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

Bilateral simultaneous presentation of posterior canal benign paroxysmal positional vertigo

OBJECTIVE

To outline the clinical picture of bilateral posterior canal benign paroxysmal positional vertigo.

METHODS

A total of 573 patients with posterior canal benign paroxysmal positional vertigo were classified as having unilateral, or true or pseudo bilateral, posterior canal benign paroxysmal positional vertigo, and were treated with the Epley manoeuvre. Statistical significance was set at p < 0.05.

RESULTS

Of the patients, 483 had unilateral and 90 (15.7 per cent) had bilateral presentation. Of the latter, 72 patients had pseudo bilateral posterior canal benign paroxysmal positional vertigo. Comparisons of site of involvement, male to female ratio and the incidence of associated problems in unilateral, and true and pseudo bilateral posterior canal benign paroxysmal positional vertigo did not reveal any statistically significant differences (p = 0.828, p = 0.200, p = 0.142). Comparisons of the number of manoeuvres required to provide symptom relief and the rate of recurrence were significant (p < 0.05).

CONCLUSION

Identification of true and pseudo bilateral posterior canal benign paroxysmal positional vertigo is important given the differences in aetiology and treatment outcome. Treatment of patients with true bilateral posterior canal benign paroxysmal positional vertigo requires several therapeutic manoeuvre attempts, and patients should be warned about recurrence.

Climatic variations and pollution on benign paroxysmal positional vertigo in Kars, Türkiye

Benign paroxysmal positional vertigo (BPPV) is the most common diagnosis for peripheral vertigo. Although pathophysiological mechanisms remain unclear, BPPV is mostly idiopathic and factors related to BPPV are still being investigated. Knowing these factors can contribute to the prevention and management of BPPV. In this study, we investigated the correlations between climatic variations, pollution, and BPPV retrospectively. 262 patients diagnosed with BPPV between 2019 and 2021 in Kars, Türkiye, were included in our study. Meteorological parameters were obtained from Turkish State Meteorological Service. Horizontal BPPV increased significantly with the humidity (p < 0.05). In addition, carbon monoxide levels significantly increased the potantial of BPPV (p < 0.05). Surprisingly, BPPV increased in the summertime and showed a significant relationship with humidity. We believe this change is related with the city-specific features as it is the coldest place in the country, emigrant province and crowded in the summer times.

Predictors of Dizziness and Hearing Disorders in People with Long COVID

Background and Objectives: Individuals report persistent symptoms after becoming infected by SARS-CoV-2 (COVID-19) that last for >4 weeks (long-COVID syndrome). Dizziness and hearing loss have been reported among long-COVID symptoms. However, little is known about the potential predictors of dizziness and hearing loss in individuals with long COVID. This study aimed to explore the presence and correlates of dizziness and hearing loss in a sample of people with long-COVID syndrome. Materials and Methods: Individuals aged 18 years and older who were infected with COVID-19 at least 8 weeks prior to the start of the study were included if they were not diagnosed with dizziness or hearing loss before getting COVID-19. Demographics and COVID-19-related information were collected. Participants completed the Dizziness Handicap Inventory (DHI), Activities-Specific Balance Confidence (ABC) scale, Falls Efficacy Scale International (FES-I), Modified Fatigue Impact Scale (MFIS), and Medical Outcomes Study Short Form 12 (SF-12). Finally, hearing was assessed using pure-tone audiometry (PTA) in a subsample. Results: Two hundred and nine individuals (66% female) with a mean (SD) age of 27 (9) participated in the study. Perceived dizziness and hearing loss were reported in 26 and 15.3% of the sample, respectively. Logistic regression was conducted to identify potential predictors of dizziness and hearing loss separately. After controlling for age and severity of dizziness, female sex and high fatigue severity were associated with an increased likelihood of reporting dizziness (R2 = 31%). The severity of dizziness and neurological symptoms during the acute stage of COVID-19 were associated with an increased likelihood of reporting hearing loss (R2 = 10.4%) after controlling for age. Conclusions: Dizziness and hearing loss present in long COVID and can be disabling. Females with high levels of fatigue should be questioned about persistent dizziness. Hearing loss should be considered in individuals with neurological symptoms and severe dizziness as a consequence of long COVID.

Cellular and Molecular Mechanisms of Vestibular Ageing

While age-related auditory deficits and cochlear alterations are well described, those affecting the vestibular sensory organs and more broadly the central vestibular pathways are much less documented. Although there is inter-individual heterogeneity in the phenomenon of vestibular ageing, common tissue alterations, such as losses of sensory hair cells or primary and secondary neurons during the ageing process, can be noted. In this review, we document the cellular and molecular processes that occur during ageing in the peripheral and central vestibular system and relate them to the impact of age-related vestibular deficits based on current knowledge.

Efficacy of Epley's maneuver plus betahistine in the management of PC-BPPV: A systematic review and meta-analysis

BACKGROUND

To evaluate the efficacy of Epley's maneuver plus betahistine in the management of patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV).

METHODS

Electronic databases including PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang were searched from their inception to April, 2022. The effect size was analyzed by calculating the pooled risk ratio estimates of efficacy rate, recurrence rate, and standardized mean differences (SMD) of dizziness handicap inventory (DHI) score with a 95% confidence interval (CI). Sensitive analysis was performed simultaneously.

RESULTS

A total of 9 randomized controlled trials with 860 PC-BPPV patients were included in the meta-analysis, in which 432 were treated with Epley's maneuver plus betahistine, and 428 received Epley's maneuver alone. The meta-analysis revealed that Epley's maneuver plus betahistine significantly improved DHI score than Epley's maneuver alone (SMD = -0.61, 95% CI -0.96 to -0.26, P = .001). In addition, both Epley's maneuver plus betahistine and Epley's maneuver groups had comparable outcomes in efficacy rate and recurrence rate.

CONCLUSION

This meta-analysis shows that Epley's maneuver plus betahistine in PC-BPPV patients had favorable effects on DHI score.

Vestibular Disorders and Hormonal Dysregulations: State of the Art and Clinical Perspectives

The interaction between endocrine and vestibular systems remains poorly documented so far, despite numerous observations in humans and animals revealing direct links between the two systems. For example, dizziness or vestibular instabilities often accompany the menstrual cycle and are highly associated with the pre-menopause period, while sex hormones, together with their specific receptors, are expressed at key places of the vestibular sensory network. Similarly, other hormones may be associated with vestibular disorders either as causal/inductive factors or as correlates of the pathology. This review was carried out according to the PRISMA method, covering the last two decades and using the MEDLINE and COCHRANE databases in order to identify studies associating the terms vestibular system and/or vestibular pathologies and hormones. Our literature search identified 646 articles, 67 of which referred directly to vestibular dysfunction associated with hormonal variations. While we noted specific hormonal profiles depending on the pathology considered, very few clinical studies attempted to establish a direct link between the expression of the vestibular syndrome and the level of circulating hormones. This review also proposes different approaches to shed new light on the link between hormones and vestibular disorders, and to improve both the diagnosis and the therapeutic management of dizzy patients.

Clinical Characteristics of persistent geotropic horizontal direction-changing positional nystagmus: Experience in 189 participants

BACKGROUND

The etiology and mechanism of persistent geotropic horizontal direction-changing positional nystagmus (DCPN) are still unclear. Whether this pattern of nystagmus is a subtype of benign paroxysmal positional vertigo (BPPV) remains controversial.

OBJECTIVE

The goal of this study was to observe the clinical characteristics of persistent geotropic horizontal DCPN involving the lateral semicircular canal.

METHODS

The analysis was performed to participants with episodic positional vertigo in our clinic from 2014 to 2021. Participants were included via positional test. We observed and summarized the distribution data, vertigo history, follow-up tests, and recurrence situations of 189 persistent geotropic horizontal DCPN participants.

RESULTS

The mean age at the first time showing of persistent geotropic horizontal DCPN was 56±14.7 and more women than men were affected by persistent geotropic horizontal DCPN (female-to-male ratio 2.4 : 1). Overall, 58.7% (57/94) of participants who came for the first-week follow-up test were asymptomatic. Thirty-three participants experienced recurrence (female-to-male ratio: 4.5 : 1). Fifty-three (28.0%) participants experienced the conversion of the patterns of DCPN in the history, the follow-up tests and the recurrence compared to the first showing of persistent geotropic horizontal DCPN. 24(12.1%) participants still experienced persistent geotropic horizontal DCPN attack in the follow-up tests and the recurrences without benign paroxysmal positional vertigo history.

CONCLUSION

Persistent geotropic horizontal DCPN affected more women than men. The persistent geotropic horizontal DCPN that with conversion to transient geotropic horizontal DCPN or to persistent apogeotropic horizontal DCPN might be a subtype of BPPV or in a stage of BPPV process. However, the persistent geotropic horizontal DCPN without conversion might be an independent disease that is not related to BPPV.

Association between Osteoporosis and Meniere's Disease: Two Longitudinal Follow-Up Cohort Studies

A high rate of Meniere's disease (MD) in patients with osteoporosis has been suggested. This research intended to estimate the bidirectional association of MD with osteoporosis. The ≥40-year-old population in the Korean National Health Insurance Service-Health Screening Cohort 2002-2019 was examined. In study I, 9529 patients with MD and 38,116 control I participants were analyzed for a previous history of osteoporosis. In study II, 65,858 patients with osteoporosis and 65,858 control II participants were analyzed for a previous history of MD. Stratified Cox proportional hazard models were applied to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) of MD for osteoporosis in study I and of osteoporosis for MD in study II. The rate of a prior history of osteoporosis was 13.3% for the MD group and 11.3% for the control I group. The patients with MD had a 1.12 times higher HR for previous osteoporosis (95% CI = 1.04-1.20). In study II, the rate or a prior history of MD was 3.7% for patients with osteoporosis and 2.0% for the control II group. The patients with osteoporosis had a 1.50 times higher HR for previous MD (95% CI = 1.40-1.61). Most subgroups according to age, sex, and comorbid conditions demonstrated consistent bidirectional associations between MD and osteoporosis. Adult patients with MD had a greater risk of osteoporosis. In addition, adult patients with osteoporosis also showed a higher risk of MD.

[Effects of age and involved semicircular canals on the caloric test in patients with primary horizontal semicircular canal benign paroxysmal positional vertigo]

Objective:To investigate the effects of age and involved semicircular canals on the results of caloric test in patients with primary horizontal semicircular canal benign paroxysmal positional vertigo（BPPV）. Methods:A total of 258 patients conforming to the diagnosis of primary horizontal semicircular canal BPPV were selected as the case group, and another 110 non-BPPV patients with dizziness/vertigo as the main complaint were selected as the control group. Both groups were divided into elderly group and young and middle-aged group according to their age, and the general information and the results of the caloric test were compared and analyzed for each group. Results: ①There was no statistically significant difference in gender composition and type of involved semicircular canal between the different age groups（P>0.05）；②In patients with horizontal semicircular canal canalolithiasis, there was no statistically significant difference in the rate of abnormal caloric test results between the different age groups（P>0.05）；③In patients with horizontal semicircular canal cupulolithiasis, there was a statistically significant difference in the rate of abnormal caloric test results between the different age groups（P<0.05）；④In the same age group, there was no statistically significant difference in the rate of abnormal caloric test results between the patients with horizontal semicircular canal canalolithiasis and the patients with cupulolithiasis（P>0.05）；⑤In the control group, there was no statistically significant difference between the different age groups in gender composition（P>0.05）；⑥In the control group, there was a statistically significant difference in the rate of abnormal caloric test results between the different age groups（P<0.05）；⑦Among the patients in the same age group, there was no statistically significant difference in the age distribution between the case and control groups（P>0.05）；⑧In patients of the same age group, there was no statistically significant difference in the rate of abnormal caloric test results between the case and control groups（P>0.05）. Conclusion:The involvement of the semicircular canal does not affect the results of the caloric test, but age can affect the results, especially in BPPV patients with horizontal semicircular canal cupulolithiasis.

Vitamin D Supplementation for Benign Paroxysmal Positional Vertigo: A Systematic Review

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is commonly attributed to displaced otoconia. These have been shown to have biomineralization close to that of bone, and vitamin D deficiency has been associated with BPPV. We aim to systematically review the available literature on vitamin D supplementation and BPPV intensity and recurrence in adults.

DATABASES REVIEWED

PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Current Controlled Trials, and ClinicalTrials.gov.

METHODS

We systematically reviewed the available literature from 1947 to April 2020. The study protocol was registered in the PROSPERO database (trial registration: CRD42020183195).

RESULTS

A total of 179 abstracts were identified and screened by two independent reviewers. Based on inclusion and exclusion criteria, six studies were selected and subjected to a quality assessment. In one randomized clinical trial (RCT), vitamin D supplementation was found to reduce annual recurrence rate of vertigo in patient with BPPV and subnormal serum vitamin D levels compared with placebo (odds ratio, 0.69; 95% confidence interval, 0.54-0.90). Non-RCTs demonstrated the possibility of a null effect in the random effects model (odds ratio, 0.08; 95% confidence interval, 0.00-1.56). The RCT considered as low risk of bias. All of the nonrandomized studies were assessed as serious risk of bias.

CONCLUSIONS

The intervention studies identified consistently demonstrated a decrease in BPPV recurrence with supplementation of vitamin D in patients with subnormal vitamin D levels. Although there is a paucity of high-quality studies, the present literature does highlight a role for optimization of vitamin D levels in patients with BPPV.

Analysis of Bone Mineral Density and Bithermal Caloric Test Results in Unilateral Idiopathic Benign Paroxysmal Positional Vertigo Patients

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is the most frequently diagnosed type of peripheral vestibular vertigo. Studies have reported a possible association between BPPV and osteoporosis; however, there is still a lack of evidence. This study aimed to investigate the characteristics of bone mineral density (BMD) and bithermal caloric test results in patients with unilateral posterior canal idiopathic benign paroxysmal positional vertigo (pc-iBPPV).

METHODS

BMD was measured in 65pc-iBPPV menopausal female patients and 65 healthy controls using dual-energy xray absorptiometry and then compared the T-score of BMD between the two groups. The bithermal caloric test was also performed with video nystagmography and the relationship between canal paresis, directional preponderance, T-score, and recurrence were analyzed.

RESULTS

Lower T-scores were observed in pc-iBPPV patients compared with the normal subjects. Among 65 pc-iBPPV patients, free recurrence was observed in 38 (58.5%), single recurrence was noted in 14 (21.5%), and multiple recurrences were seen in 13 (20%) patients. The proportion of positive T-score and CP value increased with the pc-BPPV recurrence frequency. Statistically, a significant difference was found only in T-score, indicating that recurrence was raised with a decrement of T-score. The proportion of positive CP values tended to increase as BMD decreased.

CONCLUSION

The decrement of BMD might be one of the pathogeneses in patients with unilateral pc-iBPPV and associated with multiple recurrences. Moreover, positive CP value cannot be regarded as a predictive factor for recurrence; however, there is a clear association between CP and BMD.

Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: Zuma e Maia Maneuver versus Appiani Variant of Gufoni

Benign paroxysmal positional vertigo (BPPV) is one of the most common disorders that causes dizziness. The incidence of horizontal semicircular canal (HSC) BPPV ranges from 5% to 40.5% of the total number of BPPV cases diagnosed. Several studies have focused on establishing methods to treat BPPV caused by the apogeotropic variant of the HSC, namely, the Appiani maneuver (App). In 2016, a new maneuver was proposed: the Zuma e Maia maneuver (ZeM), based on inertia and gravity. The aim of this study is to analyze the efficacy of App versus ZeM in the resolution of episodes of BPPV produced by an affectation of the horizontal semicircular canal with apogeotropic nystagmus (Apo-HSC). A retrospective, quasi-experimental study was conducted. Patients attended in office (November 2014–February 2019) at a third-level hospital and underwent a vestibular otoneurology assessment. Those who were diagnosed with Apo-HSC, treated with App or ZeM, were included. To consider the efficacy of the maneuvers, the presence of symptoms and/or nystagmus at the first follow up was studied. Patients classified as “A” were those with no symptoms, no nystagmus; “A/N+”: no symptoms, nystagmus present during supine roll test; “S”: symptoms present. Previous history of BPPV and/or otic pathology and calcium levels were also compiled. From the 54 patients included, 74% were women. The average age was 69. Mean follow-up: 52.51 days. In those patients without previous history of BPPV (n = 35), the probability of being group “A” was 63% and 56% (p = 0.687) when treated with App and ZeM, respectively, while being “A/N+” was 79% and 87% for App and ZeM (p = 0.508). Of the 19 patients who had previous history of BPPV, 13% and 64% were group “A” when treated with App and ZeM (p = 0.043), and 25% and 82% were “A/N+” after App and ZeM, respectively (p = 0.021). In conclusion, for HSC cupulolithiasis, ZeM is more effective than App in those cases in which there is a history of previous episodes of BPPV (“A”: 64% (p = 0.043); “A/N+”: 82% (p = 0.021)).

Serum 25-Hidroksi D Vitamini ve Kalsiyum Seviyeleri ile İdiyopatik Benign Paroksismal Pozisyonel Vertigo Arasındaki İlişki

Amaç: Kliniğimize baş dönmesi şikâyeti ile başvurup idiopathic benign paroksismal pozisyonel vertigo (BPPV) tanısı alan hastalar ile baş dönmesi olmayan sağlıklı kontrol grubunun 25-hidroksi vitamin D (25-OH vitamin D) ve Ca2+ düzeylerinin karşılaştırılması Ca2+ ve 25-OH vitamin D’nin BPPV gelişimindeki rolünün araştırılmasıdır. Gereç ve Yöntem: Çalışmamız geriye dönük vaka kontrol çalışması olup, 01.01.2018-01.08.2021 arası Alanya Egitim ve Araştırma Hastanesi Nöroloji polikliniğine başvuran İdiopatik BPPV tanısı alan 409 hasta ile kontrol grubu olarak kliniğimize başvuru öncesi son 1 yıl içerisinde vertigo, dizziness ya da dengesizlik nedeniyle hekim başvurusu olmayan serum D vitamini düzeyi ölçümü yapılmış 338 hasta seçilerek oluşturuldu. İstatiksel değerlendirmeler için ki-kare ve T testi testi kullanıldı. Bulgular: Ortalama serum 25-OH vitamin D düzeyleri BPPV ve kontrol grubunda sırasıyla 15,74 ng/mL ve 17,91 ng/mL idi. Serum 25-OH vitamin D düzeyleri BPPV grubunda kontrol grubuna göre anlamlı derecede düşük bulundu ((p=0,01, p

Hormones and Vestibular Disorders: The Quest for Biomarkers

The vestibular system exerts control over various functions through neural pathways that are not yet fully mapped. Functional dysregulations or tissue lesions at different levels of the peripheral and the central vestibular networks can alter these different functions, causing a wide variety of symptoms, ranging from posturo-locomotor alterations to psychiatric syndromes such as PPPD, including the deregulation of the main biological functions. These different symptoms differ by their expression kinetics (they each appear and regress with their own kinetics) by the targets affected (muscles, organs, and brain areas) and by the sensitivity specific to each individual. Vestibular pathologies thus cover a mosaic of distinct effects, and they involve various effectors—which constitute the many markers of their different types and stages. It is therefore crucial, to predict the onset of a vertigo syndrome, to follow its temporal course, or to monitor the impact of therapeutic approaches, and to have specific and reliable biomarkers. Hormonal variations are among the possible sources of biomarkers for neurotology. We know that specific hormonal profiles can promote the appearance of vestibular disorders. We also know that the expression of vertigo syndrome is accompanied by measurable hormonal variations. The link between endocrine deregulation and vestibular alterations therefore no longer needs to be proven. However, there are still few data on their precise correlations with the vertigo syndrome. This study was undertaken with the aim to deliver an extensive review of the hormonal alterations linked to vestibular disorders. A review of the literature covering the last two decades was carried out using the MEDLINE and COCHRANE databases in order to identify studies associating the terms vestibular system or vestibular pathologies and hormones. Bibliographic data provides several outcomes in terms of therapeutic innovation in the diagnosis and therapeutic follow-up of vestibular pathologies.

Risk factors for residual dizziness in patients with benign paroxysmal positional vertigo after successful repositioning: a systematic review and meta-analysis

PURPOSE

To investigate the risk factors for residual dizziness (RD) in patients with benign paroxysmal positional vertigo (BPPV) after successful repositioning.

METHODS

Searches were performed in PubMed, Embase, Cochrane library, Web of Science, Chinese National Knowledge Infrastructure, and Sino Med up to March 7, 2021 and references of relevant articles were screened. Data from eligible studies were meta-analyzed using Stata version 16.0 and Review Manager 5.4.

RESULTS

In this systematic review and meta-analysis of 4487 patients from 31 studies, the prevalence of RD was 43.0% (95% CI 39.0-48.0%). Age (MD 4.17; 95% CI 2.13-6.21, P = 0.000), female gender (OR = 1.28, 95% CI 1.11-1.47, P = 0.001), secondary BPPV (OR 1.88; 95% CI 1.27-2.77, P = 0.001), a longer duration of BPPV before treatment (MD 3.45; 95% CI 1.87-5.02, P = 0.000), abnormal ocular vestibular evoked myogenic potential (OVEMP, OR 4.34; 95% CI 2.78-6.78, P = 0.000), abnormal cervical vestibular evoked myogenic potential (CVEMP, OR 2.48; 95% CI 1.54-3.99, P = 0.000), higher Dizziness Handicap Index (DHI) score before treatment (MD 10.88; 95% CI 5.96-15.80, P = 0.000), anxiety (OR 9.58; 95% CI 6.32-14.52, P = 0.000), osteopenia (OR = 4.40, 95% CI 2.17-8.96, P = 0.000), onset in winter (OR 7.27; 95% CI 2.38-22.24, P = 0.001) and with a history of BPPV (OR 1.79; 95% CI 1.06-3.04, P = 0.03) are the risk factors for RD in patients with BPPV after successful repositioning. The affected side, location or type of semicircular involvement, hyperlipidemia, diabetes, hypertension, heart disease, migraine, sleep disorders, canalolithiasis/cupulolithiasis, the number of times the canalith repositioning procedures (CRPs) were performed and number of vertigo attacks did not correlate with the occurrence of RD.

CONCLUSIONS

Despite successful treatment, nearly half of the BPPV patients developed RD. RD seems to be a syndrome caused by multiple factors. The pathogenesis of most factors can be explained by psychological and/or physical disorders. Early recognition of these risk factors contributes to the prevention and treatment of RD.

Influence of sex hormones on vestibular disorders

PURPOSE OF REVIEW

Vestibular disorders are gender distributed with a higher prevalence in women. Although research has increased in this field, the mechanisms underlying this unbalance is unclear. This review summarises recent advances in this research sphere, and briefly discusses sex hormone effects on various vestibular conditions and highlights some recent theories.

RECENT FINDINGS

Recent work has identified a direct link between aberrant gonadal hormone levels and vestibular dysfunction. Benign paroxysmal positional vertigo research suggests that the disorder may be linked to the rapid decrease in oestrogen, observed in menopausal women, which disrupts otoconial metabolism within the inner ear. A successful hormonal therapeutic intervention study has advanced our knowledge of hormonal influences in the inner ear in Ménière's disease. Also, several studies have focused on potential mechanisms involved in the interaction between Vestibular Migraine, Mal de Debarquement Syndrome, and gonadal hormones.

SUMMARY

In females, gonadal hormones and sex-specific synaptic plasticity may play a significant role in the underlying pathophysiology of peripheral and central vestibular disorders. Overall, this review concludes that clinical assessment of female vestibular patients requires a multifaceted approach which includes auditory and vestibular medicine physicians, gynaecologists and/or endocrinologists, in conjunction with hormonal profile evaluations.

Traumatic brain injury in women across lifespan

Traumatic brain injury (TBI) is a leading cause of death and disability and a global public health challenge. Every year more than 50 million people suffer a TBI, and it is estimated that 50% of the global population will experience at least one TBI in their lifetime. TBI affects both men and women of all ages, however there is a male bias in TBI research as women have frequently been left out of the literature despite irrefutable evidence of male and female dimorphism in several posttraumatic measures. Women uniquely experience distinct life stages marked by levels of endogenous circulating sex hormones, as well as by physiological changes that are nonexistent in men. In addition to generalized sex-specific differences, a woman's susceptibility, neurological outcomes, and treatment success may vary considerably depending upon when in her lifespan she incurred a traumatic insult. How women impacted by TBI might differ from other women as a factor of age and physiology is not well understood. Furthermore, there is a gap in the knowledge of what happens when TBI occurs in the presence of certain sex-specific and sex-nonspecific variables, such as during pregnancy, with oral contraceptive use, in athletics, in cases of addiction and nicotine consumption, during perimenopause, postmenopause, in frailty, among others. Parsing out how hormone-dependent and hormone-independent lifespan variables may influence physiological, neurodegenerative, and functional outcomes will greatly contribute to future investigative studies and direct therapeutic strategies. The goal of this review is to aggregate the knowledge of prevalence, prognosis, comorbid risk, and response of women incurring TBI at differing phases of lifespan. We strive to illuminate commonalities and disparities among female populations, and to pose important questions to highlight gaps in the field in order to further the endeavor of targeted treatment interventions in a patient-specific manner.

Vitamin D deficiency in benign paroxysmal positional vertigo

Aim. To assess the level of vitamin D (D3) in patients with benign paroxysmal positional vertigo (BPPV). Materials and methods. The study included 25 patients. The control group consisted of 30 people, comparable in age with the main group, without BPPV. All patients included in the study underwent a standard examination of the vestibular sphere, which compised the Head impulse test, the Fukuda test, the Shaking test, the DixHolpike and MacluraPagnini test. Hydroxyvitamin D levels were analyzed by enzyme immunoassay. In the study of the psychological sphere, the following questionnaires were used: Dizziness Handicap Inventory, Beck Depression Scale, SpielbergerKhanin Anxiety Scale, TAS-26 alexithymia scale. Results. The average level of hydroxyvitamin D among patients was 19.658.6 ng/ml, which corresponds to a deficiency of vitamin D, in the control group, vitamin D3 was within the reference values (30100 ng/ml) and amounted to 33.7810.7 ng/ml (p0.001). There is a negative correlation between the level of hydroxyvitamin D and the age of the patients. There is a correlation (Spearman's criterion -0.463254, p0.001) between the frequency of recurrence of BPPV and a decrease in the level of hydroxyvitamin D. Conclusion. Vitamin D deficiency prevails among patients with BPPV.

The Relationship Between Disorders of Bone Metabolism and Benign Paroxysmal Positional Vertigo: A Systematic Review

OBJECTIVES

Several studies have reported an association between benign paroxysmal positional vertigo (BPPV) and bone mineral density or serum vitamin D levels. The aim of this review is to provide further clarification regarding the relationship between BPPV and calcium metabolism.

DESIGN

PubMed and MEDLINE databases were systematically reviewed to identify all English language papers regarding the relationship between BPPV and the following terms: osteoporosis, osteopenia, bone mineral density, serum vitamin D levels, and bone metabolism.

RESULTS

Of the 456 identified records, 28 studies were eligible for this review. Most were retrospective studies with inherent limitations and often conflicting results. While the literature is not conclusive, osteoporosis in patients of at least 50 years old appears to have an association with BPPV. Similarly, an association was observed between recurrent BPPV and vitamin D deficiency.

CONCLUSION

There is only weak evidence to support the relationship between BPPV and osteoporosis or low serum 25-hydroxyvitamin D levels. Further prospective studies with more robust methodologies are needed to clarify the association between BPPV and disorders of bone metabolism.

The role of low levels of vitamin D as a co-factor in the relapse of benign paroxysmal positional vertigo (BPPV)

BACKGROUND

Benign paroxysmal positional vertigo is characterized as brief episodes of vertigo that are exacerbated by the unexpected act of moving to a current provoking location. It is thought to be an otoconia-related balance disorder. Our objectives were to assess the serum concentrations of vitamin D and calcium (total and ionized) in cases with BPPV, determine if low vitamin D levels were regarded as a cause for BPPV relapse, and determine whether vitamin D supplementation would minimize the risk of BPPV relapse.

RESULTS

Sixty cases with BPPV were included in the study; 53 cases had posterior canal BPPV, while seven had lateral canal BPPV. Canalithiasis was the most common type of BPPV pathology. Forty cases had abnormally low levels of vitamin D. There was a statistically significant positive correlation between the mean vitamin D assay for all cases with BPPV and serum calcium. There was statistically significant difference in comparing the relapse of BPPV for group that receive vitamin D after one year follow up.

CONCLUSION

Abnormal vitamin D levels were linked with the incident and relapse of BPPV. Correction of low vitamin D levels was linked with the reduction of the relapse of BPPV.

Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) can lead to an increased fall risk in older adults. Therefore, we examined the influence of age on the effectiveness of canalith-repositioning procedures (CRPs) for the treatment of BPPV.

METHODS

Pubmed, Web of Science, and the bibliographies of selected articles were searched for studies conducted before September 2020 that examined the effectiveness of treatments for BPPV in various age groups. Meta-analyses were performed to compare treatment effectiveness and recurrence rates for younger and older adults. Odds ratios were calculated in a random-effects model. Mean differences were calculated using a fixed-effects model. A significance level of p < 0.05 (95% confidence interval) was set. The risk of bias and the methodological quality of all included articles were examined.

RESULTS

Forty-five studies were retrieved after full-text screening, of which 29 studies were included for a qualitative review. The remaining 16 studies were eligible for inclusion in the meta-analysis (3267 participants with BPPV). The success rate of a single CRP was higher in the younger group (72.5% vs. 67%, p < 0.001). An average of 1.4 and 1.5 CRPs was needed for complete recovery in the younger and older groups, respectively (p = 0.02). However, global treatment success did not differ between these groups (97.5% vs. 94.6%, p = 0.41). The recurrence rate was higher in the older population (23.2% vs. 18.6%, p = 0.007).

CONCLUSIONS

Although more CRPs are needed, the rate of complete recovery in older adults is similar to that observed in younger adults.

Risk Factors for Recurrence of Benign Paroxysmal Positional Vertigo. A Clinical Review

Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular dysfunctions encountered in clinical practice. Although the treatment of BPPV is relatively successful, many patients develop recurrence after treatment. Our purpose is to evaluate the mean recurrence rate and risk factors of BPPV after treatment. A review of the literature on the risk factors of BPPV recurrence was performed. A thorough search was conducted using electronic databases, namely Pubmed, CINAHL, Academic Search Complete and Scopus for studies published from 2000 to 2020. Thirty studies were included in this review with 13,358 participants. The recurrence rate of BPPV ranged from 13.7% to 48% for studies with follow-up <1 year, and from 13.3% to 65% for studies with follow-up ≥2 years. Pathophysiologic mechanisms and implication of each of the following risk factors in the recurrence of BPPV were described: advanced age, female gender, Meniere’s disease, trauma, osteopenia or osteoporosis, vitamin D deficiency, diabetes mellitus, hypertension, hyperlipidemia, cardiovascular disease, migraine, bilateral/multicanal BPPV, cervical osteoarthrosis and sleep disorders. Patients with hyperlipidemia and hypertension had the highest recurrence rates of BPPV, 67.80% and 55.89%, respectively, indicating that vascular comorbidities increase the risk of BPPV recurrence. In addition, more than half of patients (53.48%) with diabetes mellitus and BPPV experienced recurrence of BPPV. Knowledge and awareness of risk factors for recurrence of BPPV are essential for the assessment and long-term prognosis of patients. Identification of these relapse risk factors may enhance the ability of clinicians to accurately counsel patients regarding BPPV and associated comorbidities.

Relation between vitamin D deficiency and benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo. Vitamin D deficiency may be one of the causes of its development. To assess the relation between recurrent attacks BPPV and Vitamin D deficiency. A case control study in which 40 patients were clinically diagnosed as posterior canal BPPV, Serum 25(OH) D was measured at 1st visit. Patients were divided into two groups; group A (20 patients) received Vitamin D supplementation in addition to canal repositioning maneuver and group B (20 patients) treated by canal repositioning maneuver only. Follow up of all patients for 6 months, neuro-otological assessment was repeated and recurrent attacks were recorded. Serum vitamin D was repeated after 6 month. This study included 14 males and 26 females age ranged from 35 to 61 years, Average serum of 25 (OH) D at the first visit was (12.4 ± 2 ng/ml) for group A, and (12.2 ± 1.7 ng/ml) for group B, all patients had low serum level of 25(OH) D (below 20 ng/ml). Recurrent BPPV episodes, were significantly lower in group A than that of group B. There is a relation between BPPV recurrence and low serum Vitamin D.

Study on the Bone Metabolism Indices and Otoconin-90 in Benign Paroxysmal Positional Vertigo

OBJECTIVE

To investigate the correlation between benign paroxysmal positional vertigo (BPPV) and abnormal bone metabolism and to evaluate the value of otoconial protein otoconin-90 in the pathogenesis research and clinical treatment of BPPV.

STUDY DESIGN

Prospective pilot clinical trial (Level of Evidence: 2b).

SETTING

Outpatient otolaryngologic department.

PATIENTS

Twenty seven patients with a diagnosis of BPPV referred to the otolaryngologic department and 25 controls with no history of dizziness from 2018.4 to 2018.9 were reviewed.

INTERVENTIONS

No.

MAIN OUTCOME MEASURES

Dual-energy x-ray absorptiometry scanning (DEXA), bone mineral density (BMD) measurement, and assessment of serum levels of otoconin-90 and bone metabolism indices (osteocalcin, OC; 25-OH Vitamin D; total procollagen type 1 N-peptide, TP1NP; β-C-terminal telopeptide of type 1 collagen, β-CTX).

RESULTS

1) The average serum level of otoconin-90 in the BPPV group was significantly higher than that in the control group (p < 0.05), whereas both the BMD T scores and serum 25-OH Vitamin D levels of the BPPV group were significantly lower than those of the control group (p < 0.05). 2) There was a strong positive correlation between serum otoconin-90 and age (r = 0.44, p < 0.05) and a moderate negative correlation between otoconin-90 and the bone metabolism indices OC (r = -0.33, p > 0.05), 25-OH Vitamin D (r = -0.35, p > 0.05), and TP1NP (r = -0.30, p > 0.05). 3) Logistic regression analysis showed that serum otoconin-90 level was an independent risk factor for BPPV (odd ratio = 0.998, 95% confidence interval 0.997-0.999, p < 0.01).

CONCLUSION

A correlation between BPPV and abnormal bone metabolism was found. Moreover, otoconin-90 could serve as a research tool for BPPV.

Clinical significance of video head impulse test in benign paroxysmal positional vertigo: a meta-analysis

PURPOSE

To document the effect of cupula deflection in Benign Paroxysmal Positional Vertigo (BPPV) through the measured Vestibulo-Ocular Reflex (VOR) gain in individual semi-circular canals.

METHODS

A literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed on December 30, 2020. The following terms were entered in the title, abstract, and keywords in the electronic databases of PubMed, Scopus, Web of Science, and Cochrane Library search engines in different combinations: "Benign Paroxysmal Positional Vertigo" or "Benign Positional Vertigo" or "BPPV," and "Video Head Impulse" or "vHIT". All types of studies were included in the initial search. An additional inclusion criterion was the presence of numerical values of VOR gains of the tested canals in the reports.

RESULTS

A total of 122-screened articles were obtained from the electronic database search. Finally, the authors settled on five original articles for meta-analysis with a total of 168 patients (123 with posterior canal BPPV, 28 with lateral canal BPPV, and 17 with anterior canal BPPV) and 85 controls. The main outcomes of these studies comprised the VOR gains of the lateral, posterior, and anterior SCCs on the affected side relative to that in the contralesional side, and/or healthy controls.

CONCLUSION

This meta-analysis shows that vHIT can be valuable as a supporting test in the diagnosis of BPPV, especially for posterior canal BPPV.

Relationship between calcium metabolism and benign paroxysmal positional vertigo in north Sardinia population

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) has a reported recurrence ranging from 26.8 to 50%. Osteoporosis and Vitamin D deficiency seems to have an impact on recurrence of BPPV.

OBJECTIVE

to evaluate the impact of osteoporosis and Vitamin D deficiency on recurrence of BPPV.

METHODS

73 consecutive patients were divided in two groups according to the presence (group 1) or absence (group 0) of a recurrent episode. BMD, femoral and lumbar T-scores and Vitamin D levels were recorded. Statistical analysis was performed to investigate correlations.

RESULTS

patients in group 1 had statistically significant lower values of both femoral (-1,62±1,06 vs. -0,53±1,51; p = 0,001), lumbar T-score (-2,10±1,19 vs -0, 53±1.51, p = 0.001) and Vitamin D (19.53±15.33). The values of femoral T-score and Vitamin D could be combined in a model able to properly classify 65.8% of the cases (p = 0.002) as isolated or recurrent BPPV, with high accuracy (AUC 0.710 [0.590 -0.830]).

CONCLUSION

present data show a probable correlation between osteoporosis and Vitamin D with recurrent BPPV.

The effects of climate on the incidence of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders. An investigation into the factors related to BPPV could contribute to its prevention and appropriate management. We investigated the association between climatic factors and incidence of BPPV in this study. A total of 365 patients who were diagnosed with idiopathic BPPV in the emergency room of our hospital in 2015 were included. The number of patients diagnosed with BPPV per week was calculated (every week). Climatic factors, including daily average humidity, temperature, atmospheric pressure, cloud amount, sunshine amount, and daylight time, were documented daily. The weekly mean climatic value in each week was calculated. Simple correlation analysis and multivariate regression analyses were performed to identify climatic factors associated with the number of patients diagnosed with BPPV. Simple correlation analysis revealed a significant association between the humidity (r = 0.276, p = 0.048), temperature (r = 0.275, p = 0.049), and cloud amount (r = 0.293, p = 0.035) and the number of BPPV patients diagnosed per week. Multivariate regression analysis revealed that only the cloud amount was a statistically significant factor associated with the number of BPPV patients diagnosed every week. A significant positive association was discovered between the cloud amount and BPPV incidence. Cloud amount can therefore have an association with the incidence of BPPV.

Effects of Neurological Disorders on Bone Health

Neurological diseases, particularly in the context of aging, have serious impacts on quality of life and can negatively affect bone health. The brain-bone axis is critically important for skeletal metabolism, sensory innervation, and endocrine cross-talk between these organs. This review discusses current evidence for the cellular and molecular mechanisms by which various neurological disease categories, including autoimmune, developmental, dementia-related, movement, neuromuscular, stroke, trauma, and psychological, impart changes in bone homeostasis and mass, as well as fracture risk. Likewise, how bone may affect neurological function is discussed. Gaining a better understanding of brain-bone interactions, particularly in patients with underlying neurological disorders, may lead to development of novel therapies and discovery of shared risk factors, as well as highlight the need for broad, whole-health clinical approaches toward treatment.

Comparison of associated comorbid conditions in patients with benign paroxysmal positional vertigo with or without migraine history: A large single institution study

PURPOSE

In the largest reported United States (U.S.) cohort of benign paroxysmal positional vertigo (BPPV), does the presence or absence of migraine correlate with increased associations of other factors?

MATERIALS & METHODS

A retrospective chart review from a single U.S. neurotology center. Adult patients with BPPV from 2003 to 2017 classified into two groups: 1) with migraine; 2) without migraine.

RESULTS

The prevalence of self-reported migraine history in a BPPV-positive population (n = 1481) was 25.8% (n = 382). Among those with BPPV and migraine, 88.5% were female, 8.1% had diabetes, 22.5% had prior history of BPPV, 8.9% had Meniere's disease and recurrence rate was 38.3%. No statistically significant differences between recurrence or resolution rates between the two groups were demonstrated (p > 0.05). Adjusted logistic regression model found that women and those with a prior history of BPPV had significantly higher odds of having both BPPV and migraine conditions compared to their counterparts. In contrast, older age and diabetes were associated with significantly lower odds of concomitant BPPV and migraine.

CONCLUSIONS

The prevalence of migraine among the study sample was 25.8%. Female gender, prior history of BPPV, younger age, and lack of diabetes were independently associated with the concurrent comorbidity of BPPV and migraine. These data further substantiate previously reported rates (from smaller studies); and, demonstrate that recurrence and resolution rates are not worse in those with BPPV and migraine compared to the general BPPV population. Findings support an association between migraine and BPPV and enhances one's ability to accurately counsel patients regarding these diseases.

Benign Paroxysmal Positional Vertigo Risk Factors Unique to Perimenopausal Women

Many investigations have found common occurrences of benign paroxysmal positional vertigo (BPPV) in women, and clinical experience has shown that BPPV can develop due to increased hormonal fluctuations, especially during menopause. Therefore, knowledge about neurochemicals and their involvement with BPPV is imperative for the management of neurological issues in women. This review will discuss appropriate gender-based considerations of BPPV based on experimental and clinical evidence. The studies describe 2 lines of evidence regarding the association of perimenopause in women and the development of BPPV: (1) experimental evidence: the existence of estrogen receptors in the inner ear, otoconial malformations in osteopenic/osteoporotic rats, changes in otoconin 90 caused by hormone replacement therapy, and impaired calcium absorption following estrogen deprivation corrected by estrogen replacement therapy and (2) clinical evidence: epidemiological aspects, osteoporosis and estrogen deficiency. Future studies are necessary to validate the effects of hormonal replacement therapy and phytoestrogen in women with recurrent BPPV.

A novel genetic variant associated with benign paroxysmal positional vertigo within the LOXL1

Background

Benign paroxysmal positional vertigo (BPPV) is a common, self‐limited, and favorable prognostic peripheral vestibular disorder. BPPV is transmitted in an autosomal dominant fashion, but most cases occur sporadically. Little research has been reported regarding the mutation spectrum of sporadic BPPV in a large cohort. This study attempted to identify the causative candidate variants associated with BPPV in VDR, LOXL1, and LOXL1‐AS1.

Methods

An amplicon‐targeted next‐generation sequencing (NGS) method for VDR, LOXL1, and LOXL1‐AS1, was completed in 726 BPPV patients and 502 normal controls. A total of 30 variants (20 variants from VDR, nine variants from LOXL1, seven variants from LOXL1‐AS1) were identified in these two groups.

Results

Three of 30 variants were nonsynonymous mutations, but no significant difference was found between the BPPV group and the control group via association analysis. A single nucleotide variant (SNV), rs1078967, was identified that is located in intron 1 of LOXL1. The allelic frequency distribution differed significantly between the BPPV group and the control group (p = 0.002). Genotypic frequency was also significantly different (p = 0.006), as determined by gene‐based analyses.

Conclusion

This report is the first to analyze the variant spectrum of BPPV in a large Chinese population.

Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) has a high recurrence rate, but the risk factor-associated recurrence are elusive.

METHODS

Searches were performed in PubMed, Embase, Cochrane library, Web of science, Chinese National Knowledge Infrastructure, and Sino Med up to November 3, 2019. The effect size was analyzed by odds ratio and 95% CI. Data from eligible studies were meta-analyzed using Stata version 15.0.

RESULTS

Our search resulted in a total of 4076 hits. Twenty-four outcomes of sixty articles were included in the meta-analysis. Risk factors for the recurrence of BPPV included female gender, age (≥65years), hyperlipidemia, diabetes, hypertension, migraine, cervical spondylosis, osteopenia/osteoporosis, head trauma, otitis media, abnormal vestibular evoked myogenic potential, and long use of computers. No significant differences were found in side, type of the involved semicircular canals, smoking, alcohol consumption, stroke, ear surgery, duration of vertigo before treatment, the times of repositioning, Meniere disease, sleep disorders, hypercholesterolemia, and 25-hydroxy vitamin D.

CONCLUSION

These findings strengthen clinical awareness of early warning to identify patients with potential relapse risk of BPPV and clinicians should counsel patients regarding the importance of follow-up after diagnosis of BPPV.

Prevention of benign paroxysmal positional vertigo with vitamin D supplementation

Objective

To assess the effect of vitamin D and calcium supplementation in preventing recurrences of benign paroxysmal positional vertigo (BPPV).

Methods

We performed an investigator-initiated, blinded-outcome assessor, parallel, multicenter, randomized controlled trial in 8 hospitals between December 2013 and May 2017. Patients with confirmed BPPV were randomly assigned to the intervention (n = 518) or the observation (n = 532) group after successful treatment with canalith repositioning maneuvers. The primary outcome was the annual recurrence rate (ARR). Patients in the intervention group had taken vitamin D 400 IU and 500 mg of calcium carbonate twice a day for 1 year when serum vitamin D level was lower than 20 ng/mL. Patients in the observation group were assigned to follow-ups without further vitamin D evaluation or supplementation.

Results

The intervention group showed a reduction in the ARR (0.83 [95% confidence interval (CI), 0.74–0.92] vs 1.10 [95% CI, 1.00–1.19] recurrences per 1 person-year) with an incidence rate ratio of 0.76 (95% CI, 0.66–0.87, p < 0.001) and an absolute rate ratio of −0.27 (−0.40 to −0.14) from intention-to-treat analysis. The number needed to treat was 3.70 (95% CI, 2.50–7.14). The proportion of patients with recurrence was also lower in the intervention than in the observation group (37.8 vs 46.7%, p = 0.005).

Conclusions

Supplementation of vitamin D and calcium may be considered in patients with frequent attacks of BPPV, especially when serum vitamin D is subnormal.

Classification of evidence

This study provides Class III evidence that for patients with BPPV, vitamin D and calcium supplementation reduces recurrences of BPPV.

Impaired Calcium Metabolism in Benign Paroxysmal Positional Vertigo: A Topical Review

BACKGROUND AND PURPOSE

Although acute attacks of benign paroxysmal positional vertigo (BPPV) may be treated with canalith repositioning maneuvers, there have been no well-designed prospective trials to prevent this highly prevalent and recurrent disorder. This topical review explores the evidence related to the association between deficient calcium metabolism and BPPV. We also describe the development of therapeutic options to prevent recurrences of BPPV and introduce results from a recent randomized controlled trial on the effect of vitamin D and calcium supplementation in preventing BPPV recurrences.

SUMMARY OF KEY POINTS

The literature describes 3 lines of evidence on association of impaired calcium metabolism and development of BPPV: (1) decreased bone mineral density was more frequently observed in persons with BPPV than in healthy controls; (2) estrogen plays a vital role in maintenance of otoconia, and estrogen deficiency appears to precipitate degeneration of otoconia and development of BPPV; and (3) lower serum vitamin D level is associated with development of BPPV, and supplementation of vitamin D and calcium carbonate may reduce further attacks of BPPV in persons with BPPV and subnormal serum vitamin D level.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Restoration of impaired calcium metabolism with supplementation of vitamin D or estrogen should be considered in the treatment of individuals with frequent recurrences of BPPV. Future randomized controlled trials are mandatory to validate these supplementation therapies in individuals with recurrent BPPV.

Otoconia degeneration as a consequence of primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine condition which disrupts physiologic calcium regulation. PHPT causes persistent hypercalcemia via the elevated and constant secretion of parathyroid hormone. Due to the effects of parathyroid hormone on target organs such as the bones, kidneys and gastrointestinal tract, untreated PHPT can lead to complications such as decreased bone mineral density, nephrolithiasis, and chronic abdominal pain, respectively. Given PHPT's drastic effect on calcium metabolism, it is likely that the condition also affects other organ systems, such as the inner ear, which rely on calcium for normal structure and function. Specifically, the saccule and utricle have otoconia made of calcium carbonate deposited on a protein framework. We hypothesize that PHPT, the epitome calcium disorder, can cause otoconia degeneration, one manifestation of which is benign paroxysmal positional vertigo (BPPV). As a preliminarily test of this hypothesis, we measured the levels of otolin-1, an inner ear glycoprotein found in the otoconia protein framework and a proposed biomarker for otoconia degeneration in patients with PHPT. We found a positive linear relationship between PTH (parathyroid hormone) and otolin-1 levels (R² = 0.53) and total calcium and PTH levels (R² = 0.32). These findings suggest that both PTH and total calcium levels affect otolin-1 levels, implying that the calcium dysregulation caused by PHPT may contribute to the otoconia breakdown and may be associated with inner ear disorders such as BPPV.

Causes and treatment of idiopathic benign paroxysmal positional vertigo based on endocrinological and other metabolic factors

The genesis of the Benign Paroxysmal Positional Vertigo (BPPV) seems to be related to some metabolic factors. These factors, such as vitamin D, glucocorticoids, and even thyroid and growth hormones, can affect bone metabolism and the mineralization of otoconia. It also seems to link to factors related to aging or nutritional habits. Besides, since the incidence of BPPV is quantitatively higher in women than in men, female sex steroids could be associated with this process. It could be useful to understand how these factors act in otoconial mineralization if we want to develop treatments aimed at preventing or delaying BPPV recurrences. In this review, we will analyze the role of these metabolic and hormonal factors in otoconial mineralization and in the treatment of BPPV.

Nanostructure of mouse otoconia

Mammalian otoconia of the inner ear vestibular apparatus are calcium carbonate-containing mineralized structures critical for maintaining balance and detecting linear acceleration. The mineral phase of otoconia is calcite, which coherently diffracts X-rays much like a single-crystal. Otoconia contain osteopontin (OPN), a mineral-binding protein influencing mineralization processes in bones, teeth and avian eggshells, for example, and in pathologic mineral deposits. Here we describe mineral nanostructure and the distribution of OPN in mouse otoconia. Scanning electron microscopy and atomic force microscopy of intact and cleaved mouse otoconia revealed an internal nanostructure (~50 nm). Transmission electron microscopy and electron tomography of focused ion beam-prepared sections of otoconia confirmed this mineral nanostructure, and identified even smaller (~10 nm) nanograin dimensions. X-ray diffraction of mature otoconia (8-day-old mice) showed crystallite size in a similar range (73 nm and smaller). Raman and X-ray absorption spectroscopy - both methods being sensitive to the detection of crystalline and amorphous forms in the sample - showed no evidence of amorphous calcium carbonate in these mature otoconia. Scanning and transmission electron microscopy combined with colloidal-gold immunolabeling for OPN revealed that this protein was located at the surface of the otoconia, correlating with a site where surface nanostructure was observed. OPN addition to calcite growing in vitro produced similar surface nanostructure. These findings provide details on the composition and nanostructure of mammalian otoconia, and suggest that while OPN may influence surface rounding and surface nanostructure in otoconia, other incorporated proteins (also possibly including OPN) likely participate in creating internal nanostructure.

Seasonality and Cardio-Cerebrovascular Risk Factors for Benign Paroxysmal Positional Vertigo

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, especially in the elderly. Several studies have revealed a possible seasonality to BPPV. However, whether the seasonality of BPPV also exists in China is unclear. The characteristics of cardio-cerebrovascular risk factors for BPPV in the cold season have not yet been investigated. Objectives: (1) To investigate the seasonality of BPPV; (2) To explore the relationship between cardio-cerebrovascular risk factors and seasonality of BPPV. Methods: A retrospective observational study was performed in Beijing Tiantan Hospital from Jan 2016 to Dec 2018. The study included 1,409 new-onset BPPV patients aged 18-88 years. The demographic data, onset time, and medical history of BPPV were collected. The meteorological data, including temperature, atmospheric pressure, rainfall, and insolation, was obtained from Beijing Meteorological service. The x ² goodness of fit test was used to evaluate whether BPPV patients' numbers were significantly different among different months of the year. The Spearman correlation was used to detect the correlation between numbers of BPPV patients diagnosed monthly with each climatic parameter. The chi-square test for linear-by-linear association were used to investigate the relationship between cardio-cerebrovascular risk factor and seasonality of BPPV. Results: November to next March is the top 5 months with higher BPPV patient numbers (P < 0.001). The numbers of BPPV diagnosed monthly were conversely correlated with temperature and rainfall (r = -0.736, P = 0.010; r = -0.650, P = 0.022, respectively), positively correlated with atmospheric pressure (r = 0.708, P = 0.010), but no significant correlated with insolation. BPPV in the cold season (including January, February, March, November, and December) had a higher proportion, accounting for 54.2% of all BPPV patients. Among BPPV patients with ≥2, 1, and none cardio-cerebrovascular risk factors, the cold season accounted for 57.0, 56.0, 49.8%, respectively. As the number of cardio-cerebrovascular risk factors increased, the proportion of patients in the cold season of BPPV increased (P = 0.025). Conclusions: BPPV patients are seen more in the months with low temperature, low rainfall, and high atmospheric pressure. Compared with the non-cold season, BPPV patients have more risk factors for cardio-cerebrovascular diseases in the cold season.

Evaluation of the structure of the otoconial layer using micro-computed tomography

OBJECTIVE

Estrogen deficiency caused by bilateral ovariectomy (OVX) has been reported to lead to morphological changes in otoconia. Thus, we examined the morphological changes in the otoconial layer after OVX. We also investigated whether micro-computed tomography (µCT) is useful for the detection of morphological changes in the otoconial layer.

METHODS

The otic capsules of C57BL/6 J mice were removed and evaluated using histological techniques and µCT at 2, 4, and 8 weeks after OVX or sham surgery. The volume of the utricle otoconial layer was measured and compared between the OVX and sham groups. The µCT scan and histological study results were also compared.

RESULTS

The volume of the utricle otoconial layer was significantly increased 4 weeks after OVX compared to the sham group in both histological and µCT studies (p < 0.05). The volume of the otoconial layer measured using µCT was significantly correlated with the histological study results (p < 0.05).

CONCLUSION

The volume of the utricle otoconial layer increased after OVX. These morphological changes could be detected by µCT.

Bone Mineral Density in Patients Suffering from Ménière's Disease

INTRODUCTION

Previous studies have reported an association between reduced bone mineral density and the occurrence of benign paroxysmal positional vertigo, balance impairment, and saccular dysfunction. Furthermore, the results of recent animal studies have raised the possibility that vestibular dysfunction could affect bone remodeling and bone mass. The goal of the study was to compare bone mineral density of patients suffering from definite Ménière's disease to that of a matched control group.

METHODS

We conducted a case-control cross-sectional study in a tertiary referral center. The study group included 23 patients suffering from definite Ménière's disease, and the control group was comprised of 23 patients matched in their race, gender, and age parameters in whom no vestibular pathology could be found. Dual energy X-ray absorptiometry of the femoral head was used for the assessment of bone mineral density. The T and Z scores of the femoral heads' bone mineral density were compared.

RESULTS

The average T scores were -1.53 ± 1.08 in the study and -0.39 ± 0.72 (p = 0.016) in the control groups, and the Z scores were -0.4 ± 0.63 and 0.33 ± 0.31 (p = 0.018), respectively. Seventeen patients (74%) of the study group and 9 (39%) of the control group had T scores less than -1.0, indicating osteopenia/osteoporosis (p = 0.036).

CONCLUSIONS

The results showed a significant association between Ménière's disease and reduced bone mineral density of the femoral head. Bone mineral density studies of the weight-bearing bones are warranted in Ménière's disease for the early diagnosis and treatment of osteopenia/osteoporosis on the one hand and possible benefit of this treatment for the evolution of Ménière's disease on the other hand.

Can Osteopenia Induce Residual Dizziness After Treatment of Benign Paroxysmal Positional Vertigo?

OBJECTIVE

This study aimed to determine whether there is an association between osteopenia and residual dizziness after successful treatment of benign paroxysmal positional vertigo (BPPV).

METHODS

In all, 62 patients with canalolithiasis-type BPPV were included in the study. Patients were divided into two groups according to the presence of residual dizziness after resolution of BPPV. Univariate and multivariate analyses were performed to determine the factors associated with residual dizziness. Patients were analyzed based on age, sex, affected semicircular canal, affected side, BPPV duration, and presence of hypertension, diabetes mellitus, hyperlipidemia, and osteopenia.

RESULTS

In univariate analysis, BPPV duration and osteopenia showed a relatively significant association (p < 0.20) with the development of residual dizziness. On subsequent multivariate analysis using these factors, osteopenia remained a statistically significant factor in association with residual dizziness (p = 0.012, odds ratio, 9.916).

CONCLUSION

Osteopenia is associated with the development of residual dizziness. BPPV patients with osteopenia more frequently suffer from residual dizziness after successful treatment of BPPV than those without osteopenia.

Effect of Vitamin D Injection in Recurrent Benign Paroxysmal Positional Vertigo with Vitamin D Deficiency

Introduction  There have been reports indicating that patients with frequently recurring benign paroxysmal positional vertigo (BPPV) had vitamin D deficiency, and some studies indicated that the treatment of severe vitamin D deficiency is effective in the reduction of the recurrence of BPPV.

Objective  The purpose of the present study was to examine the effects of Vitamin D ₃ injection on recurrence among patients with a 10 ng/mL or lower 25-hydroxyvitamin D blood concentration diagnosed with BPPV.

Methods  Among 99 patients with idiopathic BPPV with vitamin D deficiency, 25 patients (case group) were submitted to 3 to 4 injections of 200,000 IU of vitamin D ₃ in the first year. In total, 50 patients in the control group were selected through frequency matching, with 25 patients in the case group. Age, gender, and type of BPPV are used in matching variables with 1:2 matched data. The subjects of the study group were followed up for 24 months.

Results  The differences in relapse rates between the case and the control groups were examined using the non-parametric Kruskal-Wallis test for k independent samples. With regard to the relapse rates of the entire case and control groups by period, from 0 to 6 months ( p  < 0.531), from 7 to 12 months ( p  < 1.000), and from 13 to 24 months ( p  < 0.711), and in the entire study period ( p  < 0.883) there were no statistically significant differences.

Conclusion  The present case-control study indicated that vitamin D ₃ injection had no significant effect on the recurrence of BPPV patients with vitamin D deficiency when age, gender, and type of BPPV were homogeneous between the two groups.

Evaluation of bone mineral density and 25-(OH) vitamin D levels in middle-aged and elderly women with recurrent benign paroxysmal positional vertigo

Background: Middle-aged and elderly perimenopausal women are prone to developing BPPV without definite cause. Objectives: This study aimed to investigate the correlation between bone mineral density (BMD), 25-(OH) vitamin D, and serum calcium levels in patients with benign paroxysmal positional vertigo (BPPV) in middle-aged and elderly women.Material and methods: A total of 103 women with two or more recurrent BPPV episodes (group A) and 80 age-matched healthy controls (group B) were recruited. All subjects had BMD and serum 25-(OH) D levels measurements taken, and the results were compared.Results: BMD was reduced in group A, and the proportion of osteoporosis was higher than in group B (p = .039). The BMD T-score and 25-(OH) vitamin D level were lower in group A than in group B (p = .004 and p < .0001, respectively). In group A, the BMD T-score was lower (p = .017) and serum 25-(OH) vitamin D level was higher (p < .0001) in premenopausal women than in menopausal women.Conclusions and Significance: Our study found that middle-aged and elderly women with recurrent BPPV, especially postmenopausal women, may present decreased BMD and serum vitamin D levels.

[The impairment of bone-mineral metabolism in the development of benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of systemic vertigo in clinical practice. The results of recent research demonstrated the decrease of bone mineral density, level of vitamin D and estrogen in blood serum in patients with BPPV. In summary these data points at the relationship between osteoporosis/osteopenia and BPPV. This association is most obvious in menopausal women and in those with recurrent BPPV. Patients with recurrent BPPV should undergo investigation for osteoporosis/osteopenia. Treatment of bone-mineral metabolism allows decreasing the frequency of BPPV recurrence, however more research is needed in this area.

Bone mineral density and serum 25-hydroxyvitamin D in subtypes of idiopathic benign paroxysmal positional vertigo

Although the etiology of benign paroxysmal positional vertigo (BPPV) is idiopathic in most cases, the association of osteoporosis or vitamin D deficiency with BPPV has attracted much interest recently. While it is generally accepted that osteoporosis or vitamin D deficiency is related to the occurrence and/or recurrence of BPPV, the difference in serum vitamin D level and bone mineral density (BMD) among different subtypes of BPPV has not been investigated. We aimed to compare T-score of BMD score and serum 25-hydroxyvitamin D level among idiopathic BPPV patients with a different subtype. This study included 117 consecutive patients with idiopathic BPPV (26 men and 91 women; mean age, 55 ± 11 years; age range, 25 to 78 years) who underwent blood sampling for serum 25-hydroxyvitamin D level measurement and bone mineral densitometry of the anterior-posterior lumbar spine and femur between April 2018 and February 2019. Among 117 patients, 49 were diagnosed with posterior semicircular canal (PSCC) BPPV, 24 were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, and 44 were diagnosed with LSCC cupulolithiasis. The mean T-score of BMD was -1.5 ± 0.9 in PSCC BPPV, -1.5 ± 1.3 in LSCC canalolithiasis, and -1.5 ± 1.1 in LSCC cupulolithiasis, which was not significantly different (p = 0.998, One-way ANOVA test). The mean level of 25-hydroxyvitamin D was 22.5 ± 10.6 ng/ml in PSCC BPPV, 26.8 ± 16.0 ng/ml in LSCC canalolithiasis, and 25.4 ± 9.6 ng/ml in LSCC cupulolithiasis, which was not significantly different (p = 0.262, One-way ANOVA test). The proportion of osteoporosis/osteopenia or vitamin D deficiency/insufficiency did not show significant difference among idiopathic BPPV patients with different subtypes, and findings of this study indicate that either serum level of vitamin D or T-score of BMD is not a distinguishable characteristic among different subtypes of BPPV.

Review of the pathology underlying benign paroxysmal positional vertigo

The pathophysiological mechanism underlying benign paroxysmal positional vertigo (BPPV) is related to free-floating debris/otoliths in the semicircular canal (canalolithiasis) or debris/otoliths attached to the cupula (cupulolithiasis). These debris/otoliths are considered to originally accumulate after detachment from the neuroepithelium of the utricular macula secondary to a type of degeneration. An idiopathic form, which is assumed to occur spontaneously, is diagnosed when the causative pathology is obscure. However, an association between various other systemic or inner ear conditions and BPPV has been reported, indicating the existence of secondary BPPV. This study was performed to present the first review of the pathology underlying BPPV following a complete PubMed/Medline search. In total, 1932 articles published from 1975 to 2018 were reviewed. The articles were classified according to 17 potentially causative factors (aging; migraine; Meniere's disease; infection; trauma; idiopathic sudden sensorineural hearing loss; sleeping habits; osteoporosis and vitamin D insufficiency; hyperglycemia and diabetes mellitus; chronic head and neck pain; vestibule or semicircular canal pathology; pigmentation disorders; estrogen deficiency; neurological disorders; autoimmune, inflammatory, or rheumatologic disorders; familial or genetic predisposition; and allergy). A discussion of the underlying cause of BPPV for each factor is presented.

A Relationship Between Blood Levels of Otolin-1 and Vitamin D

OBJECTIVE

Low vitamin D levels have been associated with and could play a role in the pathogenesis of idiopathic benign paroxysmal positional vertigo (iBPPV). Since otoconia degeneration contributes to iBPPV and a lack of vitamin D may impact otoconia structure and integrity, we proposed a negative association between vitamin D levels and levels of a proposed circulatory biomarker for otolithic degeneration, otolin-1.

STUDY DESIGN

Cross-sectional clinical study.

SETTING

Clinical research center.

PATIENTS

Seventy-nine men and women ranging in age from 22 to 95 years old without known vertigo.

INTERVENTIONS

Diagnostic.

MAIN OUTCOME MEASURES

Blood levels of 25-OH vitamin D and otolin-1.

RESULTS

Previously, we had reported higher otolin-1 levels in older age groups. The majority of the subjects (83%) had vitamin D levels that were below 40 ng/ml. Vitamin D level was lowest in the young and increased with age before declining in subjects 70 years of age and older (p = 0.005). There was a negative correlation between vitamin D and otolin-1 levels of subjects over 70 (r = -0.36, p = 0.036).

CONCLUSION

Our results demonstrate a relationship between vitamin D and otolin-1. The majority of our subjects had abnormally low vitamin D levels, but only those over 70 years of age showed a negative correlation with high otolin-1 levels. We postulate that a seasonal drop in vitamin D may not be sufficient for otoconia fragmentation and ultimately iBPPV, rather, chronically low vitamin D maybe required to induce otoconia degeneration.