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.

Vestibular Disorders

BACKGROUND

Recent research findings have improved the understanding of the diagnosis, pathophysiology, genetics, etiology, and treatment of peripheral, central, and functional vestibular vertigo syndromes.

METHOD

A literature search, with special attention to the current classification, treatment trials, Cochrane analyses, and other meta-analyses.

RESULTS

There are internationally accepted diagnostic criteria for benign positional paroxysmal vertigo, Menière's disease, bilateral vestibulopathy, vestibular paroxysmia, and functional dizziness. Whether an acute vestibular syndrome is central or peripheral can usually be determined rapidly on the basis of the history and the clinical examination. "Cere - bellar vertigo" is a clinically important entity. For bilateral vestibulopathy, balance training is an effective treatment. For Menière's disease, preventive treatment with betahistine (48 mg and 144 mg per day) is not superior to placebo. For vestibular paroxysmia, oxcarbazepine has been shown to be effective. Treatments that are probably effective for functional dizziness include vestibular rehabilitation, cognitive behavioral therapy, and serotonin reuptake inhibitors.

CONCLUSION

The diagnostic assessment of vestibular syndromes is much easier for clinicians now that it has been internationally standardized. There is still a lack of randomized, controlled trials on the treatment of, for example, Menière's disease, vestibular migraine, and "cerebellar vertigo."

Benign paroxysmal positional vertigo: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society

This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.

Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society

This paper presents diagnostic criteria for persistent postural-perceptual dizziness (PPPD) to be included in the International Classification of Vestibular Disorders (ICVD). The term PPPD is new, but the disorder is not. Its diagnostic criteria were derived by expert consensus from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. PPPD manifests with one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for three months or more and are exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. PPPD may be precipitated by conditions that disrupt balance or cause vertigo, unsteadiness, or dizziness, including peripheral or central vestibular disorders, other medical illnesses, or psychological distress. PPPD may be present alone or co-exist with other conditions. Possible subtypes await future identification and validation. The pathophysiologic processes underlying PPPD are not fully known. Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and threat assessment. Thus, PPPD is classified as a chronic functional vestibular disorder. It is not a structural or psychiatric condition.

Classification of postural disorders and spinal deformities in the three dimensions according to computer optical topography

The appearance of surface topography has opened up new opportunities for population-based studies of postural disorders and spinal deformities. In Russia such study began in 1996 and nowadays a large amount of statistical data on the pediatric population has been accumulated. Analysis of the postural disorder and spinal deformity varieties has allowed us to create a new classification of these disorders. Classification is based on three-dimensional estimation of the trunk and on the orthopedic division of structural scoliosis into 4 grades assumed in Russia.

Development of guideline for rating the physical impairment of otolaryngologic field

We develop a guideline for rating the physical impairment of otolaryngologic fields. Assessment of hearing disturbance and tinnitus required physical examination, pure tone audiometry, speech audiometry, impedance audiometry, brainstem evoked response audiometry, Bekesy audiometry, otoacoustic emission test, and imaging examination. History taking, physical examination, and radiological examination for the vestibular organ and brain, righting reflex test, electronystagmography, and caloric test are taken for evaluation of balance disorder. Olfactory function tests include University of Pennsylvania Smell Identification test, Connecticut Chemosensory Clinical Research Center test, T and T olfactometry and Korean Version of Sniffin's Sticks test. Medical history and physical examination is mandatory to evaluatezseverity of respiration difficulty. Examinations include flexible fiberoptic nasopharyngoscope, bronchoscopy, simple soft-tissue radiography films of upper airway and high resolution computed tomography. Evaluation of mastication and swallowing are history taking, physical examination, examination for upper jaw, lower jaw, and temporomandibular joint, dental examination and radiological studies. Endoscopy and esophagography are also needed. Voice disorder is evaluated based on physical examination, oral pharynx and larynx endoscopy, larynx stroboscopy, hearing assessment, laryngeal electromyography, sound analysis test, aerodynamic test, electroglottography, and radiologic examination. Articulation disorder is assessed by picture consonant articulation test. These are position articulation test, Lee-Kim Korean articulation picture and speech intelligibility assessment.

Clinical evaluation of elderly people with chronic vestibular disorder

Dizziness is common among the elderly.

Aim

To characterize social, demographic, clinical, functional and otoneurological data in elderly patients with chronic vestibular disorder.

Method

A sequential study of 120 patients with chronic vestibular disorder. Simple descriptive analyses were undertaken.

Results

Most of the patients were female (68.3%) with a mean age of 73.40±5.77 years. The average number of illnesses associated with the vestibular disorder was 3.83±1.84; the patients were taking on average 3.86±2.27 different medications. The most prevalent diagnosis on the vestibular exam was unilateral vestibular loss (29.8%) and the most prevalent etiology was metabolic vestibulopathy (40.0%) followed by benign paroxysmal positional vertigo (36.7%). Fifty-two patients (43.3%) had experienced dizziness for 5 years or more. Sixty-four patients (53.3%) had at least one fall in the last year and thirty-five (29.2%) had recurrent falls.

Conclusions

Most of the sample included females with associated diseases, and using many different drugs. The most prevalent vestibular diseases were metabolic and vascular labyrinth conditions. Dizziness is a chronic symptom in elderly patients. The association of two vestibular diseases is common. Falls are prevalent in chronic dizzy elderly patients.

Central vestibular disorders

Dizziness or vertigo is an erroneous perception of selfmotion or object-motion as well as an unpleasant distortion of static gravitational orientation. It is caused by a mismatch between the vestibular, visual, and somatosensory systems. Thanks to their functional overlap, the three systems are able to compensate, in part, for each other's deficiencies. Thus, vertigo is not a well-defined disease entity, but rather a multisensory syndrome that results when there is a pathological dysfunction of any of the stabilizing sensory systems (e.g., central vestibular disorders, peripheral vestibular diseases with asymmetric input into the vestibular nuclei). This article provides an overview of the most important and frequent forms of central vestibular vertigo syndromes, including basilar/vestibular migraine, which are characterized by ocular motor, postural, and perceptual signs. In a simple clinical classification they can be separated according to the three major planes of action of the vestibulo-ocular reflex: yaw, roll, and pitch. A tonic imbalance in yaw is characterized by horizontal nystagmus, lateropulsion of the eyes, past-pointing, rotational and lateral body falls, and lateral deviation of the perceived straight-ahead. A tonic imbalance in roll is defined by torsional nystagmus, skew deviation, ocular torsion, tilts of head, body, and the perceived vertical. Finally, a tonic imbalance in pitch can be characterized by some forms of upbeat or downbeat nystagmus, fore-aft tilts and falls, and vertical deviation of the perceived straight ahead. The thus defined syndromes allow for a precise topographic diagnosis as regards their level and side.

Comparison of subjective and objective measurements of balance disorders following traumatic brain injury

Patients with mild traumatic brain injury (TBI) often complain of dizziness. However, these problems may be undetected by a clinical exam. Therefore, the purpose of this study was to evaluate the relationships between the subjective and objective measures of balance impairment. Ten patients with TBI (6 men and 4 women) and 10 matched controls participated in this study. Average duration since the TBI was 2.8 years (range 0.4-14.4). Six of the 10 subjects with TBI had abnormal imaging studies. All subjects and controls had a normal neuromuscular exam. Tinetti Balance Assessments were obtained and the TBI group was not significantly different from the control group. The Dizziness Handicap Inventory (DHI) score supported their complaints of "unsteadiness" and "imbalance" from the subjects with TBI. The DHI score was 32 +/- 23 (range 4-68) out of a maximum possible score of 100. Balance was tested using computerized dynamic posturography. The Sensory Organization Test score was significantly lower for subjects who had a TBI (70 +/- 12) compared to the control subjects (80 +/- 8), which indicated that the subjects with TBI had poorer balance than the control subjects. A 13-link biomechanical model of the human body was used to compute the kinematics of the whole body center of mass (COM) while walking on a level surface. The subjects with TBI had significantly less displacement in the anterior/posterior direction, walked significantly slower, had significantly greater medial/lateral sway and velocity than the normal controls, and had significantly greater medial/lateral imbalance. There was a significant relationship between the physical aspects of the DHI and posturography. There was also significant relationship between the physical, functional, and total DHI and the motion of the COM. Overall, the motion of the COM predicted between 42 and 69% of the DHI score. The present study has demonstrated that objective measurements can quantify the patient's functional deficits. Therefore, these objective measurement techniques should be used to assess the clinical complaints of imbalance from patients with TBI.

Diagnóstico e tratamento das principais síndromes vestibulares

Os objetivos deste estudo foram identificar as síndromes vestibulares mais comuns nos ambulatórios de vertigem, suas características clínicas e semiológicas, e observar a resposta ao tratamento específico. Foram estudados retrospectivamente 515 pacientes atendidos em ambulatórios de duas instituições e avaliados aspectos da anamnese, exame físico e a resposta ao tratamento. As síndromes mais freqüentes foram: vertigem de posicionamento paroxística benigna (VPPB) (28,5%), vertigem postural fóbica (11,5%), vertigem central (10,1%), neurite vestibular (9,7%), doença de Menière (8,5%), enxaqueca (6,4%). Houve boa resposta ao tratamento nos pacientes com enxaqueca (78,8%), VPPB (64%), neurite vestibular (62%), doença de Menière (54,5%) e paroxismia vestibular (54,5%), enquanto pacientes com nistagmo para baixo e vestibulopatia bilateral não tiveram resposta satisfatória (52,6% e 42,8% respectivamente). As síndromes vestibulares foram diagnosticadas através da anamnese e exame físico com testes clínicos específicos para avaliação da função vestibular. A identificação destas síndromes permitiu o tratamento adequado levando a uma boa evolução.

Subclassification of vestibular disorders by means of statistical analysis in caloric labyrinth testing

OBJECTIVE

In the past, various attempts were made to perform a quantitative analysis of nystagmographic findings but their diagnostic value was limited. Therefore, the authors present a multivariate analysis of nystagmus findings with the aim of increasing the precision of diagnostic differentiation in cases of vestibular dysfunction.

MATERIAL AND METHODS

A group of 387 patients and 40 healthy volunteers were examined over a 14-month period using electronystagmography after stimulation by bithermal, bilateral irrigation of the labyrinth. Amplitude, slow-phase velocity, frequency and directional preponderance were evaluated.

RESULTS

No defined normal values for caloric nystagmus parameters could be obtained. However, by using the Mann Whitney U-test and logistic regression analysis a differentiation between pathological and healthy findings as well as between central and peripheral vestibular disorders and even between distinct vestibular disease entities is possible. Using these methods, the nystagmus amplitude was found to be the strongest discriminating parameter. Therefore, sole assessment of nystagmographic findings by selective calculation of the nystagmus slow-phase velocity falls short of the potential offered by electronystagmographic registration.

CONCLUSION

For daily clinical routine, counting nystagmus beats leads to the same diagnostic precision as the analysis of slow-phase velocities. In contrast, multivariate analysis of several nystagmus parameters can distinguish between distinct diseases with fairly high precision. This stepwise analysis of nystagmographic data could create the basis for an expert-system tool in the near future.

Anxiety and mood disorders in otorhinolaryngology outpatients presenting with dizziness: validation of the self-administered PRIME-MD Patient Health Questionnaire and epidemiology

The aims of the study were to: 1) assess the validity of the mood and anxiety modules of the PRIME-MD Patient Health Questionnaire (PHQ) in otorhinolaryngology outpatients consulting with dizziness; and, 2) the prevalence of anxiety and mood disorders in these patients and in 3 subgroups based on of the cause of dizziness (Functional group, with psychogenic or hyperventilation factor; Organic group with an organic cause; Unspecified group without indication of organic or psychogenic cause). The PRIME-MD PHQ was completed by 268 consecutive outpatients. In 97 patients a psychiatric interview was performed. Operating characteristics indicated good criterion validity for the assessed modules of the PRIME-MD PHQ. Thirty five percent of the patients were diagnosed with "Any Anxiety or Depressive Disorder". In the Functional group, the prevalence of "Any Anxiety or Depressive Disorder" was significantly higher than in the Organic group (P<.0001) and than in the Unspecified group (P<.0001). In the Unspecified group, the prevalence of "Any Anxiety or Depressive Disorder" was significantly lower than in the Organic group (P =.007). Our findings support the criterion validity of the PRIME-MD PHQ for anxiety and depressive disorders in otorhinolaryngology outpatients with dizziness. Psychiatric disorders were highly prevalent and differences in psychiatric status between the different subgroups were demonstrated.

Vibration-induced nystagmus in patients with vestibular disorders

OBJECTIVE

Our goal was to clarify the clinical significance of vibration-induced nystagmus (VIN).

METHODS

One hundred patients with unilateral vestibulocochlear disorders were enrolled into this study. However, patients with spontaneous nystagmus were excluded. Vibratory stimuli (approximately 100 Hz) were presented to the mastoids and the forehead. Patients also underwent caloric testing and vestibular evoked myogenic potential testing.

RESULTS

Of the 100 patients, 60 (60%) showed VIN. The nystagmus was mainly horizontal. VIN was more frequently evoked on the mastoids than the forehead. In the majority of patients, the direction of VIN was toward the healthy side, whereas some patients, especially patients with Meniere's disease, showed nystagmus toward the affected side. VIN was frequently evoked in patients with severe unilateral vestibular damages (canal paresis >50%) (39 of 43, or 90%).

CONCLUSION

VIN testing is a simple and sensitive clinical test that indicates unilateral vestibular dysfunction.

Usher syndrome clinical types I and II: could ocular symptoms and signs differentiate between the two types?

PURPOSE

Usher syndrome types I and II are clinical syndromes with substantial genetic and clinical heterogeneity. We undertook the current study in order to identify ocular symptoms and signs that could differentiate between the two types.

METHODS

Sixty-seven patients with Usher syndrome were evaluated. Based on audiologic and vestibular findings, patients were classified as either Usher type I or II. The severity of the ocular signs and symptoms present in each type were compared.

RESULTS

Visual acuity, visual field area, electroretinographic amplitude, incidence of cataract and macular lesions were not significantly different between Usher types I and II. However, the ages when night blindness was perceived and retinitis pigmentosa was diagnosed differed significantly between the two types.

CONCLUSIONS

There seems to be some overlap between types I and II of Usher syndrome in regard to the ophthalmologic findings. However, night blindness appears earlier in Usher type I (although the difference in age of appearance appears to be less dramatic than previously assumed). Molecular elucidation of Usher syndrome may serve as a key to understanding these differences and, perhaps, provide a better tool for use in clinical diagnosis, prognosis and genetic counseling.

What can posturography tell us about vestibular function?

Patients with balance disorders want answers to the following basic questions: (1) What is causing my problem? and (2) What can be done about my problem? Information to fully answer these questions must include status of both sensory and motor components of the balance control systems. Computerized dynamic posturography (CDP) provides quantitative assessment of both sensory and motor components of postural control along with how the sensory inputs to the brain interact. This paper reviews the scientific basis and clinical applications of CDP. Specifically, studies describing the integration of vestibular inputs with other sensory systems for postural control are briefly summarized. Clinical applications, including assessment, rehabilitation, and management are presented. Effects of aging on postural control along with prevention and management strategies are discussed.

Endolymphatic sac tumours

This review article surveys clinical and pathological literature on endolymphatic sac tumours (ELST) and summarizes characteristics that describe the entity. ELST are rare neuroectodermal neoplasms in the petrous bone, originating from inner ear structures. They can be encountered sporadically or in von Hippel-Lindau disease. The most prominent symptom is sensorineural deafness. Historically, nomenclature of invasive adenoid tumours in the petrous bone has been divergent, the term papillary adenocarcinoma used most frequently. Histologically, they have a follicular or papillary and adenoid pattern that can be easily confused with various other neoplastic conditions including metastatic carcinoma. It remains to be verified whether similar tumours (papillary adenocarcinomas) can originate from the middle ear. Middle ear adenomas have a similar appearance but probably originate from neural crest cells in the middle ear. ELST can express a variety of epitopes (including cytokeratin and neuroectodermal markers) which can be detected immunohistochemically. In cases in von Hippel-Lindau disease the cerebello-pontine angle should be included in routine radiological examinations to detect ELST before the tumours lead to deafness. In apparently sporadic cases of ELST, genetic testing for von Hippel-Lindau disease should be considered. Correct distinction of ELST from metastatic carcinoma prevents futile searches for unknown primary tumours.

Refined mapping of the Usher syndrome type III locus on chromosome 3, exclusion of candidate genes, and identification of the putative mouse homologous region

A locus for Usher syndrome type III (USH3; MIM No. 276902) was recently assigned to a 5-cM region on chromosome 3q. We constructed a yeast artificial chromosome contig that allowed us to position novel polymorphisms in the region. These were typed in a total of 32 pedigrees from a geographically isolated Finnish founder population in which a putative single ancestral USH3 mutation segregates. A multipoint linkage analysis assigned USH3 to a 4-cM region between D3S1555 and a novel marker D3S3625. By analysis of linkage disequilibrium and historical recombinations in 77 USH3 chromosomes, the location of the Finnish USH3 mutation could be narrowed to an approximately 1-cM interval between the markers D3S1299 and D3S3625. A gene for profilin-2 (PFN2) was mapped in the vicinity and excluded as a candidate for USH3 by sequencing. The putative mouse homolog of PFN2 was mapped to mouse chromosome 3, thus suggesting a localization for the mouse homolog of USH3.

Phenomenology of simple partial seizures

Based on a sample of 325 inpatients we present the subjective experiences during simple partial seizures. In a majority of cases, auras comprised composed forms of different symptomatic qualities. We describe rules which seem to govern sequences of aura phenomena. Autonomous and vestibular sensations were shown to have preceding positions related to others, olfactory and gustatory sensations preferred a following position. The tentative explanation of the findings favours the idea of heterogeneity rather than the concept of a focal discharge in a simple partial seizures.

Sensitivity and specificity of platform posturography for identifying patients with vestibular dysfunction

Sensitive and specific measures are needed to identify patients with vestibular impairments. The purpose of this clinical perspective is to describe the sensitivity and specificity of dynamic and static platform posturography for detecting vestibular disorders. The sensory organization test (SOT) of dynamic posturography (EquiTest), the motor "perturbation" test, and Romberg's tests on a static (fixed) force platform each had over 90% specificity. This finding means that nearly all of the subjects who should have tested negative, did test negative on each type of assessment. The sensitivity of the SOT was evaluated across five studies involving a total of 836 patients with peripheral vestibular deficits (PVDs). Abnormalities in the SOT were detected in only 40% (n = 338) of the cases. Static platform posturography sensitivity was evaluated across six studies involving a total of 571 patients with PVDs, and abnormalities were detected in 53% (n = 302) of these cases. Tests of spontaneous and positional nystagmus and the horizontal component of the vestibuloocular reflex (VOR), by comparison, detected PVDs in 48% of 798 patients with suspected vestibular impairment. For patients with vestibular deficits associated with central nervous system disease, a total of 389 cases were identified in five studies and SOT abnormalities were found in 54% (n = 209) of these cases. The motor perturbation test was abnormal in 35% (n = 41) of 119 patients with central vestibular disease. In conclusion, the sensitivity of static posturography appeared to be slightly better than that of dynamic posturography for detecting PVDs, but the level of sensitivity for each posturography test, as well as for tests of horizontal VOR function, was considered to be low. Combining either type of posturography with other tests of vestibular function, however, increased the overall sensitivity of detecting vestibular deficits to 61% to 89%. It was concluded that dynamic and static platform posturography as well as tests of VOR function lack adequate sensitivity to detect vestibular impairment when applied in isolation. Posturography appears to detect vestibular deficits in some patients who had normal VOR assessments and, therefore, provides supplemental rather than redundant information about vestibular dysfunction.

The perception of head rotation in Parkinson's disease

The accuracy in detecting angular displacements of the head and the neck was investigated in 14 patients with idiopathic Parkinson's disease (PD) and 16 age matched normal controls by the technique of vestibular and cervical "remembered" saccades. It was found that although the remembered saccades in PD patients were multiple-step and showed low initial saccadic gain, the final eye position of the eyes matched the rotational stimulus as accurately as in normals. This indicates that perception of head/neck rotation is normal in PD which is inconsistent with views that vestibulo/proprioceptive dysfunction contributes to the postural disorder in PD. The presence of multiple-step remembered vestibular and cervical saccades agrees with reported abnormalities in visual remembered saccades in PD and indicates that the difficulty in generating saccadic movements based on memorized sensory information is not confined to visual-memory.