Phenotypes and clinical subgroups in vestibular migraine: a cross-sectional study with cluster analysis

OBJECTIVE

The aim of this multicentric cross-sectional study was to collect phenotypes and clinical variability on a large sample of 244 patients enrolled in different university centers in Italy, trying to differentiate subtypes of VM.

BACKGROUND

VM is one of the most frequent episodic vertigo characterized by a great clinical variability for duration of attacks and accompanying symptoms. Diagnosis is based only on clinical history of episodic vertigo in 50% of cases associated with migrainous headache or photo/phonophobia.

METHODS

We enrolled in different university centers 244 patients affected by definite VM according to the criteria of the Barany Society between January 2022 and December 2022. An audiometric examination and a CNS MRI were performed before inclusion. Patients with low-frequency sensorineural hearing loss were not included, as well as patients with an MRI positive otherwise that for microischemic lesions. Patients were asked to characterize vestibular symptoms choosing among (multiple answers were allowed): internal vertigo, dizziness, visuo-vestibular symptoms/external vertigo; onset of vertigo and duration, neurovegetative, and cochlear accompanying symptoms (hearing loss, tinnitus, and fullness during attacks) were collected as well as migrainous headache and/or photo/phonophobia during vertigo; autoimmune disorders were also analyzed. A bedside examination was performed including study of spontaneous-positional nystagmus with infrared video goggles, post head shaking ny, skull vibration test, and video head impulse test.

RESULTS

We included 244 subjects, 181 were females (74.2%). The age of onset of the first vertigo was 36.6 ± 14.5 while of the first headache was 23.2 ± 10.1. A positive correlation has been found between the first headache and the first vertigo. The mean duration of vertigo attacks was 11 ± 16 h. We carried on a cluster analysis to identify subgroups of patients with common clinical features. Four variables allowed to aggregate clusters: age of onset of vertigo, duration of vertigo attacks, presence of migrainous headache during vertigo, and presence of cochlear symptoms during vertigo. We identified 5 clusters: cluster 1/group 1 (23 subjects, 9.4%) characterized by longer duration of vertigo attacks; cluster 2/group 2 (52 subjects, 21.3%) characterized by absence of migrainous headache and cochlear symptoms during vertigo; cluster 3/group 3 (44 subjects, 18%) characterized by presence of cochlear symptoms during vertigo but not headache; cluster 4/group 4 (57 subjects, 23.4%) by the presence of both cochlear symptoms and migrainous headache during vertigo; cluster 5/group 5 (68 subjects, 27.9%) characterized by migrainous headache but no cochlear symptoms during vertigo.

CONCLUSION

VM is with any evidence a heterogeneous disorder and clinical presentations exhibit a great variability. In VM, both symptoms orienting toward a peripheral mechanism (cochlear symptoms) and central ones (long lasting positional non-paroxysmal vertigo) may coexist. Our study is the first published trying to characterize subgroups of VM subjects, thus orienting toward different pathophysiological mechanisms.

Cochleo-Vestibular Disorders in Herpes Zoster Oticus: A Literature Review and a Case of Bilateral Vestibular Hypofunction in Unilateral HZO

The varicella-zoster virus (VZV), a member of the Herpesviridae family, causes both the initial varicella infection and subsequent zoster episodes. Disorders of the eighth cranial nerve are common in people with herpes zoster oticus (HZO). We performed a review of the literature on different databases including PubMed and SCOPUS, focusing on cochlear and vestibular symptoms; 38 studies were considered in our review. A high percentage of cases of HZO provokes cochlear and vestibular symptoms, hearing loss and vertigo, whose onset is normally preceded by vesicles on the external ear. It is still under debate if the sites of damage are the inferior/superior vestibular nerves and cochlear nerves or a direct localization of the infection in the inner ear. The involvement of other contiguous cranial nerves has also been reported in a few cases. We report the case of a patient with single-side HZO presenting clinical manifestations of cochleo-vestibular damage without neurological and meningeal signs; after 15 days, the patient developed a new episode of vertigo with clinical findings of acute contralateral vestibular loss. To our knowledge, only three other such cases have been published. An autoimmune etiology may be considered to explain these findings.

Phenotypes, bedside examination, and video head impulse test in vestibular migraine of childhood compared with probable vestibular migraine and recurrent vertigo in childhood

Introduction

Vestibular impairment and vertigo in the pediatric population have an estimated prevalence ranging between 0.4% and 5.6% and are a topic of interest in recent years. The Bárány Society has recently reclassified migraine-related vertigo syndromes as vestibular migraine of childhood (VMC), probable vestibular migraine of childhood (probable VMC), and recurrent vertigo of childhood (RVC).

Methods

Applying the criteria established by the Bárány Society, we retrospectively analyzed data on 95 pediatric patients suffering from episodic vertigo that were recruited from 2018 to 2022. In applying the revised criteria, 28 patients had VMC, 38 had probable VMC, and 29 had RVC.

Results

Visuo-vestibular symptoms (external vertigo) or internal vertigo were reported by 20 of 28 VMC patients (71.4%) compared to 8 of 38 probable VMC patients (21%) (P < .001). None of the RVC patients reported external vertigo. Duration of vertigo was demonstrably longer in the VMC patients than in the probable VMC (P < .001) and RVC (P < .001) patients. Cochlear symptoms were reported by 28.6% of VMC patients and by 13.1% of probable VMC patients. No cochlear symptoms were reported by any RVC patients. Familial cases for headache and episodic vertigo showed no significant difference between groups.

Discussion

The most frequent finding during bedside examination in all three groups was central positional nystagmus. Differences in the duration of attacks and in accompanying symptoms may underline different pathophysiological mechanisms.

Similarities and Differences between Vestibular Migraine and Recurrent Vestibular Symptoms-Not Otherwise Specified (RVS-NOS)

Menière's disease and vestibular migraine (VM) are two common inner ear disorders whose diagnoses are based on clinical history and audiometric exams. In some cases, patients have been reporting different episodes of vertigo for years but not fulfilling the Bárány Society criteria for either. These are called Recurrent Vestibular Symptoms-Not Otherwise Specified (RVS-NOS). It is still under debate if this is a single disease entity or a part of the spectrum of already established disorders. The purpose of our work was to establish similarities and differences with VM in terms of clinical history, bedside examination, and family history. We enrolled 28 patients with RVS-NOS who were followed for at least 3 years with stable diagnosis; results were compared with those of 34 subjects having a diagnosis of definite VM. The age of onset of vertigo was lower in VM than in RVS-NOS (31.2 vs. 38.4 years). As for the duration of attacks and symptoms, we detected no differences other than subjects with RVS-NOS reporting milder attacks. Cochlear accompanying symptoms were more frequently reported by VM subjects (one subject reporting tinnitus and another one reported tinnitus and fullness). Motion sickness was equally reported by subjects across two samples (around 50% for both). Bipositional long-lasting, non-paroxysmal nystagmus was the most common finding in the two groups, with no significant difference. Finally, the percentage of familial cases of migrainous headache and episodic vertigo did not differ between the two samples. In conclusion, RVS-NOS shares some common aspects with VM, including the temporal profile of attacks, motion sickness (commonly considered a migraine precursor), bedside examination, and family history. Our results are not inconsistent with the possibility that RVS-NOS may be a heterogeneous disorder, even if some of these subjects may share common pathophysiological mechanisms with VM.

Balance Rehabilitation with Peripheral Visual Stimulation in Patients with Panic Disorder and Agoraphobia: An Open-Pilot Intervention Study

Given the involvement of balance system abnormalities in the pathophysiology of panic disorder and agoraphobia (PD-AG), we evaluated initial evidence for feasibility, acceptability, and potential clinical usefulness of 10 sessions of balance rehabilitation with peripheral visual stimulation (BR-PVS) in an open-pilot 5-week intervention study including six outpatients with PD-AG who presented residual agoraphobia after selective serotonin reuptake inhibitor (SSRI) treatment and cognitive-behavioral therapy, dizziness in daily life, and peripheral visual hypersensitivity measured by posturography. Before and after BR-PVS, patients underwent posturography, otovestibular examination (no patients presented peripheral vestibular abnormalities), and panic-agoraphobic symptom and dizziness evaluation with psychometric tools. After BR-PVS, four patients achieved postural control normalization measured by posturography, and one patient exhibited a favorable trend of improvement. Overall, panic-agoraphobic symptoms and dizziness decreased, even though to a lesser extent in one patient who had not completed the rehabilitation sessions. The study presented reasonable levels of feasibility and acceptability. These findings suggest that balance evaluation should be considered in patients with PD-AGO presenting residual agoraphobia and that BR-PVS might be an adjunctive therapeutic option worth being tested in larger randomized controlled studies.

Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit

Vestibular migraine (VM) is an increasingly recognized pathology yet remains as an underdiagnosed cause of vestibular disorders. While current diagnostic criteria are codified in the 2012 Barany Society document and included in the third edition of the international classification of headache disorders, the pathophysiology of this disorder is still elusive. The Association for Migraine Disorders hosted a multidisciplinary, international expert workshop in October 2020 and identified seven current care gaps that the scientific community needs to resolve, including a better understanding of the range of symptoms and phenotypes of VM, the lack of a diagnostic marker, a better understanding of pathophysiologic mechanisms, as well as the lack of clear recommendations for interventions (nonpharmacologic and pharmacologic) and finally, the need for specific outcome measures that will guide clinicians as well as research into the efficacy of interventions. The expert group issued several recommendations to address those areas including establishing a global VM registry, creating an improved diagnostic algorithm using available vestibular tests as well as others that are in development, conducting appropriate trials of high quality to validate current clinically available treatment and fostering collaborative efforts to elucidate the pathophysiologic mechanisms underlying VM, specifically the role of the trigemino-vascular pathways.

Recurrence of benign paroxysmal positional vertigo: experience in 3042 patients

OBJECTIVES

Benign paroxysmal positional vertigo (BPPV) is a disorder of the inner ear with a high rate of recurrence. Vascular disorders, migraine and autoimmune disorders have been considered facilitating factors for relapsing episodes. Our aim was to assess the role of vascular disorders, migraine and anti-thyroid antibodies in patients with recurrences.

METHODS

We retrospectively analysed records of 3042 patients treated for BPPV without other lifetime vertigo. Clinical data included previous vascular disorders of the central nervous system, heart disorders, migraine and recent head trauma. The presence of anti-thyroid autoantibodies was assessed in all patients.

RESULTS

Mean age of the first BPPV was 52.8 ± 14.5 years; there were 2339 females (76.9%), while 2048 (67.3%) of patients presented recurrences within two years of follow-up. Previous disorders of the central nervous system, presence of anti-thyroid antibodies, head trauma and migraine showed an association with recurrences. Above all, in subjects having the first BPPV while aged between 40 and 60 years, anti-thyroid antibodies were predictive for recurrences.

CONCLUSIONS

Our data are consistent with the hypothesis that anti-thyroid autoantibodies may play a role in recurrences in subjects with initial manifestations between 40 and 60 years.

Evaluation of a large cohort of adult patients with Ménière's disease: bedside and clinical history

Objective

The purpose of this study was to assess vestibular findings and clinical history in a large cohort of patients affected by Ménière’s disease.

Methods

We retrospectively analysed 511 adult patients fulfilling criteria for definite unilateral Ménière’s disease according to Barany Society. Thorough clinical history, audiometric exam, central nervous system MRI, quantification of serum autoantibodies and complete vestibular function test were performed.

Results

Mean age at clinical record was 55.4 years, while age at onset of the first vertigo attack was 47.4 ± 14.3 years. Ménière’s disease overlapped with migraine in 43.4% of patients. In 31.7% of cases, positivity was found for at least one autoantibody. Forty-nine patients (9.6%) had family history for Ménière’s disease. Bedside examination resulted in 14.7% positivity for video head impulse test, 58.9% for skull vibration-induced nystagmus, 38.7% for the positional test and 23.1% for the post head shaking test. Complete negative examination was reported in 115 cases.

Conclusions

Ménière’s disease was seen to present a characteristic phenotypic pattern in our cohort, confirming the crucial role of thorough anamnesis and bedside examination in diagnosis.

Recurrent Vestibular Symptoms Not Otherwise Specified: Clinical Characteristics Compared With Vestibular Migraine and Menière's Disease

Despite the huge progress in the definition and classification of vestibular disorders within the last decade, there are still patients whose recurrent vestibular symptoms cannot be attributed to any of the recognized episodic vestibular syndromes, such as Menière's disease (MD), vestibular migraine (VM), benign paroxysmal positional vertigo (BPPV), vestibular paroxysmia, orthostatic vertigo or transient ischemic attack (TIA). The aim of the present international, multi-center, cross-sectional study was to systematically characterize the clinical picture of recurrent vestibular symptoms not otherwise specified (RVS-NOS) and to compare it to MD and VM. Thirty-five patients with RVS-NOS, 150 patients with VM or probable VM and 119 patients with MD were included in the study. The symptoms of RVS-NOS had been present for 5.4 years on average before inclusion, similar to VM and MD in this study, suggesting that RVS-NOS is not a transitory state before converting into another diagnosis. Overall, the profile of RVS-NOS vestibular symptoms was more similar to VM than MD. In particular, the spectrum of vestibular symptom types was larger in VM and RVS-NOS than in MD, both at group comparison and the individual level. However, in contrast to VM, no female preponderance was observed for RVS-NOS. Positional, head-motion and orthostatic vertigo were reported more frequently by patients with RVS-NOS than MD, while external vertigo was more prevalent in the MD group. At group level, the spectrum of attack durations from minutes to 3 days was evenly distributed for VM, while a small peak for short and long attacks in RVS-NOS and a big single peak of hours in MD were discernible. In general, vertigo attacks and associated vegetative symptoms (nausea and vomiting) were milder in RVS-NOS than in the other two disorders. Some patients with RVS-NOS described accompanying auditory symptoms (tinnitus: 2.9%, aural fullness and hearing loss: 5.7% each), migrainous symptoms (photophobia, phonophobia or visual aura in 5.7% each) or non-migrainous headaches (14%), but did not fulfill the diagnostic criteria for MD or VM. Absence of a life time diagnosis of migraine headache and attack duration of <5 min were further reasons not to qualify for VM. In some RVS-NOS patients with accompanying ear symptoms, attack durations of <20 min excluded them from being diagnosed with MD. These findings suggest that RVS-NOS is a stable diagnosis over time whose overall clinical presentation is more similar to VM than to MD. It is more likely to be composed of several disorders including a spectrum of mild or incomplete variants of known vestibular disorders, such as VM and MD, rather than a single disease entity with distinct pathognomonic features.

Vertigo without cochlear symptoms: vestibular migraine or Menière disease?

BACKGROUND

Menière's disease (MD) is an inner ear disorder due to raised endolymphatic pressure (hydrops), characterized by cochlear symptoms associated with episodic vertigo. In delayed hydrops, vertigo attacks begin long after the onset of a hearing loss. Few were published on MD in which the onset of vertigo precedes cochlear symptoms by several months. Vestibular migraine (VM) is also a cause of episodic vertigo and an association between migraine and MD was proposed. Purpose of our retrospective work was to assess clinical features associated with MD in which vertigo precedes by months cochlear symptoms.

METHODS

Our sample was composed by 28 subjects reporting episodic vertigo accompanied by migrainous headache or photo-phonophobia, without cochlear symptoms at onset; during follow-up, all patients developed cochlear symptoms leading to a diagnosis of MD. Results of bedside examination were compared with those of 48 VM subjects with diagnosis of VM confirmed in the follow-up. All subjects performed a bedside examination, including head-shaking, positional, and skull vibration test (SVIN).

RESULTS

SVIN was more frequent in MD, while positive positional test in VM. In the entire group of 72 subjects, migrainous headache during vertigo and positive positional test were correlated with a final diagnosis of VM.

CONCLUSIONS

Our data are not inconsistent with the hypothesis that in patients reporting only photo-phonophobia during vertigo attacks and with a positive SVIN, the clinical manifestations may be predictive for evolution toward a MD, while migrainous headache and positive positional tests more frequently are correlated to VM.

Alexithymia in Patients with Ménière Disease: A Possible Role on Anxiety and Depression

The aim of this paper was to investigate the role of the psychological variable of alexithymia both as a risk factor for the development of Ménière’s disease (MD) and as a component that influences the personal experience of MD and the individual quality of life. We collected data from 179 Italian patients who fulfilled criteria for definite MD. Patients filled out validated self-rating questionnaires to assess alexithymia (TAS-20), quality of life (WHOQOL-BREF), anxiety and depression (HADS), perception of stress (PSS) and coping strategies (COPE). Socio-demographic data and MD clinical features were collected using a specific rating form. Subjects affected by MD showed higher levels of alexithymia compared to general population. Among MD patients, those characterized by high levels of alexithymia revealed a significant increase in anxiety and depression, greater perceived stress, a lower quality of life in psychological health and social relationships domains and the use of less mature coping strategies in comparison with MD patients with low or absent alexithymia. Our preliminary data could help in hypothesizing a role of psychological functioning in MD development and in the adaptation to the disease. The presence of alexithymia in patients suffering from MD may constitute a risk factor for the development of anxiety and depression symptoms; greater perceived stress and for poorer psychological and relational quality of life. Therefore, our study design did not allow causal inferences and further studies are needed.

Could ionic regulation disorders explain the overlap between meniere's disease and migraine?

Ménière's disease (MD) is an inner ear disorder characterized by a burden of symptoms and comorbidities, including migraine. In both disorders, ionic dysregulation may play a role as a predisposing factor. In recent years. aquaporins have been widely investigated, but the results are far from conclusive. We recently studied the genetics of ionic transporters and the hormone endogenous ouabain as predisposing factors for development of MD. In particular, we found two genetic polymorphisms associated with MD: 1) rs3746951, a missense variant (Gly180Ser) in the salt-inducible kinase-1 (SIK1) gene encoding a Na+, K+ ATPase; 2) rs487119, an intronic variant of gene SLC8A1 coding for a Na+, Ca++ exchanger (NCX-1). Ionic concentration in the brain also plays a role in the pathophysiology of migraine. In this brief review we summarize what has been published on MD and migraine.

Subdiagnosis, but not presence of vestibular symptoms, predicts balance impairment in migraine patients - a cross sectional study

Background

Vestibular symptoms and balance changes are common in patients with migraine, especially in the ones with aura and chronic migraine. However, it is not known if the balance changes are determined by the presence of vestibular symptoms or migraine subdiagnosis. Therefore, the aim of this study was to verify if the migraine subdiagnosis and/or the presence of vestibular symptoms can predict balance dysfunction in migraineurs.

Methods

The study included 49 women diagnosed with migraine with aura, 53 without aura, 51 with chronic migraine, and 54 headache-free women. All participants answered a structured questionnaire regarding migraine features and presence of vestibular symptoms, such as dizziness/vertigo. The participants performed the Modified Sensory Organization Test on an AMTI© force plate. The data were analysed using a linear mixed-effect regression model.

Results

The presence of vestibular symptoms did not predict postural sway, but the subdiagnosis was a significant predictor of postural sway. Migraine with aura patients exhibited more sway than migraine patients without aura when the surface was unstable. Additionally, we found high effect sizes (ES > 0.79) for postural sway differences between patients with chronic migraine or with aura compared to controls or migraine without aura, suggesting that these results are clinically relevant.

Conclusions

The subdiagnosis of migraine, instead of the presence of vestibular symptoms, can predict postural control impairments observed in migraineurs. This lends support to the notion that balance instability is related to the presence of aura and migraine chronicity, and that it should be considered even in patients without vestibular symptoms.

Approach to residual dizziness after successfully treated benign paroxysmal positional vertigo: effect of a polyphenol compound supplementation

Purpose

To assess if a polyphenol compound supplementation (Vertigoval^®) could improve residual dizziness earlier after benign paroxysmal positional vertigo (BPPV) and relieve patients from this disabling symptomatology.

Methods

In this prospective, multicentric study, 127 patients were randomized in the treatment group (TG), who received a 60-day supplementation, while 131 patients were randomized in the control group (CG), who did not receive any medication. The dizziness handicap inventory (DHI) score, static posturography, and the visual analog scale (VAS) for both dizziness (D-VAS) and nausea/vomit (N/V-VAS) were used as measures of outcome at baseline and after 30 and 60 days. Patients were asked about efficacy and tolerance to the treatment. Side effects were examined.

Results

A statistically significant greater decrease was established in the TG for DHI, D-VAS, and N/V-VAS compared to the CG. On the other hand, static posturography did not show statistical differences between the two groups, though a better clinical improvement after 60-day supplementation was shown in the TG in comparison to the CG. We counted mild side effects in only 2 patients. Most patients reported an excellent or good efficacy and tolerance to the treatment.

Conclusion

Residual dizziness is a frequent condition of unknown origin that manifests as persistent disabling imbalance after successful repositioning maneuvers for BPPV. The decreasing postural control can affect the quality of life, contributing to falling and psychological problems. The supplementation with the polyphenol compound used in our study is safe, manageable, and appeared to be able to reduce subjective symptoms and improve instability earlier, decreasing the risk of potential complications.

Clinical Features of Headache in Patients With Diagnosis of Definite Vestibular Migraine: The VM-Phenotypes Projects

Migraine is a common neurological disorder characterized by episodic headaches with specific features, presenting familial aggregation. Migraine is associated with episodic vertigo, named Vestibular Migraine (VM) whose diagnosis mainly rely on clinical history showing a temporary association of symptoms. Some patient refers symptoms occurring in pediatric age, defined "episodic symptoms which may be associated with migraine." The aim of this cross sectional observational study was to assess migraine-related clinical features in VM subjects. For the purpose, 279 patients were recruited in different centers in Europe; data were collected by a senior neurologist or ENT specialist through a structured questionnaire. The age of onset of migraine was 21.8 ± 9. The duration of headaches was lower than 24 h in 79.1% of cases. Symptoms accompanying migrainous headaches were, in order of frequency, nausea (79.9%), phonophobia (54.5%), photophobia (53.8%), vomiting (29%), lightheadedness (21.1%). Visual or other auras were reported by 25.4% of subjects. A familial aggregation was referred by 67.4%, while migraine precursors were reported by 52.3% of subjects. Patients reporting nausea and vomiting during headaches more frequently experienced the same symptoms during vertigo. Comparing our results in VM subjects with previously published papers in migraine sufferers, our patients presented a lower duration of headaches and a higher rate of familial aggregation; moreover some common characters were observed in headache and vertigo attacks for accompanying symptoms like nausea and vomiting and clustering of attacks.

Point prevalence of vertigo and dizziness in a sample of 2672 subjects and correlation with headaches

Vertigo and dizziness are common symptoms in the general population, with an estimated prevalence between 20% and 56%. The aim of our work was to assess the point prevalence of these symptoms in a population of 2672 subjects. Patients were asked to answer a questionnaire; in the first part they were asked about demographic data and previous vertigo and or dizziness. Mean age of the sample was 48.3 ± 15 years, and 46.7% were males. A total of 1077 (40.3%) subjects referred vertigo/dizziness during their lifetime, and the mean age of the first vertigo attack was 39.2 ± 15.4 years; in the second part they were asked about the characteristics of vertigo (age of first episode, rotational vertigo, relapsing episodes, positional exacerbation, presence of cochlear symptoms) and lifetime presence of moderate to severe headache and its clinical features (hemicranial, pulsatile, associated with phono and photophobia, worse on effort). An age and sex effect was demonstrated, with symptoms 4.4 times more elevated in females and 1.8 times in people over 50 years. In the total sample of 2672 responders, 13.7% referred a sensation of spinning, 26.3% relapsing episodes, 12.9% positional exacerbation and 4.8% cochlear symptoms; 34.8% referred headache during their lifetime. Subjects suffering from headache presented an increased rate of relapsing episodes, positional exacerbation, cochlear symptoms and a lower age of occurrence of the first vertigo/dizziness episode. In the discussion, our data are compared with those of previous studies, and we underline the relationship between vertigo/dizziness from one side and headache with migrainous features on the other.

Decrease of Horizontal Canal Vestibulo-Oculomotor Reflex Gain in the Elderly with Dysequilibrium without Lifetime Vertigo

BACKGROUND/AIMS

Unsteadiness in the elderly is a frequent complaint and a strong predictor of falls and psychological distress. Although there is a general consensus that it is a multifactorial condition, recent studies have focused on the role of aging of the vestibular system as a possible cofactor. The aim of our work was to assess horizontal canal function in the elderly.

METHODS

We evaluated the gain of horizontal vestibulo-ocular reflex (VOR) with a video head impulse test on a sample of 58 subjects aged >70 years without lifetime episodes of vertigo and correlated the value with different clinical conditions (hypertension, diabetes, prior cardiovascular and vascular disorders of the central nervous system, and falls).

RESULTS

The mean value of the gain was 0.86 ± 0.12, and people aged between 70 and 80 years presented higher values (0.90 ± 0.1) compared to those >80 years (0.81 ± 0.13; p = 0.025). Previous vascular disorders of the central nervous system were a predictor of decreased VOR gain (p = 0.0003). A nonparametric analysis demonstrated that sex, age, and VOR gain (p ˂ 0.0001) were predictive of falls.

CONCLUSIONS

Our data support the hypothesis of a decrease of VOR gain in the elderly. The decrease of canal function may therefore play a role in the risk of falls in the elderly.

Extended phenotype and clinical subgroups in unilateral Meniere disease: A cross-sectional study with cluster analysis

OBJECTIVES

To define clinical subgroups by cluster analysis in patients with unilateral Meniere disease (MD) and to compare them with the clinical subgroups found in bilateral MD.

DESIGN

A cross-sectional study with a two-step cluster analysis.

SETTINGS

A tertiary referral multicenter study.

PARTICIPANTS

Nine hundred and eighty-eight adult patients with unilateral MD.

MAIN OUTCOME MEASURES

best predictors to define clinical subgroups with potential different aetiologies.

RESULTS

We established five clusters in unilateral MD. Group 1 is the most frequently found, includes 53% of patients, and it is defined as the sporadic, classic MD without migraine and without autoimmune disorder (AD). Group 2 is found in 8% of patients, and it is defined by hearing loss, which antedates the vertigo episodes by months or years (delayed MD), without migraine or AD in most of cases. Group 3 involves 13% of patients, and it is considered familial MD, while group 4, which includes 15% of patients, is linked to the presence of migraine in all cases. Group 5 is found in 11% of patients and is defined by a comorbid AD. We found significant differences in the distribution of AD in clusters 3, 4 and 5 between patients with uni- and bilateral MD.

CONCLUSIONS

Cluster analysis defines clinical subgroups in MD, and it extends the phenotype beyond audiovestibular symptoms. This classification will help to improve the phenotyping in MD and facilitate the selection of patients for randomised clinical trials.

Genetics of ion homeostasis in Ménière's Disease

Aim of this work was to assess the role of polymorphisms belonging to genes involved in the regulation of ionic homeostasis in Caucasian patients with Ménière Disease (MD). We recruited 155 patients with definite Ménière Disease and 186 controls (Control Group 1) without a lifetime history of vertigo, overlapping with patients for age and rate of hypertension. We validated the positive results on 413 Caucasian subjects selected from a European general population (Control Group 2). The clinical history for migraine and hypertension was collected; genomic DNA was characterized for a panel of 33 SNPs encoding proteins involved in ionic transport. We found a higher rate of migraineurs in MD subjects compared to Group 1 (46.8 vs 15.5%, p = 0.00005). Four SNPs displayed differences in MD patients compared to Group 1 controls: rs3746951 and rs2838301 in SIK1 gene, rs434082 and rs487119 in SLC8A1; the p values of Chi-squared test for genotype frequencies are 0.009, 0.023, 0.009 and 0.048, respectively. SLC8A1 gene encodes for Na⁺-Ca⁺⁺ exchanger, while SIK1 gene encodes for Salt Inducible Kinase 1, an enzyme associated with Na⁺-K⁺ ATPase function. The validation with Control Group 2 displayed that only rs3746951 and rs487119 are strongly associated to MD (p = 0.001 and p = 0.0004, respectively). These data support the hypothesis that a genetically induced dysfunction of ionic transport may act as a predisposing factors to develop MD.

Obstructive sleep apnea in Prader-Willi syndrome: risks and advantages of adenotonsillectomy

Obstructive sleep apnea is a well-known clinical manifestation of Prader-Willi syndrome. The aim of our study is to evaluate the efficacy of adenotonsillectomy for the treatment of the disorder as well as the improvement of their post-operative quality of life. Five patients with moderate to severe obstructive sleep apneas and adenotonsillar hypertrophy of grade III-IV underwent adenotonsillectomy. Pre- and postoperative apneas and <em>Quality of Life</em> were assessed respectively with a polysomnography with multi-sleep latency test and with the pediatric <em>Quality of Life</em> questionnaire, performed before and 6 months after surgery. A decrease of apnea/hypopnea index values has been detected between pre- and post-surgery (t=2.64, P=0.005), as well as oxygen desaturation index values (t=5.51, P=0.005), multi-sleep latency test (t=4.54, P=0.01), and of the values of pediatric <em>Quality of Life</em> questionnaire. No correlation has been detected between body mass index and apnea/hypopnea index, oxygen desaturation index and multi-sleep latency test values pre- and post-adenotonsillectomy. A correlation has been found between multi-sleep latency test and oxygen desaturation index values post-surgery (P=0.04). No post-operative complications were observed. Our data underline the efficacy of surgery in Prader-Willi patients with adenotonsillar hypertrophy in order to improve their quality of life.

Accompanying Symptoms Overlap during Attacks in Menière's Disease and Vestibular Migraine

Menière’s disease and vestibular migraine (VM) are the most common causes of spontaneous recurrent vertigo. The current diagnostic criteria for the two disorders are mainly based on patients’ symptoms, and no biological marker is available. When applying these criteria, an overlap of the two disorders is occasionally observed in clinical practice. Therefore, the present prospective multicenter study aimed to identify accompanying symptoms that may help to differentiate between MD, VM, and probable vestibular migraine (pVM). Two hundred and sixty-eight patients were included in the study (MD: n = 119, VM: n = 84, pVM: n = 65). Patients with MD suffered mainly from accompanying auditory symptoms (tinnitus, fullness of ear, and hearing loss), while accompanying migraine symptoms (migraine-type headache, photo-/phonophobia, visual aura), anxiety, and palpitations were more common during attacks of VM. However, it has to be noted that a subset of MD patients also experienced (migraine-type) headache during the attacks. On the other hand, some VM/pVM patients reported accompanying auditory symptoms. The female/male ratio was statistically higher in VM/pVM as compared to MD, while the age of onset was significantly lower in the former two. The frequency of migraine-type headache was significantly higher in VM as compared to both pVM and MD. Accompanying headache of any type was observed in declining order in VM, pVM, and MD. In conclusion, the present study confirms a considerable overlap of symptoms in MD, VM, and pVM. In particular, we could not identify any highly specific symptom for one of the three entities. It is rather the combination of symptoms that should guide diagnostic reasoning. The identification of common symptom patterns in VM and MD may help to refine future diagnostic criteria for the two disorders.

Association of cinnarizine and betahistine in prophylactic therapy for Ménière's disease with and without migraine

Prophylactic therapy of Ménière's disease (MD) includes betahistine and calcium-blockers (the latter also useful for migraine prevention). The aim of our work was to assess the efficacy of combined therapy with cinnarizine and betahistine in MD subjects both with and without migraine and poorly responsive to betahistine alone. Fifty-two MD subjects were included who were poorly responsive to betahistine during 6 months of follow-up; 29 were migraineurs. Combined therapy was administered with betahistine 48 mg/day and cinnarizine 20 mg BID for 1 month, 20 mg/day for 2 weeks and 20 mg every 2 days for 2 more weeks, and then repeated. Results were collected over 6 months of follow-up. MD subjects with and without migraine demonstrated a decrease in both vertigo spells and migrainous attacks during combined therapy (from 9.4 to 3.8 and from 6.8 to 5.9 in 6 months, respectively, for vertigo spells, while migraine decreased from 3.8 to 1 in 6 months, respectively). A correlation was seen between decrease of vertigo spells and headaches in the sample of MD subjects with migraine. Our data support a proactive role for cinnarizine in preventing vertigo spells, especially in MD patients with migraine.

Ear nose throat manifestations in hypoidrotic ectodermal dysplasia

The ectodermal dysplasias (EDs) are a large and complex group of inherited disorders. In various combinations, they all share anomalies in ectodermal derived structures: hair, teeth, nails and sweat gland function. Clinical overlap is present among EDs. Few causative genes have been identified, to date. Altered gene expression is not limited to the ectoderm but a concomitant effect on developing mesenchymal structures, with modification of ectodermal-mesenchymal signaling, takes place. The two major categories of ED include the hidrotic and hypohidrotic form, the latter more frequent; they differentiate each other for the presence or absence of sweat glands. We report Ear Nose Throat manifestations of ED, linked to the reduction of mucous glands in the nasal fossae with reduced ciliar function, and decrease salivary glands function. Often patients report an increased rate of infections of the upper respiratory tract and of the ear. Nasal obstruction due to the presence of nasal crusting, hearing loss and throat hoarseness are the most represented symptoms. Environmental measures, including a correct air temperature and humidification, is mandatory above all in subjects affected by hypohidrotic form.

Residual dizziness after successful repositioning maneuvers for idiopathic benign paroxysmal positional vertigo

OBJECTIVE

To establish a possible causal factor for residual dizziness (RD) after successful repositioning maneuvers in patients with benign paroxysmal positional vertigo (BPPV).

MATERIALS AND METHOD

Ninety consecutive patients with idiopathic BPPV were treated with repositioning maneuvers, and the rate of RD was assessed as well as clinical data. Posturography and assessment of anxiety levels were performed on patients reporting RD. Results were compared with a control group of BPPV patients of the sample after repositioning maneuvers and without RD.

RESULTS

Twenty-eight subjects (31.1%) reported RD on the second day after successful repositioning maneuvers. The mean duration of RD was 11.6 ± 3.9 days. Patients with RD presented a higher duration of BPPV (14.1 vs. 10.9 days, p = 0.01). A correlation was demonstrated between the duration of BPPV and duration of RD (p < 0.01). Subjects with RD presented increased body sways, above all in eyes-closed conditions.

CONCLUSION

RD is mainly correlated with duration of vertigo in BPPV patients. Anxiety was demonstrated to play a role in increased body sways.

Allelic variants in TLR10 gene may influence bilateral affectation and clinical course of Meniere's disease

Toll-like receptors trigger the innate immune response by activating various cell types such us macrophages and lymphocytes. We genotyped SNV of TLR3, TRL7, TLR8 and TLR10 in 863 Spanish and 150 Italian patients with Meniere's disease (MD) and 1,013 controls by using Taqman assays. Real-Time qPCR was used to measure the expression level of TLR10 in peripheral blood leukocytes. The overall dataset showed that the C allele and the CC genotype of rs11096955 in TLR10 gene were more commonly observed in controls than patients (corrected p = 1 × 10(-3), OR = 0.68 [95 % confidence interval, 0.54-0.84] for CC genotype; corrected p = 1.5 × 10(-5), OR = 0.75 [0.66-0.85] for allele C). Moreover, the CC genotype was more frequent in patients with uni- (19 %) than bilateral sensorineural hearing loss (SNHL) (13 %). Logistic regression demonstrated that the time since the onset of MD, Tumarkin crises, hearing stage and rs11096955 were independent factors influencing the risk of bilateral SNHL. In addition, rs11096955 influenced hearing loss progression in patients with bilateral MD. No change in expression of TLR10 was observed according to CC, CA or AA genotypes. Our data suggest that allelic variants of TLR10 gene may influence the susceptibility and time-course of hearing loss of MD in the European population.

Otorhinolaryngological manifestations in granulomatosis with polyangiitis (Wegener's)

Granulomatosis with polyangiitis (Wegener's, GPA) is an uncommon disease of unknown etiology classically involves the ELK triad of the ear, nose, throat (E), lungs (L) and kidneys (K) with necrotizing granulomatous inflammation and vasculitis. Most of the initial symptoms begin in the head and neck region with a wide spectrum of involvement of any site ranging from the nasal septum, paranasal sinuses, oral mucosa, larynx and even the external, middle and internal ear. Diagnosis may be delayed because the onset is heterogeneous and sometimes limited to one organ. The pathologic findings of a characteristic inflammatory reaction pattern, and the serum findings of elevated antineutrophil cytoplasmic antibodies can help to establish the diagnosis. The differentiation from other conditions that mimic GPA such as lymphoma and infections is of critical importance to initiate appropriate treatment. Treatment of the underlying disease is medical with the use of immunosuppressive agents and will not be reviewed here. This review focuses on the otorhinolaryngologic manifestation and complication of GPA as well as their surgical management and specifies the role of the otorhinolaryngologist as an integral member of the multidisciplinary care team for patients with GPA.

Does Ménière's Disease in the Elderly Present Some Peculiar Features?

Object. Aim of our study was to establish some peculiar features of Ménière's Disease (MD) in a group of elderly MD patients, in which the first vertigo spell happened when over 65 years old. Material and Methods. We analyzed a group of 73 younger than 65-years-old and a group of 30 elderly MD patients. All patients underwent a neurotological evaluation, an anamnestic evaluation including a lifetime history of migraine, and blood withdrawal for autoantibody screening. Results. Some differences were found between elderly and younger MD patients. Elderly MD patients presented a higher prevalence of Tumarkin attacks and a lower prevalence of lifetime history of migraine; moreover, they presented a faster develop of hearing loss and vertigo spells than a subgroup of 32 younger patients matched for the duration of illness. Conclusions. Some clinical features of MD in elderly have been pointed out. Particularly, the lower rate of migrainous history and positivity for autoantibodies often associated with MD, in our opinion, support the hypothesis of a vascular disorder acting as a predisposing factor for MD in elderly.

Is there a hypersensitive visual alarm system in panic disorder?

Agoraphobia in panic disorder (PD) has been related to abnormal balance system function. Vision influences balance and behavioural adaptations; peripheral vision influences orienting and fast defensive reactions whereas central vision analyzes details of objects. We have hypothesized that the abnormal balance function in PD could be mainly related to peripheral vision as part of a defensive alarm system in the brain. In 25 patients with PD and agoraphobia and 31 healthy controls we assessed, by posturography, balance system reactivity to video-films projected in peripheral and central visual fields (randomized sequence). Length, velocity and surface of body sway were calculated. Patients increased their body sway during peripheral stimulation, whereas controls did not; the two groups showed a similar increase of body sway during central stimulation. Anxiety levels during peripheral stimulation significantly influenced the postural response in the group of patients. These preliminary results suggest that the higher visual sensitivity to peripheral stimulation in patients with PD and agoraphobia may be linked to a more active "visual alarm system" involving visual, vestibular and limbic areas that might influence the development of agoraphobia in situations where environmental stimuli are uncertain.

Case reports on two patients with episodic vertigo, fluctuating hearing loss and migraine responding to prophylactic drugs for migraine. Menière's disease or migraine-associated vertigo?

Recent reports have focused on a possible association between migraine and Menière's disease; patients suffering from Menière's disease present a higher rate of migraine. In some cases, the clinical features of migraine-associated vertigo may mimic the presentation of Menière's disease. The present report focuses on two cases of females with recurrent episodes of rotational vertigo, fluctuating hearing loss and tinnitus lasting from a few minutes to several hours; both cases also presented migrainous attacks. As a result of repeated cochleovestibular attacks, both patients presented a permanent low frequency sensorineural hearing loss. Preventive therapies for Menière's disease did not reduce vertigo attacks, while topiramate and acetylsalicylic acid treatment resulted in a significant reduction of both migraine and vertigo. Both the diagnosis of Menière's disease and of migraine-associated vertigo rely on clinical history and both disorders lack a specific diagnostic test. In the early stages, differential diagnosis between Menière's disease and migraine-associated vertigo is often very difficult; previous investigations focused on the possibility that subjects with migraine may experience all symptoms of Menière's disease, including sensorineural fluctuating hearing loss. In conclusion, a trial with prophylactic drug treatment for migraine might be suggested in patients with clear symptoms of migraine and recurrent cochleovestibular disorders.

Efficacy of low-level laser therapy in Ménière's disease: a pilot study of 10 patients

OBJECTIVE

To assess the efficacy of low-level laser therapy (LLLT) for Ménière's disease (MD).

MATERIALS AND METHODS

Twenty patients with unilateral MD were included in the study; all presented with uncontrolled vertigo. The patients were randomly divided into two groups: group 1 patients received LLLT 20 min a day with a 5-mW soft laser for 6 mo, while group 2 received betahistine 16 mg twice a day for 6 mo. According to American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines, the main outcome for vertigo control was considered to be the number of spells per month in the 6 mo before treatment compared with the same parameter in the 6 mo of therapy. The duration of spells expressed in minutes was also considered. Moreover, a hearing test was performed before and after therapy and results were reported as the pure tone average of 500-, 1000-, 2000-, and 3000-Hz frequencies. All results were valued at baseline, and after 3 and 6 mo of therapy.

RESULTS

Compared to baseline, the number and duration of spells were significantly reduced in both groups; statistical significance was detected for the 3-mo control in both groups (p 0.05 with the multiple pair comparison test). Betahistine seems to have a faster action in spell reduction (p 0.05 comparing the 3-mo results between the two groups). Audiometric examination did not show a statistically significant difference between the two groups.

CONCLUSIONS

In our experience, LLLT seems to prevent vertigo spells in MD, although results indicate that it has a slower action than betahistine. Dose-dependent therapeutic effects could explain the last result. In our opinion, increased blood flow in the inner ear is the main mechanism leading to the therapeutic results.

Simultaneous pleomorphic adenoma of the parapharyngeal space and contralateral submandibular gland. Case report

Herein the case is reported of a synchronous parapharyngeal space pleomorphic adenoma arising from the pharyngeal prolongation of the parotid gland and the contralateral submandibular gland, diagnosed in a young Caucasian female. Case reports and recent literature are presented. Upon physical examination, asymmetry of the lower part of the right side of the face with overlying intact skin, and a submucosal firm swelling, filling the ipsilateral side of the oropharyngeal wall, involving the right tonsillar bed which was medially displaced was immediately recognizable. The patient did not complain of dysphagia. Palpating the left submandibular region, a painless, mobile, rounded mass, 10 mm in diameter, apparently located in the submandibular gland, was detected. Magnetic resonance imaging showed that both lesions were well-defined and encapsulated. The surgical approach is discussed. Cytological diagnosis was that of a typical pleomorphic adenoma. To the best of our knowledge this is the second case report in the English literature of a concomitant pleomorphic adenoma located both in the parapharyngeal space and the submandibular gland.

Vestibular testing in patients with panic disorder and chronic dizziness

In order to investigate the relationship between chronic dizziness and vestibular function in patients with panic disorder, in the present study neurotologic findings in 15 patients with panic disorder and chronic dizziness were compared with those in 15 patients with chronic dizziness, without panic disorder. All underwent neurotologic screening for spontaneous, positional and positioning nystagmus with head-shaking and head-thrust tests, an audiometric examination and electronystagmography with bithermal stimulation according to Freyss. A significantly higher number of patients with panic disorder and chronic dizziness showed pathological neurotologic findings in comparison to subjects with chronic dizziness only (9 and 2 patients, respectively; p < 0.05). Most patients with panic disorder showed signs of peripheral vestibular disorders. These results suggest that the complaint of dizziness in patients with panic disorder may be linked to a malfunction of the vestibular system and vestibular disorders may play a role in the pathophysiology of panic disorder. Possible mechanisms underlying this finding are discussed. In patients with panic disorder and chronic dizziness between panic attacks, a careful neurotologic examination is warranted.

Stiff-person syndrome with acute recurrent peripheral vertigo: possible evidence of gamma aminobutyric acid as a neurotransmitter in the vestibular periphery

OBJECTIVE

We report a case of a 58-year-old man suffering from stiff-person syndrome and recurrent peripheral vertigo.

METHOD

A case report and a review of the recent literature on stiff-person syndrome are presented.

RESULTS

The patient presented with recurrent episodes of vertigo with a pure peripheral pattern and with concomitant episodes of burning muscle pain, muscle twitching, weight gain and fatigue, worsening with tension or stress that also occurred in periods without vertigo. Cochlear examinations only showed presbyacusis-like hearing loss. The diagnosis of stiff-person syndrome was made with electromyographic examination and from findings in the blood and cerebrospinal fluid of high titres of anti-glutamic acid decarboxylase (GAD67) autoantibodies. In a two-year follow-up period, therapy for stiff-person syndrome abolished episodes of both stiffness and vertigo.

CONCLUSION

As far as we know, no other clinical case of acute vestibular damage with a possible correlation with anti-glutamic acid decarboxylase antibodies has been described. Peripheral vertigo possibly related to a lack of gamma aminobutyric acid underlines a possible role of gamma aminobutyric acid as a neurotransmitter in the peripheral vestibular system.