them with the items in the Vertigo Symptom Scale.

DESIGN

A descriptive study from a sample of patients with peripheral vestibular disorders.

SETTING

Patients visiting a department of audiology at a university hospital.

PARTICIPANTS

Twenty patients with peripheral vestibular disorders. The inclusion criteria were that the patient had had at least three spontaneous attacks of vertigo and/or was constantly unsteady during the last 3 months for at least 75% of the time when awake.

MAIN OUTCOME MEASURES

Patients were instructed to complete a diary where they recorded symptoms that arose during an episode of dizziness. These symptoms were compared with the content of the Vertigo Symptom Scale.

RESULTS

The most frequent symptoms as mentioned by the patients in their diaries were a feeling that things are spinning or moving around, nausea, feeling unsteady/about to lose one's balance, fatigue, headache, a feeling as if the ground you walk on is distant and ear-related such as tinnitus and a feeling of pressure in the ear. Pain in the heart or chest region, a heavy feeling in the arms or legs, pain in the lower part of the back and excessive sweating were not mentioned at all or by very few patients. Analysis showed that some of the symptoms included in the Vertigo Symptom Scale occurred less during an episode of dizziness than others in this sample of patients with peripheral vestibular disorders.

CONCLUSION

It was found that the Vertigo Symptom Scale is an adequate base but may need to be developed for use in patients diagnosed with peripheral vestibular symptoms to be able to evaluate care and treatment.

Quality of life instruments in Ménière's disease

OBJECTIVE

Evaluate the sensitivity of quality of life (QoL) instruments over time in patients with Ménière's disease using general, symptom-specific, and disease-specific QoL instruments.

STUDY DESIGN

Prospective study using QoL instruments administered serially over 4 months in patients undergoing treatment for Ménière's disease.

METHODS

Sixty-one people aged 33 to 71 years with active, unilateral, cochleovestibular Ménière's disease refractory to medical management completed two general QoL instruments, Sense of Coherence (SOC) and World Health Organization Quality of Life-Abbreviated Version (WHOQOL-BREF), one symptom-specific QoL instrument, Vertigo Symptom Scale (VSS), and one disease-specific QoL instrument, Ménière's Disease Patient Oriented Severity Index (MDPOSI). All measures were administered at baseline and again 2 and 4 months later.

RESULTS

Disease- and symptom-specific instruments including the MDPOSI and VSS were positively correlated with vertigo control category (Pearson's R=0.345, MDPOSI; 0.279, VSS), indicating sensitivity to the frequency of vertigo spells. These instruments were also sensitive to changes in vertigo over time. Standardized response means showed greatest responsiveness to change on the MDPOSI (0.80) and the VSS (0.79). Standardized response means for SOC and WHOQOL-BREF were 0.03, and 0.32, respectively, suggesting poor responsiveness to change of symptoms. The VSS and MDPOSI were highly correlated (Pearson's r coefficient 0.744; P<.001).

CONCLUSIONS

A disease-specific QoL instrument such as the MDPOSI and a symptom-specific instrument such as the VSS more accurately reflect changes in control of vertigo in people with Ménière's disease over time than do general QoL instruments. These instruments can be used to determine the life impact of Ménière's disease and how aggressive therapy should be for the patient.

The relevance of an elevation in the plasma vasopressin levels to the pathogenesis of Meniere's attack

An elevation of plasma vasopressin levels has been frequently observed in Meniere's disease patients. However, little is known regarding the mechanism behind this elevation. The plasma vasopressin levels and plasma osmolality were therefore determined in 18 diagnosed Meniere's disease patients and 20 patients with other types of vertigo, who required admission for severe vertigo attacks. All participants were given questionnaires regarding their clinical and psychological status, including their stress levels and depression status, to evaluate environmental stress events. The plasma vasopressin levels of Meniere's disease patients in the acute phase (4.1 +/- 1.37 pg/ml) were significantly higher compared with with those of other vertigo patients in the acute phase (2.1 +/- 0.41 pg/ml) (P < 0.01). The average plasma osmolality of the Meniere's disease group was higher than that of the other vertigo patients group (P < 0.05). No significant difference in reported stress levels, depression status and prevalence of primary headache between the groups was observed. The plasma vasopressin showed no significant correlation with the patients' clinical data (occurrence of emesis or nausea, prevalence of primary headache, depression status and stress). No correlation between the plasma vasopressin and the plasma osmolarity was observed in the Meniere's disease group. These results suggest that the elevation of plasma vasopressin in the acute phase of Meniere's disease is therefore related to the pathogenesis of Meniere's attacks, and the results obtained may provide helpful information for distinguishing between Meniere's disease and other various inner ear diseases.

Hippocampal volume measurement in patients with Ménière's disease: a pilot study

CONCLUSION

No signs of chronic stress as in hippocampal atrophy were present in patients with Ménière's disease.

OBJECTIVE

To evaluate the effect of chronic stress (allostatic load) by measuring hippocampal volume in patients with Ménière's disease.

SUBJECTS AND METHODS

Ten patients with Meniere's disease and 10 healthy controls were evaluated for absolute and relative hippocampal volumes measured on MRI scans, saliva cortisol levels and frequency of daily stressors. The study was performed in a prospective, controlled setting with two raters who were blinded as to subject identity.

RESULTS

Saliva cortisol levels and presence of daily stressor scores were similar in both groups. The first rater measured mean hippocampal volumes of 2.80 +/- 0.36 cm3 vs 3.15 +/- 0.52 cm3 (right) and 2.49 +/- 0.32 cm3 vs 3.06 +/- 0.46 cm3 (left), for the Ménière's disease and control group, respectively. The second rater measured 3.44 +/- 0.35 cm3 vs 3.60 +/- 0.52 cm3 (right) and 3.00 +/- 0.40 cm3 vs 3.42 +/- 0.45 cm3 (left), respectively. The volume of the left hippocampus was significantly smaller in patients with Ménière's disease compared with the controls for both raters (p < 0.05) and the right hippocampal volume was not different between the two groups. With correction for variation in head size (partial brain and partial intracranial volume) no significant differences in relative hippocampal volumes were observed between patients with Ménière's disease and the control group.

Conscientiousness in Patients With Ménière's Disease

OBJECTIVE

To assess whether a conscientious personality profile is more prevalent in patients with Ménière's disease (MD) in comparison with other vertigo patients. Second, to investigate a sex effect and compare the obtained conscientiousness scores with published normative values.

PATIENTS

A total of 108 patients were included and subdivided into one of five pathology groups: MD, benign paroxysmal positional vertigo, vestibular neuritis, vestibular schwannoma, and posttraumatic nonbenign paroxysmal positional vertigo.

INTERVENTION

The conscientiousness domain of the self-reporting NEO Five-Factor Inventory questionnaire.

MAIN OUTCOME MEASURE

Conscientiousness score.

RESULTS

There was no significant difference between the diagnostic groups or a sex effect. MD patients had a higher score than published normal values.

CONCLUSION

As assessed with the NEO Five-Factor Inventory questionnaire, MD patients do not demonstrate a higher conscientious personality profile in comparison with other vertigo patients. Therefore, this limits the clinical use of the personality profile to discriminate between patient groups.

An analysis for a cross-over cohort study with an application to the study of triggers of Menière's disease

When studying the effect of a transient exposure on the risk of a rare illness, for time and cost effectiveness it is desirable to follow a cohort of individuals who are 'prone' to the illness over an observation period. In this paper, we present a method of analysis for data arising from such a study. The proposed method can be used to estimate the relative risk of an exposure triggering the illness and the distribution of the time delay from exposure to the onset of illness. The model is extended to include covariate effects and to the situation where there are two types of exposure. For the two types of exposures situation, a model to handle a possible synergism of the exposures is proposed. Finally, the method is applied to study the potential triggers of attacks of Menière's disease.

Water may cure patients with Meniere disease

OBJECTIVES/HYPOTHESIS

We examined whether sufficient water intake is effective in the long-term control of vertigo and hearing activity in patients with Meniere disease (MD) for whom conventional therapy has proven unsuccessful.

STUDY DESIGN

The authors conducted a time-series study with historical control.

METHODS

Eighteen patients with MD in group 1 drank 35 mL/kg per day of water for 2 years. Twenty-nine patients with MD treated with the conventional dietary and diuretic therapy for more than 2 years during 1992 to 1999 at the same hospital were enrolled in a historical control of group 2.

RESULTS

Patients in group 1 dramatically relieved vertigo and significantly improved in the hearing of the worst pure-tone average of three frequencies (0.125, 0.25, and 0.5 kHz) (low PTA) during the last 6 months of the study period. In contrast, patients in group 2 became worse in both the four- (0.5, 1, 2, and 4 kHz) frequency PTA and the low PTA, although their vertigo did improve. The number of patients whose hearing were improved, unchanged, and worse were 4, 12, and 2 in group 1 and 2, 11, and 16 in group 2, respectively.

CONCLUSION

Deliberate modulation of the intake of water may be the simplest and most cost-effective medical treatment for patients with MD. Larger studies will be needed to confirm these results in a larger patient cohort.

Life events and benign paroxysmal positional vertigo: a case-controlled study

CONCLUSIONS

Within the poorly understood mechanisms implicated in the aetiology of benign paroxysmal positional vertigo (BPPV), the results of this trial provide clinical evidence of a potential role of emotional stress connected to adverse life events as a trigger of otoconial dysfunction. High levels of anxiety, depression and somatization were recorded and considered psychogenic precursors of BPPV, thus emphasizing the role of psychological distress in precipitating peripheral vestibular disorders. Therefore, appraisal of life stress and psychological attitudes may have potential implications in the clinical assessment of this labyrinthine vertigo and its frequent relapses.

OBJECTIVES

BPPV is one of the most common peripheral vestibular disorders, and although it has been the subject of several studies and debates, its aetiology still remains unknown in most cases. Because it has been shown that emotional stress is related to the onset or worsening of other inner ear dysfunctions such as Ménière's disease and sudden hearing loss, this study investigated the hypothesis that life events, mood and psychological attitudes may have a causal relationship with BPPV.

PATIENTS AND METHODS

Fifty patients (40 females and 10 men; mean age 43.5+/-10.1 years, range 30-65 years) were recruited and compared with 50 healthy volunteers matched for sex, age and socio-demographic variables. Patients were selected among dizzy patients who were referred to the ENT Clinic of the University of Modena and Reggio Emilia from the emergency unit with a primary diagnosis of 'positional vertigo' and enrolled in the study only if they had a paroxysmal positional nystagmus as diagnosed by Dix-Hallpike and Semont's manoeuvres. Patients with a history of recurrent vertigo and additional otoneurological diseases were excluded. The Paykel Life Events Scale, Spielberger State-Trait Anxiety Inventory, Symptom Check List-90 Revisited and Hamilton Depression Scale were the psychometric questionnaires used to complete the audiological and vestibular examinations.

RESULTS

Patients with BPPV reported significantly more life events than control subjects in the year preceding the onset of vertigo (p<0.005). Negative life events, objective negative impact and a poor degree of control were also significantly more frequent in patients compared with controls (p<0.005). There were no significant differences between groups concerning positive life events (p>0.05). Psychometric questionnaires recorded significantly higher levels of anxiety, depression and somatization in the pathological sample (p<0.005), as well as an increased obsessive-compulsive attitude (p<0.05).

The association of antidiuretic hormone levels with an attack of Meniere's disease

OBJECTIVES

An elevation of the plasma antidiuretic hormone (ADH) levels has frequently been observed in Meniere's disease patients. However, little is known regarding the mechanism behind such an elevation of ADH level in Meniere's disease patients. Therefore, we measured the plasma ADH in Meniere's disease patients and other vertigo patients to elucidate the association between the ADH levels, stress levels and the development of Meniere's symptom.

DESIGN AND SETTING

The plasma ADH levels and plasma osmotic pressure were determined in 23 definite Meniere's disease patients and 160 patients with other types of vertigo/dizziness. All participants were administered questionnaire regarding their psychological status including their stress levels.

RESULTS

The ADH levels of Meniere's disease patients in the acute phase (5.80 +/- 1.37 pg/mL) were significantly higher in comparison with that of Meniere's disease patients in the remission phase (2.26 +/- 0.41 pg/mL) (P < 0.05). In other peripheral vertigo patients, the ADH level in the acute phase (1.71 +/- 0.23 pg/mL) was not significantly different from that in the remission phase (1.45 +/- 0.15 pg/mL). Meniere's disease patients in the acute phase had a significantly higher stress score (114 +/- 23) than Meniere's disease patients in the remission phase (56 +/- 13) (P < 0.05). However, there was no significant correlation between their stress score and the ADH levels.

CONCLUSIONS

These results suggest that the elevation of the plasma ADH levels in Meniere's disease patients in the acute phase is, therefore, associated with the pathogenesis of Meniere's disease attacks rather than with stress.

Tinnitus and Ménière's disease: characteristics and prognosis in a tinnitus clinic sample

The aim of this study is to describe tinnitus epidemiological characteristics in Ménière's disease (MD), the prognosis and its interaction with other MD symptoms. It is a descriptive transversal study. One hundred two MD patients were referred to a tinnitus clinic. Tinnitus was evaluated according to psychoacoustical tinnitogram, visual analogue scale, and tinnitus handicap inventory (THI). All patients were diagnosed with definitive MD (following AAO-HNS' 95 criteria). Pitch was more commonly identified in low and medium frequencies. Psychoacoustical intensity was matched in 12.7 dB. The visual analogue scale showed a value of 7.1, while THI score reached an average of 49%. Compared with other aetiologies (acoustic trauma, otosclerosis), MD showed a statistical difference in tinnitus severity parameters (P<0.05). Tinnitus increased VAS and THI score as a function of duration and bilateral disease (P<0.01). We found a statistical association (P<0.05) between tinnitus intensity and worse hearing loss or hyperacusis, but it was not influenced by number of vertigo spells. Higher MD stage increased tinnitus intensity and handicap. Tinnitus in MD patients referred to our tinnitus clinic presents a high intensity and handicap levels and represents the most troublesome symptom. Severity is influenced by the longer duration of the disease, the bilateral affection, hearing impairment or hyperacusis and a higher MD stage.

Terapia de reentrenamiento (TRT) en el acúfeno de la enfermedad de Ménière

OBJECTIVE

To evaluate the response of tinnitus in Meniere's disease patients (MD) using the Tinnitus Retraining Therapy (TRT). This management includes a wide cognitive medical counselling and natural or prosthetic sound therapies (hearing aid or noise generator).

DESIGN

Descriptive prospective study (EBM level 3).

PATIENTS

Twenty-five patients diagnosed as definitive MD (AAO-HNS 95 criteria) were enrolled in our tinnitus protocol.

MAIN OUTCOME MEASURES

Tinnitus changes were reported according to patient's self-evaluation, a visual analogue scale on tinnitus intensity (EVA) and the Tinnitus Handicap Inventory (THI).

RESULTS

Seventy-three percent of the patients improved their tinnitus after 6 months of treatment (p < 0.05). THI scores were reduced from the initial 47% to 24% (p < 0.05) and EVA from 6.6 to 5.2 (p < 0.05). After 12 months, the response was slightly worse: 68% improved according to their self-evaluation (p < 0.05), THI score reached 20% (p < 0.05) but EVA did not improve significantly (6.4). Patients that refused prosthesis adaptation (hearing aid or noise generator) did not improved and the THI score (48%) and EVA score (6.6) did not change.

CONCLUSIONS

TRT has proved to be an effective method for tinnitus treatment in MD that improves patient's self-evaluation, tinnitus loudness and handicap scores. Individualized medical counselling and an exhaustive prosthesis adaptation are crucial to guarantee satisfactory results.

Personal factors involved in onset or progression of Ménière's disease and low-tone sensorineural hearing loss

PURPOSE

To identify personal causative factors for Ménière's disease.

PROCEDURES

Patterns of hearing loss progression were studied in patients with Ménière's disease and low-tone sensorineural hearing loss, and the involvement of stress and the relation of stressors to the onset or progression of the disease were analyzed.

RESULTS

Low-tone loss recurred in 40% of patients even after hearing was restored, and low-tone loss progressed to high-tone loss after frequent repetitions of recovery and recurrence. High-tone loss tended to proceed to all-tone loss. Eighty percent of patients reported that stress was involved or deeply involved in the onset or progression of the disease. Common causative stressors were business-related pressure, insufficient sleep, and troubles at the workplace or at home.

CONCLUSIONS

The present findings indicate that recovery and recurrence may be influenced by the strength and duration of stress that is produced when patients do not feel rewarded for engrossment in their work or for self-inhibiting behaviors.

Computed tomography of the inner ear: size of anatomical structures in the normal temporal bone and in the temporal bone of patients with Menière's disease

The purpose of the study was to obtain reference values for the sizes of anatomical structures of the inner ear on computed tomography (CT) images and to compare these values with those obtained from patients with Menière's disease. CT images of the temporal bone of 67 patients without inner ear pathology and 53 patients with Menière's disease have been evaluated. CT was performed in the sequential mode (1-mm slice thickness, 120 kV, 125 mA). Anatomical structures, such as the length and the width of the cochlea and of the vestibule, the height of the basal turn, the length and the width of the cochlear, the vestibular and the singular aqueduct and the internal auditory meatus and the diameter of the semicircular canals, were measured, using a dedicated postprocessing workstation. Reference values from the control group could be obtained. In the patients with Menière's disease, the length and the width of the vestibular aqueduct were smaller, compared with the values from the control group. The values obtained from the control group can serve as reference values for adult patients. The different sizes of anatomical structures of the control group and of patients suffering from Menière's disease suggest that functional impairment might be related to subtle morphological changes.