Prednisone Treatment for Vestibular Neuritis

Objective Neurological Testing Methods Used to Follow Up Vestibular Neuritis Depending on Different Factors

Purpose

We analyze the impact of different factors on clinical performance and prognosis in vestibular neuritis (VN) and explore indicators that could accurately reflect changes in patients' symptoms at different stages.

Methods

We observed patients with VN during the acute and recovery phases. Clinical symptoms, vertigo-related scales, neurological examination, vestibular function tests (caloric test, video head impulse test (vHIT), vestibular evoked myogenic potential (VEMP)), and the history of disease (underlying diseases, glucocorticoid therapy) were recorded at onset and at 4 and 12 weeks after onset in VN patients. Multiple linear regression analysis was used to identify vestibular function tests that had a linear regression relationship with the subjective quantitative results.

Results

At 4 weeks after onset, the group without underlying disease had better improvement in EEV, gain, and UW than the group with underlying disease (P < 0.05). There was a significant difference in the change in DHI, EEV, gain of the affected horizontal semicircular canal in the vHIT and unilateral weakness (UW) between the glucocorticoid treatment group and the no glucocorticoid treatment group (P < 0.05), and glucocorticoid treatment group was better. The change value in the gain of horizontal canals in the vHIT was mainly positively and linearly correlated with the EEV scores (P<0.001). Possible dynamic correlation between vHIT results and vestibular symptoms.

Conclusion

The absence of underlying disease and the receipt of glucocorticoid therapy significantly contributed to the improvement of objective vestibular function tests in the short term, while the improvement of subjective vertigo may correlate with the different objective measures and questionnaire. We believe that the improvement of the affected horizontal semicircular canal gain value in the vHIT can be used as a reference indicator of the degree of improvement of vestibular symptoms with superior vestibular neuritis.

Acute vestibular neuritis may provoke atrial fibrillation

BACKGROUND

Exclusion of stroke is the focus of guidelines in the emergency department assessment of acute vertigo, especially with new-onset atrial fibrillation (AF). Early diagnosis of vestibular neuritis (VN) is also important but may be deferred awaiting brain magnetic resonance imaging (MRI) for exclusion of stroke. This may delay potentially beneficial corticosteroid therapy.

AIMS

To highlight that VN can provoke acute AF.

METHODS

In the course of a prospective study of acute vertigo in patients assessable within 24 h of admission, we encountered three patients with acute onset transient AF associated with VN. We performed a detailed neurological examination and quantitated the vestibulo-ocular reflex (VOR) gain with video-oculography. Brain MRI was performed in all patients.

RESULTS

There were two men and one woman, aged 58-66 (mean 61) years. All patients had typical non-direction-changing rotatory nystagmus and positive head impulse tests. The horizontal VOR gains ranged 0.38-0.62 (mean 0.47). Diffusion-weighted MRI within 36 h was normal in all. AF reverted in all three within 24 h.

CONCLUSIONS

Acute AF can be precipitated by vertigo such as in VN. In VN, the concurrence of acute AF may distract from the correct neurological diagnosis, delaying potentially beneficial corticosteroid therapy, especially if exclusion of stroke is dependent on MRI, which may be delayed.

Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians

OBJECTIVE

To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders.

DATA SOURCES

PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines.

REVIEW METHODS

A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings.

CONCLUSIONS

Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss.

IMPLICATIONS FOR PRACTICE

Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

Vestibular Rehabilitation Therapy and Corticosteroids for Vestibular Neuritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: Besides corticosteroids, clinicians found that vestibular rehabilitation therapy (VRT) has a potential effect on vestibular neuritis (VN) improvement. This study aimed to investigate the efficacy of both corticosteroid therapy (CT) compared to VRT, and each group compared to their combination (CT vs. (CT+VRT) and VRT vs. (CT + VRT). Materials and Methods: Systematic searches were performed in PubMed, CINAHL, and Scopus for randomized controlled trials (RCTs) reporting the administration of at least CT and VRT for VN. The outcome of interest was VN's subjective and objective improvement parameters. Results: Four RCTs involving a total of 182 patients with VN were eligible for systematic review and meta-analysis. The weighted mean difference (WMD) of canal paresis (objective parameter) in the CT group is significantly lower than in the VRT group after a 1 month follow-up (8.31; 95% CI: 0.29, -16.32; p = 0.04; fixed effect). Meanwhile, the WMD of Dizziness Handicap Inventory (DHI) (subjective parameter) in the VRT group is significantly lower than in the CT group after a 1 month follow-up (-3.95; 95% CI: -7.69, -0.21; p = 0.04; fixed effect). Similarly, the WMD of DHI in the combination group (CT+VRT) is significantly lower than in the CT group after a 3 month follow-up (3.15; 95% CI: 1.50, 4.80; p = 0.0002; fixed effect). However, there is no significant difference in all outcomes after 12 months of follow-ups in all groups (CT vs. VRT, CT vs. combination, and VRT vs. combination). Conclusions: This study indicates that CT enhances the earlier canal paresis improvement, as the objective parameter, while VRT gives the earlier DHI score improvement, as the subjective parameter. However, their long-term efficacy does not appear to be different. VRT has to be offered as the primary option for patients with VN, and corticosteroids can be added to provide better recovery in the absence of its contraindication. However, whether to choose VRT, CT, or its combination should be tailored to the patient's condition. Future studies are still needed to revisit this issue, due to the small number of trials in this field. (PROSPERO ID: CRD42021220615).

Corticosteroids in patients with vestibular neuritis: An updated meta-analysis

Vestibular neuritis is a common neuro-otological entity. Therapeutically, corticosteroids are advised, although the evidence is limited. The objective of this review is to update meta-analyses of clinical trials that address the question of whether patients with vestibular neuritis treated with corticosteroids show better recovery than control patients. The electronic databases Medline, Scopus and Cochrane were searched for clinical trials for the years 1970-2020 without language restriction. Data were extracted, and outcome parameters were subjected to conventional and cumulative meta-analysis using a commercially available software program (www.meta-analysis.com). Finally, 15 trials with 363 participants in the treatment and 489 in the control groups were identified and could be included. Eight studies were judged to be at high risk of bias. The odds ratio (OR) for good outcome in the acute phase was 3.1 (95% CI 1.2-7.8; p = .015) in favour of steroid treatment leading to the number needed to treat (NNT) = 6 (95% CI 4-23). The odds ratio (OR) for restoration of vestibular function in the follow-up was 2.4 (95% CI 1.3-4.4; p = .004) for the benefit of steroid treatment resulting in a NNT = 7 (95% CI 5-18). The results of the cumulative statistics did not differ. The risk of adverse effects was higher in patients treated with steroids with an OR of 10.9 (95% CI 1.3-93.8; p = .015) and an estimated number needed to harm (NNH) = 4 (95% CI 3-19). The advantage for corticosteroids remained when differentiating between patients who participated in randomized or non-randomized clinical trials. Steroid treatment in vestibular neuritis resulted in a statistically significant benefit compared to control therapies. However, broad heterogeneity of the studies, mostly low-grade quality of studies, high risk of bias and broad confidence intervals put the findings into perspective allowing only a careful judgement of some benefit of corticosteroids. The findings, however, support the call for an adequately powered and well-designed randomized controlled trial to re-evaluate the effectiveness of corticosteroids.

Corticosteroids for patients with vestibular neuritis: an evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN.

METHODS

We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids as compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed.

RESULTS

From 149 titles, 5 systematic reviews were selected for quality assessment, and 2 reviews were of higher methodological quality and were included. These 2 reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of 2 RCTs including a total of 50 patients, the use of corticosteroids (as compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% CI 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide confidence interval for the outcome of dizziness handicap score (1 study, 30 patients, 20.9 points in corticosteroids group vs 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low.

CONCLUSIONS

There is limited evidence to support the use of corticosteroids for the treatment of vestibular neuritis in the emergency department.

Therapeutic effect of steroids on vestibular neuritis: Systematic review and meta-analysis

OBJECTIVES

The present meta-analysis sought to assess further evidence for the efficacy of steroids in vestibular neuritis (VN).

METHODS

The PubMed, EMBASE and Cochrane Library databases were searched through 30 August 2019. The main outcome measure was dizziness handicap inventory (DHI) and secondary outcomes included complete caloric recovery and improvement of canal paresis (CP). The follow-up times were divided into short, mid and long-term.

RESULTS

Among 276 records identified, 5 studies (n = 253) were included in the analysis. The therapeutic effect of steroid on VN was confirmed (Hedges' g = 0.172, 95% CI 0.05-0.30, p = .006). Although there was no significant difference between steroids and control in the DHI score (Hedges' g = -0.323, 95% CI -0.533 to -0.113, p < .01), significant effect was seen on complete caloric recovery and improvement in CP (Hedges' g = 0.364, 95% CI 0.18-0.55, p < .0001; Hedges' g = 0.592, 95% CI 0.32-0.59, p < .0001).

CONCLUSIONS

The results suggest that corticosteroids have an effect on the results of caloric tests for VN recovery, especially in long-term follow-up. However, in terms of dizziness handicap, we did not find any evidence of positive effect on corticosteroid. More data are required before recommendations can be made regarding management in patients on corticosteroids.

Breaking a dogma: acute anti-inflammatory treatment alters both post-lesional functional recovery and endogenous adaptive plasticity mechanisms in a rodent model of acute peripheral vestibulopathy

BACKGROUND

Due to their anti-inflammatory action, corticosteroids are the reference treatment for brain injuries and many inflammatory diseases. However, the benefits of acute corticotherapy are now being questioned, particularly in the case of acute peripheral vestibulopathies (APV), characterized by a vestibular syndrome composed of sustained spinning vertigo, spontaneous ocular nystagmus and oscillopsia, perceptual-cognitive, posturo-locomotor, and vegetative disorders. We assessed the effectiveness of acute corticotherapy, and the functional role of acute inflammation observed after sudden unilateral vestibular loss.

METHODS

We used the rodent model of unilateral vestibular neurectomy, mimicking the syndrome observed in patients with APV. We treated the animals during the acute phase of the vestibular syndrome, either with placebo or methylprednisolone, an anti-inflammatory corticosteroid. At the cellular level, impacts of methylprednisolone on endogenous plasticity mechanisms were assessed through analysis of cell proliferation and survival, glial reactions, neuron's membrane excitability, and stress marker. At the behavioral level, vestibular and posturo-locomotor functions' recovery were assessed with appropriate qualitative and quantitative evaluations.

RESULTS

We observed that acute treatment with methylprednisolone significantly decreases glial reactions, cell proliferation and survival. In addition, stress and excitability markers were significantly impacted by the treatment. Besides, vestibular syndrome's intensity was enhanced, and vestibular compensation delayed under acute methylprednisolone treatment.

CONCLUSIONS

We show here, for the first time, that acute anti-inflammatory treatment alters the expression of the adaptive plasticity mechanisms in the deafferented vestibular nuclei and generates enhanced and prolonged vestibular and postural deficits. These results strongly suggest a beneficial role for acute endogenous neuroinflammation in vestibular compensation. They open the way to a change in dogma for the treatment and therapeutic management of vestibular patients.

Update on current diagnosis and treatment of vestibular neuritis

Vertigo is the sensation of self-motion of the head or body when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement. Representative peripheral vertigo disorders include benign paroxysmal positional vertigo, Ménière disease, and vestibular neuritis. Vestibular neuritis, also known as vestibular neuronitis, is the third most common peripheral vestibular disorder after benign paroxysmal positional vertigo and Ménière disease. The cause of vestibular neuritis remains unclear. However, a viral infection of the vestibular nerve or ischemia of the anterior vestibular artery is known to cause vestibular neuritis. In addition, recent studies on immune-mediated mechanisms as the cause of vestibular neuritis have been reported. The characteristic clinical features of vestibular neuritis are abrupt true-whirling vertigo lasting for more than 24 hours, and no presence of cochlear symptoms and other neurological symptoms and signs. To accurately diagnose vestibular neuritis, various diagnostic tests such as the head impulse test, bithermal caloric test, and vestibular-evoked myogenic potential test are conducted. Various treatments for vestibular neuritis have been reported, which are largely divided into symptomatic therapy, specific drug therapy, and vestibular rehabilitation therapy. Symptomatic therapies include generalized supportive care and administration of vestibular suppressants and antiemetics. Specific drug therapies include steroid therapy, antiviral therapy, and vasodilator therapy. Vestibular rehabilitation therapies include generalized vestibular and customized vestibular exercises.

Systematic Review and Meta-analysis: Effectiveness of Corticosteroids in Treating Adults With Acute Vestibular Neuritis

OBJECTIVES

To determine whether steroids are effective in treating adults with acute vestibular neuritis.

DATA SOURCES

PubMed, Embase, CINAHL, Cochrane CENTRAL, Web of Science, CAB Abstract, ICTRP, LILACS, PEDRO, ClinicalTrials.Gov, Google Scholar, NARIC, and OT Seeker.

REVIEW METHODS

A systematic review was undertaken for articles reporting subjective and/or objective outcomes of corticosteroids in adults with acute vestibular neuritis between December 2010 and October 2019. Reports of patient recovery from clinical vestibular outcomes at various time points and adverse effects from corticosteroids were of interest. Statistical analysis included qualitative and quantitative assessments. A limited meta-analysis of the data was performed through a random effects model.

RESULTS

Eight studies met the criteria, and 6 were included in the meta-analysis. No significant differences between the groups (corticosteroid vs placebo, corticosteroid vs vestibular exercise, or corticosteroid vs combination of vestibular exercise and corticosteroid) were reported in the proportion of patients with complete recovery at 1, 6, and 12 months. The corticosteroid group had significantly better caloric recover at 1 month (95% CI, -16.33 to -0.32); however, there was no significant difference to the overall effect between the groups across 12 months. Subjective recovery did not differ between the groups. Five of the 8 studies reported on adverse effects from corticosteroids.

CONCLUSION

There is insufficient evidence to support the use of corticosteroids in managing acute vestibular neuritis in adults. At present, corticosteroids appear to have short-term benefits in canal paresis but no long-term benefits in canal paresis and symptomatic recovery. Future studies should consider including a wider variety of clinical vestibular tests and frequent acute follow-ups to monitor the effects of corticosteroids.

Vestibular disorders: clinician ENT perspective on the need for research and innovation

OBJECTIVE

Vertigo and dizziness are a frequent reason for medical consultation. However, diagnostic and therapeutic management is sometimes limited, and clinicians are faced with many unmet needs. The purpose of this study was to identify and prioritize these needs.

METHODS

A questionnaire methodology was used to determine the need for innovation in vestibular disorder management. The questionnaire was sent to 19 teams in French-speaking ENT centers. We measured the concordance of the panel of experts on 56 questions related to the different vestibular pathologies encountered and the desired modalities of innovations.

RESULTS

Thirteen questions were identified as priorities. The needs expressed by the experts had better knowledge of the pathophysiological mechanisms of the main diseases encountered and the development of new treatment modalities. Particular attention was paid to inner ear imaging techniques and the development of specific electrophysiology techniques.

DISCUSSION

Some of the anticipated innovations are already under development, such as new inner ear fluid imaging techniques (hydrops visualization using MRI) or in situ treatments (transtympanic dexamethasone or gentamicin injections). Others, such as new electrophysiological techniques, are still not fully developed CONCLUSION: This study provides a snapshot of the needs of the medical profession in vestibular disorder management. It highlights a real concern of the attending personnel, as well as a critical need to optimize the means of diagnosing and treating patients with vestibular disorders.

Steroids for Acute Vestibular Neuronitis-the Earlier the Treatment, the Better the Outcome?

Objective:

To present findings that suggest steroid treatment within 24 hours of onset of vestibular neuronitis results in better restitution of vestibular function than treatment between 25 and 72 hours.

Patients:

Thirty-three consecutive patients (17 men, 16 women, mean age 57 yr, range 17–85 yr) with acute vestibular neuronitis and treated with steroids within 72 hours after symptom onset. Patients were divided into two groups depending on if they were treated within the first 24 hours or not.

Interventions:

Oral prednisolone 50 mg/d for 5 days with tapering of doses for the next 5 days, or combined with initial intravenous betamethasone 8 mg the first 1 to 2 days if the patient was nauseous.

Main Outcome Measures:

Proportion of patients with normal caloric test result (canal paresis value < 32%) at follow-up after 3 or 12 months.

Results:

All 9 patients (100%) treated within 24 hours from onset of vestibular neuronitis had normal caloric test results at follow-up after 3 months, as compared with 14 of 24 (58%) of the patients treated between 25 and 72 hours (p < 0,05, Fisher's exact test).

Conclusions:

The timing of steroid treatment of vestibular neuronitis may be of importance for subsequent vestibular restitution, and hence, for both time to recovery and late symptoms according to the literature.

Effect of the novel histamine H4 receptor antagonist SENS-111 on spontaneous nystagmus in a rat model of acute unilateral vestibular loss

BACKGROUND AND PURPOSE

Histamine H₄ receptors are expressed in the peripheral vestibular system, and their selective inhibition improves vertigo symptoms in rats with unilateral vestibular lesions. The effects of SENS-111, a selective oral H₄ receptor antagonist with high affinity to both animal and human receptors, on vertigo symptoms was evaluated in a translational in vivo model of unilateral vestibular loss.

EXPERIMENTAL APPROACH

Pharmacokinetics of SENS-111 in rats was determined to aid dose selection for efficacy testing. Vestibular lesions were induced in rats by unilateral transtympanic injection of kainic acid. The effect of SENS-111 (10 or 20 mg·kg^-1 ) on spontaneous nystagmus was evaluated compared with placebo vehicle using video-nystagmography, and the effective dose was compared with those of similar drugs used clinically, as single agents or combined with SENS-111.

KEY RESULTS

Doses were selected for plasma exposure were consistent with published phase 1 results from healthy volunteers. SENS-111 of 10 mg·kg^-1 gave a 21-22% reduction in nystagmus at 1 hr post-administration, whereas a loss of efficacy was seen with 20 mg·kg^-1 . Compared with SENS-111, meclizine and methylprednisolone had minimal effects on nystagmus as single agents, and meclizine abolished the effect of SENS-111 when combined with SENS-111. All evaluated drugs were well tolerated.

CONCLUSIONS AND IMPLICATIONS

The exposure-efficacy relationship for improved spontaneous nystagmus seen with SENS-111 in this in vivo model is consistent with phase 1 clinical results and provides preclinical support for pharmacokinetic/pharmacodynamic modelling and selection of effective clinical drug concentrations.

LINKED ARTICLES

This article is part of a themed section on New Uses for 21st Century. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.3/issuetoc.

Vestibular and Multi-Sensory Influences Upon Self-Motion Perception and the Consequences for Human Behavior

In this manuscript, we comprehensively review both the human and animal literature regarding vestibular and multi-sensory contributions to self-motion perception. This covers the anatomical basis and how and where the signals are processed at all levels from the peripheral vestibular system to the brainstem and cerebellum and finally to the cortex. Further, we consider how and where these vestibular signals are integrated with other sensory cues to facilitate self-motion perception. We conclude by demonstrating the wide-ranging influences of the vestibular system and self-motion perception upon behavior, namely eye movement, postural control, and spatial awareness as well as new discoveries that such perception can impact upon numerical cognition, human affect, and bodily self-consciousness.

Safety, tolerability, pharmacokinetics and pharmacokinetic-pharmacodynamic modelling of the novel H4 receptor inhibitor SENS-111 using a modified caloric test in healthy subjects

AIM

A Phase 1 study was performed to evaluate safety, pharmacokinetics (PK) and pharmacodynamics (PD) of the selective histamine H₄ receptor antagonist SENS-111, an oral small molecule.

METHODS

One hundred healthy subjects were randomized in a placebo-controlled, double-blind study evaluating single-ascending doses (SAD; 100-500 mg) and multiple-ascending doses (MAD; 50-150 mg day^-1 , 4 days; 200-250 mg day^-1 , 7 days). Effects of SENS-111 on nystagmus and vertigo induced by modified caloric tests were measured in the MAD studies. Population PK and PK/PD models were developed using a nonlinear mixed-effects approach.

RESULTS

SENS-111 was well tolerated with mild to moderate events. No sedation was reported. A maximal tolerated dose was not reached. Dose-proportional increases in concentrations were seen up to 200 mg and more than dose-proportional thereafter, with mean half-life between 24 and 56 h. The caloric test induced mild but measurable vertigo and nystagmus with large intra/inter-individual variation for all parameters. SENS-111 did not significantly impact nystagmus but significantly improved latency of vertigo appearance/disappearance, duration and European Evaluation of Vertigo questionnaire parameters vs. baseline. A two-compartment model with first-order absorption, distribution and elimination best fit the data. PK/PD indirect modelling applied to vertigo duration and latency of appearance indicated maximum activity between 100 and 500 ng ml^-1 plasma concentrations, corresponding to 100 and 200 mg day^-1 , which are appropriate for clinical efficacy evaluations in vestibular diseases.

CONCLUSIONS

SENS-111 is a well-tolerated first-in-class H₄ receptor antagonist with acceptable PK for oral daily dosing. PK/PD modelling determined plasma concentrations and doses for efficacy studies in patients with vertigo symptoms.

The extent of vestibular impairment is important in recovery of canal paresis of patients with vestibular neuritis

OBJECTIVES

We questioned whether the extent of vestibular impairment affected the recovery of vestibular function in acute vestibular neuritis (VN). The objective of this study was to identify how the extent of vestibular impairment influenced the recovery from canal paresis (CP) in patients with VN.

METHODS

We retrospectively reviewed the medical records of 46 patients diagnosed with acute vestibulopathy between January 2012 and December 2015. Pure-tone audiometry, a caloric test, and cervical vestibular evoked myogenic potential (cVEMP) testing were performed in all patients. Patients were divided into two groups, superior VN and total VN, according to the results of the cervical vestibular evoked myogenic potential (cVEMP) testing. The caloric test was rechecked 6-12months after diagnosis and the CP values were compared at 6 and 12months. The degree of recovery was evaluated by comparing the CP values. We defined good recovery as CP<25% at follow-up.

RESULTS

We found no significant difference in age, sex ratio, lesional site, or follow-up period between patients with superior VN and total VN. The follow-up CP in patients with superior VN was significantly lower than that in those with total VN. Twenty patients (65%) in the superior VN group exhibited good recovery as did three (20%) in the total VN group; the between-group difference was significant.

CONCLUSIONS

We found that CP values recovered well in patients with superior VN. We suggest that the extent of vestibular impairment is important in the recovery of CP in acute vestibulopathy.

Clinical value of 4-hour delayed gadolinium-Enhanced 3D FLAIR MR Images in Acute Vestibular Neuritis

OBJECTIVE

To investigate the clinical significance of 4-hour delayed-enhanced 3.0 Tesla three-dimensional (3D) fluid-attenuated inversion recovery (FLAIR) magnetic resonance (MR) imaging in acute vestibular neuritis.

STUDY DESIGN

A prospective observational study.

METHODS

Twenty-nine vestibular neuritis patients were enrolled between January 2017 and June 2017. Vestibular function tests, comprising the caloric and video head impulse tests and vestibular-evoked myogenic potential measurements, were performed. Precontrast, 10-minute, and 4-hour delayed-enhanced 3D-FLAIR MR images using double-dose IV gadolinium were obtained. After laterality and extent of inner ear enhancement were defined, the patients were divided into groups based on the patterns of enhancement, and clinical parameters were analyzed according to the groups.

RESULTS

Twenty patients (20 of 29, 69.0%) had obviously asymmetric enhancement of the affected inner ear structures on 4-hour delayed images, whereas only three patients (10.3%) had marked enhancement on 10-minute delayed images. The duration of spontaneous nystagmus (DurSN) was significantly longer in the patients with enhancement, especially with enhancement of the whole inner ear, including the vestibule and semicircular canals (P < 0.033). Spontaneous nystagmus resolved within 12 days in patients without laterality of enhancement, and within 16 days in ipsilesional enhancement confined to the inner auditory canal and fundus. Other results of vestibular function tests did not reveal any significant associations with MR enhancement.

CONCLUSIONS

Contrast enhancement of the vestibular nerve and inner ear structures can be identified on 4-hour delayed-enhanced 3T 3D-FLAIR MR images in acute vestibular neuritis. The extent of inner ear enhancement may be associated with the DurSN.

LEVEL OF EVIDENCE

4. Laryngoscope, 1946-1951, 2018.

Disorders of the inner-ear balance organs and their pathways

Disorders of the inner-ear balance organs can be grouped by their manner of presentation into acute, episodic, or chronic vestibular syndromes. A sudden unilateral vestibular injury produces severe vertigo, nausea, and imbalance lasting days, known as the acute vestibular syndrome (AVS). A bedside head impulse and oculomotor examination helps separate vestibular neuritis, the more common and innocuous cause of AVS, from stroke. Benign positional vertigo, a common cause of episodic positional vertigo, occurs when otoconia overlying the otolith membrane falls into the semicircular canals, producing brief spells of spinning vertigo triggered by head movement. Benign positional vertigo is diagnosed by a positional test, which triggers paroxysmal positional nystagmus in the plane of the affected semicircular canal. Episodic spontaneous vertigo caused by vestibular migraine and Ménière's disease can sometimes prove hard to separate. Typically, Ménière's disease is associated with spinning vertigo lasting hours, aural fullness, tinnitus, and fluctuating hearing loss while VM can produce spinning, rocking, or tilting sensations and light-headedness lasting minutes to days, sometimes but not always associated with migraine headaches or photophobia. Injury to both vestibular end-organs results in ataxia and oscillopsia rather than vertigo. Head impulse testing, dynamic visual acuity, and matted Romberg tests are abnormal while conventional neurologic assessments are normal. A defect in the bony roof overlying the superior semicircular canal produces vertigo and oscillopsia provoked by loud sound and pressure (when coughing or sneezing). Three-dimensional temporal bone computed tomography scan and vestibular evoked myogenic potential testing help confirm the diagnosis of superior canal dehiscence. Collectively, these clinical syndromes account for a large proportion of dizzy and unbalanced patients.

New mouse model for inducing and evaluating unilateral vestibular deafferentation syndrome

BACKGROUND

Unilateral vestibular deafferentation syndrome (uVDS) holds a particular place in the vestibular pathology domain. Due to its suddenness, the violence of its symptoms that often result in emergency hospitalization, and its associated original neurophysiological properties, this syndrome is a major source of questioning for the otoneurology community. Also, its putative pathogenic causes remain to be determined. There is currently a strong medical need for the development of targeted and effective countermeasures to improve the therapeutic management of uVDS.

NEW METHODS

The present study reports the development of a new mouse model for inducing and evaluating uVDS. Both the method for generating controlled excitotoxic-type peripheral vestibular damages, through transtympanic administration of the glutamate receptors agonist kainate (TTK), and the procedure for evaluating the ensuing clinical signs are detailed.

COMPARISON WITH EXISTING METHODS

Through extensive analysis of the clinical symptoms characteristics, this new animal model provides the opportunity to better follow the temporal evolution of various uVDS specific symptoms, while better appreciating the different phases that composed this syndrome.

RESULTS

The uVDS evoked in the TTK mouse model displays two main phases distinguishable by their kinetics and amplitudes. Several parameters of the altered vestibular behaviour mimic those observed in the human syndrome.

CONCLUSION

This new murine model brings concrete information about how uVDS develops and how it affects global behaviour. In addition, it opens new opportunity to decipher the etiopathological substrate of this pathology by authorizing the use of genetically modified mouse models.

Asymmetric vestibular stimulation reveals persistent disruption of motion perception in unilateral vestibular lesions

Self-motion perception was studied in patients with unilateral vestibular lesions (UVL) due to acute vestibular neuritis at 1 wk and 4, 8, and 12 mo after the acute episode. We assessed vestibularly mediated self-motion perception by measuring the error in reproducing the position of a remembered visual target at the end of four cycles of asymmetric whole-body rotation. The oscillatory stimulus consists of a slow (0.09 Hz) and a fast (0.38 Hz) half cycle. A large error was present in UVL patients when the slow half cycle was delivered toward the lesion side, but minimal toward the healthy side. This asymmetry diminished over time, but it remained abnormally large at 12 mo. In contrast, vestibulo-ocular reflex responses showed a large direction-dependent error only initially, then they normalized. Normalization also occurred for conventional reflex vestibular measures (caloric tests, subjective visual vertical, and head shaking nystagmus) and for perceptual function during symmetric rotation. Vestibular-related handicap, measured with the Dizziness Handicap Inventory (DHI) at 12 mo correlated with self-motion perception asymmetry but not with abnormalities in vestibulo-ocular function. We conclude that 1) a persistent self-motion perceptual bias is revealed by asymmetric rotation in UVLs despite vestibulo-ocular function becoming symmetric over time, 2) this dissociation is caused by differential perceptual-reflex adaptation to high- and low-frequency rotations when these are combined as with our asymmetric stimulus, 3) the findings imply differential central compensation for vestibuloperceptual and vestibulo-ocular reflex functions, and 4) self-motion perception disruption may mediate long-term vestibular-related handicap in UVL patients.

NEW & NOTEWORTHY A novel vestibular stimulus, combining asymmetric slow and fast sinusoidal half cycles, revealed persistent vestibuloperceptual dysfunction in unilateral vestibular lesion (UVL) patients. The compensation of motion perception after UVL was slower than that of vestibulo-ocular reflex. Perceptual but not vestibulo-ocular reflex deficits correlated with dizziness-related handicap.

Efficacy of steroid therapy based on symptomatic and functional improvement in patients with vestibular neuritis: a prospective randomized controlled trial

The aim of this study was to examine the efficacy of methylprednisolone in vestibular neuritis (VN) by objective and subjective measures. This prospective controlled randomized study was conducted at one tertiary hospital. Twenty-nine VN patients were randomized to either the steroid (n = 15) or the control (n = 14) group. The steroid group received methylprednisolone for 2 weeks, whereas control patients did not; both groups underwent regular vestibular exercises and were prescribed a Ginkgo biloba. Vestibular function tests including caloric test, video head impulse test (vHIT), and sensory organization test (SOT) were performed, and dizziness handicap index (DHI) was determined at enrollment; all tests were repeated at 1 and 6 months after enrollment. Both groups showed statistically significant improvements in caloric weakness and vHIT gain at 1- and 6-month follow-up evaluations compared to the initial examination; however, differences were not significant. The rates of normalization of canal paresis at 1 and 6 months were 50 and 64% in the control group and 33 and 60% in the steroid group, respectively, with no differences between the two groups. The rates of vHIT normalization at 1 and 6 months after treatment were 57 and 78% in the control group and 53 and 87% in the steroid group, respectively, with no differences between the two groups. Finally, there were no significant differences in the improvement of composite scores of SOT and the DHI scores between the two groups. In this prospective RCT, methylprednisolone had no additional benefit in patients with VN who underwent vestibular exercises and received a Ginkgo biloba.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier, NCT02098330; Trial title, The Efficacy of Steroid Therapy in Vestibular Neuritis.

Relapsing Ipsilateral Vestibular Neuritis

In 2013, a 70-year-old male was admitted with an acute episode of vertigo, nausea, and vomiting with duration of one day. The patient's background included prehypertension, vitiligo, left ventricular hypertrophy, and Sjögren's syndrome. He denied any previous episode of vertigo or migraine manifestations. Neither hearing loss nor tinnitus or otorrhea was detected at the time of evaluation. No neurological symptoms were found. There was a left-beating spontaneous nystagmus Grade 3. The patient could stand still and walk on his own with some help without falling. Day 1 vHIT showed a significant reduction in VOR gain and refixation saccades after head impulses were delivered in the planes of the right anterior and horizontal semicircular canals. MRI showed no significant findings. He was treated with steroids. A vHIT performed 14 days later showed recovery of gains and no refixation saccades. In 2015, the patient had a new episode of acute vertigo. The clinical examination was similar, and the vHIT revealed a new drop of right superior and lateral canal gains. Cervical and ocular VEMPs were performed, and no significant asymmetry was detected. Serum PCR for herpes viruses resulted negative. Contrast MRI was performed without relevant brain findings.

A video-oculographic study of acute vestibular syndromes

OBJECTIVES

To quantitate the vestibulo-ocular reflex (VOR) gain in patients with acute vestibular neuritis (VN) and repeat this daily using a portable video head impulse test device to assess vestibular recovery in the acute stage of VN.

MATERIALS AND METHODS

We enrolled adults with symptoms and signs of VN presenting to the emergency department within 48 h of symptom onset. We recorded the eye movement response to rapid head impulses using the ICS Impulse(™) video head impulse test device on each day of their hospital admission.

RESULTS

There were eight patients (75% men, aged 35-85 years) who had marked variation in their initial vestibulo-ocular reflex gains. Three patients had vestibulo-ocular reflex gains in the normal range initially, despite having physical signs of VN. Two patients had initial contralesional gains below the normal range, associated with markedly reduced ipsilesional gains. Most patients' vestibulo-ocular reflex gains increased during admission, but four patients' ipsilesional gains remained in the abnormal range. Patients with lower vestibulo-ocular reflex gains were less likely to improve into the normal range. No patient with initially abnormal VOR gain recovered normal vestibulo-ocular reflex gain along with resolution of physical signs.

CONCLUSION

Early video head impulse testing in the emergency department and each day of admission is feasible and well tolerated. There is marked variation in VOR gain in patients with symptoms and signs of VN, and low initial VOR gains are a predictor for low VOR gains on subsequent days. Improvement in VOR gains was seen in most patients.

Chronic unilateral vestibular loss

Chronic unilateral vestibular loss is a condition defined by the presence of reduced function of the peripheral vestibular system on one side, which has generally persisted for 3 or more months. The deficit is demonstrated by a reduction of the vestibular-ocular reflex either at the bedside or on laboratory testing. Though some patients with chronic vestibular loss have disabling symptoms, others are asymptomatic. Causes include a viral/postviral disorder, Menière's disease, structural lesions, ischemia, and trauma. Any other systemic or genetic disorder would be expected to involve both sides at some point.

Chronic Symptoms After Vestibular Neuritis and the High-Velocity Vestibulo-Ocular Reflex

HYPOTHESIS

As the anterior and posterior semicircular canals are vital to the regulation of gaze stability, particularly during locomotion or vehicular travel, we tested whether the high-velocity vestibulo-ocular reflex (VOR) of the three ipsilesional semicircular canals elicited by the modified Head Impulse Test would correlate with subjective dizziness or vertigo scores after vestibular neuritis (VN).

BACKGROUND

Recovery after acute VN varies with around half reporting persistent symptoms long after the acute episode. However, an unanswered question is whether chronic symptoms are associated with impairment of the high-velocity VOR of the anterior or posterior canals.

METHODS

Twenty patients who had experienced an acute episode of VN at least 3 months earlier were included in this study. Participants were assessed with the video head impulse test (vHIT) of all six canals, bithermal caloric irrigation, the Dizziness Handicap Inventory (DHI), and the Vertigo Symptoms Scale short-form (VSS).

RESULTS

Of these 20 patients, 12 thought that they had recovered from the initial episode whereas 8 did not and reported elevated DHI and VSS scores. However, we found no correlation between DHI or VSS scores and the ipsilesional single or combined vHIT gain, vHIT gain asymmetry orcaloric paresis. The high-velocity VOR was not different between patients who thought they had recovered and patients who thought they had not.

CONCLUSION

Our findings suggest that chronic symptoms of dizziness after VN are not associated with the high-velocity VOR of the single or combined ipsilesional horizontal, anterior, or posterior semicircular canals.

Principles of vestibular pharmacotherapy

Ideally, vestibular pharmacotherapy is intended, through specific and targeted molecular actions, to significantly alleviate vertigo symptoms, to protect or repair the vestibular sensory network under pathologic conditions, and to promote vestibular compensation, with the eventual aim of improving the patient's quality of life. In fact, in order to achieve this aim, considerable progress still needs to be made. The lack of information on the etiology of vestibular disorders and the pharmacologic targets to modulate, as well as the technical challenge of targeting a drug to its effective site are some of the main issues yet to be overcome. In this review, my intention is to provide an account of the therapeutic principles that have shaped current vestibular pharmacotherapy and to further explore crucial questions that must be taken into consideration in order to develop targeted and specific pharmacologic therapies for each type and stage of vestibular disorders.

The Effect of Intravenous Dexamethasone on the Nausea Accompanying Vestibular Neuritis: A Preliminary Study

PURPOSE

We undertook a preliminary assessment of the efficacy of administering intravenous dexamethasone (DEX) for relieving the nausea and dizziness accompanying vestibular neuritis (VN).

METHODS

Between November 2013 and October 2014, 26 patients with VN were prospectively enrolled in this study. The patients were randomly assigned to treatment with a combination of 20 mg/d of intravenous metoclopramide, 100 mg of oral dimenhydrinate, and 5 mg/d of intravenous DEX or 20 mg/d of intravenous metoclopramide, 100 mg of oral dimenhydrinate, and intravenous normal saline as a placebo therapy. Patients' subjective assessments of the severity of their nausea and dizziness were recorded using a visual analog scale on the day of admission and 2 days, 3 days, 1 month, and 3 months thereafter. Bedside examinations consisted of spontaneous nystagmus (SPN) assessment, the head shaking nystagmus test, and the head impulse test, which were performed at every follow-up visit.

FINDINGS

The severity of nausea and dizziness was significantly reduced over time (both P < 0.05). However, there was no significant effect of DEX injection on the severity of nausea or dizziness (P > 0.05). The presence of SPN was solely associated with nausea (hazard ratio = 3.34; 95% CI, 1.85-6.02).

IMPLICATIONS

The administration of intravenous DEX did not relieve nausea or dizziness any better than a placebo treatment. However, further research is required to confirm whether there is a dose-dependent effect of DEX on the control of nausea or dizziness in VN.

Glucocorticoids improve acute dizziness symptoms following acute unilateral vestibulopathy

Acute unilateral vestibulopathy (AUV) is characterized by acute vertigo, nausea, and imbalance without neurological deficits or auditory symptomatology. Here, we explore the effect of glucocorticoid treatment on the degree of canal paresis in patients with AUV, and critically, establish its relationship with dizziness symptom recovery. We recruited consecutive patients who were retrospectively assigned to one of the two groups according to whether they received glucocorticoid treatment (n = 32) or not (n = 44). All patients underwent pure-tone audiometry, bithermal caloric testing, MRI brain imaging, and were asked to complete a dizziness handicap inventory on admission to hospital and just prior to hospital discharge. In the treatment group, the canal paresis at discharge was significantly lower than in the control group (mean ± SD % 38.04 ± 21.57 versus 82.79 ± 21.51, p < 0.001). We also observed a significant reduction in the intensity of nystagmus in patients receiving glucocorticoid treatment compared to the non-treatment group (p = 0.03). DHI test score was significantly lower at discharge in the treatment group (mean ± SD % 23.15 ± 12.40 versus 64.07 ± 12.87, p < 0.001), as was the length of hospital stay (2.18 ± 1.5 days versus 3.6 ± 1.7 days, p = 0.002). Glucocorticoid treatment leads to acute symptomatic improvement, with a reduced hospital stay and reduction in the intensity of acute nystagmus. Our findings suggest that glucocorticoids may accelerate vestibular compensation via a restoration of peripheral vestibular function, and therefore has important clinical implications for the treatment of AUV.

Visual dependency and dizziness after vestibular neuritis

Symptomatic recovery after acute vestibular neuritis (VN) is variable, with around 50% of patients reporting long term vestibular symptoms; hence, it is essential to identify factors related to poor clinical outcome. Here we investigated whether excessive reliance on visual input for spatial orientation (visual dependence) was associated with long term vestibular symptoms following acute VN. Twenty-eight patients with VN and 25 normal control subjects were included. Patients were enrolled at least 6 months after acute illness. Recovery status was not a criterion for study entry, allowing recruitment of patients with a full range of persistent symptoms. We measured visual dependence with a laptop-based Rod-and-Disk Test and severity of symptoms with the Dizziness Handicap Inventory (DHI). The third of patients showing the worst clinical outcomes (mean DHI score 36-80) had significantly greater visual dependence than normal subjects (6.35° error vs. 3.39° respectively, p = 0.03). Asymptomatic patients and those with minor residual symptoms did not differ from controls. Visual dependence was associated with high levels of persistent vestibular symptoms after acute VN. Over-reliance on visual information for spatial orientation is one characteristic of poorly recovered vestibular neuritis patients. The finding may be clinically useful given that visual dependence may be modified through rehabilitation desensitization techniques.

Disrupted functional connectivity of the default mode network due to acute vestibular deficit

Vestibular neuritis is defined as a sudden unilateral partial failure of the vestibular nerve that impairs the forwarding of vestibular information from the labyrinth. The patient suffers from vertigo, horizontal nystagmus and postural instability with a tendency toward ipsilesional falls. Although vestibular neuritis is a common disease, the central mechanisms to compensate for the loss of precise vestibular information remain poorly understood. It was hypothesized that symptoms following acute vestibular neuritis originate from difficulties in the processing of diverging sensory information between the responsible brain networks. Accordingly an altered resting activity was shown in multiple brain areas of the task-positive network. Because of the known balance between the task-positive and task-negative networks (default mode network; DMN) we hypothesize that also the DMN is involved.

Here, we employ functional magnetic resonance imaging (fMRI) in the resting state to investigate changes in the functional connectivity between the DMN and task-positive networks, in a longitudinal design combined with measurements of caloric function. We demonstrate an initially disturbed connectedness of the DMN after vestibular neuritis. We hypothesize that the disturbed connectivity between the default mode network and particular parts of the task-positive network might be related to a sustained utilization of processing capacity by diverging sensory information. The current results provide some insights into mechanisms of central compensation following an acute vestibular deficit and the importance of the DMN in this disease.

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fMRI connectivity analyses after vestibular neuritis in a longitudinal design

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Initially disturbed connectedness between the DMN and task positive networks

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Connectivity restoration after complete clinical recovery of patients

The role of cervical and ocular vestibular-evoked myogenic potentials in the follow-up of vestibular neuritis

This study evaluates the recovery of vestibular nerve function after vestibular neuritis (VN) by vestibular-evoked myogenic potentials (VEMPs). Twenty-six patients with the diagnosis of VN were included. All patients underwent ocular VEMP (oVEMP) and cervical VEMP (cVEMP) recordings, at 6 days and 6 months from the onset of the symptoms. Of the 26 patients, 14 showed improvement on oVEMP at month 6 (group 1), and 12 showed no change or worsening on oVEMP at 6 months (group 2). At the same time, there was no change in the amplitudes of the cVEMP on either healthy or affected sides in both groups. Inability to perform the Fukuda test, and chronic white matter supratentorial lesions present on brain magnetic resonance imaging (MRI) were more frequent in patients with worse outcome on oVEMP (P = 0.044 and 0.045, respectively). Although involvement of the inferior branch of the vestibular nerve was not associated with oVEMP outcome, oVEMP latencies (N10 and P13) were associated with improvement or worsening in oVEMP amplitudes, showing that prolonged latencies correlate with 6-month improvement in oVEMP amplitudes (Pearson correlation -0.472, P = 0.041 and -0.580, P = 0.009, respectively). This study identified clinical, MRI and neurophysiological predictors of recovery in patients with superior VN, and offers additional insight into, and better understanding of, the role of VEMP in diagnosis and prognosis of patients with VN. Further studies are needed to validate this diagnostic procedure and to assess its clinical usefulness in VN management.

Changes in resting-state fMRI in vestibular neuritis

Vestibular neuritis (VN) is a sudden peripheral unilateral vestibular failure with often persistent head movement-related dizziness and unsteadiness. Compensation of asymmetrical activity in the primary peripheral vestibular afferents is accomplished by restoration of impaired brainstem vestibulo-ocular and vestibulo-spinal reflexes, but presumably also by changing cortical vestibular tone imbalance subserving, e.g., spatial perception and orientation. The aim of this study was to elucidate (i) whether there are changes of cerebral resting-state networks with respect to functional interregional connectivity (resting-state activity) in VN patients and (ii) whether these are related to neurophysiological, perceptual and functional parameters of vestibular-induced disability. Using independent component analysis (ICA), we compared resting-state networks between 20 patients with unilateral VN and 20 age- and gender-matched healthy control subjects. Patients were examined in the acute VN stage and after 3 months. A neural network (component 50) comprising the parietal lobe, medial aspect of the superior parietal lobule, posterior cingulate cortex, middle frontal gyrus, middle temporal gyrus, parahippocampal gyrus, anterior cingulate cortex, insular cortex, caudate nucleus, thalamus and midbrain was modulated between acute VN patients and healthy controls and in patients over time. Within this network, acute VN patients showed decreased resting-state activity (ICA) in the contralateral intraparietal sulcus (IPS), in close vicinity to the supramarginal gyrus (SMG), which increased after 3 months. Resting-state activity in IPS tended to increase over 3 months in VN patients who improved with respect to functional parameters of vestibular-induced disability (VADL). Resting-state activity in the IPS was not related to perceptual (subjective visual vertical) or neurophysiological parameters of vestibular-induced disability (e.g., gain of vestibulo-ocular reflex, caloric responsiveness, postural sway). VN leads to a change in resting-state activity of the contralateral IPS adjacent to the SMG, which reverses during vestibular compensation over 3 months. The ventral intraparietal area in the IPS contains multimodal regions with directionally selective responses to vestibular stimuli making them suitable for participating in spatial orientation and multisensory integration. The clinical importance is indicated by the fact that the increase in resting-state activity tended to be larger in those patients with only little disability at the follow-up examination. This may indicate powerful restitution-related or compensatory cortical changes in resting-state activity.

Comparison of the therapeutic efficacy of a fixed low-dose combination of cinnarizine and dimenhydrinate with betahistine in vestibular neuritis: a randomized, double-blind, non-inferiority study

BACKGROUND

Vestibular neuritis (VN) is a strongly disabling disease of the peripheral vestibular system. Rapid and effective relief of symptoms is important to allow patients to promptly return to normal physical activity.

OBJECTIVE

The aim of this prospective, randomized, double-blind study was to evaluate the efficacy of a fixed low-dose combination of cinnarizine and dimenhydrinate in unilateral VN in comparison with betahistine in terms of improvement of vertigo and concomitant symptoms, and performance in neurotological testing.

METHODS

Sixty-two patients were randomized to receive either cinnarizine 20 mg/dimenhydrinate 40 mg as a fixed combination or betahistine 12 mg, each three times daily for 4 weeks. Vertigo and concomitant symptoms, activities of daily living (ADL), posturography and a battery of vestibulo-ocular tests, registered by electronystagmography including spontaneous nystagmus, bithermal caloric and rotatory test, among others, were assessed at baseline (t(0)), after 1 week (t(1w)) and after 4 weeks (t(4w)). The primary endpoint was the Mean Vertigo Score (MVS) at t(1w), a composite of 12 individual scores for unprovoked and provoked vertigo, each assessed using a 10 cm visual analogue scale (VAS). Non-inferiority of the fixed combination versus betahistine would be assumed if the two-sided 95% confidence intervals (CIs) for between-group differences in MVS lay entirely below the non-inferiority margin of 1.25 (12.5% of VAS range).

RESULTS

The fixed combination led to significantly greater improvements in MVS than betahistine both at t(1w) (primary endpoint) and at t(4w) (95% CI for the difference in baseline-adjusted means -0.95, -0.64 at t(1w), -0.77, -0.44 at t(4w); p < 0.001). Vegetative symptoms and ADL also improved significantly more under the fixed combination than under betahistine at t(1w) (p < 0.001, each parameter) and t(4w) (p < 0.001 and p < 0.01, respectively), both showing a nearly complete remission at t(4w). In the two groups, pathological posturography and electronystagmography parameters normalized during the 4-week treatment. The fixed combination group showed an earlier recovery of spontaneous nystagmus than the betahistine group (t(1w), p < 0.001) and slightly higher improvements in asymmetry of rotation-induced nystagmus at t(1w) and t(4w) (p = 0.041, each time point). No significant differences were found between the treatments in abatement of spontaneous nystagmus at t(4w) and decrease of caloric lateralization or improvement of equilibrium (sensory organization test [SOT], conditions 5/6) at t(1w) and t(4w). No patient reported any adverse event.

CONCLUSION

The results showed that the fixed low-dose combination of cinnarizine and dimenhydrinate is an effective and well tolerated option for symptomatic treatment in unilateral VN. The fixed combination led to significant improvements in vertigo and ADL within the first week, and to a nearly complete recovery after 4 weeks. Neurotological testing revealed no signs of a possible detrimental influence of the 4-week treatment with the fixed combination compared with betahistine in terms of recovery of caloric responsiveness and abatement of rotation-induced nystagmus.

Insufficient evidence for the effect of corticosteroid treatment on recovery of vestibular neuritis

The authors studied the effect of corticosteroid treatment on clinical recovery and recovery of vestibular function in patients with vestibular neuritis. The comprehensive search (March 29, 2012) yielded 496 original papers, of which 5 (including 199 patients) during full-text screening satisfied our eligibility criteria. Methods assessment showed that 1 study (30 patients) provided direct evidence and carried low risk of bias. Two studies properly reported on their random and concealed allocation of treatment. In 1 study, patients were not randomly allocated to treatment. Blinding of outcomes was lacking in 2 studies, whereas outcome data were clearly incomplete for 2 studies. Given the wide variety in outcome measures and scales and follow-up duration, the meaning of the size of reported effects is not clear. Therefore, the reported effects cannot simply be compared between studies, and this precludes pooling of study results. Still, there are large differences between studies in the size of the reported absolute effects after the placebo treatment. Moreover, the difference in effects between treatments is rather small and does not always favor corticosteroids. The moderate to high risk of bias of studies precludes firm conclusions, whereas the reported short-term effects on symptom recovery and improvement of peripheral vestibular function are too small to be clinically important. No long-term effect on symptom recovery has been shown. Recommendations or decisions for corticosteroid treatment in patients with vestibular neuritis cannot be based on current best evidence and therefore should be discussed with the patient.

Interactions between Stress and Vestibular Compensation - A Review

Elevated levels of stress and anxiety often accompany vestibular dysfunction, while conversely complaints of dizziness and loss of balance are common in patients with panic and other anxiety disorders. The interactions between stress and vestibular function have been investigated both in animal models and in clinical studies. Evidence from animal studies indicates that vestibular symptoms are effective in activating the stress axis, and that the acute stress response is important in promoting compensatory synaptic and neuronal plasticity in the vestibular system and cerebellum. The role of stress in human vestibular disorders is complex, and definitive evidence is lacking. This article reviews the evidence from animal and clinical studies with a focus on the effects of stress on the central vestibular pathways and their role in the pathogenesis and management of human vestibular disorders.

Treatment of acute vestibular neuronitis with glucocorticoids

OBJECTIVE

To report the effects of glucocorticoid treatment of acute vestibular neuronitis on recovery of vestibular function and length of hospital stay.

STUDY DESIGN

Prospective, consecutive case series compared with historic controls.

SETTING

Secondary referral academic hospital.

PATIENTS

Patients with acute vestibular neuronitis. One group treated with glucocorticoids within 3 days after symptom onset (n = 33) and 2 historic untreated control groups (n = 41 and n = 67).

INTERVENTIONS

Oral prednisolone 50 mg/d for 5 days with tapering of doses for the next 5 days, alternatively with intravenous betamethasone 8 mg on the first 1 to 2 days if nauseated.

MAIN OUTCOME MEASURES

Extent of unilateral vestibular paresis (%) in the caloric test at presentation and at 12 months of follow-up. Length of hospital stay (days).

RESULTS

The initial vestibular paresis value did not differ between the treatment group and the control group. At follow-up, the treatment group showed a lower value (22.8% versus 47.2%, p = 0.0003) and greater improvement (53.4% versus 35.6%, p = 0.002). At follow-up, 70% of the treatment group had a normal caloric test result compared to only 34% of the control group. The mean hospital stay of the treatment group was significantly shorter than that of the control group (1.8 versus 3.0 d, p = 0.001).

CONCLUSION

Glucocorticoids administered within 3 days after onset of vestibular neuronitis improves long-time recovery of vestibular function and reduces length of hospital stay.

Visual dependence and BPPV

The increased visual dependence noted in some vestibular patients may be secondary to their vertigo. We examine whether a single, brief vertigo attack, such as in benign paroxysmal positional vertigo (BPPV), modifies visual dependency. Visual dependency was measured before and after the Hallpike manoeuvre with (a) the Rod and Frame and the Rod and Disc techniques whilst seated and (b) the postural sway induced by visual roll-motion stimulation. Three subject groups were studied: 20 patients with BPPV (history and positive Hallpike manoeuvre; PosH group), 20 control patients (history of BPPV but negative Hallpike manoeuvre; NegH group) and 20 normal controls. Our findings show that while both patient groups showed enhanced visual dependency, the PosH and the normal control group decreased visual dependency on repetition of the visual tasks after the Hallpike manoeuvre. NegH patients differed from PosH patients in that their high visual dependency did not diminish on repetition of the visual stimuli; they scored higher on the situational characteristic questionnaire ('visual vertigo' symptoms) and showed higher incidence of migraine. We conclude that long term vestibular symptoms increase visual dependence but a single BPPV attack does not increase it further. Repetitive visual motion stimulation induces adaptation in visual dependence in peripheral vestibular disorders such as BPPV. A positional form of vestibular migraine may underlie the symptoms of some patients with a history of BPPV but negative Hallpike manoeuvre. The finding that they have non adaptable increased visual dependency may explain visuo-vestibular symptoms in this group and, perhaps more widely, in patients with migraine.

Recovery after acute unilateral vestibular loss and predictors for remaining symptoms

PURPOSE

The aims of this study were to follow recovery during the first 6 months after acute unilateral vestibular loss (AUVL) and to determine predictors for self-rated remaining symptoms.

MATERIALS AND METHODS

Forty-two subjects were included less than 10 days after AUVL. Static and dynamic clinical balance tests, visual analogue scales, University of California Los Angeles Dizziness Questionnaire, Dizziness Beliefs Scale, European Quality of Life questionnaire, Dizziness Handicap Inventory, and Hospital Anxiety and Depression Scale were performed at inclusion and at 7 follow-ups over 6 months. Subjects rated their symptoms on visual analogue scales daily at home. Videonystagmography was performed in the acute stage and after 10 weeks.

RESULTS

Decrease of symptoms and improvement of balance function were larger during the first compared with the latter part of the follow-up period. Visual analogue scale ratings for balance problems were higher than those for dizziness. A prediction model was created based on the results of 4 tests in the acute stage: standing on foam with eyes closed, standing on 1 leg with eyes open, visual analogue scale rating of vertigo at rest, and European Quality of Life questionnaire rating of health-related quality of life. The prediction model identified subjects at risk of having remaining symptoms after 6 months with a sensitivity of 86% and a specificity of 79%.

CONCLUSIONS

Recovery mainly takes place during the first weeks after AUVL. Subjects rate more balance problems than dizziness. Self-rated remaining symptoms after 6 months may be predicted by clinical balance tests and subjective ratings in the acute stage.

Vestibular neuritis

The epidemiology, diagnostic features, differential diagnosis, and treatment of vestibular neuritis are reviewed. The authors present considerations for physical examination, imaging, and management in both the acute and chronic phases of this disease. The authors also present a dizziness questionnaire in the Appendix of this publication.

Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)

BACKGROUND

Idiopathic acute vestibular dysfunction (vestibular neuritis) is the second most common cause of peripheral vertigo after benign paroxysmal positional vertigo (BPPV) and accounts for 7% of the patients who present at outpatient clinics specialising in the treatment of dizziness. The exact aetiology of the condition is unknown and the effects of corticosteroids on the condition and its recovery are uncertain.

OBJECTIVES

To assess the effectiveness of corticosteroids in the management of patients with idiopathic acute vestibular dysfunction (vestibular neuritis).

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 28 December 2010.

SELECTION CRITERIA

Randomised controlled trials comparing corticosteroids with placebo, no treatment or other active treatments, for adults diagnosed with idiopathic acute vestibular dysfunction.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies from the search results and extracted data. Three authors independently assessed risk of bias.

MAIN RESULTS

Four trials, involving a total of 149 participants, compared the effectiveness of oral corticosteroids against placebo. All the trials were small and of low methodological quality. Although there was an overall significant effect of corticosteroids compared with placebo medication on complete caloric recovery at one month (risk ratio (RR) of 2.81; 95% confidence interval (CI) 1.32 to 6.00, P = 0.007), no significant effect was seen on complete caloric recovery at 12 months (RR 1.58; 95% CI 0.45 to 5.62, P = 0.48), or on the extent of caloric recovery at either one month (mean difference (MD) 9.60%; 95% CI -20.66 to 39.86, P = 0.53) or at 12 months (MD 6.83%; 95% CI -27.69 to 41.36, P = 0.70). In addition, there was no significant difference between corticosteroids and placebo medication in the symptomatic recovery of vestibular function following idiopathic acute vestibular dysfunction with respect to vertigo at 24 hours (RR 0.39; 95% CI 0.04 to 3.57, P = 0.40) and use of the Dizziness Handicap Inventory score at one, three, six and 12 months.

AUTHORS' CONCLUSIONS

Overall, there is currently insufficient evidence from these trials to support the administration of corticosteroids to patients with idiopathic acute vestibular dysfunction. We found no trials with a low risk of methodological bias that used the highest level of diagnostic criteria and outcome measures. We recommend that future studies should include health-related quality of life and symptom-based outcome measures, in addition to objective measures of vestibular improvement, such as caloric testing and electronystagmography.

Acute vestibulopathy

The presentation of acute vertigo may represent both a common benign disorder or a life threatening but rare one. Familiarity with the common peripheral vestibular disorders will allow the clinician to rapidly "rule-in" a benign disorder and recognize when further testing is required. Key features of vertigo required to make an accurate diagnosis are duration, chronicity, associated symptoms, and triggers. Bedside tests that are critical to the diagnosis of acute vertigo include the Dix-Hallpike maneuver and canalith repositioning manuever, occlusive ophthalmoscopy, and the head impulse test. The goal of this review is to provide the clinician with the clinical and pathophysiologic background of the most common disorders that present with vertigo to develop a logical differential diagnosis and management plan.

Corticosteroids in the treatment of vestibular neuritis: a systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyze the results of all randomized controlled trials comparing corticosteroids with placebo for the treatment of patients with vestibular neuritis.

DATA SOURCES

An electronic search was performed in MEDLINE, EMBASE, Cochrane Library, and CENTRAL databases, and then extensive hand-searching was performed for the identification of relevant studies. No time and language limitations were applied.

STUDY SELECTION

Prospective randomized controlled trials comparing corticosteroids with placebo for the treatment of patients with vestibular neuritis.

DATA EXTRACTION

Odds ratios (ORs), weighted mean differences (WMD), 95% confidence intervals (CIs), and tests for heterogeneity were reported.

DATA SYNTHESIS

Four studies were eventually identified and systematically reviewed. Meta-analysis was feasible for 3 studies. Regarding the recovery of clinical symptoms, the proportion of patients with clinical recovery at 1 month after the initiation of therapy did not differ significantly between the corticosteroids and placebo groups (OR, 1.45; 95% CI, 0.26-8.01; p = 0.67). The proportion of patients with caloric complete recovery was significantly different between the corticosteroids and placebo groups both at 1 (OR, 12.64; 95% CI, 2.6-61.52; p = 0.002; heterogeneity, p = 0.53; fixed effects model) and 12 months (OR, 3.35; 95% CI, 1.45-7.76; p = 0.005; heterogeneity, p = 0.03; random effects model) after the initiation of therapy. The caloric extent of canal paresis at 12 months after the initiation of therapy seemed to differ significantly between patients who received corticosteroids and those who received placebo (WMD, -12.15; 95% CI, -19.85 to -4.46; p < 0.05; heterogeneity, p < 0.05; random effects model).

CONCLUSION

The present systematic review and meta-analysis, based on the currently available evidence, suggests that corticosteroids improve only the caloric extent and recovery of canal paresis of patients with vestibular neuritis. At present, clinical recovery does not seem be better in patients receiving corticosteroids.

Clinical signs, magnetic resonance imaging findings and outcome in 77 cats with vestibular disease: a retrospective study

Medical records of 77 cats that had clinical signs of vestibular disease and magnetic resonance imaging (MRI) of the head were reviewed retrospectively. The aetiological, clinical and MRI characteristics were described and evaluated for a relationship with patient outcome. Forty cats (52%) had signs of central vestibular dysfunction (CVD), which was part of a multifocal disease in 17 cats (43%). The most frequent causes of CVD were inflammatory conditions (18 cats; 45%), including bacterial inflammation as an intracranial extension of otitis interna (five cats; 13%), feline infectious peritonitis (three cats; 8%) and toxoplasmosis (two cats; 5%). Neoplasia (12 cats; 30%) and vascular disease (four cats; 10%) were respectively the second and the third most frequent causes of CVD. Thiamine deficiency was diagnosed in one cat based on MRI findings and improvement following vitamin B(1) supplementation. Of 37 cats (48%) with peripheral vestibular dysfunction (PVD), idiopathic vestibular syndrome (IVS) was suspected in 16 (43%) and otitis media/interna was suspected in 16 (43%). Within the group of cats with evident MRI lesions, the location of the imaged lesions agreed with the clinical classification of vestibular dysfunction in 52/55 (95%) cats. Most of the cats (nine cases; 56%) with presumed IVS had rapid and complete recovery of their clinical signs. As most of these cats presented with progressive clinical signs over 3 weeks they were classified as having 'atypical' IVS to differentiate them from cats with the typical non-progressive IVS. No underlying systemic diseases were documented in any of these cases. Statistically significant predictors of survival included neurolocalisation (central or peripheral vestibular system), age and gender. No difference in survival was observed between cats with presumed idiopathic peripheral syndrome and cats with otitis media/interna.

Medical treatment of vestibular disorders

BACKGROUND

The lifelong prevalence of rotatory vertigo is 30%. Despite this high figure, patients with vertigo generally receive either inappropriate or inadequate treatment. However, the majority of vestibular disorders have a benign cause, take a favorable natural course, and respond positively to therapy.

OBJECTIVE

This review puts special emphasis on the medical rather than the physical, operative, or psychotherapeutic treatments available.

METHODS

A selected review of recent reports and studies on the medical treatment of peripheral and central vestibular disorders.

RESULTS/CONCLUSIONS

In vestibular neuritis, recovery of the peripheral vestibular function can be improved by oral corticosteroids; in Menière's disease, there is first evidence that high-dose, long-term administration of betahistine reduces attack frequency; carbamazepine or oxcarbamazepine is the treatment of first choice in vestibular paroxysmia, a disorder mainly caused by neurovascular cross-compression; the potassium channel blocker aminopyridine provides a new therapeutic principle for treatment of downbeat nystagmus, upbeat nystagmus, and episodic ataxia type 2.