Diagnostic and therapeutic strategies for vestibular neuritis of the Japan Society for Equilibrium Research

OBJECTIVE

To provide diagnostic and therapeutic strategies for vestibular neuritis in accordance with the Japanese Clinical Practice Guidelines for Vestibular Neuritis 2021.

METHODS

The Committee for Clinical Practice Guidelines for Vestibular Neuritis was entrusted with a review of the relevant scientific literature on the above topic. Clinical Questions (CQs) concerning the treatment of vestibular neuritis were produced, and a search of the literature was conducted to identify studies related to the CQs. The recommendations were based on the literature review and the expert opinion of a subcommittee.

RESULTS

We proposed the diagnostic criteria for vestibular neuritis, as well as answers to CQs, recommendations, and evidence levels for the treatment of vestibular neuritis.

CONCLUSION

The diagnostic criteria for vestibular neuritis were based on clinical history and examination findings after completing the differential diagnosis process. The treatment of vestibular neuritis was divided into acute, subacute, and chronic stages. The Japanese Clinical Practice Guidelines for Vestibular Neuritis 2021 should be used as a reference in the diagnosis and treatment of vestibular neuritis.

Neurological update: neuro-otology 2023

Much has changed since our last review of recent advances in neuro-otology 7 years ago. Unfortunately there are still not many practising neuro-otologists, so that most patients with vestibular problems need, in the first instance, to be evaluated and treated by neurologists whose special expertise is not neuro-otology. The areas we consider here are mostly those that almost any neurologist should be able to start managing: acute spontaneous vertigo in the Emergency Room-is it vestibular neuritis or posterior circulation stroke; recurrent spontaneous vertigo in the office-is it vestibular migraine or Meniere's disease and the most common vestibular problem of all-benign positional vertigo. Finally we consider the future: long-term vestibular monitoring and the impact of machine learning on vestibular diagnosis.

Vestibular Neuritis: Recent Advances in Etiology, Diagnostic Evaluation, and Treatment

Purpose of Chapter: This chapter highlights the recent advances in etiology, diagnostic evaluation, and management of vestibular neuritis (VN). Recent Findings: The viral hypothesis has been strengthened with new evidence as the main etiology of VN. Recent evidence indicates that bedside oculomotor findings play a critical role in differentiating VN from stroke. The implementation of cervical and ocular vestibular evoked myogenic potential, and video head impulse test in vestibular function testing has made it possible to diagnose selective damage of the vestibular nerves. The management of the acute phase of VN is primarily medical, while long-term treatment is designed to improve vestibular compensation. Summary: VN is clearly defined as an important viral inner ear disorder.

[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.

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: 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.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

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.

Visual dependency and dizziness after vestibular neuritis

Symptomatic recovery after acute vestibular neuritis (VN) is variable, with around 50% of patients reporting long term vestibular symptoms; hence, it is essential to identify factors related to poor clinical outcome. Here we investigated whether excessive reliance on visual input for spatial orientation (visual dependence) was associated with long term vestibular symptoms following acute VN. Twenty-eight patients with VN and 25 normal control subjects were included. Patients were enrolled at least 6 months after acute illness. Recovery status was not a criterion for study entry, allowing recruitment of patients with a full range of persistent symptoms. We measured visual dependence with a laptop-based Rod-and-Disk Test and severity of symptoms with the Dizziness Handicap Inventory (DHI). The third of patients showing the worst clinical outcomes (mean DHI score 36-80) had significantly greater visual dependence than normal subjects (6.35° error vs. 3.39° respectively, p = 0.03). Asymptomatic patients and those with minor residual symptoms did not differ from controls. Visual dependence was associated with high levels of persistent vestibular symptoms after acute VN. Over-reliance on visual information for spatial orientation is one characteristic of poorly recovered vestibular neuritis patients. The finding may be clinically useful given that visual dependence may be modified through rehabilitation desensitization techniques.

Is vestibular neuritis an immune related vestibular neuropathy inducing vertigo?

OBJECTIVES

To review the current knowledge of the aetiology of vestibular neuritis including viral infections, vascular occlusion, and immunomediated mechanisms and to discuss the pathogenesis with relevance to pharmacotherapy.

SYSTEMATIC REVIEW METHODOLOGY

Relevant publications on the aetiology and treatment of vestibular neuritis from 1909 to 2013 were analysed.

RESULTS AND CONCLUSIONS

Vestibular neuritis is the second most common cause of peripheral vestibular vertigo and is due to a sudden unilateral loss of vestibular function. Vestibular neuronitis is a disorder thought to represent the vestibular-nerve equivalent of sudden sensorineural hearing loss. Histopathological studies of patients who died from unrelated clinical problems have demonstrated degeneration of the superior vestibular nerve. The characteristic signs and symptoms include sudden and prolonged vertigo, the absence of auditory symptoms, and the absence of other neurological symptoms. The aetiology and pathogenesis of the condition remain unknown. Proposed theories of causation include viral infections, vascular occlusion, and immunomediated mechanisms. The management of vestibular neuritis involves symptomatic treatment with antivertiginous drugs, causal treatment with corticosteroids, and physical therapy. Antiviral agents did not improve the outcomes.

[Vestibular neuritis: treatment and prognosis]

Vestibular neuritis is a sudden unilateral peripheral vestibular deficit of unknown origin without associated hearing loss. It is the second cause of peripheral vertigo after Benign Paroxysmal Positional Vertigo (BPPV). The etiology remains unclear and some treatments are still controversial. The prognosis is good. The differential diagnosis of the disease mainly includes an acute vertigo of central origin. This article summarizes the management and prognosis of vestibular neuritis.

[Vestibular neuronitis: pathophysiology, diagnosis and treatment]

Vestibular neuritis (VN) is one of the most common causes of peripheral vertigo. Caloric testing has been the traditional gold standard for detecting a peripheral vestibular deficit, but some recently developed bedside tests (head thrust, head heave, head shake and vibration test) were evaluated as a good alternative with similar sensitivity and specificity. These tests have shown both diagnostic value in the short term and prognostic value in the long term, and have availability and ease of use as an advantage. As an addition to clinical examination, vestibular evoked myogenic potentials can differentiate between involvement of superior and inferior branch of the vestibular nerve, but also between peripheral and central lesions. Although glucocorticoids are currently widely used in the treatment of VN, there is a lack of evidence for the validity of their administration. There are a number of high quality clinical trials that suggest vestibular rehabilitation exercises, which are based on the mechanisms of vestibular compensation, in the managment of VN. This review will focus on the latest developments in the pathophysiology, diagnosis and treatment of patients with VN.

Clinical and epidemiological study on inpatients with vertigo at the ENT Department of Kyoto University Hospital

CONCLUSION

The number of studies on inpatients with vertigo is limited. This study provides useful information for clarifying the underlying causes of vertigo.

OBJECTIVE

To investigate the epidemiological features of patients with vertigo.

METHODS

This retrospective study investigated 78 patients who had been emergently hospitalized in the Otolaryngology Department of Kyoto University Hospital with vertigo.

RESULTS

The number of female patients was significantly higher than the number of male patients. Meniere's disease was the most common underlying pathology among hospitalized patients. Mean patient age was 56.1 years, with no significant difference between male and female patients.

[Vestibular neuritis]

Vestibular neuritis is the second most common cause of peripheral vestibular vertigo. Its assumed cause is a reactivation of herpes simplex virus type 1 infection. Methylprednisolone significantly improves the recovery of peripheral vestibular function in patients with vestibular neuritis. Clinical studies suggest that specific vestibular exercises improve vestibulo-spinal and vestibulo-ocular compensation in patients with vestibular neuritis. This review discusses the above and comments etiology, epidemiology, pathophysiology, diagnostic procedures and differential diagnosis.

Late and sudden recovery of sudden deafness or vestibular neuronitis

INTRODUCTION

Vestibular neuronitis (VN) and sudden deafness (SD) are well-defined entities. The abrupt appearance of symptoms in both disorders represents an important element for the diagnosis. In cases of VN, symptoms regress gradually over time as the peripheral function recovers, or the central nervous system compensates for the balance deficit. In cases of SD, the recovery occurs in about half the cases and is generally progressive. The chances to recover normal levels of hearing are better if the recovery occurs early after the onset of the deficit. The goal of the paper is to present new insights of these disorders based on four unusual cases and on an evaluation of the delay for the function's recovery.

MATERIAL AND METHODS

1) We report two cases of VN and two of SD whose the recovery was late and sudden; 2) The recovery time after a SD was retrospectively analysed using the chart of 36 patients seen<or=24 hours after the onset of the deficit, who recovered hearing, and who had undergone at least one audiogram per month up to 6 months after the deficit, whether treated or not.

RESULTS

Twenty-eight patients recovered hearing within 6 months following the deficit. In eight patients, an audiogram was performed months later and showed a normalization of hearing. In these patients, the exact time of the recovery remained unknown.

CONCLUSION

A few patients may recover their inner ear function more than 6 months after the deficit. The recovery of function after SD or VN does not always follow the generally accepted pattern, as it can be late and sudden. These observations raise new questions to the hypothetical etiologies of SD and VN.

Simultaneous acute superior nerve neurolabyrinthitis and benign paroxysmal positional vertigo

An acutely vertiginous 47-year-old woman presented to the emergency department with simultaneous acute left neurolabyrinthitis and left posterior canal benign paroxysmal positional vertigo (BPPV). Gaze nystagmus from the neurolabyrinthitis hampered diagnosis of the BPPV. However, once the BPPV was identified and treated, the patient's subjective vertigo improved rapidly. Concomitant BPPV should not be overlooked when a diagnosis of acute neurolabyrinthitis is made in the emergency department.

[Childhood peripheral vestibular disorders: a report of three cases]

Vertigo is uncommon in childhood. Its etiology is different from that of adults. Both central and peripheral disorders may give rise to vertigo symptoms in pediatric patients. The evaluation of vertigo in children requires a detailed history taking, clinical examination, audiometric assessment, and vestibular function tests. We present three pediatric patients with vertigo symptoms, together with treatment methods and results of treatment. Their ages ranged from 10 to 14 years. The diagnoses were vestibular neuritis in one patient, and benign paroxismal positional vertigo in two patients. Treatment was comprised of vestibular rehabilitation for vestibular neuritis, and canalith repositioning maneuver for benign paroxismal positional vertigo. All the patients benefited well from the procedures applied.

Treatment and rehabilitation in vestibular neuritis

During the acute phase, symptomatic treatment is practically the only option, and a wide variety of drugs are available. For years, much has been focused on the possibility of using corticosteroids in the treatment of vestibular neuritis. Clearly, if we suspect an inflammatory cause, a treatment that reduces that inflammatory process would, if not reduce the severity of the attack, at least help recovery. If the different studies on this matter failed to concord in many aspects, they do however agree that the use of corticosteroids in the acute phase entails long term beneficial effects for the recovery of vestibular function and allows for a better vestibular compensation. The second part of the treatment is the rehabilitation. In my experience most of the patients undergo a spontaneous vestibular compensation in a short time. Nevertheless, some exercises of visual fixation while the patient is still bed-ridden, can accelerate the recovery process. Those patients, in whom certain instability persists, who are too anxious after their experience or those who will demand this type of treatment, are candidates to undergo a rehabilitative vestibular program. In this paper I will comment on the instrumental and non-instrumental techniques that I use in my daily practice.

[Recurrent paroxystic vertigo]

The author describes the pathology, the symptoms and the treatment of these vertigo.

Visual Vertigo: an Observational Case Series of Eleven Patients

BACKGROUND

Dizziness is a common symptom which is frequently due to either peripheral or central vestibular dysfunction. However, some patients may lack typical signs suggesting a vestibular or cerebellar lesion and they mostly complain of vertigo or posture imbalance induced by visual stimulation. The symptoms immediately improve either on cessation of the visual input or upon closure of the eyes. Such a presentation is typical of visual vertigo.

PATIENTS AND METHODS

From 1993 to 2003, 242 patients were examined for either "vertigo" or "dizziness". The diagnosis of visual vertigo was based on both history and clinical examination and was present in 11 patients.

RESULTS

Visual vertigo was diagnosed in 11/242 patients (4.5 %). Age range was 31 - 77 years (mean 47 years) with a sex ratio of 8 females for 3 males. Neuro-ophthalmological examination was normal in all cases.

CONCLUSIONS

Visual vertigo is not a rare condition but the disease is underdiagnosed. The symptoms result from a mismatch between vestibular, proprioceptive and visual inputs. Neuro-ophthalmological, neurological and neuro-otological examination are often normal or not relevant and the diagnosis is largely based on history. It is important to recognize this entity because the symptoms might improve if the patients are treated with psycho-motor rehabilitation.

Walk-rotate-walk test identifies patients responding to Lempert's maneuver, with benign paroxysmal positional vertigo of the horizontal canal

Two hundred and fifteen patients were diagnosed and treated for benign paroxysmal positional vertigo of the horizontal canal (BPPV-HC). All patients were tested with conventional positional nystagmus tests lying supine and rotating head for geotropic nystagmus, registered with Frenzels glasses, and in 109 cases with ENG. The walk-rotate-walk (WRW) test, developed by one of us (T.R.) and described in the text, was applied to all patients. The immediate good treatment results with Lempert's maneuver verify the correct diagnosis of BPPV-HC. The WRW test is a more sensitive test for BPPV-HC than earlier positional tests. The unhabituated acute phase of vestibular neuritis shows positive test results and must be eliminated with caloric tests. The WRW test identifies as a dynamic test patients with symptoms of even lesser magnitude, where the compensatory capacity of the equilibrium system suppresses the diagnostic findings with earlier positional horizontal canal tests.

Distinguishing and treating causes of central vertigo

A patient's dizziness can be caused by a peripheral vestibular disorder, VIIIth nerve compression, brain stem ischemia, or cerebellar stroke. Clues from the history and physical examination are mentioned, and diagnostic entities, such as demyelination, cerebrovascular disease, migraine, Arnold-Chiari malformation, cerebellar degeneration, and neoplastic disease are discussed. Treatment options are outlined so that therapeutic and diagnostic trials can be initiated. Guidelines are offered for when to image the brain or posterior circulation vasculature and when a patient with acute vertigo should be admitted for observation.