Diagnosis and treatment of vertigo and dizziness

Consensus paper on the management of acute isolated vertigo in the emergency department

Acute vertigo is defined as the perception of movement of oneself or the surroundings in the absence of actual motion and it is a frequent cause for emergency department admissions. The utilization of medical resources and the duration of hospital stay for this kind of symptom is high. Furthermore, the efficiency of brain imaging in the acute phase is low, considering the limited sensitivity of both CT and MRI for diagnosing diseases that are the causes of central type of vertigo. Relying on imaging tests can provide false reassurance in the event of negative results or prolong the in-hospital work-up improperly. On the other hand, clinical examinations, notably the assessment of nystagmus' features, have proven to be highly accurate and efficient when performed by experts. Literature data point out that emergency physicians often do not employ these skills or use them incorrectly. Several clinical algorithms have been introduced in recent years with the aim of enhancing the diagnostic accuracy of emergency physicians when evaluating this specific pathology. Both the 'HINTS and 'STANDING' algorithms have undergone external validation in emergency physician hands, showing good diagnostic accuracy. The objective of this consensus document is to provide scientific evidence supporting the clinical decisions made by physicians assessing adult patients with acute vertigo in the emergency department, particularly in cases without clear associated neurological signs. The document aims to offer a straightforward and multidisciplinary approach. At the same time, it tries to delineate benchmarks for the formulation of local diagnostic and therapeutic pathways, as well as provide a base for the development of training and research initiatives.

Risk of Obstructive Sleep Apnea, Chronic Dizziness, and Sleep Duration

BACKGROUND

Although it is recommended that obstructive sleep apnea (OSA) be screened for using a validated self-report questionnaire in patients experiencing dizziness, there is still a lack of research on the relationship between high risk of OSA and chronic dizziness.

OBJECTIVES

The study aimed to examine the relationship between the high risk of OSA and chronic dizziness and investigate how this relationship is affected by sleep duration.

METHODS

This cross-sectional study used data from the 8th Korea National Health and Nutrition Examination Survey (2019-2021). Adults aged 40 years or older were included and divided into two groups using the STOP-Bang Questionnaire (SBQ): a high-risk group for OSA or not. Complex samples logistic regression analyses were performed to examine the odds ratios of chronic dizziness based on the national population estimates.

RESULTS

Our findings showed that individuals in the high-risk group for OSA were significantly more likely to experience chronic dizziness. Specifically, among subgroups based on sleep duration, the high-risk group for OSA with a short sleep duration of ≤5 hours demonstrated the highest odds of chronic dizziness, showing a significantly 2.48-fold increased likelihood compared to the non-high risk for OSA with a sleep duration of 5-9 hours.

DISCUSSION

The SBQ can be beneficial when other causes do not explain chronic dizziness, helping to rule in the possibility of OSA. Educating individuals suspected of having OSA or who have been diagnosed with OSA about the importance of adequate sleep duration may help reduce the risk of chronic dizziness.

The Relationship Between Vertigo/Dizziness and Somatoform Complaints: A Systematic Review

To systematically synthesize published literature on somatoform complaints as psychological factors in vertigo/dizziness to determine the characteristics of comorbidities, relationships and causality. Following PRISMA guidelines, systematic searches of PubMed, WOS, and Cochrane Library databases and manual follow-up reference searches were performed for articles published in English up to 2021. All original research studies and retrospective or prospective studies focusing on the relationship between vertigo/dizziness and somatoform complaints/somatization were systematically retrieved. Studies that did not include data on the association between somatoform complaints/somatization and vertigo/dizziness were excluded, as were reviews, comments, case reports, editorials, letters, and practice guidelines. Extracted data included research type, number of participants, assessment tools for vertigo/dizziness and somatoform complaints/somatization, statistical methods, and the main results. The quality of included studies was evaluated. Records identified through database searching n = 1238. After removing duplicates and unrelated articles based on abstract and title search, 155 articles recorded as relevant. Except for the 5 articles, title and abstract of all records screened and 88 of them excluded. Critically evaluating those full texts, 28 studies included. The present study highlights the relationship between the vertigo/dizziness and somatoform complaints/somatization. It is determined that somatoform complaints of the individuals suffering from vertigo/dizziness is highly prevelant and some other factor such as personality characteristics or accompanying psychopathology have affect on the prevelance. The main results of all reviewed studies emphasize the requirement for assessment and intervention of vertigo/dizziness, in collaboration with the department of psychiatry. PROSPERO REGISTRATION: PROSPERO: CRD42020222273.

[Validity of the German Menière's Disease Patient-Oriented Symptom Severity Index]

BACKGROUND

The MD POSI is a disease-specific questionnaire to determine the health-related quality of life (HRQoL) of patients with Menière's disease (MD).

OBJECTIVES

Validity and reliability of the German translation of the MD POSI.

MATERIAL AND METHODS

Prospective data analysis of a patient group with vertigo (n = 162), which was treated in the otorhinolaryngology of a University Hospital from 2005-2019. A clinical selection was made according to the new Bárány classification in a "definite" and "probable" Menière's disease. HRQoL was assessed using the German translation of the MD POSI, the Vertigo Symptom Score (VSS) and the Short Form (SF-36). Reliability was measured by Cronbach's α and test-retesting after 12 months and again 2 weeks later. Content and agreement validity were examined.

RESULTS

Cronbach α values greater than 0.9 indicated good internal consistency. There was no statistically significant difference from baseline to 12 months, except for the subscore "during the attack". There were significant positive correlations between the VSS overall/VER/AA and the overall index of the MD POSI and negative significant correlations with the SF-36 domains physical functioning, physical role functioning, social functioning, emotional role functioning, mental well-being. There were low SRM (standardized response mean) values below 0.5.

CONCLUSIONS

The German translation of the MD POSI is a valid and reliable instrument to evaluate the impact of MD on patients' disease-specific quality of life.

Impact of 14 Days of Bed Rest in Older Adults and an Exercise Countermeasure on Body Composition, Muscle Strength, and Cardiovascular Function: Canadian Space Agency Standard Measures

INTRODUCTION

Head-down bed rest (HDBR) has long been used as an analog to microgravity, and it also enables studying the changes occurring with aging. Exercise is the most effective countermeasure for the deleterious effects of inactivity. The aim of this study was to investigate the efficacy of an exercise countermeasure in healthy older participants on attenuating musculoskeletal deconditioning, cardiovascular fitness level, and muscle strength during 14 days of HDBR as part of the standard measures of the Canadian Space Agency.

METHODS

Twenty-three participants (12 males and 11 females), aged 55-65 years, were admitted for a 26-day inpatient stay at the McGill University Health Centre. After 5 days of baseline assessment tests, they underwent 14 days of continuous HDBR followed by 7 days of recovery with repeated tests. Participants were randomized to passive physiotherapy or an exercise countermeasure during the HDBR period consisting of 3 sessions per day of either high-intensity interval training (HIIT) or low-intensity cycling or strength exercises for the lower and upper body. Peak aerobic power (V̇O2peak) was determined using indirect calorimetry. Body composition was assessed by dual-energy X-ray absorptiometry, and several muscle group strengths were evaluated using an adjustable chair dynamometer. A vertical jump was used to assess whole-body power output, and a tilt test was used to measure cardiovascular and orthostatic challenges. Additionally, changes in various blood parameters were measured as well as the effects of exercise countermeasure on these measurements.

RESULTS

There were no differences at baseline in main characteristics between the control and exercise groups. The exercise group maintained V̇O2peak levels similar to baseline, whereas it decreased in the control group following 14 days of HDBR. Body weight significantly decreased in both groups. Total and leg lean masses decreased in both groups. However, total body fat mass decreased only in the exercise group. Isometric and isokinetic knee extension muscle strength were significantly reduced in both groups. Peak velocity, flight height, and flight time were significantly reduced in both groups with HDBR.

CONCLUSION

In this first Canadian HDBR study in older adults, an exercise countermeasure helped maintain aerobic fitness and lean body mass without affecting the reduction of knee extension strength. However, it was ineffective in protecting against orthostatic intolerance. These results support HIIT as a promising approach to preserve astronaut health and functioning during space missions, and to prevent deconditioning as a result of hospitalization in older adults.

Cross-cultural adaptation and validation of the Norwegian Dizziness Catastrophizing Scale in persons with dizziness

BACKGROUND AND PURPOSE

Dizziness Catastrophizing Scale (DCS) is a questionnaire covering catastrophizing thoughts related to dizziness. The aims of this study were to cross-culturally adapt the DCS into Norwegian (DCS-N) and to examine the internal consistency, content and construct validity, and test-retest reliability of the instrument.

METHOD

Patients (18-67 years) with long-term dizziness were recruited from an ear, nose, and throat (ENT) clinic in Western Norway. Validity of the DCS-N was assessed by evaluating data quality (missing, floor and ceiling effects), content validity (relevance, comprehensiveness, and comprehensibility), structural validity (principal component analysis), internal consistency (Cronbach's alpha), and construct validity (predefined hypotheses). Test-retest reliability was examined by intraclass correlation coefficient (ICC1.1 ), standard error of measurement (SEM), smallest detectable change (SDC), and limits of agreement.

RESULTS

In total, 97 women and 53 men, mean age (SD) 46.5 (12.7) with dizziness were included (in the study). A subgroup of 44 patients participated in test-retest assessment. Overall, the DCS-N was easy to comprehend. The principal component analysis supported a one-factor solution and internal consistency was satisfactory (α 0.93). Construct validity was acceptable; all the predefined hypotheses were confirmed. Test-retest reliability demonstrated ICC1.1 of 0.90 and a SEM of 4.9. SDC was estimated to be ±13.6.

DISCUSSION

The DCS-N demonstrated acceptable measurement properties for assessing catastrophizing thoughts in patients with long-term dizziness. Further studies should examine the responsiveness of the DCS-N and a factor analysis should be undertaken in a larger population.

Evaluation of Types of Vertigo With Electronystagmography: An Experience From a Tertiary Care Hospital in West Bengal, India

Background Electronystagmography (ENG) is a diagnostic test that measures the electrical activity of the muscles that control eye movements. ENG has the potential to identify the cause of vertigo by assessing the function of the vestibular system. Vertigo can be of two types - peripheral or central. In addition, a combination of peripheral and central types may coexist. Peripheral vertigo is caused by pathology in the inner ear and central vertigo is caused by pathology in the brainstem or cerebellum. Objective This study aimed to evaluate the applicability of ENG in assisting the diagnosis of the type of vertigo in a remote tertiary care center in West Bengal, India. Materials and methods This cross-sectional study was conducted in tertiary care hospital in West Bengal, India. Any patient presenting first time with a complaint of vertigo was approached and recruited for the study after taking written informed consent. We collected demographics and conducted a complete ear, nose, and throat examination, including otoscopy and audiological evaluation. A consensus between two expert otorhinolaryngologists was reached for the categorization of vertigo. Then, ENG was performed to assess the vestibular function to help aid the categorization. Magnetic resonance imaging (MRI) and computed tomography (CT) scans were done in central vertigo patients according to the necessity to diagnose the cause. Data were presented in descriptive statistical terms and categorical data were compared by Chi-square test. Result A total of 84 patients (male 31, female 53) with a median age of 25 years (Q1-Q3: 21-30.25) participated in the study. We found 75% of the patients were complaining of instability, 50% rotatory objective vertigo, 29.76% falling tendency, 22.62% blackout, and 2.38% sinking sensation. The majority of the patients (63%) had two or more symptoms. A total of 68 (80.95%) patients could be categorized into peripheral (46 [54.76%]) and central (22 [26.19%]) types. When we added ENG to the tests, we could categorize all the patients and found that 48 (57.14%) had peripheral, 27 (32.14%) had central, and nine (10.71%) had mixed lesions. Conclusion ENG when used in conjunction with clinical examination, otoscopy, and an audiological examination can help to categorize all patients into peripheral, central, or mixed lesion types of vertigo. Hence, ENG can be an important tool in identifying the type of vertigo and can aid in appropriate treatment decisions.

Does Thyroid Hormone Metabolism Correlate with the Objective Assessment of the Vestibular Organ in Patients with Vertigo?

The aim of this study was to assess the relationship between the results of the objective assessment of the vestibular organ in patients with peripheral vertigo with Hashimoto's thyroiditis and thyroid hormone metabolism. Twenty eight women with Hashimoto's thyroiditis and chronic vertigo were enrolled in the study. Patients underwent audiological assessment of hearing, Dix-Hallpike test, videonystagmography with caloric test, head impulse test (HIT) and cervical vestibular-evoked myogenic potentials (cVEMPs). Levels of thyroid hormones and anti-thyroid antibodies were determined. Relationships between age, weight, height, BMI and the results of the objective assessment of the vestibular organ were calculated. The mean age in the study group was 48 years, while the mean BMI was 26.425. The causes of peripheral vertigo in the study group were benign paroxysmal positional vertigo (BPPV) (n = 19), Meniere's disease (n = 7) and vestibular neuronitis (n = 2). No correlation was found between age, weight, height, BMI and the results of thyroid function tests or the objective assessment of the vestibular organ. The study did not confirm the influence of thyroid metabolism (i.e., thyroid hormone levels or the increase in antithyroid antibodies) on the results of cVEMP or the directional preponderance in the caloric test.

Dynamic changes of otolith organ function before and after repositioning in patients with benign paroxysmal positional vertigo detected by virtual reality auxiliary technology: A cohort study

Objectives

To dynamically investigate otolith function in patients with benign paroxysmal positional vertigo (BPPV) before, after, and 1 month after repositioning, and explore the possible compensation mechanisms.

Methods

Thirty-six patients confirmed with BPPV (canal lithiasis) treated in our hospital between August 2020 and March 2021, as well as 36 health controls matched for age and gender (normal control group, NC group) were enrolled. For NC group, the virtual reality (VR) auxiliary static subjective visual vertical (SVV), subjective visual horizontal (SVH), and SVV of dynamic unilateral centrifugation (DUC), were measured at inclusion. For the BPPV group, visual analog scale (VAS) was used to assess the vertigo degree, while static SVV, SVH, and DUC were performed before, after, and 1 month after repositioning. First, we compare the deviations of SVV0/SVH0° when the subject's head is in the positive position, and SVV of DUC between BPPV and NC groups before repositioning, after which we compared the deviations in SVV45, SVV90, SVH45, SVH90°, and SVV of DUC between the affected and unaffected sides before repositioning. Finally, paired t-test was used to compare the VAS score, deviations in static SVV0, SVV45, SVV90, SVH0, SVH45, and SVH90°, and deviations in SVV of DUC before, after, and 1 month after repositioning. (Here, 0, 45, and 90° refer to the angle which the center axis of head deviates from the gravity line.)

Results

SVV0 SVH0°, and SVV of DUC at 120 and 180°/s 0 significantly differed between BPPV and NC group before repositioning. The deviations in SVV45, SVV90, SVH45, SVH90°, and SVV of DUC at 120°/s-2 and 180°/s-4.5 did not significantly differ between bilateral sides in BPPV patients before repositioning. The deviation in SVH90° was significantly lower after repositioning than before. The deviation in SVH45° was significantly higher 1 month after repositioning than before. The deviation angle of SVV of DUC at 180°/s-0 was significantly lower after repositioning than before. The vertigo VAS score of patient with BPPV continued to decrease after repositioning.

Conclusion

Before repositioning, the otolithic organ function of BPPV patients was obviously impaired, with no significant difference between the healthy and affected ear. After repositioning, there was a transient recovery of otolithic organ dysfunction followed by a sustained decline to similar levels to before repositioning.

A prospective study on the application of HINTS in distinguishing the localization of acute vestibular syndrome

BACKGROUND

Acute vestibular syndrome (AVS) is a common clinical syndrome in neurology clinics and emergency department. Canonical standard for AVS diagnosis requires the presence of persistent vertigo for more than 24 h. HINTS (head impulse-nystagmus-test of skew) is an emerging scheme in the diagnosis of AVS. In this prospective study, we evaluated the specificity and sensitivity of HINTS in distinguishing between central and peripheral AVS.

METHODS

A cohort of 239 cases with complete clinical record was recruited in the study. All patients completed emergency brain CT examination to exclude hemorrhagic stroke. HINTS examination was conducted to distinguish between central AVS and peripheral AVS, and all patients completed head MRI, BAEP and vestibular function examinations within one week. Patients diagnosed as central AVS were subject to angiography (CTA/MRA/DSA), and patients with peripheral AVS were considered for a 3-month follow-up to correct the initial diagnosis.

RESULTS

Patients with central AVS were associated with an elder age, higher incidences of hypertension, atrial fibrillation, family history of stroke and previous history of stroke. Posterior circulation cerebral infarction, vestibular migraine and cerebellitis were the dominant diseases associated with central AVS. The sensitivities of HIT, GE, and TS in the diagnosis of central AVS were 73.5%, 61.2%, and 26.5%, and the specificities were 97.9%, 92.6%, and 93.2% respectively.

CONCLUSIONS

The sensitivity of HINTS for central AVS diagnosis is 89.8% and the specificity is 84.2%. HINTS is an easy-to-operate, low-cost, high-sensitivity and specific examination technique, which is practical in neurology outpatient clinics and emergency departments.

A Holistic Approach to a Dizzy Patient: A Practical Update

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

Effectiveness of a training intervention to improve the management of vertigo in primary care: a multicentre cluster-randomised trial, VERTAP

Background

Benign paroxysmal positional vertigo (BPPV) is the most common type of vertigo. While BPPV is best treated with canalicular repositioning manoeuvres, they are not routinely performed in primary care (PC).

Methods

To evaluate the effectiveness of blended training (online and face-to-face) on the diagnosis and management of vertigo to improve adherence of family doctors to clinical practice guidelines, we designed a community multicentre cluster-randomised open-label trial with an intervention (IG) and a control (GC) group of 10 primary care teams (PCT) each. Outcome variables will be ICD-10 diagnostic codes (proportion of nonspecific diagnoses such as dizziness and vertigo versus specific diagnoses such as BPPV, vestibular neuritis, and Menière’s disease); number of referrals to ENT or neurology specialists; prescription of antivertigo agents; and duration of sick leave due to vertigo. The baseline comparability of the two study groups will be analysed to ensure homogeneity. A description of all baseline variables will be performed. Student’s t-test will be used to evaluate the differences between the groups. Logistic regression multivariate analysis will be performed to study the relationship between baseline variables of professionals and centres with outcome variables.

Discussion

With the improvement of the diagnosis and management of vertigo by family doctors after this training, we expect an increase in the proportion of specific diagnoses, a decrease in the prescription of antivertigo agents, a decrease in referrals to ENT or neurology specialists and a reduction in the duration of sick leave due to temporary disability. The blended training will be easily expanded within primary care services, since it is mainly delivered online, with a single face-to-face session to ensure that the manoeuvres have been adequately learned.

Trial registration

ClinicalTrials.govNCT04929444. Registered June 18, 2021. This protocol has been approved by the Ethics Committee of the Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) with the code 20/004-P. All patient data will be anonymised in agreement with the 2016/679 European Regulation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06548-7.

Dizziness in the Emergency Department: Insights and Epidemiological Data - a Population Based Study

Background:Dizziness is a commonly referred symptom in emergency departments (EDs). The aim of this study is to describe the epidemiology of dizziness included acute vestibular syndrome (AVS) in the ED of the University Hospital of Ioannina, Grecce, during a six-month period. Methods:A total of 60 patients presenting with dizziness to the ED of our hospital during a short period of six months in 2021 were identified. Data were obtained through retrospective and prospective review of medical records. Statistical analysis was based on ÉBM-SPSS Statistics 26.0. Results:Among the 60 patients, 16.67% received the diagnosis of cerebellar stroke, 3.33% Meniere disease, 16.67% vestibular neuritis, 20% benign paroxysmal positional vertigo, 3.33% cardiovascular disease, and 1.67% had a neurological disease. Finally, 35% of patients left the ED undiagnosed. Conclusion:Benign paroxysmal positional vertigo was found to be the most common cause of dizziness in the ED, followed by cerebellar stroke and vestibular neuritis. A detailed neurological examination is recommended for the diagnosis of dizziness in the ED. Our data confirm the findings of previous studies in the GreeK population of patients presenting with dizziness to the ED of our hospital.

Applicability of Oculomotor Tests for Predicting Central Vestibular Disorder Using Principal Component Analysis

The videonystagmography oculomotor test battery is considered useful method for diagnosing vertigo. However, its role in diagnosing central vestibular disorder has not been clarified due to variations in interpretation. Patients (n = 103) with vertigo or dizziness symptoms undergoing the oculomotor tests and brain MRI within 1 month were analyzed. Two otology specialists retrospectively interpreted the oculomotor tests, and three neurology and neuroradiology specialists determined whether central lesions were present on brain MRI. Multivariable logistic regression analysis was performed to determine the factors contributing to discordant interpretation between oculomotor tests and brain MRI. Oculomotor tests predicting central lesions were assessed using principal component analysis. The intra- and inter-rater reliability in oculomotor test interpretation was moderate to good. Age > 60 years and multiple comorbidities were significant predictors of a discordant interpretation between MRI and oculomotor tests. Positive neurological symptoms and a higher oculomotor index (according to saccade (vertical axis), smooth pursuit (horizontal axis), and gaze-evoked nystagmus (horizontal/vertical axes) tests) significantly predicted central vestibular disorder in vertigo patients. Caution is required when interpreting the results of the oculomotor test battery for diagnosis of central lesions in older patients, as well as in those with multiple comorbidities.

Negative Impact of Vestibular Suppressant Drugs on Provocative Positional Tests of BPPV: A Study from the Western Part of India

Aims:

To study the impact of vestibular suppressant drugs (VSD) on provocative positional tests (PPT) in patients with benign paroxysmal positional vertigo (BPPV).

Settings and Design:

A prospective case-control observational study.

Materials and Methods:

Patients with a history suggestive of BPPV were tested for PPT. Patients with vertiginous symptoms and with nystagmus on PPT were classified as objective BPPV (O-BPPV, control group), while those without nystagmus with no alternate diagnosis were classified as subjective BPPV (S-BPPV, case group). Details of VSD treatment were noted in all the patients. In both groups, patients were instructed to discontinue VSD and were further assigned as the VSD and non-VSD subgroups. Patients were followed for 2 months with PPT every week. PPT positive patients were treated by vestibular rehabilitation maneuvers.

Statistics:

Student t-test with two-tailed, unpaired, was used for continuous scale and Chi-square test for categorical differences between the two groups.

Results:

295 consecutive BPPV patients were enrolled in the study, 55 in the S-BPPV group and 240 in the O-BPPV group. Significantly higher proportion of patients in the S-BPPV group were on VSD at presentation, 80.00% vs. 53.75% (OR 2.52; 95% CI: 1.30–4.86), P = 0.006. In an unadjusted analysis of the S-BPPV group following discontinuation of VSD, PPT became positive in 79.54% of patients as compared to 18.19% in the non-VSD group (OR 35.0; 95% CI: 6.2–197.3), P < 0.001.

Conclusion:

A higher proportion of S-BPPV patients were receiving VSD in comparison to O-BPPV at the initial visit. The PPT converted positive four times higher after ceasing the VSD in S-BPPV patients.

Study Design:

Prospective case-control observational study.

A Set of Eight Key Questions Helps to Classify Common Vestibular Disorders-Results From the DizzyReg Patient Registry

Precise history taking is the key to develop a first assumption on the diagnosis of vestibular disorders. Particularly in the primary care setting, algorithms are needed, which are based on a small number of questions and variables only to guide appropriate diagnostic decisions. The aim of this study is to identify a set of such key variables that can be used for preliminary classification of the most common vestibular disorders. A four-step approach was implemented to achieve this aim: (1) we conducted an online expert survey to collect variables that are meaningful for medical history taking, (2) we used qualitative content analysis to structure these variables, (3) we identified matching variables of the patient registry of the German Center for Vertigo and Balance Disorders, and (4) we used classification trees to build a classification model based on these identified variables and to analyze if and how these variables contribute to the classification of common vestibular disorders. We included a total of 1,066 patients with seven common vestibular disorders (mean age of 51.1 years, SD = 15.3, 56% female). Functional dizziness was the most frequent diagnosis (32.5%), followed by vestibular migraine (20.2%) and Menière's disease (13.3%). Using classification trees, we identified eight key variables which can differentiate the seven vestibular disorders with an accuracy of almost 50%. The key questions comprised attack duration, rotational vertigo, hearing problems, turning in bed as a trigger, doing sport or heavy household chores as a trigger, age, having problems with walking in the dark, and vomiting. The presented algorithm showed a high-face validity and can be helpful for taking initial medical history in patients with vertigo and dizziness. Further research is required to evaluate if the identified algorithm can be applied in the primary care setting and to evaluate its external validity.

Upper cervical spine dysfunction and dizziness

Although various causes of dizziness have been identified, many patients suffer from dizziness of unknown etiology and continue to visit hospitals to resolve their symptoms. Problems that occur in the ligaments or muscles of the upper cervical spine can cause confusion in proprioception. These changes can convey misinformation to the vestibular nucleus, resulting in abnormal reactions that can lead to cervicogenic dizziness (CGD). Though CGD remains controversial, it should be considered while diagnosing patients with dizziness. Understanding CGD can help create treatment strategies for them. This article suggested a relationship between the structure and function of the upper cervical spine and dizziness, and presented evaluations and treatments for the same.

[Acute vestibular syndrome in emergency departments : Clinical differentiation of peripheral and central vestibulopathy]

INTRODUCTION

The differentiation between central and peripheral vestibular disorders is difficult in some cases, especially during the clinical routine of an emergency department (ED) without otoneurological diagnostic equipment. This study evaluated the frequency of vestibular pseudoneuritis as distinguished from acute peripheral vestibular disorders in patients who were admitted to hospital with the suspicion of vestibular neuropathy (VN).

METHODS

This retrospective study analyzed the results of anamnestic and clinical examinations of 315 patients admitted to the emergency department and the inpatient otoneurological examination results as well as the imaging of morphological alterations. In the ED, the clinical examination by a neurologist and an otorhinolaryngologist resulted in the characteristic signs of peripheral VN but no further evidence of a neurological disorder. Patients without signs of a peripheral vestibular disorder in the otoneurological diagnostics subsequently underwent cerebral magnetic resonance imaging scans (cMRI).

RESULTS

Suspected isolated VN could be confirmed in 69% of the patients; however, in a further 29% of the patients neither the suspected isolated VN nor an ischemic pathology of the central nervous system as a cause of the vertigo could be confirmed. Additional cMRI scans revealed that 2% of patients suffered from an infarction of the mesencephalon, the pons, the medulla oblongata and the cerebellum.

CONCLUSION

In rare cases central cerebral disorders mimic the pattern of a peripheral vestibular disorder. Despite thorough history taking, neurological and otolaryngological clinical examinations, it is not always possible to distinguish central and peripheral vestibular disorders of patients in emergency care suffering from acute vertigo. Video oculography-assisted caloric testing and the video head impulse test are recommended to confirm a peripheral VN. In cases without confirmation of suspected NV in otoneurological diagnostics, infarction of the mesencephalon, brain stem and cerebellum should be excluded by diffusion-weighted cMRI.

Effects of Craniosacral Osteopathy in Patients with Peripheral Vestibular Pathology

INTRODUCTION

Vertigo appears as a result of a sudden neural activity imbalance of the vestibular system. The vertigo prevalence is higher in patients over 60 years of age compared to patients under 40 years of age.

OBJECTIVES

The purpose of this study was to analyze the effect of craniosacral osteopathy on dizziness and balance in individuals who have peripheral vestibular pathology.

METHODS

A total of 30 individuals, aged 24-50 years, participated in this study. Twenty-four of the participants were female (80%) and 6 were male (20%). The participants were separated into 2 groups, with 15 patients included in the cranial osteopathy treatment group (study group) and 15 patients included in the group that used dimenhydrinate (control group). The individuals were evaluated in terms of dizziness and balance. A visual analog scale was used to evaluate dizziness. Balance was evaluated using the Berg balance scale and the Activities-Specific Balance Confidence scale. The craniosacral treatment program was applied once per week for 6 sessions. All of the individuals included in this study were evaluated 3 times, i.e., prior to treatment, on the third week of treatment, and on the sixth week of treatment.

RESULTS

Significant improvement was noted within each group in terms of dizziness and balance (p < 0.05). When the groups were compared with each other, it was observed that craniosacral osteopathy was more effective than dimenhydrinate treatment for dizziness and balance (p < 0.05).

CONCLUSION

Craniosacral osteopathy is an effective treatment choice in individuals who have chronic peripheral vestibular pathology. In individuals who have resistant and chronic vestibular pathology, craniosacral osteopathy should be evaluated among the treatment choices.

Telling friend from foe in emergency vertigo and dizziness: does season and daytime of presentation help in the differential diagnosis?

Distinguishing between serious (e.g., stroke) and benign (e.g., benign paroxysmal positional vertigo, BPPV) disorders remains challenging in emergency consultations for vertigo and dizziness (VD). A number of clues from patient history and clinical examination, including several diagnostic index tests have been reported recently. The objective of the present study was to analyze frequency and distribution patterns of specific vestibular and non-vestibular diagnoses in an interdisciplinary university emergency room (ER), including data on daytime and season of presentation. A retrospective chart analysis of all patients seen in a one-year period was performed. In the ER 4.23% of all patients presented with VD (818 out of 19,345). The most frequent-specific diagnoses were BPPV (19.9%), stroke/transient ischemic attack (12.5%), acute unilateral vestibulopathy/vestibular neuritis (UVH; 8.3%), and functional VD (8.3%). Irrespective of the diagnosis, the majority of patients presented to the ER between 8 a.m. and 4 p.m. There are, however, seasonal differences. BPPV was most prevalent in December/January and rare in September. UVH was most often seen in October/November; absolute and relative numbers were lowest in August. Finally, functional/psychogenic VD was common in summer and autumn with highest numbers in September/October and lowest numbers in March. In summary, daytime of presentation did not distinguish between diagnoses as most patients presented during normal working hours. Seasonal presentation revealed interesting fluctuations. The UVH peak in autumn supports the viral origin of the condition (vestibular neuritis). The BPPV peak in winter might be related to reduced physical activity and low vitamin D. However, it is likely that multiple factors contribute to the fluctuations that have to be disentangled in further studies.

Etiologic distribution of dizziness and vertigo in a referral-based dizziness clinic in South Korea

This study aimed to determine the etiologic distribution of dizziness and vertigo in a referral-based dizziness clinic in South Korea. We analyzed the diagnoses of 21,166 consecutive dizzy patients (12,691 women, mean age = 57.9 ± 15.7, age range = 3-97) seen from 2003 to 2019 using a registry and medical records. Overall, dizziness and vertigo were more common in women (60.0%, CI 0.59-0.61) than in men without a difference in age (57.7 ± 15.5 vs. 58.1 ± 16.1, p = 0.094). Benign paroxysmal positional vertigo (BPPV, 24.1%) was the most common cause of dizziness/vertigo, followed by psychiatric or persistent postural perceptual dizziness (20.8%), vascular disorders (12.9%), vestibular migraine (10.2%), Meniere's disease (7.2%), and vestibular neuritis (5.4%). These six disorders comprised more than 80% of all disorders. The etiology could not be determined in 5.0%, and more than one etiology was found in 14.1%. Vestibular migraine was the most common disorder in children and adolescents (< 19 years), psychiatric or persistent postural perceptual dizziness (26.3%) in the adults (19-64 years), and BPPV (28.2%) in the elderly (≥ 65 years). This etiologic distribution is similar to that reported in another country, and indicates no significant differences in the proportion of diseases causing dizziness and vertigo across different ethnic groups. This study provides valuable information to establish healthcare policy for dizziness and vertigo.

Physical therapy interventions for cervicogenic dizziness in a military-aged population: protocol for a systematic review

BACKGROUND

Traumatic cervicogenic dizziness is dizziness that is temporally associated with neck pain and injury after other causes of dizziness have been excluded. It can lead to activity limitations and participation restrictions that may include lost duty or work days. The objective of this systematic review is to determine which interventions are most effective in decreasing dizziness or vertigo and neck pain in military-aged adults with traumatic cervicogenic dizziness.

METHODS

The literature will be systematically searched using the following online databases: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, CENTRAL, Cochrane Methodology Register), CINAHL, SCOPUS, Web of Science, and J-STAGE. The review will include randomized controlled trials (RCTs), including cluster RCTs and controlled (non-randomized) clinical trials or cluster trials, and observational studies (including prospective and retrospective comparative cohort and case-control or nested case-control studies) and determine the effectiveness of physical therapy interventions for the treatment of traumatic cervicogenic dizziness in military-aged adults. Assessment of methodological quality will be performed by two independent, blinded reviewers using the PEDro scale. The level of evidence will be determined using the GRADE scale. The primary outcome measures will be change in dizziness and neck pain and disability from baseline to the last available follow-up, measured using the Dizziness Handicap Inventory and Neck Disability Index. Other relevant outcome measures will include self-reported change in symptoms, time to return to duty or work, and quality of life.

DISCUSSION

This systematic review will identify, evaluate, and integrate the evidence on the effectiveness of physical therapy interventions for cervicogenic dizziness in a military-aged population. We anticipate our findings may inform individual treatment and future research. Clinical recommendations generated from this systematic review may inform military physical therapy treatment of individuals with cervicogenic dizziness.

SYSTEMATIC REVIEW REGISTRATION

In accordance with the guidelines, our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 21 January 2020 (registration number CRD42020150853). In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.

Efficacy and Safety of a Fixed Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg vs Betahistine Dihydrochloride 16 mg in Patients with Peripheral Vestibular Vertigo: A Prospective, Multinational, Multicenter, Double-Blind, Randomized, Non-inferiority Clinical Trial

Background and Objective

Vertigo derived from peripheral vestibular disorders is quite frequently encountered in daily clinical practice and can be a severely disabling symptom associated with substantial impairment of health-related quality of life for the affected patients. Betahistine, a structural analogue of histamine and presumably the most widely prescribed anti-vertigo drug worldwide, has previously been shown to be an effective and safe treatment for these patients. The objective of the present study was to evaluate whether the fixed combination of cinnarizine and dimenhydrinate (Arlevert^®) is non-inferior and thus a potentially useful alternative to betahistine dihydrochloride in the treatment of patients suffering from peripheral vestibular vertigo.

Methods

In this prospective, multicenter, double-blind, randomized, non-inferiority clinical trial, outpatients from 8 ENT clinics in Austria, Bulgaria, the Czech Republic and Russia were randomly assigned to receive three times daily one tablet of either the fixed combination cinnarizine 20 mg/dimenhydrinate 40 mg or betahistine dihydrochloride 16 mg for 4 weeks. Primary endpoint was the reduction of the mean vertigo score (MVS), a validated 12-item composite score defined as the mean of 6 vertigo symptoms (dystasia and walking unsteadiness, staggering, rotary sensation, tendency to fall, lift sensation, blackout) and 6 trigger factors for vertigo (change of position, bowing, getting up, driving by car/train, head movements, eye movement), after 4 weeks of therapy, as judged by the patient on a 5-point visual analogue scale (VAS). The non-inferiority margin was set to 0.3. Secondary outcomes included the patient’s and investigator’s judgment of global efficacy, the patient’s rating of impairment of daily activities, and safety/tolerability of the treatments.

Results

Three hundred and six patients (mean age 53.5 years, approximately 60% female) were enrolled and randomized to the fixed combination cinnarizine/dimenhydrinate (n = 152) or betahistine (n = 154) groups; 297 patients completed the study and 294 (146 and 148, respectively) were valid for the per-protocol analysis, which was used for the non-inferiority analysis. Treatment with cinnarizine/dimenhydrinate led to a stronger reduction of the MVS [least squares mean (LSM)] after 4-week therapy (primary endpoint) in comparison to betahistine (0.395 vs 0.488; difference: − 0.093, 95% CI − 0.180; − 0.007, p = 0.035); since the upper limit of the two-sided 95% confidence interval was not only below the non-inferiority margin of 0.3, but also entirely below 0, superiority of the fixed combination could be demonstrated. The combination preparation was also more effective after 1 week of therapy and received more favorable patient’s ratings on overall efficacy and impairment of daily activities. Both treatments were very well tolerated. Only 12 patients (3.92%) reported 13 non-serious adverse events; 2 cinnarizine/dimenhydrinate-treated patients discontinued the study prematurely due to adverse events as compared to 5 betahistine-treated patients.

Conclusion

The fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg was found to be not only non-inferior, but superior to betahistine 16 mg in the improvement of peripheral vestibular vertigo. Furthermore, taking into account a good and slightly favorable safety profile, the present study provides evidence that the fixed-combination preparation is a potent and even superior alternative to betahistine in the treatment of vertigo related to peripheral vestibular disorders.

Study Registration

EudraCT No. 2011-004025-27.

Economic burden of vertigo: a systematic review

BACKGROUND

Vertigo, a highly prevalent disease, imposes a rising burden on the health care system, exacerbated by the ageing of the population; and further, contributes to a wide span of indirect burden due to reduced capacity to work or need of assistance in activities of daily living. The aim of this review was to summarise the evidence on the economic burden of vertigo.

METHODS

All original studies published between 2008 and 2018 about the economic evaluation of peripheral or central vestibular vertigo in developed countries were considered eligible, unrestricted to setting, health care provider, or study type.

RESULTS

The electronic search in three databases identified 154 studies from which 16 qualified for inclusion. All studies presented partial economic evaluation referring to a variety of vestibular vertigo including unspecified vertigo. Nine studies presented monetised cost results and seven studies reported health care utilization. Direct costs derived mainly from repeated and not well-targeted consultations at all levels of health care, excessive use of diagnostic imaging, and/or of emergency care. Considerable societal burden was caused by decreased productivity, mainly due to work absenteeism.

CONCLUSION

To the best of our knowledge, this is the first systematic review of the existing evidence of the economic burden of vertigo. The lack of conclusive evidence revealed apparent targets of future research. First, studies of diagnostics and therapies for vestibular disease should include cost-effectiveness considerations. Population-based studies of health services utilization should include simple vestibular assessments to get more reliable estimates of the burden of disease and associated costs on the level of the general population. Further, clinical and population-based registries that include patients with vestibular disease, should consider collecting long-term data of societal burden. Primary data collection should increasingly include assessment of health care utilization e.g. by linking their diagnoses and outcomes to routine data from health insurances.

Audiovestibular Symptoms in Systemic Autoimmune Diseases

Immune-mediated inner ear disease can be primary, when the autoimmune response is against the inner ear, or secondary. The latter is characterized by the involvement of the ear in the presence of systemic autoimmune conditions. Sensorineural hearing loss is the most common audiovestibular symptom associated with systemic autoimmune diseases, although conductive hearing impairment may also be present. Hearing loss may present in a sudden, slowly, rapidly progressive or fluctuating form, and is mostly bilateral and asymmetric. Hearing loss shows a good response to corticosteroid therapy that may lead to near-complete hearing restoration. Vestibular symptoms, tinnitus, and aural fullness can be found in patients with systemic autoimmune diseases; they often mimic primary inner ear disorders such as Menière's disease and mainly affect both ears simultaneously. Awareness of inner ear involvement in systemic autoimmune diseases is essential for the good response shown to appropriate treatment. However, it is often misdiagnosed due to variable clinical presentation, limited knowledge, sparse evidence, and lack of specific diagnostic tests. The aim of this review is to analyse available evidence, often only reported in the form of case reports due to the rarity of some of these conditions, of the different clinical presentations of audiological and vestibular symptoms in systemic autoimmune diseases.

Predictive Capability of an iPad-Based Medical Device (medx) for the Diagnosis of Vertigo and Dizziness

Background

Making the correct diagnosis of patients presenting with vertigo and dizziness in clinical practice is often challenging.

Objective

In this study we examined the performance of the iPad based program medx in the prediction of different clinical vertigo and dizziness diagnoses and as a diagnostic tool to distinguish between them.

Patients and methods

The data collection was done in the outpatient clinic of the German Center of Vertigo and Balance Disorders. The “gold standard diagnosis” was defined as the clinical diagnosis of the specialist during the visit of the patient based on standardized history and clinical examination. Another independent and blinded physician finalized each patient’s case in the constellatory diagnostic system of medx based on an algorithm using all available clinical information. These diagnoses were compared to the “gold standard” by retrospective review of the charts of the patients. The accuracy provided by medx was defined as the number of correctly classified diagnoses. In addition, the probability of being test positive when a disease was present (sensitivity), of being test negative when a disease was absent (specificity), of having the disease when the test is positive (positive predictive value) and of not having the disease when the test is negative (negative predictive value) for the most common diagnoses were reported. Sixteen possible different vertigo and dizziness diagnoses could be provided by medx.

Results

A total of 610 patients (mean age 58.1 ± 16.3 years, 51.2% female) were included. The accuracy for the most common diagnoses was between 82.1 and 96.6% with a sensitivity of 40 to 80.5% and a specificity of more than 80%. When analyzing the quality of medx in a multiclass problem for the six most common clinical diagnoses, the sensitivity, specificity, positive and negative predictive values were as follows: Bilateral vestibulopathy (81.6, 97.1, 71.1, and 97.5%), Menière’s disease (77.8, 97.6, 87.0, and 95.3%), benign paroxysmal positional vertigo (61.7, 98.3, 86.6, and 93.4%), downbeat nystagmus syndrome (69.6, 97.7, 71.1, and 97.5%), vestibular migraine (34.7, 97.8, 76.1, and 88.3%), and phobic postural vertigo (80.5, 82.5, 52.5, and 94.6%).

Conclusion

This study demonstrates that medx is a new and easy approach to screen for different diagnoses. With the high specificity and negative predictive value, the system helps to rule out differential diagnoses and can therefore also lead to a cost reduction in the health care system. However, the sensitivity was unexpectedly low, especially for vestibular migraine. All in all, this device can only be a complementary tool, in particular for non-experts in the field.

The effectiveness of manual therapy in treating cervicogenic dizziness: a systematic review

[Purpose] This review provides an evaluation of the evidence for the effectiveness of using manual therapy to treat cervicogenic dizziness. [Subjects and Methods] The literature was systematically searched on the May 2, 2016 using the following online databases: Medline, EMBASE, CINAHL and PEDro. This review included randomised controlled trials and compared the efficacy of manual therapy for the treatment of cervicogenic dizziness, compared to other types of intervention. This study measured changes based on dizziness intensity and frequency. [Results] The primary search found 30 articles, but only four articles met the inclusion criteria. Assessment of methodological quality was performed by two researchers using the PEDro scale. The level of evidence was determined using a recognised grading scale. Three out of the four articles were deemed to have high methodological quality, while the fourth was rated as moderate quality. The attributed level of evidence was moderate (level 2). [Conclusion] Manual therapy is potentially effective for managing cervicogenic dizziness. However, due to the heterogeneity of the results and techniques and the low number of studies, further research is recommended to provide conclusive evidence.

[Dizziness and vertigo associated with vestibular neuronitis: the approaches to the diagnostics and treatment]

This article is focused on the peculiar features of diagnostics and treatment of dizziness and vertigo in the patients presenting with vestibular neuronitis. The authors present the detailed overview of various theories concerning etiology and pathogenesis of this condition, describe the methods for its clinical and instrumental diagnostics (including its differential diagnostics from other diseases associated with acute dizziness and vertigo). Special attention is given to the methods of pharmacological and physical rehabilitation of the patients suffering from vestibular neuronitis.

Recent surgical options for vestibular vertigo

Vertigo is not a well-defined disease but a symptom that can occur in heterogeneous entities diagnosed and treated mainly by otolaryngologists, neurologists, internal medicine, and primary care physicians. Most vertigo syndromes have a good prognosis and management is predominantly conservative, whereas the need for surgical therapy is rare, but for a subset of patients often the only remaining option. In this paper, we describe and discuss different surgical therapy options for hydropic inner ear diseases, Menière's disease, dehiscence syndromes, perilymph fistulas, and benign paroxysmal positional vertigo. At the end, we shortly introduce the most recent developments in regard to vestibular implants. Surgical therapy is still indicated for vestibular disease in selected patients nowadays when conservative options did not reduce symptoms and patients are still suffering. Success depends on the correct diagnosis and choosing among different procedures the ones going along with an adequate patient selection. With regard to the invasiveness and the possible risks due to surgery, in depth individual counseling is absolutely necessary. Ablative and destructive surgical procedures usually achieve a successful vertigo control, but are associated with a high risk for hearing loss. Therefore, residual hearing has to be included in the decision making process for surgical therapy.

Vertigo and dizziness in adolescents: Risk factors and their population attributable risk

OBJECTIVES

To assess potential risk factors for vertigo and dizziness in adolescents and to evaluate their variability by different vertigo types. The role of possible risk factors for vertigo and dizziness in adolescents and their population relevance needs to be addressed in order to design preventive strategies.

STUDY DESIGN

The study population consisted of 1482 school-children between the age of 12 and 19 years, who were instructed to fill out a questionnaire on different vertigo types and related potential risk factors. The questionnaire specifically asked for any vertigo, spinning vertigo, swaying vertigo, orthostatic dizziness, and unspecified dizziness. Further a wide range of potential risk factors were addressed including gender, stress, muscular pain in the neck and shoulder region, sleep duration, migraine, coffee and alcohol consumption, physical activity and smoking.

RESULTS

Gender, stress, muscular pain in the neck and shoulder region, sleep duration and migraine were identified as independent risk factors following mutual adjustment: The relative risk was 1.17 [1.10-1.25] for female sex, 1.07 [1.02-1.13] for stress, 1.24 [1.17-1.32] for muscular pain, and 1.09 [1.03-1.14] for migraine. The population attributable risk explained by these risk factors was 26%, with muscular pain, stress, and migraine accounting for 11%, 4%, and 3% respectively.

CONCLUSION

Several established risk factors in adults were also identified in adolescents. Risk factors amenable to prevention accounted for 17% of the total population risk. Therefore, interventions targeting these risk factors may be warranted.

Switch to Semont maneuver is no better than repetition of Epley maneuver in treating refractory BPPV

The objectives of this study is to compare the efficacy between repetition of Epley maneuver and switch to alternate Semont maneuver in treating posterior canal benign paroxysmal positional vertigo (PC-BPPV) that does not respond to the initial Epley maneuver. In the nationwide, seven dizziness clinics of Korea, 506 consecutive patients (303 women, age range 22-87, mean age ± SD = 64 ± 12, median = 61) with idiopathic PC-BPPV were initially treated with a single Epley maneuver. Of those, 144 (28.5%) patients, who did not respond to the therapy, were randomized to the repetition of Epley maneuver (n = 70) or switch to Semont maneuver (n = 74). The therapeutic efficacy was determined within 1 h by a blinded examiner after the trial of each second maneuver. The efficacy did not differ between the repetition of Epley maneuver and switch to Semont maneuver groups (38.6 vs. 27.0%, p = 0.14, Chi-square test). However, the patients with a long duration (p < 0.001, linear regression) and latency (p = 0.01) of the positional nystagmus during Dix-Hallpike maneuver showed a higher rate of the initial and second treatment failures. Either Epley or Semont maneuver may be applied as a second treatment to the patients with PC-BPPV refractory to the initial Epley maneuver. This study provides Class I evidence that repeated Epley and switch to Semont maneuver shows a similar efficacy in treating PC-BPPV that does not respond to the initial Epley maneuver.

CLINICAL TRIAL REGISTRATION

NCT01822002.

Ocular Motor Function in Patients with Bilateral Vestibular Weakness

INTRODUCTION

Patients with bilateral weakness (BW) have many difficulties in gaze stability that interfere with their normal function. The aim of this study was to evaluate ocular motor functions in patients with BW to better understand the problem of gaze instability in these patients.

MATERIALS AND METHODS

Patients were referred from the Otolaryngology Department for Vestibular Assessment to our clinic between November 2014 and March 2015. We assessed ocular motor function (gaze, saccade, and smooth pursuit) in patients over the age of 18 years with BW, as verified by a caloric test.

RESULTS

Seventy-eight patients completed all the tests. The mean age of patients was 51.9 (±15.9) years, and 47 (60%) were female. Abnormal results were found in five (6.4%), 32 (41%), and seven (9%) patients with respect to gaze, smooth pursuit, and saccade, respectively. There were positive but relatively weak relationships between age and ocular motor results.

CONCLUSION

Patients with BW suffer from dizziness and unsteadiness. These patients have abnormal function in ocular motor (especially smooth pursuit) tests. The ocular motor dysfunction is responsible for gaze instability in static positions such as standing.

Unilateral peripheral vestibular disorders in the emergency room of the ENT Department of Cluj-Napoca, Romania

Objective

To asses the management of unilateral peripheral vestibular disorders in the emergency room of the ENT Department of Cluj-Napoca, Romania.

Material and method

The study was prospective, non-randomized, and included the patients presented for dizziness or balance disorders at the emergency room of the ENT Department between March 2012 and March 2013. Demographic characteristics, specific clinical history, the onset of peripheral vestibular disorders, and co-morbidities were recorded. The patients charts included the type of onset and the treatment (medical, surgical, and rehabilitation) performed in the emergency room or, in case of hospital admission, the relieving measures for the vestibular symptoms with or without hearing recovery.

Results

One hundred and fifty-two subjects were included in our study, 97 with pure peripheral vestibular dysfunction (VD), 34 with cochlear-vestibular dysfunction (CVD), and 21 with Ménière’s disease (MD). No significant differences were identified when the proportion of patients with a certain onset (acute, subacute or chronic) were compared. Hypertension was the most frequent co-morbidity in all investigated groups. No significant difference was observed when the relief of vertigo or hearing recovery were compared between all groups.

Conclusion

This first Romanian report on the management of unilateral peripheral vestibular disorders showed that early corticosteroids treatment associated with electrolytes, antiemetic, and vasodilation drugs led to the recovery of the vestibular function without any differences between the types of peripheral vestibular dysfunction. In addition, we obtained the complete recovery of the vestibular and acoustic dysfunction in the cases treated with metylprednisolone intratympanic injection.

Effects and safety profile of betahistine in patients in the Russian contingent of OSVaLD, an open-label observational study in vestibular vertigo

BACKGROUND

We report here data from the >200 patients recruited in Russia to take part in OSVaLD, a 12-week, open-label, post-marketing surveillance study of the response to betahistine 48 mg/day in vertigo of peripheral vestibular origin carried out in a total of 13 countries.

METHODS

The primary efficacy endpoint was change in the Dizziness Handicap Inventory (DHI; 100-point scale). Changes in Hospital Anxiety and Depression Scale (HADS) and Medical Outcomes Study Short-Form 36, version 2 (SF-36v2(®)) scores were a priori secondary Outcomes.

RESULTS

Total DHI score improved by 43 points during betahistine treatment. This aggregate improvement was equally distributed across the three domains of the DHI (physical, emotional, and functional; P<0.0001 for main and subscore changes from baseline). Statistically significant improvements versus baseline were also observed in mean HADS scores for anxiety and depression (both P<0.0001), and in the Physical Component Summary and Mental Component Summary scores of the SF-36v2 (both P<0.0001 versus baseline). Only one suspected adverse drug reaction was recorded in the Russian safety population (n=204), indicating that betahistine was well tolerated in those patients.

CONCLUSION

Betahistine 48 mg/day was associated with clear improvements in well-configured and widely validated measures of health-related quality of life and an encouraging tolerability profile in patients in Russia who took part in OSVaLD.

Treatment of Vertigo: A Randomized, Double-Blind Trial Comparing Efficacy and Safety of Ginkgo biloba Extract EGb 761 and Betahistine

A multicenter clinical trial was performed to compare the efficacy and safety of Ginkgo biloba extract EGb 761 and betahistine at recommended doses in patients with vertigo. One hundred and sixty patients (mean age 58 years) were randomly assigned to double-blind treatment with EGb 761 (240 mg per day) or betahistine (32 mg per day) for 12 weeks. An 11-point numeric analogue scale, the Vertigo Symptom Scale—short form, the Clinical Global Impression Scales and the Sheehan Disability Scale were used as outcome measures. Both treatment groups were comparable at baseline and improved in all outcome measures during the course of treatment. There was no significant intergroup difference with regard to changes in any outcome measure. Numerically, improvements of patients receiving EGb 761 were slightly more pronounced on all scales. Clinical global impression was rated “very much improved” or “much improved” in 79% of patients treated with EGb 761 and in 70% receiving betahistine. With 27 adverse events in 19 patients, EGb 761 showed better tolerability than betahistine with 39 adverse events in 31 patients. In conclusion, the two drugs were similarly effective in the treatment of vertigo, but EGb 761 was better tolerated. This trial is registered with controlled-trials.com ISRCTN02262139.

Central vestibular dysfunction in an otorhinolaryngological vestibular unit: incidence and diagnostic strategy

Introduction Vertigo can be due to a variety of central and peripheral causes. The relative incidence of central causes is underestimated. This may have an important impact of the patients' management and prognosis. Objective The objective of this work is to determine the incidence of central vestibular disorders in patients presenting to a vestibular unit in a tertiary referral academic center. It also aims at determining the best strategy to increase the diagnostic yield of the patients' visit. Methods This is a prospective observational study on 100 consecutive patients with symptoms suggestive of vestibular dysfunction. All patients completed a structured questionnaire and received bedside and vestibular examination and neuroimaging as required. Results There were 69 women and 31 men. Their ages ranged between 28 and 73 (mean 42.48 years). Provisional videonystagmography (VNG) results were: 40% benign paroxysmal positional vertigo (BPPV), 23% suspicious of central causes, 18% undiagnosed, 15% Meniere disease, and 4% vestibular neuronitis. Patients with an unclear diagnosis or central features (41) had magnetic resonance imaging (MRI) and Doppler studies. Combining data from history, VNG, and imaging studies, 23 patients (23%) were diagnosed as having a central vestibular lesion (10 with generalized ischemia/vertebra basilar insufficiency, 4 with multiple sclerosis, 4 with migraine vestibulopathy, 4 with phobic postural vertigo, and 1 with hyperventilation-induced nystagmus). Conclusions Combining a careful history with clinical examination, VNG, MRI, and Doppler studies decreases the number of undiagnosed cases and increases the detection of possible central lesions.

The Burden and Impact of Vertigo: Findings from the REVERT Patient Registry

OBJECTIVE

Despite the high prevalence of vertigo globally and an acknowledged, but under-reported, effect on an individual's wellbeing, few studies have evaluated the burden on healthcare systems and society. This study was aimed to quantitatively determine the impact of vertigo on healthcare resource use and work productivity.

METHODS

The economic burden of vertigo was assessed through a multi-country, non-interventional, observational registry of vertigo patients: the Registry to Evaluate the Burden of Disease in Vertigo. Patients included were those with a new diagnosis of Meniere's disease, benign paroxysmal positional vertigo, other vertigo of peripheral vestibular origin, or peripheral vestibular vertigo of unknown origin.

RESULTS

A total of 4,294 patients at 618 centers in 13 countries were included during the registry. Of the 4,105 patients analyzed, only half were in employment. Among this working patient population, 69.8% had reduced their workload, 63.3% had lost working days, and 4.6% had changed and 5.7% had quit their jobs, due to vertigo symptoms. Use of healthcare services among patients was high. In the 3 months preceding Visit 1, patients used emergency services 0.4 ± 0.9 times, primary care consultations 1.6 ± 1.8 times, and specialist consultations 1.4 ± 2.0 times (all mean ± SD). A mean of 2.0 ± 5.4 days/patient was also spent in hospital due to vertigo.

CONCLUSION

In addition to the negative impact on the patient from a humanistic perspective, vertigo has considerable impact on work productivity and healthcare resource use.

The treatment and natural course of peripheral and central vertigo

BACKGROUND

Recent studies have extended our understanding of the pathophysiology, natural course, and treatment of vestibular vertigo. The relative frequency of the different forms is as follows: benign paroxysmal positional vertigo (BPPV) 17.1%; phobic vestibular vertigo 15%; central vestibular syndromes 12.3%; vestibular migraine 11.4%; Menière's disease 10.1%; vestibular neuritis 8.3%; bilateral vestibulopathy 7.1%; vestibular paroxysmia 3.7%.

METHODS

Selective literature survey with particular regard to Cochrane reviews and the guidelines of the German Neurological Society.

RESULTS

In more than 95% of cases BPPV can be successfully treated by means of liberatory maneuvers (controlled studies); the long-term recurrence rate is 50%. Corticosteroids improve recovery from acute vestibular neuritis (one controlled, several noncontrolled studies); the risk of recurrence is 2-12%. A newly identified subtype of bilateral vestibulopathy, termed cerebellar ataxia, neuropathy, and vestibular areflexia syndrome (CANVAS), shows no essential improvement in the long term. Long-term high-dose treatment with betahistine is probably effective against Menière's disease (noncontrolled studies); the frequency of episodes decreases spontaneously in the course of time (> 5 years). The treatment of choice for vestibular paroxysmia is carbamazepine (noncontrolled study). Aminopyridine, chlorzoxazone, and acetyl-DL-leucine are new treatment options for various cerebellar diseases.

CONCLUSION

Most vestibular syndromes can be treated successfully. The efficacy of treatments for Menière's disease, vestibular paroxysmia, and vestibular migraine requires further research.

Persistent benign paroxysmal positional vertigo: our experience and proposal for an alternative treatment

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Despite the great efficacy of canalith repositioning procedures (CRPs), BPPV may persist (PBPPV). The aim of the study was to evaluate whether a prolonged and self-assessed temporal bone vibration (TBV) could change the outcome of PBPPV after 12 months of repeated treatments, in order to avoid further invasive and/or drug therapies. This evaluation was also conducted with respect to the entire BPPV population treated with CRPs. Seventy-two patients affected by PBPPV were enrolled in the study: 51 and 21 of them suffering from posterior semicircular canal (PSC) and lateral semicircular canal (LSC), respectively. PBPPV patients underwent a twice-a-day self-assessed TBV, using a common low-intensity massaging cushion. Patients were re-tested 1 week later and they were considered free from disease as the results of the positioning tests continued to be negative after 1 month. 70.6 % of PSC PBPPV and 61.9 % of LSC PBPPV patients had positive and statistically significant (P < 0.01) outcomes not biased by "age" and "gender" variables. The recurrence rate of BPPV (RBPPV) was also studied in the BPPV and PBPPV groups after a 12/24-month follow-up and any statistically significant result was found in multiple regression analysis between nuisance variables and RBPPV patients previously treated by CRPs or TBV. The present study suggests that the self-assessed and prolonged TBV could be an alternative treatment in patients affected by PBPPV otherwise addressed to undergo more invasive procedures and pharmacological treatment that are not completely side effects free.

Clinical and Demographic Features of Vertigo: Findings from the REVERT Registry

Introduction: Despite being a common disease, data on vertigo management in a real-world setting are scarce.

Aims: To provide information on the vertigo and its management in a real-world setting.

Methods: Data were collected from 4,294 patients with vertigo in 13 countries over 28 months via a multi-national, non-interventional observational study (the so-called REVERT registry). Data included medical history and details of anti-vertigo therapy. “Clinical global impression” (CGI) of severity (CGI-S) was assessed at baseline (V1) and then at 6 months follow-up (V2) along with CGI change (CGI-C). All variables were analyzed descriptively.

Results: The majority of patients were female, >40 years of age, and almost half had co-morbid cardio-vascular disease. Diagnoses were split into four categories: 37.2% “other vertigo of peripheral vestibular origin,” 26.9% benign paroxysmal positional vertigo (BPPV), 20.5% “peripheral vestibular vertigo of unknown origin,” and 15.4% Ménière’s disease (MD). Betahistine was the most commonly prescribed therapy prior to and after enrollment, and was followed by piracetam, ginkgo biloba, and diuretics. MD had the highest proportion of betahistine treated patients. Almost half of patients were “moderately ill” at V1 based on CGI-S. At V2, patient distribution moved toward “less severe illness” (91.0% improved). The greatest improvements were in the more severely ill, and those with BPPV or “other vertigo of peripheral origin.”

Conclusion: There was a reduction in illness severity over the course of the study, some of which is likely to be due to pharmacological intervention. Further studies are needed to confirm these results.

[Diagnosis of vertigo: keep an eye on central eye movement disorders]

With specialist knowledge ophthalmologists can make a valuable contribution to the interdisciplinary work-up of patients with vertigo as the leading symptom. The neuro-ophthalmological examination of eye movements by an ophthalmologist and/or orthoptist is an important contribution because the various vertigo syndromes can only be correctly evaluated by a combined examination of the vestibular and ocular motor systems. If the ophthalmologist is the first doctor to examine a patient suspected disorders from other specialist fields can be indicated, in particular neurology and otorhinolaryngology. When taking the patient history the ophthalmologist should inquire about the type and duration of the vertigo, triggering or modifying factors and accompanying symptoms. This is followed by a systematic examination of the eye position and the different types of eye movements, the head-impulse test and a special examination to check for the presence of nystagmus.

Referral and final diagnoses of patients assessed in an academic vertigo center

Objective: To identify under-diagnosed neuro-otological disorders and to evaluate whether under-diagnosing depends on the age of the patient. Materials and methods: Retrospective analysis of medical charts from 951 consecutive patients (685 under and 266 above the age of 65 years) who entered diagnostic procedures at the Interdisciplinary Center for Vertigo and Balance Disorders, University Hospital Zurich, Switzerland. Final diagnoses were compared to referral diagnoses. Results: Relative to referral diagnoses, the proportion of patients finally diagnosed with benign paroxysmal positional vertigo (BPPV) almost doubled both in younger (<65 year from 12.7 to 25.1%) and older patients (from 20.7 to 37.6%). Striking relative increases were found for the diagnoses multisensory dizziness in older patients (from 20.7 to 37.6%) and vestibular migraine in younger patients (1.8 to 20.2%). In both age groups, the proportion of patients with undetermined diagnoses was reduced by about 60% (younger: 69.8 to 9.8%; older: 69.2 to 12.4%) by the diagnostic procedures in the vertigo center. These changes were all significant (p < 0.05) in McNemar tests with continuity correction (2 × 2 tables: focused diagnosis vs. other diagnoses, referral vs. final). Conclusion: Significant changes of diagnoses can be expected by a specialized neuro-otological work-up. In particular, BPPV, multisensory dizziness, and vestibular migraine are under-diagnosed by referring physicians. This finding calls for better education of primary care takers in the field of neuro-otology.

A Third Labyrinthine Window: An Overview of Perilymph and Labyrinthine Fistulae and Superior Semicircular Canal Dehiscence

The membranous labyrinth is contained within the bony labyrinth and surrounded by perilymph. The only two ‘potentially yielding’ parts of the otherwise solid bony labyrinth are the oval and round windows, which by their relative movements, pressure differentials and resilience are responsible for all the functions attributed to the inner ear. In pathologies, such as trauma, infection or occasionally congenital dehiscence, there may develop a ‘third window’ that may serve as an abnormal communication for the inner ear fluids and manifest with audiovestibular symptoms. Three such distinct entities have been identified, namely ‘superior semicircular canal dehiscence syndrome, perilymphatic fistulae and labyrinthine fistulae’. This overview intends to discuss these above-mentioned entities, as regards their characteristic presentations and principles of management.

How to cite this article

Hathiram BT, Khattar VS. A Third Labyrinthine Window: An Overview of Perilymph and Labyrinthine Fistulae and Superior Semicircular Canal Dehiscence. Otorhinolaryngol Clin Int J 2012;4(2):100-105.

Central oculomotor disturbances and nystagmus: a window into the brainstem and cerebellum

BACKGROUND

Oculomotor disturbances and nystagmus are seen in many diseases of the nervous system, the vestibular apparatus, and the eyes, as well as in toxic and metabolic disorders. They often indicate a specific underlying cause. The key to diagnosis is systematic clinical examination of the patient's eye movements. This review deals mainly with central oculomotor disturbances, i.e., those involving smooth pursuit, saccades, gaze-holding, and central types of nystagmus.

METHODS

We searched the current literature for relevant publications on the diagnosis and treatment of oculomotor disturbances and nystagmus, and discuss them selectively in this review along with the German Neurological Society's guidelines on the topic.

RESULTS

A detailed knowledge of the anatomy and physiology of eye movements usually enables the physician to localize the disturbance to a specific area in the brainstem or cerebellum. The examination of eye movements is an even more sensitive method than magnetic resonance imaging for the diagnosis of acute vestibular syndromes and for the differentiation of peripheral from central lesions. For example, isolated dysfunction of horizontal saccades is due to a pontine lesion, while isolated dysfunction of vertical saccades is due to a midbrain lesion. Generalized gaze-evoked nystagmus (GEN) has multiple causes; purely vertical GEN is due to a midbrain lesion, while purely horizontal GEN is due to a pontomedullary lesion. Internuclear ophthalmoplegia involves a constellation of findings, the most prominent of which is impaired adduction to the side of the causative lesion in the ipsilateral medial longitudinal fasciculus. The most common pathological types of central nystagmus are downbeat and upbeat nystagmus (DBN, UBN). DBN is generally due to cerebellar dysfunction, e.g., because of a neurodegenerative disease.

CONCLUSION

This short review focuses on the clinical characteristics, pathophysiology and current treatment of oculomotor disorders and nystagmus.

Diagnostic indices for vertiginous diseases

Background

Vertigo and dizziness are symptoms which are reported frequently in clinical practice. We aimed to develop diagnostic indices for four prevalent vertiginous diseases: benign paroxysmal positional vertigo (BPPV), Menière's disease (MD), vestibular migraine (VM), and phobic postural vertigo (PPV).

Methods

Based on a detailed questionnaire handed out to consecutive patients presenting for the first time in our dizziness clinic we preselected a set of seven questions with desirable diagnostic properties when compared with the final diagnosis after medical workup. Using exact logistic regression analysis diagnostic scores, each comprising of four to six items that can simply be added up, were built for each of the four diagnoses.

Results

Of 193 patients 131 questionnaires were left after excluding those with missing consent or data. Applying the suggested cut-off points, sensitivity and specificity were 87.5 and 93.5% for BPPV, 100 and 87.4% for MD, 92.3 and 83.7% for VM, 73.7 and 84.1% for PPV, respectively. By changing the cut-off points sensitivity and specificity can be adjusted to meet diagnostic needs.

Conclusions

The diagnostic indices showed promising diagnostic properties. Once further validated, they could provide an ease to use and yet flexible tool for screening vertigo in clinical practice and epidemiological research.

Gait disturbances in old age: classification, diagnosis, and treatment from a neurological perspective

BACKGROUND

Gait disturbances are among the more common symptoms in the elderly. Reduced mobility markedly impairs quality of life, and the associated falls increase morbidity and mortality.

METHODS

Review of the literature based on a selective search (PubMed) on the terms "gait," "gait disorder," "locomotion," "elderly," "geriatric" and "ageing" (2000-11/2009) and the findings of the authors' own studies on gait changes in old age and on the functional brain imaging of gait control.

RESULTS

Gait disturbances in the elderly are often of multifactorial origin. The relevant pathogenetic factors include sensory deficits (visual, vestibular, somatosensory), neurodegenerative processes (cortical, extrapyramidal motor, cerebellar), toxic factors (medications, alcohol), and anxiety (primary or concerning falls). A clinically oriented classification of gait disorders is proposed, which, on the basis of the characterization of gait and the accompanying clinical findings, enables identification of the etiological factors and points the way to rational therapy. Current research topics in the study of gait disturbances are also discussed, including quantitative gait analysis, interactions between locomotion and cognition (dual tasking), and functional imaging approaches.

CONCLUSIONS

The evaluation of elderly patients whose chief complaint is a gait disturbance should be directed toward the identification of specific deficits. This is the prerequisite for rational therapy, even when the problem is of multifactorial origin. The preservation of mobility is important in itself, and also because the ability to walk is closely correlated with cognitive performance.