Persistent postural-perceptual dizziness: A functional neuro-otologic disorder

Persistent postural-perceptual dizziness (PPPD) is a functional neuro-otologic disorder that is the most frequent cause of chronic vestibular syndrome. The core vestibular symptoms include dizziness, unsteadiness, and non-spinning vertigo, which are exacerbated by an upright posture or walking, active or passive motion, and exposure to moving or complex visual stimuli. PPPD is mostly precipitated by acute or episodic vestibular diseases; however, its symptoms cannot be accounted for by its precipitants. PPPD is not a diagnosis of exclusion, but may coexist with other structural diseases. Thus, when diagnosing PPPD, the patient's symptoms must be explained by PPPD alone or by PPPD in combination with a structural illness. PPPD is most frequently observed at approximately 50 years of age, with a female predominance. Conventional vestibular tests do not reveal any specific signs of PPPD. However, the head roll-tilt subjective visual vertical test and gaze stability test after exposure to moving visual stimuli may detect the characteristic features of PPPD, that is, somatosensory- and visually-dependent spatial orientation, respectively. Therefore, these tests could be used as diagnostic tools for PPPD. Regarding the pathophysiology of PPPD, neuroimaging studies suggest shifts in interactions among visuo-vestibular, sensorimotor, and emotional networks, where visual inputs dominate over vestibular inputs. Postural control also shifts, leading to the stiffening of the lower body. To treat PPPD, selective serotonin reuptake inhibitors/serotonin noradrenaline reuptake inhibitors, vestibular rehabilitation, and cognitive behavioral therapy are used alone or in combination.

Vestibular migraine: an update

PURPOSE OF REVIEW

We performed a narrative review of the recent findings in epidemiology, clinical presentation, mechanisms and treatment of vestibular migraine.

RECENT FINDINGS

Vestibular migraine is an underdiagnosed condition that has a high prevalence among general, headache and neuro-otology clinics. Vestibular migraine has a bimodal presentation probably associated with a hormonal component in women. These patients could have a complex clinical phenotype including concomitant autonomic, inflammatory or connective tissue conditions that have a higher prevalence of psychological symptoms, which may mistakenly lead to a diagnosis of a functional neurological disorder. A high proportion of patients with postural perceptual persistent dizziness have a migraine phenotype. Independently of the clinical presentation and past medical history, patients with the vestibular migraine phenotype can respond to regular migraine preventive treatments, including those targeting the calcitonin gene-related peptide pathways.

SUMMARY

Vestibular migraine is an underdiagnosed migraine phenotype that shares the pathophysiological mechanisms of migraine, with growing interest in recent years. A thorough anamnesis is essential to increase sensitivity in patients with unknown cause of dizziness and migraine treatment should be considered (see supplemental video-abstract).

Effects of the Kahramanmaras, Turkey 2023 earthquakes on balance perception, dizziness and post-traumatic stress: A relational screening model between subjective balance problems and post-traumatic stress

OBJECTIVE

The aim of the present study was to investigate the effects of the February 6, 2023, earthquakes in Turkey and recurrent aftershocks on balance and post-traumatic stress in surviving victims.

METHODS

Our study included 1004 participants aged 18-65 years who were exposed to the February 6 earthquakes and aftershocks in Turkey. After obtaining online consent from all participants, the Vertigo Symptom Scale (VSS), the Dizziness Handicap Index (DHI), and the Posttraumatic Post-Traumatic Disorder Checklist Scale (PCL-5) were administered online, and the interactions between the variable sets were examined using a correlational screening model.

RESULTS

As a result of the structural equation model established with the observed variables, it was found that VSS total scores had a statistically significant positive effect on PCL-5 (β1 = 0.56; p = 0.001 < 0.05). In addition, statistically significant positive high-level correlations were found between VSS and DHI (covVSS-DHI = 0.71), and a positive low level correlation with the number of days with dizziness (covVSS-number of days with dizziness = 0.34), and a positive low level correlation with frequency of days with dizziness (covVSS-frequency of days with dizziness = 0.37). A statistically significant positive low-level relationship was found between DHI and the number of days with dizziness (covDHI-number of days with dizziness = 0.34) and a positive low-level correlation between DHI and the frequency of days with dizziness (covDHI-frequency of days with dizziness = 0.29).

CONCLUSION

The structural equation modeling analysis showed that post-traumatic stress disorder had a significant effect on balance and dizziness.

Usefulness of thermography for differentiating Wallenberg's syndrome from noncentral vertigo in the acute phase

OBJECTIVES

Wallenberg's syndrome (WS) is caused by a stroke in the lateral medulla and can present with various symptoms. One of the main symptoms is vertigo, which can be misdiagnosed as noncentral vertigo (NCV). Approximately 90% of the patients with acute WS have a lateral difference in body surface temperature (BST) due to autonomic pathway disturbances from infarction. Additionally, thermography can aid in WS diagnosis; however, whether BST differences occur in patients with acute NCV is unclear.

METHODS

This study used thermography to measure the BST of patients with NCV and acute WS to determine the effectiveness of BST to differentiate between the conditions. Forty-eight consecutive patients diagnosed with NCV whose BST was measured using thermography during a hospital visit or admission were enrolled. The left and right BST of four sites (face, trunk, and upper and lower limbs) were measured and compared with obtained BST of nine patients with WS.

RESULTS

Twenty-two patients had lateral differences in BST ≥ 0.5°C, three with ≥1.5°C, and none with ≥2.5°C. Only one patient with NCV had lateral differences in BST at two or more ipsilateral sites. When WS differentiated from NCV, a left-right difference ≥0.5°C in two or more ipsilateral sites had a sensitivity of 89% and specificity of 98%, and ≥1.0°C had a sensitivity of 78% and specificity of 98%.

DISCUSSION

Acute WS can be differentiated from NCV through BST and the number of sites with lateral differences via thermography, even in rooms where conditions are unregulated.

Hearing loss in Takayasu's arteritis

OBJECTIVES

Neurosensory hearing loss is well-documented in chronic autoimmune conditions such as systemic lupus erythematosus (SLE). However, the literature lacks data on the prevalence and characteristics of hearing impairment in Takayasu's arteritis (TAK). In this cross-sectional study, our principal objective was to systematically assess the auditory function of individuals diagnosed with TAK, against SLE patients and healthy controls (HC).

METHODS

Age and gender matched TAK and SLE patients followed up in a tertiary centre along with healthy controls were included in a two-phase study. In the first phase, a questionnaire on ENT symptoms was administered to the patient (TAK: n=104 and SLE: n= 151) and HC (n=174) groups. In the second phase, patients (TAK: n=53 and SLE: n=33) and HC (n=45) underwent audiometric tests.

RESULTS

The questionnaire survey revealed that both TAK and SLE patients reported hearing loss (27.9%, 25.8%, 7.4%, p<0.001), tinnitus (49%, 35.8%, 13.8%, p<0.001) and vertigo (46.2%, 33.8%, 16.7%, p<0.001) at significantly higher rates than HC. Audiometry results indicated that both TAK (30.2%) and SLE patients (18.2%) had increased hearing loss compared to HC (8.9%), however, only TAK patients were found to have significantly increased risk in age adjusted logistic regression analysis (OR= 3.915, 95%CI: 1.179-12.998, p=0.026). Hearing loss was mainly neurosensory in all groups. TAK patients were affected at both low (<6000 Hz) and high (>6000 Hz) frequencies, whereas SLE patients were affected only at high frequencies. Hearing loss was significantly associated only with older age. No association was observed with the anatomical location of vascular involvement or history of stroke.

CONCLUSIONS

Our study reveals an increased prevalence of hearing loss in TAK. Further research is crucial to uncover the underlying causes.

Differences in semicircular canal function in the video head impulse test in patients in the chronic stage of sudden sensorineural hearing loss with vertigo and vestibular neuritis

BACKGROUND

Sudden sensorineural hearing loss with vertigo (SHLV) and vestibular neuritis (VN) can result in prolonged dizziness.

OBJECTIVES

This study aimed to compare the video head impulse test (vHIT) of patients with SHLV and VN.

METHODS

Fifteen patients with SHLV and 21 patients with VN who visited the Vertigo/Dizziness Center of our hospital between December 2016 and February 2023 were included. vHIT was performed at the time of admission, and the VOR gain and catch up saccade (CUS) in the three types of semicircular canals (SCCs) were analyzed.

RESULTS

Pathologic vHIT results were observed most frequently in the posterior SCC (73%), followed by lateral (53%) and anterior (13%) SCCs in the SHLV group. In contrast, pathologic vHIT results were observed most frequently in the lateral SCC (100%), followed by the anterior (43%) and posterior SCC (24%) SCCs in the VN group. Pathological vHIT results in the lateral and posterior SCC showed significant differences between the two groups, but for anterior SCC, no significant differences were found.

CONCLUSIONS AND SIGNIFICANCE

Comparison of the two vHIT results revealed differences in the SCC dysfunction patterns. This may be due to the different pathophysiological mechanisms of the two vestibular disorders, which may result in prolonged vertigo.

The vestibular symptomatology of Machado-Joseph Disease

BACKGROUND

Machado Joseph Disease (MJD) is an autosomal dominant neurodegenerative disease. In previous studies, we described significant bilateral horizontal Vestibulo-Ocular Reflex (VOR) deficit within this population without any reference to the presence of vestibular symptomatology.

OBJECTIVE

To evaluate whether, beyond cerebellar ataxia complaints, MJD patients have typical vestibular symptomatology corresponding to the accepted diagnostic criteria of Bilateral Vestibulopathy (BVP) according to the definition of the International Barany Society of Neuro-Otology.

METHODS

Twenty-one MJD, 12 clinically stable chronic Unilateral Vestibulopathy (UVP), 15 clinically stable chronic BVP, and 22 healthy Controls underwent the video Head Impulse Test (vHIT) evaluating VOR gain and filled out the following questionnaires related to vestibular symptomatology: The Dizziness Handicap Inventory (DHI), the Activities-specific Balance Confidence Scale (ABC), the Vertigo Visual Scale (VVS) and the Beck Anxiety Inventory (BAI).

RESULTS

The MJD group demonstrated significant bilateral vestibular impairment with horizontal gain less than 0.6 in 71% of patients (0.54±0.17). Similar to UVP and BVP, MJD patients reported a significantly higher level of symptoms than Controls in the DHI, ABC, VVS, and BAI questionnaires.

CONCLUSIONS

MJD demonstrated significant VOR impairment and clinical symptoms typical of BVP. We suggest that in a future version of the International Classification of Vestibular Disorders (ICVD), MJD should be categorized under a separate section of central vestibulopathy with the heading of bilateral vestibulopathy. The present findings are of importance regarding the clinical diagnosis process and possible treatment based on vestibular rehabilitation.

Video-nystagmographic evidence in more than 700 consecutive cases of road traffic whiplash injury

PURPOSE

Whiplash injury is a frequent traumatic lesion occurring mainly in road accidents, which may also cause dizziness severe enough to impact everyday life. Vestibular examination is routinely performed on these patients, although the role of the neuro-otologist is still not clearly defined. The main endpoint of this study was to describe the videonystagmography (VNG) evidence in a large cohort of patients who underwent road traffic whiplash injury.

METHODS

717 consecutive patients who reported whiplash-associated disorders due to a road traffic accident underwent clinical examination and VNG.

RESULTS

Patients with saccadic test latency anomalies more frequently complained of vertigo, nausea and cochlear symptoms after trauma (p = 0.031, 0.028 and 0.006), while patients with bilateral vestibular weakness at caloric stimulation more often displayed neck pain after trauma (p = 0.005). Patients complaining of positional or cochlear symptoms or with accuracy anomalies at the saccadic test were significantly older than those with no positional, no cochlear symptoms and without accuracy anomalies (p = 0.022, p = 0.034 and p = 0.001). Patients with bilateral vestibular hypofunction were significantly younger (p < 0.001).

CONCLUSIONS

VNG evidence, particularly vestibular function and saccadic tests, may be related to damage in the cervical region due to whiplash trauma. These findings suggest that neuro-otologic examination may play a role in properly identifying those who suffer damage caused by whiplash trauma, and in characterizing the severity and prognosis of whiplash-associated disorders.

The therapeutic effect and mechanism of Chinese medicine Xuan-Yun-Ding on posterior circulation ischemia with vertigo in a rabbit model

The aim of research is to unveil the mechanisms of the beneficial effects of XYD on PCIV in a rabbit model. 40 New Zealand white rabbits were randomly divided into 5 groups,including normal control group (NC), model control group (MC), low-dose of XYD group (LXYD), high-dose of XYD group (HXYD) and Yang-Xue-Qin-Nao group (YXQN). PCIV rabbit model was established by feeding high-fat diet companied with paravertebral sclerotherapy and rotation exercise. The general observation, step-down test, rheoencephalogram, blood tests, histopathological detection and the plasma concentration of the effective component of XYD were investigated. After pharmacological intervening, the step-down time, REG, PL, IPL, blood viscosity, the levels of blood lipids, CRGP were significantly improved. Moreover, the vertebral artery showed the reduced stenosis of arterial lumen and less proliferation of fibrous tissue in the arterial wall in the LXYD, HXYD and YXQN group. Based on the LC-MS detection, the blood concentrations of puerarin in the LXYD and HXYD group were significantly increased after pharmacological intervening. XYD could ameliorate the symptoms of vertigo, Qi-deficiency and blood stasis in PCIV rabbits via effectively regulating the levels of blood lipids and vasoactive substances, decreasing blood viscosity, increasing CBF and protecting vestibular function.

Compensatory image of the stability of people with multiple sclerosis and atrial vertigo based on posturography examination

Pathophysiology of balance disorders due to multiple sclerosis (MS) and atrial vertigo (AV) is different. We evaluated posture stability when maintaining balance in people with MS presenting symptoms of ataxia and those with AV. We included 45 women (15 with MS; 15 with AV; 15 controls). A posturography platform was used to measure balance parameters. To characterize the image of stability and the compensation of balance disorders, the surface area of the stabilogram (SAS), vision control index (VCI) and the vision-motion control index (VMCI) were used. The stability image of people with MS and AV with eyes open (p = 0.002), with eyes closed (p = 0.080) and with visual biofeedback (p = 0.0008) differed significantly. SAS depended on visual biofeedback regardless of the occurrence of balance disorders and was the basis for determining the compensatory share of vision-motor coordination. Differences in VCI between groups were insignificant. VMCI was significantly higher in people with balance disorders than in those without, but similar in the MS and AV groups. The image of stability is different in people with MS and AV. Thanks to visual biofeedback, it becomes possible to launch effective vision-motor coordination when compensating balance disorders. VCI may become the measure of compensation for balance disorders.

Neurologic Syndromes Predict Higher In-Hospital Mortality in COVID-19

OBJECTIVE

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is protean in its manifestations, affecting nearly every organ system. However, nervous system involvement and its effect on disease outcome are poorly characterized. The objective of this study was to determine whether neurologic syndromes are associated with increased risk of inpatient mortality.

METHODS

A total of 581 hospitalized patients with confirmed SARS-CoV-2 infection, neurologic involvement, and brain imaging were compared to hospitalized non-neurologic patients with coronavirus disease 2019 (COVID-19). Four patterns of neurologic manifestations were identified: acute stroke, new or recrudescent seizures, altered mentation with normal imaging, and neuro-COVID-19 complex. Factors present on admission were analyzed as potential predictors of in-hospital mortality, including sociodemographic variables, preexisting comorbidities, vital signs, laboratory values, and pattern of neurologic manifestations. Significant predictors were incorporated into a disease severity score. Patients with neurologic manifestations were matched with patients of the same age and disease severity to assess the risk of death.

RESULTS

A total of 4,711 patients with confirmed SARS-CoV-2 infection were admitted to one medical system in New York City during a 6-week period. Of these, 581 (12%) had neurologic issues of sufficient concern to warrant neuroimaging. These patients were compared to 1,743 non-neurologic patients with COVID-19 matched for age and disease severity admitted during the same period. Patients with altered mentation (n = 258, p = 0.04, odds ratio [OR] 1.39, confidence interval [CI] 1.04-1.86) or radiologically confirmed stroke (n = 55, p = 0.001, OR 3.1, CI 1.65-5.92) had a higher risk of mortality than age- and severity-matched controls.

CONCLUSIONS

The incidence of altered mentation or stroke on admission predicts a modest but significantly higher risk of in-hospital mortality independent of disease severity. While other biomarker factors also predict mortality, measures to identify and treat such patients may be important in reducing overall mortality of COVID-19.

Reversible Splenial Lesion Syndrome with Some Novel Causes and Clinical Manifestations

Objective Reversible splenial lesion syndrome (RESLES) is a clinical radiological syndrome characterized by a reversible lesion of the splenium of the corpus callosum with a decreased apparent diffusion coefficient (ADC) value. The clinical manifestations of RESLES are diverse. Methods Fifteen cases of adult RESLES patients (10 males and 5 females) were retrospectively selected from the radiology system using the key word "corpus callosum" at a university-affiliated tertiary care hospital between May 1, 2015 and December 31, 2019. The possible precipitating factors, clinicoradiological findings and modified Rankin Scale (mRS) on follow-up were then analyzed. Results The patient ages ranged from 22 to 53 years old. The mean age was 34 years old. The most common neurological symptoms included headache (3/15), dizziness (3/15), first onset of seizure (3/15), paroxysmal blurred vision (2/15), vertigo (2/15), amnesia (2/15), and confused consciousness without seizure (2/15), followed by drowsiness (1/15), paresthesia (1/15), dysmetria (1/15) and dysarthria (1/15). The precipitating factors included infection, seizure, anti-epileptic treatment with levetiracetam, carbamazepine, valproate, hyperglycemia, hypoglycemia, cerebral venous sinus thrombosis, and rabies vaccine injection prior to the onset of RESLES. All cases were carefully followed up and had excellent prognoses. Conclusion RESLES manifests as variety of symptoms with less specificity and precipitating factors. Paroxysmal blurred vision may be a relatively specific symptom of RESLES. Levetiracetam, carbamazepine or valproate could be the cause of RESLES, exposure to the rabies vaccine could be another predisposing factors for RESLES as well. RESLES type 1 was therefore found to be highly "reversible" with an excellent prognosis.

A review on the alterations in the brain of persistent postural-perceptual dizziness patients and non-pharmacological interventions for its management

Persistent postural perceptual dizziness (PPPD) is a relatively newer term, and this term is included in the International Classification of Diseases in its 11th revision. The typical features of PPPD include the presence of persistent dizziness, non-spinning vertigo, and unsteadiness, and these symptoms are exacerbated during upright posture, movement, or visual stimuli. Moreover, the structural changes have also been identified in the brains of PPPD patients, particularly in visual, vestibular, and limbic areas. These include a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region, and alterations in the structural and functional connectivity, particularly in the visual-vestibular networks. Moreover, the impairment in sensory processing is restricted not only to the vestibular and visual regions; instead, there is a generalized impairment in the sensory processing, and thus, there is a multisensory dimension of sensory impairment. Selective serotonin uptake inhibitors and serotonin-norepinephrine reuptake inhibitors are the mainstay drugs for the management of PPPD patients. However, a significant proportion of PPPD patients do not show improvement in response to standard drug therapy. The employment of alternative and complementary treatment strategies, including vestibular rehabilitation therapy, cognitive behavioral therapy, and non-invasive vagal nerve stimulation, is effective in the management of PPPD patients. The present review discusses the alterations in the brains of PPPD patients along with the possible non-pharmacological treatment options in these types of patients.

Ménière's Disease Review 2005

Ménière's disease (MD) is a complex, multifactorial disorder of the inner ear that is the most common cause of the syndrome of episodic vertigo combined with fluctuating hearing loss. In spite of a century of investigation, the etiology and pathophysiology of MD remain controversial and incompletely understood. Among the factors that have contributed to these controversies are the absence of (1) a validated clinical test, (2) an appropriate animal model, and (3) a specific treatment. Nonetheless, physicians are able to assist MD patients with a variety of tailored, symptom-specific medications and therapies. Given that the vertigo induced by MD, in general, is self-limited, the long-term outlook for balance function is good. The same cannot be said for the hearing dysfunction of MD.

Treatment of Benign Paroxysmal Positional Vertigo: Necessity of Postmaneuver Patient Restrictions

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, resulting from migration of otoconia into the semicircular canals. Several treatment methods involving positioning maneuvers that return the otoconia to the utricle have been described. Following treatment, most patients are provided with a variety of activity restrictions. Previous studies suggest that, overall, BPPV treatment may be successful without these restrictions. The purpose of this study was to determine the necessity of postmaneuver restrictions using an experimental and control group with participants matched for age, gender, involved ear, and symptoms. A canalith repositioning maneuver was used to treat the BPPV. During postmaneuver instruction, the 21 participants assigned to the restricted group were provided with typical activity restrictions. Twenty-one participants assigned to the nonrestricted group were given no postmaneuver restrictions. Only one participant in the restricted group and two participants in the nonrestricted group were not clear at the one-week follow-up appointment. Results indicated that postmaneuver restrictions do not improve treatment efficacy.

Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria

This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.

Transient Vertigo with Horizontal Nystagmus to Loud Noise and Pressure: Utricular Hydrops or Vestibular Atelectasis?

We present an unusual case of a patient with a positive Tullio phenomenon, brief Valsalva-induced transient horizontal nystagmus, reduced left caloric response, and bilateral vestibulo-ocular reflex loss. This study discusses the pathophysiology and differential diagnosis concerning the suspected pathology for the phenomenon of utricular hydrops or vestibular atelectasis and presents a literature review.

Functional Pathway Between Cervical Spinal and Sympathetic Ganglia: A Neurochemical Foundation Between Neck Pain and Vertigo

BACKGROUND

Cervical vertigo commonly concurs in patients with neck pain, but the concurrent mechanism of these 2 symptoms still remains unclear. We previously reported a bidirectional segmental nerve fiber connection between cervical spinal and sympathetic ganglia, which provided a hypothesis that this connection between the 2 ganglia may be the anatomic basis for the concurrence of neck pain and cervical vertigo. However, this concurrent mechanism needs biochemical and functional evidence.

OBJECTIVES

This study aimed to investigate a possible noradrenergic pathway between cervical spinal and sympathetic ganglia.

STUDY DESIGN

We performed both clinical and laboratory research. Clinical observation was a prospective case-control study.

SETTING

Clinical study took place in our hospital; laboratory study was in an orthopedic laboratory.

METHODS

Cervical lamina block therapy used in patients with cervical vertigo was clinically evaluated; norepinephrine (NE) expressions in cervical sympathetic ganglia were analyzed using immunohistochemical staining after electrical stimulation to the cervical spinal ganglia; the influence of phentolamine local injection to the vertebrobasilar artery flow was experimentally measured.

RESULTS

Cervical lamina block therapy could significantly shorten the clinical hospital stays of patients with cervical vertigo (P = 0.000) and improve vertebral artery flow (P < 0.05). NE expressions in superior cervical sympathetic ganglia (SCG) or inferior cervical sympathetic ganglia (ICG) increased significantly when ipsilateral C2 to C3 or C6 to C8 spinal ganglia were electrically stimulated, respectively. Adrenergic receptor block with phentolamine significantly inhibited the decrease of basilar artery (BA) flow induced by electrical stimulation of the cervical spinal ganglia. The change range of BA flow caused by stimulations of C2 to C3 and C6 to C8 spinal ganglia was more than that of C4 and C5.

LIMITATIONS

The inpatients observed in this clinical study might be influenced by some factors including emotion, diet, sleep, and others. The limitations of the laboratory study included animal species and small sample size.

CONCLUSIONS

Adrenergic system could play a part in cervical spinal ganglia altering the vertebrobasilar artery system. It could provide a neurochemical foundation between neck pain and vertigo, and that segmental functional connections exist between cervical spinal and sympathetic ganglia.

KEY WORDS

Cervical vertigo, neck pain, cervical sympathetic ganglia, cervical spinal ganglia, noradrenaline.

Rehabilitation of dynamic visual acuity in patients with unilateral vestibular hypofunction: earlier is better

PURPOSE

Patients with acute peripheral unilateral hypofunction (UVH) complain of vertigo and dizziness and show posture imbalance and gaze instability. Vestibular rehabilitation therapy (VR) enhances the functional recovery and it has been shown that gaze stabilization exercises improved the dynamic visual acuity (DVA). Whether the effects of VR depend or not on the moment when it is applied remains however unknown, and investigation on how the recovery mechanisms could depend or not on the timing of VR has not yet been tested.

METHODS

Our study investigated the recovery of DVA in 28 UVH patients whose unilateral deficit was attested by clinical history and video head impulse test (vHIT). Patients were tested under passive conditions before (pre-tests) and after (post-tests) being subjected to an active DVA rehabilitation protocol. The DVA protocol consisted in active gaze stabilization exercises with two training sessions per week, each lasting 30 min, during four weeks. Patients were sub-divided into three groups depending on the time delay between onset of acute UVH and beginning of VR. The early DVA group (N = 10) was composed of patients receiving the DVA protocol during the first 2 weeks after onset (mean = 8.9 days), the late group 1 (N = 9) between the 3rd and the 4th week (mean = 27.5 days after) and the late group 2 (N = 9) after the 1st month (mean: 82.5 days). We evaluated the DVA score, the angular aVOR gain, the directional preponderance and the percentage of compensatory saccades during the HIT, and the subjective perception of dizziness with the Dizziness Handicap Inventory (DHI). The pre- and post-VR tests were performed with passive head rotations done by the physiotherapist in the plane of the horizontal and vertical canals.

RESULTS

The results showed that patients submitted to an early DVA rehab improved significantly their DVA score by increasing their passive aVOR gain and decreasing the percentage of compensatory saccades, while the late 1 and late 2 DVA groups 1 and 2 showed less DVA improvement and an inverse pattern, with no change in the aVOR gain and an increase in the percentage of compensatory saccades. All groups of patients exhibited significant reductions of the DHI score, with higher improvement in subjective perception of dizziness handicap in the patients receiving the DVA rehab protocol in the first month.

CONCLUSION

Our data provide the first demonstration in UVH patients that earlier is better to improve DVA and passive aVOR gain. Gaze stabilization exercises would benefit from the plastic events occurring in brain structures during a sensitive period or opportunity time window to elaborate optimal functional reorganizations. This result is potentially very important for the VR programs to restore the aVOR gain instead of recruiting compensatory saccades assisting gaze stability.

Shi-Style Cervical Mobilizations Versus Massage for Cervical Vertigo: A Multicenter, Randomized, Controlled Clinical Trial

Objectives: Large sample and high-quality evidence to evaluate the preliminary safety of the mobilizations and massage for cervical vertigo are not yet available. Thus, the present study aimed to investigate the comparative effectiveness and preliminary safety of Shi-style cervical mobilizations (SCM) compared with traditional massage (TM) in cervical vertigo patients. Design: A prospective, multicenter, open-label, randomized, controlled clinical trial with a 1:1 allocation ratio. Settings: Five academic medical centers. Subjects: A total of 360 adult patients with a diagnosis of cervical vertigo. Interventions: The patients were randomly allocated to either an SCM (n = 180) or TM (n = 180) group. The patients were treated during six sessions over 2 weeks. The primary outcome was the Dizziness Handicap Inventory (DHI) total scale score, and secondary outcomes included the DHI subscales, Chinese version of the Short-Form 36 Health Survey (CSF-36), and adverse events (AEs). Outcomes were assessed in the short term at 2 weeks, 1 month, and 3 months, and in the intermediate term at 6 months after randomization. Results: Significant changes were observed from the baseline in the DHI total scale and subscales at 2 weeks and 1, 3, and 6 months in both groups (all p < 0.05). However, the differences between the two groups were not significant (all p > 0.05). Furthermore, we noted significant changes from the baseline in SF-36 scores at 2 weeks in both groups (all p < 0.05), whereas CSF-36 scores were not significantly higher in the SCM group (all p > 0.05) compared with the TM group. No serious AEs were reported in either of the two groups. Conclusions: No differences in outcomes were detected between the SCM and TM groups in terms of treatment of cervicogenic dizziness. Efficacy trials are required to determine whether the improvement observed for each treatment was causally related to the interventions.

A bedside application-based assessment of spatial orientation and memory: approaches and lessons learned

Spatial orientation and memory deficits are an often overlooked and potentially powerful early marker for pathological cognitive decline. Pen-and-paper tests for spatial abilities often do not coincide with actual navigational performance due to differences in spatial perspective and scale. Mobile devices are becoming increasingly useful in a clinical setting, for patient monitoring, clinical decision-making, and information management. The same devices have positional information that may be useful for a scale appropriate point-of-care test for spatial ability. We created a test for spatial orientation and memory based on pointing within a single room using the sensors in mobile phone. The test consisted of a baseline pointing condition to which all other conditions were compared, a spatial memory condition with eyes-closed, and two body rotation conditions (real or mental) where spatial updating were assessed. We examined the effectiveness of the sensors from a mobile phone for measuring pointing errors in these conditions in a sample of healthy young individuals. We found that the sensors reliably produced appropriate azimuth and elevation pointing angles for all of the 15 targets presented across multiple participants and days. Within-subject variability was below 6° elevation and 10° azimuth for the control condition. The pointing error and variability increased with task difficulty and correlated with self-report tests of spatial ability. The lessons learned from the first tests are discussed as well as the outlook of this application as a scientific and clinical bedside device. Finally, the next version of the application is introduced as an open source application for further development.

The potential protective effects of temporal bone pneumatization: A shock absorber in temporal bone fracture

Objectives

We hypothesize that when temporal bone fractures occur, the pneumatic cells in the temporal bone are able to absorb most of the impact force during a traumatic event. This study aims to correlate the degree of pneumatization of the temporal bone with the severity of temporal bone fracture (TBF).

Methods

Charts and computed tomography scans representing 54 TBFs, diagnosed from 2012 to 2017 at a single tertiary hospital, were retrospectively reviewed. Temporal bone pneumatization (TBP) in the petrous apex and mastoid region was evaluated using previously published classification systems. TBP classifications and fracture types were correlated with TBF complications such as sensorineural hearing loss (SNHL), facial nerve palsy (FNP), and vestibular dysfunction.

Results

Patients with increased pneumatization of the temporal bone had significantly fewer and less severe SNHL. SNHL more strongly correlated with the degree of pneumatization in the mastoid (P = 0.005) than that in the petrous apex (P = 0.024). On the other hand, the degree of TBP correlated poorly with FNP and vestibular dysfunction. However, the mastoid hypopneumatization demonstrated significant correlation with otic-capsule violations (P = 0.002). Fractures with otic-capsule violation were 4 times more likely to have vestibular dysfunction (P = 0.043) and 3 times more likely to have SNHL (P = 0.006). FNP was not associated with otic-capsule violating fractures but was 3.5 times more common in comminuted fractures (P = 0.025).

Conclusions

The degree of temporal bone pneumatization was negatively correlated to the incidence of otic-capsule violation and the severity of hearing impairment in patients with temporal bone fracture. This study substantiated the potential protective effect of temporal bone pneumatization in TBFs.

Serum oxidative stress, inflammatory response and platelet activation in patients with vascular vertigo

The aim of this study was to investigate the correlation and clinical significance of oxidative stress and inflammatory response in vascular vertigo (VV). The subjects were divided into three groups: vascular vertigo (group A), non-vascular vertigo (group B) and controls (group C). The serum levels of IL-6 (interleukins-6), SOD (superoxide dismutase), MDA (malondialdehyde) and TNF-α (tumor necrosis factor-α) and CD62P (also called P-Selectin) activation rates were determined and compared among the three groups. The levels of IL-6, TNF-α, MDA and CD62P in group A were significantly higher than those of group B and group C (P less than 0.05). The SOD level of group A was lower than that of group B and group C (P less than 0.05). There was no significant difference between groups B and C in IL-6, TNF- αMDA, SOD and CD62P (P>0.05). In patients with vascular vertigo, TNF-α levels had a weak linear correlation with those of low-density lipoprotein (P = 0.025, r = 0.312). There was no linear correlation between TNF-α and SOD in patients with VV and non-VV. The occurrence of inflammatory reaction and oxidative stress may cause abnormal lipid metabolism in the body and promote the occurrence of VV, and platelet activation may be involved in its formation.

Migraine Associated Vertigo

This chapter is a brief overview of migraine associated vertigo (MAV), focusing on the points most relevant to the practicing clinician. We review the definition of MAV, theories regarding its underlying pathophysiology, clinical presentation, epidemiology, findings on physical examination and oto vestibular testing, differential diagnosis, management and prognosis.

Balance control of children and adolescents suffering from vertigo symptoms: in what way posturography is helpful in clinical evaluation of vestibular system pathology?

PURPOSE

The aim of the study was to determine balance parameters in a group of young patients with vertigo symptoms and to verify posturography helpfulness in clinical evaluation of vestibular system pathology.

METHODS

77 children and adolescents of age 3-18 suffering from vertigo episodes participated in the study (46 girls, 31 boys). They underwent audiology objective tests and balance test on stable surface. Calculated balance parameters were analyzed in reference to: eyes opened and closed, age influence, sway comparison in anterior-posterior and medial-lateral, differences between subgroups with and without vestibular deficits. Discriminant analysis was performed to assess classification ability to impaired group in two cases: only balance parameters and both audiology and balance parameters.

RESULTS

Patients with vertigo symptoms generally keep their balance properly on stable surface. Balance parameters do not depend on presence of vestibular system pathology. Values increased in eyes closed conditions. Left/Right and Anterior/Posterior differences were not statistically significant. The negative correlation between age and some balance parameters is present, stronger in the case of eyes opened and weaker or absent in vestibular impaired group. Also, correlations between axes were found, higher in impaired group in comparison with not impaired one.

CONCLUSIONS

Discrimination based on balance parameters is poor not comparable to one built on combined: audiology and balance parameters, so typical balance parameters' analysis is not so useful in clinical practice when the reason of vertigo episodes should be assessed, but verify compensation process and measure with objective numbers the progress of recovering, the actual functional patient's status.

Veterans have greater variability in their perception of binocular alignment

Introduction

A significant population of our wounded veterans suffer long-term functional consequences of visual deficit, disorientation, dizziness, and an impaired ability to read. These symptoms may be related to damage within the otolith pathways that contribute to ocular alignment. The purpose of this study was to compare perception of vertical and torsional ocular alignment between veterans and healthy controls in an upright and supine test position.

Materials and methods

Veterans (n = 26) with reports of dizziness were recruited from the East Orange Veterans Administration Hospital. Healthy controls (n = 26) were recruited from both Johns Hopkins University and the East Orange VA. Each subject performed 20 trials each of a novel vertical and torsional binocular alignment perception test. Veterans underwent semicircular canal and otolith pathway function testing.

Results

88% of the Veterans had an absent otolith response. Only the veterans had an abnormally large variability in perception of both vertical and torsional ocular alignment, and in both upright and supine position. Neither post-traumatic stress disorder, nor depression contributed to the misperception in binocular alignment.

Conclusions

Our novel method of measuring vertical and torsional misalignment distinguishes veterans with dizziness from healthy controls. The high prevalence of absent otolith function seems to explain this result. Further studies are needed to better understand the fundamental mechanism responsible for the increased variability of perception of binocular alignment.

Vestibular system dysfunction in patients after mild traumatic brain injury

INTRODUCTION

In the literature there are some discrepancies concerning the occurrence of vertigo and disequilibrium, as well as the type of vestibular dysfunction in patients after mild traumatic brain injury (MTBI).

OBJECTIVE

The aim of the study was to assess the type of vestibular system dysfunction in MTBI patients after injury at baseline and 6-month follow-up.

MATERIAL AND METHODS

From a group of 188 patients with vertigo/dizziness and balance instability after MTBI, prospective analysis in 50 patients with abnormal videonystagmography (VNG) were conducted. Anamnesis, otoneurological examination, self-assessed Dizziness Handicap Inventory (DHI) and VNG test were carried in each patient twice - at baseline and after 6 months.

RESULTS

A significant improvement in the DHI total score (9.8 points, p<0.001) and in the subscales was found after 6 months. At baseline, VNG test showed the peripheral vestibular system dysfunction in 19 cases (38%), central vestibular dysfunction in 20 patients (40%) and mixed vestibular dysfunction in 11 cases (44%). After 6 months, the VNG records normalization was observed in 19 patients (38%), an improvement was significantly more frequently related to peripheral disorders, compared to central ones (p,0.001).

CONCLUSIONS

In patients after mild traumatic brain injury, about one-fourth of them had vestibular system dysfunction with the same frequency of peripheral, central and mixed lesions in videonystagmography. Subjective post-traumatic symptoms and vestibular system dysfunction in patients after MTBI decrease after 6-month follow-up. However, more than half of patients still have abnormal VNG results, which indicate dysfunction of the central vestibular system.

Use of HINTS in the acute vestibular syndrome. An Overview

Following the initial description of HINTS to diagnose acute vestibular syndrome (AVS) in 2009, there has been significant interest in the systematic evaluation of HINTs to diagnose stroke and other less common central causes of AVS. This trend increased with availability of the video head impulse test (video-HIT). This article reviews the original papers and discusses the main publications from 2009 to 2017. Many authors use video-HIT in the diagnosis of patients with AVS; this paper focuses on the major publications on the topic featuring nystagmus, manual and video-HIT, and skew deviation. Twenty-five papers provide a summary of the last 8 years' application of HINTS, the video-HIT added quantitative information to the early clinical observations. Further research will undoubtedly provide specific combination of abnormalities with high degree of lesion localisation and aetiology. In a short time following the original description, neurotologist and neurologists in the evaluation of AVS use the HINTS triad. The introduction of the video-HIT added greater understanding of the complex interaction between the primary vestibular afferents, brainstem and cerebellum. In addition, it permits evaluation of the angular vestibulo-ocular reflex in the plane of all six semicircular canals, with accurate peripheral versus central lesion localisation often corroborated by brain imaging.

Early MRI-negative posterior circulation stroke presenting as acute dizziness

The aim of this study was to determine the frequency, clinical and radiological features, and efficacy of clinical evaluation and perfusion-weighted imaging (PWI) for the prediction of final stroke in patients with DWI/MRI-negative posterior circulation stroke (PCS) presenting acute dizziness/vertigo. From our comprehensive prospective stroke registry of acute ischemic stroke during a 7-year period, we identified 1846 consecutive patients with PCS, 850 of whom presented with acute dizziness/vertigo. Of these 850 patients, initial DWI-MRI was negative in 35 (4.1%). In these 35 patients, dizziness/vertigo was acute prolonged in 31 and recurrent transient in 4. Focal neurological signs or profound imbalance were present in 16/35 or 18/34, respectively. Spontaneous nystagmus was absent in 21/35; the HINTS protocol (head impulse, nystagmus, and test-of-skew) was not applicable to them. In 12/26 patients, PWI was positive and the same time as DWI was negative. The usual site of lesion was the lateral medulla (n = 18). Twenty-nine patients (83%) had small strokes, while 19 (54%) had large vessel strokes. The sensitivity of systematic clinical evaluation adopting neurological examination, HINTS plus, and assessment of equilibrium was 83%, for prediction of final stroke and 100% when combined with PWI. An integrated approach using systematic neurological and neuro-otological examinations combined with PWI accurately diagnoses PCS presenting with acute dizziness/vertigo. Although most patients with acute vertigo and MRI-negative PCS have small brainstem strokes, about a half have large vessel stroke with greater risk of progression requiring prompt treatment.

Semicircular Canal Dehiscence Syndrome and Vestibular Dysfunction Disqualify a Military Student Pilot

BACKGROUND

Humans detect motion and gravity via the labyrinthine system of the inner ear, which consists of the vestibule and the semicircular canals. The vestibular system provides three major functions for maintaining balance and orientation. First, it maximizes the effectiveness of the visual system. Second, it provides orientational information necessary for performing both skilled and reflexive motor activities. Third, in the absence of vision, the vestibular system provides a reasonably accurate perception of motion and position. Although these organs provide important cues for basic orientation on the ground, they often provide misleading information during flight. A superior semicircular canal dehiscence can cause an individual to experience disorientation and vertigo-like symptoms.

CASE REPORT

A 30-yr-old male student pilot experienced airsickness on his first several flights in the T-6A Texan II aircraft. Airsickness is common among student pilots in the early stages of flight training; however, the subject pilot's symptoms lasted well beyond the normal 24 h, and included vertiginous symptoms lasting days after his last flight. His persistent symptoms required he be held out of training for further evaluation. Comprehensive vestibular and audiological testing were normal; however, a CT scan of the temporal bones showed a left superior semicircular canal dehiscence, and he was diagnosed with left labyrinthine fistula as the cause of his vertigo. He was medically eliminated from pilot training and permanently disqualified from U.S. Air Force flying duties.

DISCUSSION

Spatial disorientation remains one of the deadliest factors related to aircraft mishaps every year. In this case, an abnormal presentation of airsickness that prompted further evaluation may have prevented a dangerous situation in the air. In standard airsickness, the goal is to keep the pilot flying to expedite adaptation, so this case highlights the importance of distinguishing between normal airsickness and a spatially disorienting medical condition.Dreibelbis JA, Organ BE. Semicircular canal dehiscence syndrome and vestibular dysfunction disqualify a military student pilot. Aerosp Med Hum Perform. 2018; 89(10):923-926.

Benign paroxysmal positional vertigo in patients after mild traumatic brain injury

BACKGROUND

Post-traumatic vertigo, dizziness and balance disorders following head trauma range from 15% to 78% in the general population. Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder in such patients.

OBJECTIVES

The aim of the study was to assess the occurrence of BPPV in patients with mild traumatic brain injury (MTBI) and determine the outcome of treatment.

MATERIAL AND METHODS

A group of 179 patients, with a mean age of 45.2 years, complaining of vertigo/ /dizziness and balance instability after MTBI, was enrolled into the study. All these patients were diagnosed and treated in the Department of Otolaryngology (Medical University of Lodz, Poland) between the years 2012 and 2014. Anamnesis and otoneurological examination were conducted in each patient. The diagnosis was based on the medical history, the Dix-Hallpike test or the rollover test. The treatment comprised the Epley, barbecue and particle repositioning (RM) maneuvers.

RESULTS

Nineteen patients (10.6%) complained about attacks of vertigo elicited by positional changes. The diagnosis of BPPV was confirmed in 9 (47.4%) patients: 8 cases with a positive Dix-Hallpike test and 1 with the roll test. In 10 cases, a high probability of BPPV was diagnosed based on the medical history. Eight patients were treated by a single Epley maneuver and 1 patient by the barbecue roll. In 4 (44.4%) patients, the maneuvers were repeated. On the follow-up examination, the patients were not found to have vertigo.

CONCLUSIONS

Benign paroxysmal positional vertigo should be diagnosed and treated successfully in patients after head trauma.

Aviation Fuel Exposure Resulting in Otitis Externa with Vertigo

BACKGROUND

Otitis externa secondary to irritant or chemical exposure is well documented; however, specifically secondary to jet fuel exposure and its associated toxicology is not. Over 2 million military and civilian personnel per year are occupationally exposed to aviation fuels.

CASE REPORT

An aircraft maintainer presented with noninfectious acute otitis externa secondary to external ear canal exposure to JP-5 jet fuel. Proper exposure guidelines were followed, but it was not realized that the external ear canal was involved. The first symptoms to emerge were vertigo, dizziness, and disequilibrium; however, on physical exam it appeared that there was no middle ear involvement.

DISCUSSION

Otitis externa normally does not present with vestibular symptoms as the pathology affects the external ear canal dermal tissue. Upon review of JP-5's toxicology profile, dermal absorption is a route of entry and can cause general neurological symptoms, including loss of coordination. This case highlights potential deficiencies in the standardized safety data sheets that are used after exposure. Without mention of possible auricular exposure one may focus on the logical protection of the eyes, mouth, and visible skin. This is concerning due to potential delayed exposure symptoms, dermal absorption, high level of dermal destruction, and the close proximity to the sensory system. The goal of this case report is to improve the knowledge of providers caring for personnel who may be exposed and to suggest possible revisions to the Safety Data Sheets for jet fuel.Long RJ, Charles RA. Aviation fuel exposure resulting in otitis externa with vertigo. Aerosp Med Hum Perform. 2018; 89(7):661-663.

Multicenter data banking in management of dizzy patients: first results from the DizzyNet registry project

PURPOSE

Comprehensive phenotypical data across countries is needed to understand the determinants, prognosis and consequences of vestibular disease. The registry is a data repository for the members of the European DizzyNet. We report results from a pilot study using data from Turkey and Germany.

METHODS

The pilot study included a convenience sample of patients aged 18 or above referred to Ege University Medical School Hospital, Dokuz Eylül University Hospital, Izmir, Turkey, and the German Center for German Center for Vertigo and Balance Disorders, University on Munich, Germany, with symptoms of vertigo or dizziness. Health-related quality of life was assessed with the EQ5-D and the Dizziness Handicap Inventory (DHI). To obtain comparable groups we matched data from the two countries for age, sex and diagnosis by propensity score.

RESULTS

We included 80 adult patients, 40 from each country (60% female, mean age 54.1, SD 12.4). Matching was successful. Vestibular migraine (34%) was the most frequent diagnosis, followed by benign paroxysmal positional vertigo (29%) and Menière's disease (12%). Clinical signs and symptoms were comparable in both countries. Patients from Turkey were more likely to report headaches (65 vs. 32%) and to show gait unsteadiness (51 vs. 5%). Patients from Germany reported significantly higher quality of life and lower values of the DHI score.

CONCLUSIONS

Sharing data facilitates research, enhances translation from basic science into clinical applications, and increases transparency. The DizzyNet registry is a first step to data sharing in vestibular research across Europe.

Duplex Sonography of Vertebral Arteries for Evaluation of Patients with Acute Vertigo

We evaluated the role of vertebral artery extracranial color-coded duplex sonography (VAECCS) in predicting vertebrobasilar stroke in consecutive patients presenting to the emergency department with vertigo of suspected ischemic origin. The final diagnosis was established by a panel of experts consisting of an emergency physician, a neurologist, and an otoneurologist. Vertebrobasilar stroke was diagnosed when an acute brain ischemic lesion congruent with symptoms was detected by neuroimaging during the index visit or a stroke was diagnosed within a 3-mo period after emergency department presentation. Among 126 patients, 28 (22%) were diagnosed with vertebrobasilar stroke. Fifteen (75%) of 20 patients with abnormal VAECCS results and 13 (12%) of 106 with normal VAECCS results had a final diagnosis of vertebrobasilar stroke. The sensitivity and specificity of VAECCS were 53.6% and 94.9%, respectively. Detecting an abnormal flow pattern at VAECCS significantly increased the risk of vertebrobasilar stroke (odds ratio = 21.5). The flow patterns most frequently related to vertebrobasilar stroke were absence of flow and high resistance pattern velocity (odds ratio = 9.3 and 22.7, respectively). VAECCS predicts vertebrobasilar stroke and could be a useful bedside screening tool in patients with vertigo.

The Follow-Up Role of the Vestibular Evoked Myogenic Potential Test in Meniere's Disease

Despite some proposed roles for the diagnostic impact of the cervical vestibular evoked myogenic potential test in the patients with Meniere's disease, the role of this test as an objective instrument in following up the patients with Meniere's disease who underwent. Intratympanic steroid injection is not cleared. In a prospective study, thirty-one adult patients with definite one-sided Meniere's disease with vertigo as main complaint refractory to medical treatments for three months, were selected. Patients underwent three times of intratympanic dexamethasone injection with one-week intervals. We performed cervical vestibular evoked myogenic potential test at first and four weeks after the last injection for all participants. We followed the patients for one year. The study results were analyzed with the chi-square test. Cervical vestibular evoked myogenic potential test could not be recorded in 26 patients (83.9%), and the test results were abnormal in the remaining 5 patients. The results were abnormal in the healthy ear of 32.3% of the patients. Despite the clinical improvement of the symptoms after intratympanic injection, the test results were not changed. Cervical vestibular evoked myogenic potential test could not be recorded in the majority of the patients with Meniere's disease; while it is usually recorded in normal ears. On the other hand, results of the cervical vestibular evoked myogenic potential test do not change during the early phase after treatment and could not be a good option for follow up and evaluating the response in this situation.

[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.

[Approach to patients with vertigo]

Vertigo is defined as an abnormal sensation of body motion or of its surrounding objects. It is a common chief complaint in emergency departments comprising 2 to 3% of these consultations worldwide. Vertigo is classified as peripheral or central, according to its origin, and can also be occasionally mixed, the most common cause of peripheral involvement being benign paroxysmal positional vertigo. The initial findings on clinical evaluation of patients are the clues for making a correct diagnosis. The differentiation between central and peripheral vertigo can be optimized by analysing nystagmus, by using the skew test and the head impulse test (HINTS), as also by performing the appropriate tests to evaluate the integrity of the vestibular-cerebellar pathway. In addition, tonal threshold audiometry could raise the diagnostic sensibility from 71 to 89% on initial approach. Appropriate diagnosis is the principal key for managing this clinical condition.

Combined exercise training reduces climacteric symptoms without the additive effects of isoflavone supplementation: A clinical, controlled, randomised, double-blind study

BACKGROUND

Exercise and supplementation with isoflavones are therapies used to prevent and treat climacteric symptoms.

AIM

To verify the effects of 10 weeks of combined aerobic and resistance training and isoflavone supplementation on climacteric symptoms in postmenopausal women.

METHODS

A randomised, double-blind, controlled clinical trial was performed. A total of 32 postmenopausal women, aged 54.4 ± 5.4 years, with a body mass index of 26.6 ± 3.0 kg/m² and 5.6 ± 4.6 years after menopause, were randomly assigned to groups: placebo and exercise (PLA + EXE, n = 15) or 100 mg of isoflavone and exercise (ISO + EXE, n = 17). At the beginning and after 10 weeks of aerobic + resistance (20 min each, moderate intensity) training, climacteric symptoms were evaluated using the Blatt-Kupperman Menopausal Index, Cervantes Scale and Menopause Rating Scale. ANCOVA was used for analysis between groups and at different times, with the covariate adjusted by the pre-value. The level of significance considered was p < 0.05.

RESULTS

A reduction in climacteric symptoms was observed in both groups, without differences between the interventions. The reductions were 45% and 50% for the Blatt-Kupperman Menopausal Index, 41% and 52% for the MRS and 39% and 39% for the Cervantes Scale in the ISO + EXE and PLA + EXE groups, respectively. In the descriptive analysis of the Blatt-Kupperman Menopausal Index values, there was an increase in the absence of symptoms from 48-77% in the ISO + EXE group and 24-58% in the PLA + EXE group.

CONCLUSIONS

A period of 10 weeks of combined training was effective in improving climacteric symptoms in post-menopausal women. However, isoflavone supplementation did not promote additional effects in improving symptoms.

Health-related quality of life and disability in patients with acute unilateral peripheral vestibular disorders

Introduction

Health-related quality of life is used to denote that portion of the quality of life that is influenced by the person's health.

Objectives

To compare the health-related quality of life of individuals with vestibular disorders of peripheral origin by analyzing functional, emotional and physical disabilities before and after vestibular treatment.

Methods

A prospective, non randomized case-controlled study was conduced in the ENT Department, between January 2015 and December 2015. All patients were submitted to customize a 36 item of health survey on quality of life, short form 36 health survey questionnaire (SF-36) and the Dizziness Handicap Inventory for assessing the disability. Individuals were diagnosed with acute unilateral vestibular peripheral disorders classified in 5 groups: vestibular neuritis, Ménière Disease, Benign Paroxysmal Positional Vertigo, cochlear-vestibular dysfunction (other than Ménière Disease), or other type of acute peripheral vertigo (as vestibular migraine).

Results

There was a statistical significant difference for each parameter of Dizziness Handicap Inventory score (the emotional, functional and physical) between the baseline and one month both in men and women, but with any statistical significant difference between 7 days and 14 days. It was found a statistical significant difference for all eight parameters of SF-36 score between the baseline and one month later both in men and women; the exception was the men mental health perception. The correlation between the Dizziness Handicap Inventory and the SF-36 scores according to diagnostics type pointed out that the Spearman's correlation coefficient was moderate correlated with the total scores of these instruments.

Conclusion

The Dizziness Handicap Inventory and the SF-36 are useful, proved practical and valid instruments for assessing the impact of dizziness on the quality of life of patients with unilateral peripheral vestibular disorders.

Dizziness in the Outpatient Care Setting

PURPOSE OF REVIEW

This article summarizes an approach to evaluating dizziness for the general neurologist and reviews common and important causes of dizziness and vertigo.

RECENT FINDINGS

Improved methods of diagnosing patients with vertigo and dizziness have been evolving, including additional diagnostic criteria and characterization of some common conditions that cause dizziness (eg, vestibular migraine, benign paroxysmal positional vertigo, chronic subjective dizziness). Other uncommon causes of dizziness (eg, superior canal dehiscence syndrome, episodic ataxia type 2) have also been better clarified. Distinguishing between central and peripheral causes of vertigo can be accomplished reliably through history and examination, but imaging techniques have further added to accuracy. What has not changed is the necessity of obtaining a basic history of the patient's symptoms to narrow the list of possible causes.

SUMMARY

Dizziness and vertigo are extremely common symptoms that also affect function at home and at work. Improvements in the diagnosis and management of the syndromes that cause dizziness and vertigo will enhance patient care and cost efficiencies in a health care system with limited resources. Clinicians who evaluate patients with dizziness will serve their patient population well by continuing to manage patients with well-focused workup and attentive care.

[The significance of directional preponderance in the evaluation of vestibular function in patients with vertigo]

Objective: To analyze the relationship between directional preponderance (DP), spontaneous nystagmus(SN) and vestibular disorders, and to investigate the significance of DP in directing peripheral vestibular function in patients with vertigo. Methods: This was a retrospective analysis of 394 cases diagnosed with peripheral vestibular disease accompanied by vertigo from March 2012 to June 2014 in the Outpatient Department of the Eye & ENT Hospital of Fudan University. Results of static and dynamic posture equilibrium tests, SN, unilateral weakness(UW), and DP in videonystagmography(VNG) were analyzed and compared. Results: The mean interval time between the last vertigo attack and examination in patients with SN or DP in caloric test were 4.4 d and 7.3 d respectively, and those without SN or DP were 18.3 d and 17.5 d respectively. The patients were divided into two groups according to DP results of caloric test. DP-normal group had 203 cases and DP-abnormal group had 191 cases. Spontaneous nystagmus was presented in 44 cases in the DP-normal group (21.67%) and four in the DP-abnormal group (2.09%). A significant difference was found between the two groups (χ²=35.27, P=0.000). Deficiency of vestibular function was noted in 165 cases in the DP-normal group (81.28%) and 123 (64.40%) in the DP-abnormal group in static and dynamic posture equilibrium tests. The difference between the two groups was statistically significant (χ²=14.26, P=0.000). Conclusion: Compared with DP-normal patients, DP-abnormal patients are more likely to have spontaneous nystagmus and balance disorders due to vestibular dysfunction.

Vestibular click-evoked myogenic potentials: sensitivity and factors determining abnormality in patients with multiple sclerosis

Vestibular evoked myogenic potential (VEMP) assesses the sacculo-spinal pathway. The aim of our study was to examine sensitivity and factors determining abnormality of VEMP, indicative of brainstem dysfunction, in patients with multiple sclerosis (MS). Thirty healthy subjects and 30 MS patients were examined. All healthy subjects showed a normal biphasic response. Twelve of the 30 MS patients (40%) had abnormal recordings. There was a significant difference between MS patients and control subjects with respect to P13 latency (longer in the MS group) and P13-N23 amplitude (lower in the MS group). VEMP abnormalities were statistically significantly related to the presence of brainstem demyelinative lesions and a weaker correlation was found with disease duration. Clinical signs of vestibular dysfunction at any point during the course of the disease did not seem to affect the chances of obtaining abnormal VEMPs. Although the sensitivity of VEMP in detecting abnormality in MS patients is relatively low, its significance is evident in that it is the only electrophysiological method that is able to detect dysfunction in central vestibular pathways. Multiple Sclerosis 2007; 13: 193–198. http://msj.sagepub.com

Balance Ability in Patients with Benign Paroxysmal Positional Vertigo

OBJECTIVE: The purpose of the study was to investigate the balance ability of the patients with benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN AND SETTING: Twenty-three patients (63.3 ± 9.2 years of age) with a diagnosis of unilateral posterior semicircular canal BPPV were recruited. Static balance was measured in 4 conditions with eyes open and eyes closed: stance on firm surface, stance on foam surface, left leg stance, and right leg stance. Dynamic balance was measured in tandem walk test. Data of the patients with BPPV were compared to age-matched norm values of the healthy adults.

RESULTS: The patients with BPPV demonstrated greater sway velocity in stance on foam surface with eyes closed ( P < 0.05), in single leg stance with eyes closed ( P < 0.001), and in tandem walk test ( P < 0.05) compared to the healthy adults.

CONCLUSIONS: Patients with BPPV demonstrated impaired static and dynamic balance ability particularly when depriving visual and changing proprioceptive inputs.

SIGNIFICANCE: Clinically, in addition to canalith repositioning maneuver, balance retraining on different conditions may be a useful adjunct to treatment for patients with BPPV.

Characteristics of hearing loss in patients with herpes zoster oticus

Patients with herpes zoster oticus (HZO) may commonly show symptoms associated with 7th and 8th cranial nerve (CN VII and CN VIII) dysfunction. The aim of this study is to investigate the characteristics of hearing loss in patients with HZO and discuss possible mechanisms.Ninety-five HZO patients who showed at least one of the symptoms of CN VII and CN VIII dysfunction between January 2007 and October 2014 were included in this study. Hearing loss was defined when the mean thresholds of pure tone audiometry (PTA) in speech frequency (0.5 kHz + 1 kHz + 2 kHz/3) or isolated high frequency (4 kHz + 8 kHz/2) were greater than 10 dB in the affected ear compared with the healthy ear, and a total of 72 patients were classified as the hearing loss group.The difference of mean PTA thresholds between affected and healthy ears was significantly greater in the high frequency range than in low range (20.0 ± 11.5 dB vs. 12.9 ± 15.7 dB, P = 0.0026) in patients with hearing loss (n = 72). The difference between affected and healthy ear was significantly greater in patients with vertigo (n = 34) than those without vertigo (n = 38) in both the high (P = 0.033) and low (P = 0.024) frequency ranges. In contrast, the differences between affected and healthy ears were not significantly different between patients with facial palsy (n = 50) and those without facial palsy (n = 22) in both the high (P = 0.921) and low (P = 0.382) frequency ranges.In patients with HZO, hearing loss is more severe in the high frequency range than in the low frequency range. Hearing impairment is more severe in patients with vertigo than in those without vertigo in both the high and low frequency ranges, even though the degree of hearing impairment is not significantly different between patients with and without facial palsy. These findings indicate that the mechanisms of viral spread from CN VII to CN VIII may differ between vestibular and audiologic deficits.

Incidence and localizing value of vertigo and dizziness in patients with epilepsy: Video-EEG monitoring study

Vertigo and dizziness are common neurological complaints that have long been associated with epilepsy. However, studies of patients with epileptic vertigo or dizziness with concurrent EEG monitoring are scarce. We performed the present study to investigate the incidence and localizing value of vertigo and dizziness in patients with epilepsy who had confirmation of EEG changes via video-EEG monitoring. Data of aura and clinical seizure episodes of 831 consecutive patients who underwent video-EEG monitoring were analyzed retrospectively. Out of 831 patients, 40 patients (4.8%) experienced vertigo or dizziness as aura (mean age, 32.8±11.8years), all of whom had partial seizures. Eight had mesial temporal, 20 had lateral temporal, four had frontal, one had parietal, and seven had occipital lobe onset seizures. An intracranial EEG with cortical stimulation study was performed in seven patients, and the area of stimulation-induced vertigo or dizziness coincided with the ictal onset area in only one patient. Our study showed that vertigo or dizziness is a common aura in patients with epilepsy, and that the temporal lobe is the most frequent ictal onset area in these patients. However, it can be suggested that the symptomatogenic area in patients with epileptic vertigo and dizziness may not coincide with the ictal onset area.

Vestibular evoked myogenic potentials in multiple sclerosis: clinical and imaging correlations

Patients with multiple sclerosis (MS) frequently report symptoms related to vestibular disorders in the course of their disease. At present, the fundamental tests assessing vestibulospinal involvement are posturography and vestibular evoked myogenic potentials (VEMPs). While posturography cannot be performed in every subject requiring minimal stance control, VEMPs do not require any specific skill on the part of the subjects and they may be investigated in all patients able to sit. VEMPs were recorded for 40 patients (17 men, 23 women; mean age 38 years, range 17-71 years) fulfilling diagnostic criteria of clinically defined MS, by means of rarefaction clicks, recording modulation of sterno-cleido-mastoideus tonic contraction saccule-mediated modulation. VEMPs were found to be abnormal in 28 of 40 patients. In 18 of the cases the VEMPs were asymmetric, i.e., had a prolonged latency on one side. In six cases latency was increased on both sides (mean delay 4.1 ms). In four subjects VEMPs were absent on one side. C oncordance with clinical findings of presence/absence of brainstem involvement was found in 55% and with MRI findings in 65% of the cases. A bnormal VEMPs indicated brainstem dysfunction in four patients (10%) with normal MRI and no specific clinical signs.

Influence of asymmetry of vestibular caloric response and age on balance and perceived symptoms after acute unilateral vestibular loss

Objective: To evaluate the influence of asymmetry of vestibular caloric response and age on balance and perceived symptoms after acute unilateral vestibular loss.

Design: Prospective study.

Setting: Ear, nose and throat departments in three hospitals.

Subjects: Fifty-four patients (mean age 52 years) with acute unilateral vestibular loss participating in a randomized controlled training study were included.

Main measures: Electronystagmography testing was performed within one week after onset of symptoms and after 10 weeks. The outcome measures clinical static balance tests (sharpened Romberg's test with eyes closed, standing on foam with eyes closed, and standing on one leg with eyes open and closed) and subjective symptom ratings on a visual analogue scale were done after one week, 10 weeks and six months. The correlation between age and asymmetry of vestibular caloric response, respectively, and the outcome measures were analysed.

Results: Greater caloric asymmetry correlated with poorer performance at the sharpened Romberg's test and standing on one leg with eyes closed at all three follow-ups (rho=-0.31 to -0.54), and with higher symptom ratings at the 10-week and six-month follow-ups (rho=0.30-0.60). Higher age was associated with poorer performance on the sharpened Romberg's test and standing on one leg at all three follow-ups (rho=0.31-0.64), but did not change over time. Higher age was also associated with higher ratings of vertigo at the six-month follow-up, and less reduction of vertigo between the 10-week and six-month follow-ups (rho=0.29-0.48).

Conclusions: A higher degree of asymmetry of vestibular caloric response and high age seem to be associated with poor outcome in balance and perceived symptoms after acute unilateral vestibular loss.