Vestibular function is associated with immune inflammatory response

Association between vestibular function and immune inflammatory response has garnered increasing interest. Immune responses can lead to anatomical or functional alterations of the vestibular system, and inflammatory reactions may impair hearing and balance. Vestibular disorders comprise a variety of conditions, such as vestibular neuritis, benign paroxysmal positional vertigo, Meniere's disease, vestibular migraine, posterior circulation ischemia, and bilateral vestibular disease. Moreover, some patients with autoimmune diseases develop vestibulocochlear symptom. This paper offers an overview of prevalent vestibular diseases and discusses associations between vestibular dysfunction and immune diseases.

Effects of high-dose betahistine on intractable dizziness in patients with uncompensated unilateral vestibulopathy

OBJECTIVE

In the present study, we examined the effects of high-dose betahistine on dizziness handicap inventory (DHI) scores in patients with unilateral vestibulopathy.

METHODS

An uncontrolled, open-label, multicenter clinical trial was conducted. Fifteen patients with unilateral vestibulopathy, such as vestibular neuritis, who complained of intractable dizziness for more than three months were enrolled. Initially, all patients were orally administered betahistine at a dose of 36 mg/day for four weeks, which is the standard dose and dosing period for the treatment of dizziness in Japan. The patients were then administered betahistine at a double dose of 72 mg/day for four weeks. Six patients who became aware of the benefits of high-dose betahistine were further administered betahistine at 72 mg/day for an additional 12 weeks (a total of 16 weeks). Perceived disability due to dizziness was assessed by DHI scores.

RESULTS

In all 15 patients, short-term administration with high-dose (72 mg/day) betahistine for four weeks, but not low-dose betahistine (36 mg/day) for four weeks significantly decreased DHI scores. In particular, in six responding patients with self-reported benefits after short-term administration with high-dose betahistine, long-term administration with high-dose betahistine for 16 weeks further significantly decreased DHI scores. However, DHI scores of the remaining nine non-responding patients were not changed after short-term administration with high-dose betahistine for four weeks.

CONCLUSION

Short-term administration with the standard dose and dosing period of betahistine did not improve DHI scores in the enrolled patients, indicating that they were not compensated for unilateral vestibulopathy with intractable dizziness. The present findings suggest that long-term administration with high-dose betahistine facilitates vestibular compensation to improve intractable dizziness in some, but not all patients with uncompensated unilateral vestibulopathy.

The co-existence of peripheral and vestibular neuropathy in diabetes: a cross-sectional study

PURPOSE

Diabetic neuropathy can lead to decreased peripheral sensation and motor neuron dysfunction associated with impaired postural control and risk of falling. However, the relationship between decreased peripheral sensation and impaired vestibular function in diabetes mellitus is poorly investigated. Therefore, the aim of this study was to investigate the relationship between peripheral and autonomic measurements of diabetic neuropathy and measurements of vestibular function.

METHODS

A total of 114 participants with type 1 diabetes (n = 52), type 2 diabetes (n = 51) and controls (n = 11) were included. Vestibular function was evaluated by video head impulse testing. Peripheral neuropathy was assessed by quantitative sensory testing and nerve conduction. Autonomic neuropathy using the COMPASS 31 questionnaire. Data were analyzed according to data type and distribution.

RESULTS

Measurements of vestibular function did not differ between participants with type 1 diabetes, type 2 diabetes or controls (all p-values above 0.05). Subgrouping of participants according to the involvement of large-, small- or autonomic nerves did not change this outcome. Correlation analyses showed a significant difference between COMPASS 31 and right lateral gain value (ρ = 0.23, p = 0.02,), while no other significant correlations were found.

CONCLUSION

Diabetic neuropathy does not appear to impair vestibular function in diabetes, by means of the VOR.

CLINICAL TRIALS

NCT05389566, May 25th, 2022.

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.

Post Cochlear Implantation Vertigo: Ictal Nystagmus and Audiovestibular Test Characteristics

OBJECTIVE

To investigate ictal nystagmus and audiovestibular characteristics in episodic spontaneous vertigo after cochlear implantation (CI).

STUDY DESIGN

Retrospective and prospective case series.

PATIENTS

Twenty-one CI patients with episodic spontaneous vertigo after implantation were recruited.

INTERVENTIONS

Patient-initiated home video-oculography recordings were performed during one or more attacks of vertigo, using miniature portable home video-glasses. To assess canal and otolith function, video head-impulse tests (vHITs) and vestibular-evoked myogenic potential tests were conducted.

MAIN OUTCOME MEASURES

Nystagmus slow-phase velocities (SPVs), the presence of horizontal direction-changing nystagmus, and post-CI audiovestibular tests.

RESULTS

Main final diagnoses were post-CI secondary endolymphatic hydrops (48%) and exacerbation of existing Ménière's disease (29%). Symptomatic patients demonstrated high-velocity horizontal ictal-nystagmus (SPV, 44.2°/s and 68.2°/s in post-CI secondary endolymphatic hydrop and Ménière's disease). Direction-changing nystagmus was observed in 80 and 75%. Two were diagnosed with presumed autoimmune inner ear disease (SPV, 6.6°/s and 172.9°/s). One patient was diagnosed with probable vestibular migraine (15.1°/s).VHIT gains were 0.80 ± 0.20 (lateral), 0.70 ± 0.17 (anterior), and 0.62 ± 0.27 (posterior) in the implanted ear, with abnormal values in 33, 35, and 35% of each canal. Bone-conducted cervical and ocular vestibular-evoked myogenic potentials were asymmetric in 52 and 29% of patients (all lateralized to the implanted ear) with mean asymmetry ratios of 51.2 and 35.7%. Reversible reduction in vHIT gain was recorded in three acutely symptomatic patients.

CONCLUSION

High-velocity, direction-changing nystagmus time-locked with vertigo attacks may be observed in post-CI implant vertigo and may indicate endolymphatic hydrops. Fluctuating vHIT gain may be an additional marker of a recurrent peripheral vestibulopathy.

Vestibular Nucleus Involvement in Patients With Acute Vertigo Due to Herpes Zoster Oticus or Vestibular Neuritis

OBJECTIVES

Herpes zoster oticus (HZO) typically provokes vestibular symptoms and is traditionally viewed as a cranial nerve equivalent of shingles, but in contrast to vestibular neuritis (VN), it is unclear whether the pathology of HZO is limited to the vestibular nerve (neuritis) or can also involve the brainstem (nucleitis).

METHODS

We retrospectively compared brain MRIs of patients with HZO with those of patients with VN to study radiologic changes in the brainstem.

RESULTS

Five of 10 patients with HZO showed signal abnormalities in the vestibular nuclei, which lie in multiple vascular territories, whereas no patients with VN exhibited such findings.

DISCUSSION

HZO may at least in part reflect vestibular nucleitis, as opposed to a pure neuritis.

[Demographic and epidemiological risk factors in patients with acute vestibular neuritis]

OBJECTIVE

Vestibular neuritis (VN) is one of the most common peripheral vestibular balance disorder. Demographic and other risk factors associated with VN are insufficiently published. Therefore, the aim of this study is to identify associated risk factors in patients with acute VN.

METHODS

This study evaluated all hospitalized VN cases between 2017-2019. Inclusion criteria was an otoneurologically confirmed diagnosis of acute VN. Patient data was compared with data of the German normal population (Robert Koch Institute, "Gesundheit in Deutschland aktuell").

RESULTS

168 patients (Ø 59.8 years) were included. Compared with the normal German population, the study population was significantly more likely to have preexisting cardiovascular diseases, and the male patients were significantly more likely to have arterial hypertension. No significant differences were measurable between the study population and the normal population for other secondary diseases. Leukocytosis was present in 23% on admission, and 9% of patients reported a history of VZV or HSV-1 disease.

DISCUSSION

Etiology and pathogenesis of VN are poorly understood. Inflammatory and vascular causes are discussed. In this study, patients had increased prevalence of cardiovascular disease compared with the normal population, but the study population had a higher average age. Currently, it is unclear what significance nonspecific elevated leukocyte values could have as a possible sign of VN triggered by an infection. Since the number of inpatient cases with VN is rising, prospective studies should be performed to get a better understanding of the pathogenesis of the disease.

Acute vestibular neuritis may provoke atrial fibrillation

BACKGROUND

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

AIMS

To highlight that VN can provoke acute AF.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Vertigo symptom scores and videonystagmographic examinations in recovered coronavirus disease 2019 patients

OBJECTIVE

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may be among the viral agents that affect the audio-vestibular system. This study aimed to investigate vestibular symptoms and videonystagmographic examinations in recovered coronavirus disease 2019 (Covid-19) patients compared with the control group.

METHOD

The patients were evaluated with Vertigo Symptom Scale questionnaire and audiometric, tympanometric, stapedial reflex and videonystagmographic examinations.

RESULTS

A total of 92 of the patients in the coronavirus disease 2019 patients group and 25 of the volunteers in the control group were included in the study. The mean Vertigo Symptom Scale score was found to be significantly higher (p < 0.001) in the coronavirus disease 2019 group. Furthermore, one of the hospitalised patients was diagnosed with vestibular neuritis.

CONCLUSION

The vestibular system may also be affected in some coronavirus disease 2019 patients. Although this may be seen as dizziness in some patients, in rare cases it can cause severe issues, such as vestibular neuritis.

Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study

OBJECTIVES

We aimed to determine the frequency of vestibular syndromes, diagnoses, diagnostic errors and resources used in patients with dizziness in the emergency department (ED).

DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Adult patients presenting with dizziness.

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected clinical data from the initial ED report from July 2015 to August 2020 and compared them with the follow-up report if available. We calculated the prevalence of vestibular syndromes and stroke prevalence in patients with dizziness. Vestibular syndromes are differentiated in acute (AVS) (eg, stroke, vestibular neuritis), episodic (EVS) (eg, benign paroxysmal positional vertigo, transient ischaemic attack) and chronic (CVS) (eg, persistent postural-perceptual dizziness) vestibular syndrome. We reported the rate of diagnostic errors using the follow-up diagnosis as the reference standard.

RESULTS

We included 1535 patients with dizziness. 19.7% (303) of the patients presented with AVS, 34.7% (533) with EVS, 4.6% (71) with CVS and 40.9% (628) with no or unclassifiable vestibular syndrome. The three most frequent diagnoses were stroke/minor stroke (10.1%, 155), benign paroxysmal positional vertigo (9.8%, 150) and vestibular neuritis (9.6%, 148). Among patients with AVS, 25.4% (77) had stroke. The cause of the dizziness remained unknown in 45.0% (692) and 18.0% received a false diagnosis. There was a follow-up in 662 cases (43.1%) and 58.2% with an initially unknown diagnoses received a final diagnosis. Overall, 69.9% of all 1535 patients with dizziness received neuroimaging (MRI 58.2%, CT 11.6%) in the ED.

CONCLUSIONS

One-fourth of patients with dizziness in the ED presented with AVS with a high prevalence (10%) of vestibular strokes. EVS was more frequent; however, the rate of undiagnosed patients with dizziness and the number of patients receiving neuroimaging were high. Almost half of them still remained without diagnosis and among those diagnosed were often misclassified. Many unclear cases of vertigo could be diagnostically clarified after a follow-up visit.

Recurrent Vestibulopathy: Comparison of Vestibular Test Results with Ménière’s Disease and Vestibular Migraine

<b><i>Introduction:</i></b> Recurrent and episodic vestibular symptoms not fulfilling criteria for known episodic vestibular syndromes are named as recurrent vestibulopathy (RV). We aimed to compare the vestibular test results of RV patients with vestibular migraine (VM) and Ménière’s disease (MD). <b><i>Methods:</i></b> Twenty patients with MD, 20 patients with VM, 18 patients with RV, and 20 healthy volunteers (HC) were evaluated. Pure-tone hearing thresholds (PTHTs), video head impulse test (vHIT), functional head impulse test (fHIT), and cervical vestibular evoked myogenic potentials (cVEMPs) were studied. <b><i>Results:</i></b> PTHT of the MD-affected ears were significantly high, and cVEMP-corrected amplitudes were low when compared with the VM, RV, and HC (<i>p</i> &#x3c; 0.001 for all). Amplitude asymmetry ratio was significantly high in MD-affected ears when compared with the HC (<i>p</i> = 0.014), VM (<i>p</i> = 0.038), and RV (<i>p</i> = 0.045). VEMP latencies and lateral canal vHIT gain were not different between groups (<i>p</i> &#x3e; 0.05). The percentage of correctly identified optotypes on fHIT of the MD (<i>p</i> &#x3e; 0.001), VM (<i>p</i> = 0.004), and RV (<i>p</i> = 0.001) patients were low in comparison with the HC. <b><i>Conclusion:</i></b> Apart from hearing loss, low cVEMP amplitudes on the affected side were the main feature in MD differentiating it from VM and RV. Vestibular test results of patients with RV and VM were similar. Low fHIT results in all groups indicate a functional deficit in gaze stabilization. Disabling vertigo attacks disturbing attention may be the cause of this functional impairment. MD, VM, and RV may be parts of a broad-spectrum disorder, RV patients representing milder forms not associated with cochlear or migrainous features.

[Serum 25-hydroxyvitamin D expression and its correlation in patients with vestibular neuritis]

Objective:To investigate the expression level of serum 25-（OH） D and its correlation in patients with vestibular neuritis（VN）. Methods:30 acute VN patients and 50 age-and sex-matched healthy controls who attended the Otolaryngology, Head and Neck Surgery Department of the First Hospital of Shanxi Medical University from October 2020 to October 2021 were selected. The demographic and clinical data of all subjects were recorded, the levels of serum 25-（OH） D and inflammatory markers were measured and compared, and the changes of serum 25-（OH） D levels in convalescent patients with VN were followed up. Results:The serum level of 25-（OH） D in the acute phase VN group was significantly lower than that in healthy controls[（10.14±2.92） ng/mL vs （20.61±4.70） ng/mL, P<0.01], and the deficiency rate of 100.0%（30/30） was significantly higher than 54.0%（27/50）. Moreover, the serum level of 25-（OH） D in the recovery period（3 months later） was significantly higher[（10.14±2.92） ng/mL vs （15.94±4.88） ng/mL, P<0.01], and the deficiency rate was significantly decreased by 76.7%（23/30）. However, the serum 25-（OH） D level was significantly lower in both the VN group than that in both the acute period and the recovery group, and the deficiency rate was significantly higher than that in the control group. Multivariate binary Logistic regression model analysis showed that low-level serum 25-（OH） D was associated with the onset of VN, with an OR value of 0.193（95%CI=0.043-0.861, P=0.031）. In addition, the results of this study showed that peripheral blood leukocyte（WBC） and neutrophil / lymphocyte ratio（NLR） levels in the acute VN group were significantly higher than in healthy controls[（7.65±3.02） ×10⁸/L vs （5.50±2.50） ×10⁸/L, P<0.01; （2.46±2.95） ×100% vs（1.67±0.92） ×100%, P<0.01 ], and there was no significant difference in Platelet / lymphocyte ratio（PLR） and and average platelet volume（MPV） levels in the two groups（P>0.05）. There were no significant differences in age distribution, sex ratio, body mass index, persistent health problems, or lifestyle groups（P>0.05）. Conclusion:This study is the first to detect serum 25-（OH） D level and inflammation index level, and dynamically assess the serum 25-（OH） D level in different stages, found that low serum 25-（OH） D is associated with the onset of VN, physiological concentration of serum 25-（OH） D is a protective factor of VN, vitamin D supplementation therapy may be a new target of VN treatment.

Is Inadequate Water Intake a Risk Factor for Vestibular Disorders?

BACKGROUND

Water is a vital nutrient for the human body system and failing to consume enough water could cause health problems. The purpose of this study is to investigate the relationship between water intake and vestibular system disorders.

METHODS

Data from 93 patients (aged between 20 and 76 years) with vestibular disorders were analyzed in the study. The mean age of the patients was 46.96 ±13.94 years (female: 45.68 ±13.45, male: 49.96 ±14.85), and 69.9% (n=65) were female. Participants were sub-categorized into diagnostic groups as follows: benign paroxysmal positional vertigo, Meniere's disease, vestibular neuritis, vestibular migraine, and persistent postural perceptual dizziness. The water intake information was analyzed for total water, plain water, and caffeinated beverages separately and compared between groups.

RESULTS

There was a significant difference between vestibular neuritis and benign paroxysmal positional vertigo (P < .001) and also between vestibular neuritis and Meniere's disease (P = .021) in terms of the intake values of plain water and total water. No significant difference was found between groups in caffeinated beverages intake (P = .151), and it was found that there is no statistically significant difference in plain water and total water intake in terms of gender (P > .05).

CONCLUSION

The most significant result of this study is that inadequate water intake can be a risk factor for some forms of peripheral vestibular disorders. People should be informed about the importance of drinking water and be encouraged to increase their water intake.

Effects of stabilizing reversal technique and vestibular rehabilitation exercise on dizziness and balance ability in patients with vestibular neuritis: An observational study

Vestibular neuritis is a common disease of peripheral dizziness. Studies have shown that vestibular rehabilitation exercise (VRE) and proprioceptive neuromuscular facilitation (PNF) are effective to treat the symptoms of vestibular neuritis. However, the effect of VRE and PNF on the balance ability and dizziness in this patient cohort remains unclear.The aim of our observational study was to determine the changes in dizziness and balance ability of patients with vestibular neuritis who participated in the VRE program with stabilizing reversal technique (SRT).The reporting of this study conforms to the STROBE statement. Ten men and women aged ≥ 20 years who were diagnosed with vestibular neuritis were included. Patients performed VRE with SRT for 4 weeks with assistance from a therapist. VRE without SRT can also be performed at home. Dizziness was evaluated using the dizziness handicap inventory (DHI) and visual analog scale (VAS). Balance ability was assessed using the Berg's balance scale (BBS) and timed up and go test (TUG). At pre- and post-exercise, paired t test was performed to compare the within-group differences.After the program, DHI (45.40 ± 6.74 to 21.00 ± 7.07), VAS (5.90 ± 1.20 to 2.80 ± 0.92), BBS (45.10 ± 2.77 to 52.70 ± 1.83), and TUG (15.29 ± 1.13 to 12.06 ± 1.61) scores improved significantly in the VRE program group (P = .05).The VRE program combined with SRT was effective in reducing dizziness and increasing balance ability in patients with vestibular neuritis.

Cerebellar ataxia, neuropathy, vestibular areflexia syndrome due to RFC1 repeat expansion

Ataxia, causing imbalance, dizziness and falls, is a leading cause of neurological disability. We have recently identified a biallelic intronic AAGGG repeat expansion in replication factor complex subunit 1 (RFC1) as the cause of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) and a major cause of late onset ataxia. Here we describe the full spectrum of the disease phenotype in our first 100 genetically confirmed carriers of biallelic repeat expansions in RFC1 and identify the sensory neuropathy as a common feature in all cases to date. All patients were Caucasian and half were sporadic. Patients typically reported progressive unsteadiness starting in the sixth decade. A dry spasmodic cough was also frequently associated and often preceded by decades the onset of walking difficulty. Sensory symptoms, oscillopsia, dysautonomia and dysarthria were also variably associated. The disease seems to follow a pattern of spatial progression from the early involvement of sensory neurons, to the later appearance of vestibular and cerebellar dysfunction. Half of the patients needed walking aids after 10 years of disease duration and a quarter were wheelchair dependent after 15 years. Overall, two-thirds of cases had full CANVAS. Sensory neuropathy was the only manifestation in 15 patients. Sixteen patients additionally showed cerebellar involvement, and six showed vestibular involvement. The disease is very likely to be underdiagnosed. Repeat expansion in RFC1 should be considered in all cases of sensory ataxic neuropathy, particularly, but not only, if cerebellar dysfunction, vestibular involvement and cough coexist.

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.

Examination of patients with acute dizziness in a neurological department

BACKGROUND

Acute dizziness may have a number of causes, including cerebrovascular stroke which can present as isolated acute vestibular syndrome. It is recommended that acute episodic dizziness be assessed using positioning tests, and acute persistent dizziness with a focus on the HINTS (Head Impulse, Nystagmus, Test of Skew) battery of tests, which can distinguish cerebrovascular stroke from vestibular neuritis. We wished to identify the prevalence, diagnostic spectrum and approach to acute dizziness in a neurological department.

MATERIAL AND METHOD

We undertook a retrospective review of the medical records of all patients with acute dizziness as the primary symptom who where admitted to the department of neurology at Sørlandet Hospital, Kristiansand in 2015.

RESULTS

Of 2 231 patients admitted to the department of neurology in 2015, altogether 243 (11 %) had dizziness as the primary symptom. A total of 106 patients (44 %) were examined using HINTS in its entirety. A cranial CT was performed in 213 (88 %) and MRI in 91 (37 %), and these showed relevant pathology in 1 and 4 patients, respectively. Upon discharge, 122 patients (50 %) were given a non-specific symptom diagnosis, 59 (24 %) received the diagnosis vestibular neuritis, 41 (17 %) benign paroxysmal positional vertigo, and 5 (2 %) were diagnosed with cerebrovascular stroke. Four out of five cases of cerebrovascular stroke could be classified retrospectively as acute vestibular syndrome, whereof three had typical findings determined by the HINTS test.

INTERPRETATION

Acute dizziness is a frequent symptom in patients admitted to the department of neurology. Evidence-based diagnostic recommendations for the assessment of acute dizziness were not satisfactorily implemented in practice.

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.

[Advances in peripheral vestibular diseases with downbeat nystagmus]

Downbeat nystagmus is not rare and usually considered as a central nervous system disease. However, there are a lot of diseases that present with downbeat nystagmus only or downbeat component in nystagmus, including peripheral and central vestibular diseases and Chiari malformations. This review will briefly summarize the vestibulo ocular reflexes and the mechanisms of the downbeat nystagmus with a peripheral origin, and then common vestibular disease such as the anterior semicircular canal benign paroxysmal positional vertigo,posterior semicircular canal benign paroxysmal positional vertigo, posterior semicircular canal light cupula, Meniere's disease and inferior vestibular neuritis are reviewed.

[Etiological characteristics analysis of 3 137 outpatients with vertigo or dizziness in ENT department]

Objective: To analyze the etiological characteristics of patients in department of ENT with chief complaint of vertigo or dizziness in order to reduce the rate of misdiagnosis and wrong treatment. Method: A total of 3 137 patients in department of ENT with chief complaint of vertigo or dizziness from Sep 2015 to Sep 2017 were included and the etiologies were clarified retrospectively. And in which with any of the 8 kinds of disease including benign paroxysmal positional vertigo(BPPV), vestibular neuritis, vestibular migraine (VM), Meiniére disease, recurrent vestibular disease, sudden deafness with vertigo, psychogenic vertigo, posterior circulation ischemia (PCI) together 2 138 patients were further stratified analyzed by gender and age. Result: ①Etiological characteristics of patients with vertigo or dizziness：among the 3 137 patients with vertigo or dizziness in ENT department in our hosipital, the peripheral diseases of vestibular were the most common disease with a total of 1 607 cases, accounting for 51.23%. And there were 506 cases of the central diseases of vestibular accounting for 16.13%, 382 cases of other systemic diseases accounting for 12.18%, 85 cases（2.71%）of psychogenic vertigo, 557 cases （17.76%）of unknown etiology. ②Analysis of the frequent and serious causing of patients with vertigo or dizziness: among the 2 138(68.15%) patients with vertigo or dizziness, BPPV with a total of 827 cases (26.36%) was the most prevalent,while 215(25.99%) of them were diagnosed as self-cured BPPV,vestibular neuritis and VM were the second prevalent with 420 cases (13.39%) and 329 cases (10.49%) respectively, Meiniére disease, recurrent vestibular disease, sudden deafness with vertigo were the third prevalent with 209 cases (6.66%), 144 cases (4.59%), 102 cases (3.25%), respectively; well psychogenic vertigo and PCI were relatively rare, with respectively 85 cases (2.71%) and 22 cases (0.70%). Eotiology analysis stratified by age: The causes of vertigo or dizziness were ranged with age, and patients of 50-70 years old were most common with a total of 1 011 cases, accounting for 49.6%. Etiology analysis stratified by gender: There was gender difference in patients with vertigo or dizziness,such as BPPV, VM, recurrent vestibular disease, sudden deafness with vertigo and psychogenic vertigo were common in female, while PCI in male insteadly. Conclusion: ①Among the patients with vertigo or dizziness, the pheripheral diseases of vestibular are the most prevalent, in which BPPV takes the highest accidence. ②Patients ranging from 50 to 70 years old take the main parts in patients with vertigo or dizziness. And there is an obvious gender difference in patients with BPPV, VM, recurrent vestibular disease, sudden deafness with vertigo, psychogenic vertigo and PCI.

Binocular cyclotorsion in superior vestibular neuritis

SUMMARY

Conjugated cyclotorsion of the eyes toward the affected side can commonly be observed in vestibular neuritis. The aim of this study was to assess the differences in cyclotorsion between the ipsi- and contralesional eye during selective involvement of the superior branch of the vestibular nerve. We studied binocular cyclotorsion through ocular fundus photographs in 10 patients affected by acute superior vestibular neuritis (SVN). Cyclotorsion was also studied in 20 normal subjects. All SVN patients showed an ipsilesional cycloversion of the eyes. Normal subjects exhibited a constant mild excyclovergence (6.42 ± 2.34°). In SVN patients, contralateral incyclotorsion (8.4 ± 8.14°) was lower and not normally distributed compared to ipsilateral eye excyclotorsion (17.9 ± 4.36°) with no correlation between them. The interocular difference in cyclodeviation could be related to the starting physiological excyclovergence, to different tonic effects on the extraocular muscles of the two eyes and to the different influence of spontaneous nystagmus on cyclodeviation in the two eyes. We recommend referring only to ipsilateral excyclotorsion in the evaluation of utricular function during SVN and its subsequent compensation. Further studies are required to determine the binocular cyclotorsion in the case of other kinds of selective involvement of the vestibular nerve.

[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.

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Zusammenfassung. Schwindel ist nach Kopfschmerzen eines der häufigsten Symptome, die zu einem Arztbesuch führen. Ausgehend von dieser Tatsache stellen sich ca. 25 % der Patienten mit akuten Schwindelbeschwerden in einer Notfallaufnahme vor. Die Herausforderung der betreuenden Kollegen besteht darin, ein akut zentral-vestibuläres Syndrom nicht zu übersehen, was verheerende Folgen mit sich bringen könnte. Eine sorgfältige und strukturierte Anamneseerhebung zusammen mit der klinischen Untersuchung trägt bereits zu ca. 90 % zur Diagnosestellung bei und ist sensitiver als die diffusionsgewichtete Kernspintomografie. Der Fokus der Anamnese liegt bei der Dauer der Symptome und deren Triggerfaktoren. Ein Bedside-Test, bestehend aus Kopfimpulstest, Nystagmusprüfung, Test auf Skew und zusätzliche Hörprüfung mittels Fingerreiben, hilft bei der differenzialdiagnostischen Eingrenzung im Hinblick auf die Differenzierung zwischen akutem zentralen und peripheren Schwindelsyndrom.

Treatment of peripheral vestibular dysfunction using photobiomodulation

Gentamicin, which is still used in modern medicine, is a known vestibular toxic agent, and various degrees of balance problems have been observed after exposure to this pharmacologic agent. Photobiomodulation is a candidate therapy for vertigo due to its ability to reach deep inner ear organs such as the cochlea. Previous reports have suggested that photobiomodulation can improve hearing and cochlea function. However, few studies have examined the effect of photobiomodulation on balance dysfunction. We used a rat model to mimic human vestibulopathy resulting from gentamicin treatment and evaluated the effect of photobiomodulation on vestibular toxicity. Slow harmonic acceleration (SHA) rotating platform testing was used for functional evaluation and both qualitative and quantitative epifluorescence analyses of cupula histopathology were performed. Animals were divided into gentamicin only and gentamicin plus laser treatment groups. Laser treatment was applied to one ear, and function and histopathology were evaluated in both ears. Decreased function was observed in both ears after gentamicin treatment, demonstrated by low gain and no SHA asymmetry. Laser treatment minimized the damage resulting from gentamicin treatment as shown by SHA asymmetry and recovered gain in the treated ear. Histology results reflected the functional results, showing increased hair cell density and epifluorescence intensity in laser-treated cupulae.

Dizziness: Approach to Evaluation and Management

Dizziness is a common yet imprecise symptom. It was traditionally divided into four categories based on the patient's history: vertigo, presyncope, disequilibrium, and light-headedness. However, the distinction between these symptoms is of limited clinical usefulness. Patients have difficulty describing the quality of their symptoms but can more consistently identify the timing and triggers. Episodic vertigo triggered by head motion may be due to benign paroxysmal positional vertigo. Vertigo with unilateral hearing loss suggests Meniere disease. Episodic vertigo not associated with any trigger may be a symptom of vestibular neuritis. Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment. The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies. The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver. Laboratory testing and imaging are not required and are usually not helpful. Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver). Treatment of Meniere disease includes salt restriction and diuretics. Symptoms of vestibular neuritis are relieved with vestibular suppressant medications and vestibular rehabilitation.

[Frequency and position characteristics of the vestibular dysfunction in vestibular neuritis patients]

Objective:To investigate frequency and position characteristics of the vestibular dysfunction in vestublar neuritis patients. Method:Colaric test (CT), head impulse test (HIT), cervical vestibular evoked myogenic potential (cVEMP) and ocular vestibular evoked myogenic potential (oVEMP) were applied in 43 vestublar neuritis patients to assess their vestublar dysfunction. Superior vestublar nerve (S-VN), inferior vestibular nerve (I-VN), total vestibular nerve (T-VN) and each vestibular end organ incidence rate were calculated and statistically analyzed. Result:CT incidence rate (93.0%) was statistically higher than that of HIT (72.1%) (P<0.01). Total frequency incidence rate (72.1%) was statistically higher than that of low frequency (20.9%) (P<0.01). No high frequency only case was observed. The incidence rate of S-VN only, I-VN only and T-VN was 44.2%, 4.7% and 51.2% respectively. Among them, the incidence rate of I-VN was significantly lower than the others (P<0.01). The incidence rate of vestibular end organs was 17.4% (S-SCC), 44.2% (H-SCC), 20.9% (P-SCC), 39.5% (utricule) and 26.7% (saccule) respectively. The incidence rate of H-SCC was remarkably higher than the other semicircular canals (P<0.01). The difference between utricule and saccule was not statistically significant. Conclusion:The semicricular canal dysfunction in vestibular neuritis patients mainly involves total frequency of vestibular function, low frequency is more common than high frequency. Total vestibular nerve and single S-VN are mostly involved in vestibular neuritis.

An approach to vertigo in general practice

BACKGROUND

Dizziness is a common and very distressing presentation in general practice. In more than half of these cases, the dizziness is due to vertigo, which is the illusion of movement of the body or its surroundings. It can have central or peripheral causes, and determining the cause can be difficult.

OBJECTIVE

The aim of this article is to provide a clear framework for approaching patients who present with vertigo. A suggested approach to the assessment of vertigo is outlined.

DISCUSSION

The causes of vertigo may be central (involving the brainstem or cerebellum) or peripheral (involving the inner ear). A careful history and physical examination can distinguish between these causes. The most common causes of vertigo seen in primary care are benign paroxysmal positional vertigo (BPPV), vestibular neuronitis (VN) and Ménière's disease. These peripheral causes of vertigo are benign, and treatment involves reassurance and management of symptoms.

You're the Flight Surgeon: vestibular neuritis

Brown MR. You're the flight surgeon: vestibular neuritis. Aerosp Med Hum Perform. 2016; 87(2):150-152.

[Neuritis vestibularis can be a cause of vertigo among children]

Neuritis vestibularis (NV) as a cause of vertigo is common among adults but very rare among children and is often underrecognized and underdiagnosed. Viral infection is suspected to be the most common cause and symptoms are sudden onset of vertigo, nausea, vomiting, impaired balance and horizontal nystagmus. This case report describes a three-year-old boy diagnosed with NV. To our knowledge it is the first case diagnosed in Denmark.

[Peripheral vertigo versus central vertigo. Application of the HINTS protocol]

INTRODUCTION

One of the most important dilemmas concerning vertigo in emergency departments is its differential diagnosis. There are highly sensitive warning signs in the examination that can put us on the path towards finding ourselves before a case of central vertigo.

AIM

To determine how effective the application of the HINTS protocol is in the diagnosis of cerebrovascular accidents that mimics peripheral vertigo.

PATIENTS AND METHODS

We conducted a descriptive observation-based study on patients admitted to hospital with a diagnosis of acute vestibular syndrome in the emergency department. All the patients were monitored on a day-to-day basis until their symptoms improved, with information about nystagmus, the oculocephalic manoeuvre and the skew test. The results from the magnetic resonance imaging study were compared with the alteration of any of those three signs during the time the patient was hospitalised.

RESULTS

Altogether 91 patients were examined, with a mean age of 55.8 years. A cerebrovascular accident was observed in eight cases. Of these (mean age: 71 years), in seven of them there were alterations in some of the HINTS signs, and in one case the study was normal (sensitivity: 0.88; specificity: 0.96). All of them had some vascular risk factor.

CONCLUSIONS

Faced with a patient who visits the emergency department with an acute vestibular syndrome, a suitably directed examination is essential to be able to establish the differential diagnosis between peripheral and central pathology, since some cerebrovascular accidents can present with the appearance of acute vertigo. Applying a protocol like HINTS makes it possible to suspect the central pathology with a high degree of sensitivity and specificity.

Dizziness in the elderly: diagnosing its causes in a multidisciplinary dizziness unit

We conducted a study to determine the causes of dizziness in patients aged 70 years and older who had been referred to our multidisciplinary dizziness clinic between Nov. 1, 2000, and Dec. 31, 2008. This population was made up of 731 patients--254 men (34.7%) and 477 women (65.3%). During their consultations, all of these patients were evaluated simultaneously by an ENT surgeon and a neurologist. We were able to identify the cause of dizziness in 620 of these patients (84.8%). The two most common causes were benign paroxysmal positional vertigo (BPPV), which was found in 202 patients (27.6%), and hyperventilation/anxiety, which was diagnosed in 112 patients (15.3%). Based on our findings, we conclude that the cause of dizziness can be established in the vast majority of elderly patients. We also compare our findings in these older patients with those of a group of 2,556 younger patients who were seen at our hospital and with the findings reported in other studies.

[Malfunction of the inner ear is the most frequent cause of dizziness]

Half of all dizziness patients suffer from a malfunction of the inner ear and benign paroxysmal positional vertigo causes 25-30% of these malfunctions. During the latest two decades new vestibular test equipment has been developed and has made it possible to refine the vestibular diagnoses and consequently treat patients more efficiently. This brief overview describes the benefit of Epley's Omniax Chair, video head impulse tests and the Vestibular Autorotation Test. The need for vestibular rehabilitation programmes and for a closer collaboration between physicians and the social authorities is pointed out.

Caloric test and video-head-impulse: a study of vertigo/dizziness patients in a community hospital

The head-impulse test (HIT) is an important test for examining unilateral vestibular hypofunction. The new video-head-impulse test (vHIT) is more sensitive and specific than the clinical bedside-head-impulse test (bHIT). Alternatively, one can test for vestibular hypofunction with the caloric irrigation test. Various studies showed that both tests may not always identify vestibular hypofunction; instead, the results of the tests might be contradictory. To evaluate the diagnostic value of these tests, we routinely measured patients exhibiting vertigo or dizziness at our community hospital with bithermal caloric irrigation, the bHIT and the vHIT. Only those patients (n = 172) with a pathological caloric irrigation test of more than 25 % unilateral weakness in the Jongkee's formula were included. Out of these patients, 41 % had a pathologic vHIT. Among the subgroup with acute symptoms (symptom onset within 5 days), 63 % had a pathological video-head-impulse, whereas only 33 % of the non-acute group (symptom onset more than 5 days) tested pathological. A pathological HIT depended on the disease stage, the amount of unilateral weakness in caloric examination and on the test itself.

Diagnosing the cause of vertigo: a practical approach

Dizziness is among the commonest of chief complaints. It often presents a significant challenge to the attending physician, because the symptoms and signs are often vague and non-specific. However, a robust systematic approach can usually arrive at the diagnosis. Maintaining balance requires sensory inputs from the vestibular, visual, and somatosensory systems and the cerebellum fine-tunes inaccurate motor outputs. Causes of vertigo are most commonly otological, followed by central, somatosensory, and visual. The first question in approaching patients with dizziness is to categorise dizziness into one of the four groups: lightheadedness, pre-syncope, disequilibrium, and vertigo. Secondly, central vertigo has to be differentiated with peripheral vertigo. For peripheral vertigo, the most common cause is benign paroxysmal positional vertigo and should be specifically looked for. The tempo of the vertiginous attacks and other associated symptoms can help differentiate the other causes of peripheral vertigo, including Meniere's disease, vestibular neuronitis, labyrinthitis, and a perilymph fistula.

Recurrence of vertigo in patients with vestibular neuritis

CONCLUSION. The recurrence rate of vertigo due to any cause in patients with vestibular neuritis (VN) was about 26.0% in our study. No clinical characteristics were significantly associated with recurrences.

OBJECTIVE

We aimed to: 1) determine the prevalence of recurrent VN; 2) compare the clinical characteristics and epidemiologic factors of patients with non-recurrent and recurrent VN; and 3) determine the prevalence of benign paroxysmal positional vertigo (BPPV) in patients with VN.

METHODS

In 131 patients diagnosed as having VN (68 males, aged 49.8 ± 14.9 years and 63 females, aged 57.5 ± 12.5 years), a retrospective chart review and telephone survey about the recurrent vertigo were performed. Vestibular function testing, inner ear magnetic resonance imaging (MRI), and pure tone audiograms were performed on every patient. Vestibular function testing was repeated in patients with recurrences.

RESULTS

Fourteen of 131 patients (10.7%) had recurrent VN. The subjective intensity of recurrent VN was less than the first attack. There were no significant differences in clinical characteristics such as accompanying headache or preceding respiratory infection and in epidemiologic risk factors between patients with recurrent and non-recurrent VN. Twenty of 131 patients (15.3%) experienced BPPV during the follow-up period.

Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support?

OBJECTIVES

Dizziness is a common presenting complaint to the emergency department (ED), and emergency physicians (EPs) consider these presentations a priority for decision support. Assessing for nystagmus and defining its features are important steps for any acute dizziness decision algorithm. The authors sought to describe nystagmus documentation in routine ED care to determine if nystagmus assessments might be an important target in decision support efforts.

METHODS

Medical records from ED visits for dizziness were captured as part of a surveillance study embedded within an ongoing population-based cohort study. Visits with documentation of a nystagmus assessment were reviewed and coded for presence or absence of nystagmus, ability to draw a meaningful inference from the description, and coherence with the final EP diagnosis when a peripheral vestibular diagnosis was made.

RESULTS

Of 1,091 visits for dizziness, 887 (81.3%) documented a nystagmus assessment. Nystagmus was present in 185 of 887 (20.9%) visits. When nystagmus was present, no further characteristics were recorded in 48 of the 185 visits (26%). The documentation of nystagmus (including all descriptors recorded) enabled a meaningful inference about the localization or cause in only 10 of the 185 (5.4%) visits. The nystagmus description conflicted with the EP diagnosis in 113 (80.7%) of the 140 visits that received a peripheral vestibular diagnosis.

CONCLUSIONS

Nystagmus assessments are frequently documented in acute dizziness presentations, but details do not generally enable a meaningful inference. Recorded descriptions usually conflict with the diagnosis when a peripheral vestibular diagnosis is rendered. Nystagmus assessments might be an important target in developing decision support for dizziness presentations.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Three-dimensional video-oculography in patients with vestibular neuritis

CONCLUSIONS

The nystagmus recorded without visual fixation contained all three components in most patients with vestibular neuritis (VN). The nystagmus was unidirectional, strongly visually suppressed with the loss of vertical component in most patients, and it obeyed Alexander's law. Video-oculography (VOG) is a non-invasive tool for detailed analysis of nystagmus, and hence may improve differential diagnostics in dizzy patients.

OBJECTIVE

To characterize three-dimensional nystagmus findings in patients with acute VN using the VOG technique.

PATIENTS AND METHODS

A prospective study in 16 patients with VN was carried out in a tertiary referral centre. Nystagmus was measured on average 3 days after the beginning of symptoms. Subjective assessment of dizziness and quality of life was performed. The slow phase velocity, frequency, visual suppression and gaze position dependency of nystagmus were analysed.

RESULTS

The mean slow phase velocity without visual fixation was 7.7+/-2.3 degrees /s in horizontal, 3.4+/-1.6 degrees /s in vertical, and 3.5+/-1.6 degrees /s in torsional plane, and it decreased significantly with visual fixation to 1.5+/-1.0 degrees /s (p<0.000), 0.2+/-0.4 degrees /s (p=0.001), 1.6+/-1.2 degrees /s (p=0.004), respectively. The nystagmus was unidirectional, and horizontal gaze shifts enhanced or suppressed it on average 1.5 degrees /s per 10 degrees . Quality of life score of 3.7+/-0.7 improved significantly (p=0.002) to 1.5+/-0.5 during the follow-up period.

Who is at risk for ongoing dizziness and psychological strain after a vestibular disorder?

Patients with vestibular vertigo syndromes often suffer from anxiety and depression, whereas patients with psychiatric disorders often experience subjective unsteadiness, dizziness, or vertigo. Thus, it has been hypothesized that the vestibular system may be interlinked with the emotion processing systems. The aim of the current study was to evaluate this hypothesis by correlating vestibular and psychiatric symptoms with the course of the disease over 1 year. This interdisciplinary, prospective, longitudinal study included a total of 68 patients with acute vestibular vertigo syndromes. Four subgroups of patients with benign paroxysmal positioning vertigo (BPPV, n=19), acute vestibular neuritis (VN, n=14), vestibular migraine (VM, n=27), or Menière's disease (MD, n=8) were compared. All patients underwent neurological and neuro-otological examinations and filled out standardized self-report inventories including the Vertigo Symptom Scale (VSS), the Vertigo Handicap Questionnaire (VHQ) and the Symptom Checklist 90R (GSI, SCL-90R) at five different times (T0-T4) in the course of 1 year. VM patients experienced significantly more "vertigo and related symptoms" (VSS-VER), "somatic anxiety and autonomic arousal" (VSS-AA), and "vertigo induced handicap" (VHQ) than all other patients (P<0.001-P=0.006). Patients with a positive history of psychiatric disorders had significantly more emotional distress (GSI, SCL-90R), regardless of the specific phenomenology of the four diagnostic subgroups. Finally, fluctuations of vestibular excitability correlated positively with the extent of subjectively perceived vertigo. VM patients are significantly more handicapped by vertigo and related symptoms. They show significantly elevated fluctuations of vestibular excitability, which correlate with the (subjective) severity of vertigo symptoms.

Dizziness, a review of walk-in patients at a specialised neurotology clinic

A retrospective review of 100 walk-in patients at a specialized neurotology clinic in dizziness at a tertiary referral centre is presented. The most common cause of dizziness was BPPV, forming 31% of the cases. Other causes in order of frequency include recurrent vestibulopathy, idiopathic causes, Meniere's disease and central causes.

[Gaze-evoked suppression of the vestibular-ocular reflex in patients with posterior cervical sympathetic syndrome]

This vestibulometric (sinusoidal rotation) study included patients with posterior cervical sympathetic syndrome (n=40) and with vestibular neuronitis (n=20) as well as 20 healthy subjects of the control group. Vestibular dysfunction was induced by the method proposed by de Klein. The patients with posterior cervical sympathetic syndrome in the decompensation phase displayed abnormal gaze-evoked suppression of the vestibular-ocular reflex when their head movements lined up with sinusoidal rotation. This symptom is considered to be of primary value for the diagnosis of vestibular dysfunction in these patients.

Evaluation of patients with acute vestibular syndrome

Acute vestibular syndrome is characterized by a rapid unilateral injury to either peripheral or central vestibular structures. It consists of severe vertigo, nausea and vomiting, spontaneous nystagmus, and postural instability. In many cases, a peripheral etiology is considered although it may be due to an underlying serious central pathology. The present study was designed to investigate the feasibility of differentiating the cause of acute vestibular syndrome in such patients using clinical, audiovestibular and radiologic tools. We performed a case series study of patients complaining of acute vertigo at a university referring center for hearing and balance disorders. Thirty patients with history of acute vertigo within 3 days onset with no history of previous otological or neurological disorders. Eighteen patients were due to acute peripheral vestibular lesion, 1 due to psychiatric illness under antidepressant drugs and 11 were of central vestibular lesion. The most important step in the diagnosis of acute vertigo is a thorough and detailed history. The common error of carrying out investigations in place of a detailed history is to be avoided. The clinical evaluation has the highest sensitivity and specificity in differentiating central from peripheral vestibular lesions.

Predicting continued dizziness after an acute peripheral vestibular disorder

OBJECTIVE

To identify individuals at risk of developing ongoing dizziness 3 months after an acute peripheral vestibular disorder episode, which is usually functionally compensated or even healed within a few weeks.

METHODS

In a prospective longitudinal study, we assessed fear of bodily sensations and cognitions related to anxiety at the time of hospital admission and 3 months later in 43 patients with an episode of vestibular neuritis (VN) or benign paroxysmal positional vertigo (BPPV). All participants were assessed for mental disorders using a structured clinical interview.

RESULTS

Only the interaction between fear of bodily sensations within the first 2 weeks after admission and the type of vestibular disorder predicted the extent of dizzy complaints 3 months later; this accounts for 21% of the variance in a multiple regression analysis. Specifically, the prediction was valid only in patients with VN but not in patients with BPPV. Further analysis demonstrated that the interaction was not due to the peripheral vestibular disorder per se but rather determined by the initial severity of dizziness, which was significantly different in BPPV and VN patients.

CONCLUSIONS

The present study demonstrates that, for the development of persistent psychogenic dizziness after a peripheral vestibular disorder, the fear of bodily sensations is only relevant in interaction with the initial severity of dizziness experienced during the acute organic episode. To prevent development of persistent psychogenic dizziness, we feel that our results indicate the need to screen patients with vestibular disorders for at-risk status and offer them psychological support to deal with their symptoms.

Subjective visual horizontal in patients with posterior canal benign paroxysmal positional vertigo

CONCLUSION

Patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) could have mild excitation in the vestibular system on the affected side.

OBJECTIVE

p-BPPV is considered to be caused by small particles dislodged from the utricular macula. While subjective visual horizontal (SVH) mainly reflects utricular function, there is less documentation on SVH in patients with p-BPPV. The purpose of this study was to clarify whether p-BPPV could affect SVH.

PATIENTS AND METHODS

Twenty-eight patients with unilateral idiopathic p-BPPV were enrolled. For comparison, 17 patients with vestibular neuritis and 45 patients with cerebello-pontine angle (CPA) tumor were also examined. For measurement of SVH, we used a device that has a red bar of light-emitting diodes (LEDs) in front of the patient. Subjects were asked to rotate the bar to the position that they felt was horizontal in a completely dark room.

RESULTS

Deviation of SVH toward the unaffected side down was seen in 82.1% (23/28) of patients with p-BPPV. Mean+/-SD deviation of SVH from the true horizontal to the unaffected side down was 0.49+/-1.21 degrees. Conversely, deviation of SVH was toward the affected side down in 88.2% of patients with vestibular neuritis and in 75.6% of patients with CPA tumor.

[Frequently occurring forms of dizziness and their treatment]

Dizziness is not a unique clinical picture, but rather is the unspecific symptom of numerous diseases. Dizziness always develops when the real incoming vestibular, visual and somatosensory information contradict each other and the expected input signals. Disorders of the vestibular apparatus are the most frequent cause of dizziness; in contrast, cervicogenic causes play a secondary role. Dizziness syndromes usually have a favourable prognosis and can be successfully treated.