Peripheral Vertigo Research Articles

Age-Related Increases in Benign Paroxysmal Positional Vertigo Are Reversed in Women Taking Estrogen Replacement Therapy: A Population-Based Study in Taiwan.

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo. Numerous investigations have reported an increased BPPV incidence in females and in the aged population. The hormonal characteristics of BPPV patients have not been previously investigated. This study aimed to determine the risk of BPPV in relation to menopause in a population-based study.Materials and Methods: This retrospective population-based study was designed to use a nationwide longitudinal health insurance database to follow and analyze the incidence of and protective factors against BPPV in a Taiwanese population.Data Analyses: Univariate and multivariate analyses were performed to calculate the adjusted hazard ratio (aHR) for the incidence of BPPV using Cox-proportional regression models.Results: In the multivariate analyses, we found that older people (older than 65 years old) were more prone to develop BPPV (aHR: 5.37, 95% CI: 0 4.83–5.97, p < 0.001). The risk of BPPV was analyzed in two specific age subgroups of elderly females. Results revealed that in both age groups (45–65 years old and >65 years old), patients who took estrogen for menopausal syndromes had a significantly lower incidence of BPPV (aHR; 0.01, 95% CI: 0.06–0.23, p < 0.001).Conclusion: Our study provides a novel etiology and possible treatment method for the prevention of BPPV. Further studies may focus on the pathophysiological mechanism of estrogen in BPPV patients and the development of new drugs for the prevention and treatment of BPPV.

Referral patterns from emergency department to otolaryngology clinic.

Patients who present to the emergency department (ED) with various otolaryngologic disorders are frequently referred to an otolaryngologist for follow-up care. Our aim was to further characterize this group as it has not been well described in the literature. Cross-sectional retrospective study. We reviewed the charts of patients seen during an 18-month period in an urban public hospital trauma center adult ED and referred to an otolaryngology clinic for follow-up care. Seven hundred thirty-eight patients were seen and referred; the most common diagnoses made by ED providers were peripheral vertigo (12%), otitis externa (8%), and nasal fractures (8%). Nine percent of patients were evaluated during their ED visit by an otolaryngology provider. Three hundred seventy-two (50%) patients returned for their otolaryngology clinic visit; facial trauma patients were least likely to return. The most common diagnoses made by otolaryngology providers were otitis externa (12%), peripheral vertigo (12%), and nasal fractures (7%). There was 50% concordance between patients' diagnoses made by ED and otolaryngology providers. The most common differences were otitis media versus otitis externa (10%) and acute pharyngitis versus laryngopharyngeal reflux (8%). During 37% of follow-up visits, an in-office procedure was performed, most commonly flexible fiberoptic laryngoscopy, cerumen removal, and nasal endoscopy. Our analysis reports comprehensive characteristics of this referral group, identifying potential areas for improvement in patient management, resident education and efficiency. Otolaryngologists covering EDs should be familiar with this population in terms of types of cases that may affect their practices. 4. Laryngoscope, 128:1062-1067, 2018.

Validation of the Italian Version of the Dizziness Handicap Inventory, the Situational Vertigo Questionnaire, and the Activity-Specific Balance Confidence Scale for Peripheral and Central Vestibular Symptoms.

Neurophysiological measurements of the vestibular function for diagnosis and follow-up evaluations provide an objective assessment, which, unfortunately, does not necessarily correlate with the patients’ self-feeling. The literature provides many questionnaires to assess the outcome of rehabilitation programs for disequilibrium, but only for the Dizziness Handicap Inventory (DHI) is an Italian translation available, validated on a small group of patients suffering from a peripheral acute vertigo. We translated and validated the reliability and validity of the DHI, the Situational Vertigo Questionnaire (SVQ), and the Activities-Specific Balance Confidence Scale (ABC) in 316 Italian patients complaining of dizziness due either to a peripheral or to a central vestibular deficit, or in whom vestibular signs were undetectable by means of instrumental testing or clinical evaluation. Cronbach’s coefficient alpha, the homogeneity index, and test–retest reproducibility, confirmed reliability of the Italian version of the three questionnaires. Validity was confirmed by correlation test between questionnaire scores. Correlations with clinical variables suggested that they can be used as a complementary tool for the assessment of vestibular symptoms. In conclusion, the Italian versions of DHI, SVQ, and ABC are reliable and valid questionnaires for assessing the impact of dizziness on the quality of life of Italian patients with peripheral or central vestibular deficit.

Useful parameters to distinguish between stroke and peripheral vertigo at the emergency room

Background: Dizziness and vertigo symptoms are commonly seen in emergency room.

Eficacia de las maniobras de reposicionamiento canalicular en el vértigo posicional paroxístico benigno: revisión de 176 casos tratados en un centro hospitalario de tercer nivel

Introduction and objectivesBenign paroxysmal positional vertigo is the most common peripheral vertigo disease. The aim of this paper is to review the results obtained with the different specific particle repositioning manoeuvres, evaluating the possible risk factors linked to a poorer prognosis. MethodsOne hundred and seventy-six patients with a diagnosis of benign paroxysmal positional vertigo were reviewed retrospectively, of whom 150 had vertigo of the posterior canal, 20 had vertigo of the horizontal canal, 3 had vertigo of the superior canal, and 3 had a double vertigo. The Epley manoeuvre was used to treat the posterior and superior canals, and Lempert manoeuvre was used to treat the horizontal canal. An imaging study by nuclear magnetic resonance with gadolin was always used in refractory cases. ResultsThe Epley manoeuvre showed an efficacy of 74.6 and 100% at first attempt for posterior and superior canals respectively. The efficacy of the Lempert manoeuvre for the horizontal canal was 72.72% in the patients with canalolithiasis, and 58.33% in the patients with cupulolithiasis. The treatment of patients with more than one affected canal and a history of surgery in the previous month was more difficult. ConclusionsParticle repositioning manoeuvres show a very high success rate, allowing better results in the treatment of the posterior canal. We need more studies to confirm the suspicion that surgery may be a factor of poorer prognosis.

P 111 Clinical trials in neurological disorders causing vertigo

The German Center for Vertigo and Balance Disorders (DSGZ) is an interdisciplinary center for research and treatment of vertigo, balance and ocular motor disorders. The long-term aim is to establish a patient-oriented research institution that is networked with all involved disciplines and methods. This includes also the establishment of a study infrastructure for prospective multicenter clinical trials. With this abstract we would like to give an overview over the current clinical trials conducted in collaborations with other investigational sites throughout Germany. During the last 20 years vestibular migraine has been identified as a distinct type of migraine with the leading symptom of vertigo. These attacks lasting minutes to hours, have considerable impact on quality of life, and can result in economical and social losses. The trial drug metoprolol with proven efficacy in migraine prevention is commonly used in the treatment of vestibular migraine. So far its indication in vestibular migraine is only based on expert opinion. The aim of the PROVEMIG study (a double-blind, placebo-controlled trial) is to demonstrate the superiority of metoprolol succinate treatment regarding the number of vertigo attacks and the number of headache attacks per month compared to placebo in patients with vestibular migraine. The leading symptom of vestibular paroxysmia (VP) are spontaneous recurrent attacks of rotatory or postural vertigo lasting seconds to a few minutes sometimes with accompanying symptoms like tinnitus or hypoacusis. The high frequency as well as the unpredictability of these vertigo attacks result in strong impact on quality of life. Based on the pathophysiological concept of neurovascular compression as for trigeminus neuralgia the sodium channel blocker Carbamazepin (CBZ) is used as off-label therapy for patients with VP. The purpose of the VesPa study is to demonstrate within a controlled clinical trial that CBZ is efficacious in reducing the frequency, duration and severity of vertigo attacks, the number of vertigo per month and improving quality of life in patients with VP. Benign peripheral paroxysmal positional vertigo (BPPV) is characterized by short but intense attacks of rotatory vertigo induced by changes in the position of the head or body, accompanied oscillopsia, nausea and vomiting. Furthermore, nearly 50 percent of these patients also experience a relapse of BPPV. Retrospective studies revealed that patients with BPPV show decreased vitamin D levels. The goal of the [email protected] study is to investigate the efficacy of vitamin D in reducing the amount of patients with one or more recurrences of BPPV. Interested study sites are welcome to contact the clinical study center of the DSGZ at http://ifb.klinikum.uni-muenchen.de/de/Studienzentrum or [email protected].

Diagnostic Accuracy of Neuron Specific Enolase (NSE) and S100B in Distinguishing Central from Peripheral Vertigo

Diagnostic Accuracy of Neuron Specific Enolase (NSE) and S100B in Distinguishing Central from Peripheral Vertigo

Guía práctica del vértigo posicional paroxístico

Introduction and objective: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo, characterized by brief attacks of rotatory vertigo associated with nystagmus, which are elicited by specific changes in head position relative to gravity. The observation of positional nystagmus is essential for the diagnosis of BPPV. The treatment consists in maneuvers of canalith repositioning procedure to move otoconial debris from the affected semicircular canal to the utricle. These guidelines are intended for all who treat the BPPV in their work, with an intention to assist in the diagnosis and application of an appropriate therapeutic method. Method: The experience and analysis of different national and international consensus on BPPV, has allowed to a large group of ENT specialists of the Communities of Castilla y Leon, Cantabria and La Rioja (Spain), carry out this guide. Results: The different clinical entities are reviewed. BPPV of the posterior semicircular canal, horizontal canal and anterior canal, BPPV affecting several canals, atypical and central BPPV, subjective BPPV and the characteristics of this process in the elderly. Canalith repositioning procedures have been illustrated with explanatory drawings. Discussion and conclusions: Although the pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula, there are still many issues to be resolved. We think that the best way to find answers is part of using a common methodology in the diagnosis and treatment of these patients.

Italian survey on benign paroxysmal positional vertigo.

SUMMARYBenign paroxysmal positional vertigo (BPPV) is the most common type of peripheral vertigo. BPPV often relapses after the first episode, with a recurrence rate between 15% and 50%. To date both the aetiopathogenetic processes that lead to otoconia detachment and the factors that make BPPV a relapsing disease are still unclear, but recent epidemiological studies have shown a possible association with cardiovascular risk factors. The aim of the present study (Sesto Senso Survey) was to evaluate in the Italian population through an observational survey, the main demographic and clinical characteristics of patients with BPPV (first episode or recurrent) with particular focus on the potential cardiovascular risk factors. The survey was conducted in 158 vestibology centres across Italy on 2,682 patients (mean age 59.3 ± 15.0 years; 39.1% males and 60.9% females) suffering from BPPV, from January 2013 to December 2014. The results showed a high prevalence of cardiovascular risk factors such as high blood pressure (55.8%), hypercholesterolaemia (38.6%) and diabetes (17.7%), as well as a family history of cardiovascular disease (49.4%). A high percentage of patients also had hearing loss (42.9%), tinnitus (41.2%), or both (26.8%). The presence of hypertension, dyslipidaemia and pre-existing cardiovascular comorbidities were significantly related to recurrent BPPV episodes (OR range between 1.84 and 2.31). In addition, the association with diabetes and thyroid/autoimmune disease (OR range between 1.73 and 1.89) was relevant. The survey results confirm the significant association between cardiovascular comorbidities and recurrent BPPV and identify them as a potential important risk factor for recurrence of BPPV in the Italian population, paving the way for the evaluation of new therapeutic strategies in the treatment of this disease.

Advances in the diagnosis and treatment of benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) (otolith disease) is the most common neurological and position change related vertigo, accounting for 17–20% of peripheral vertigo. BPPV occur in the elderly. The high incidence age for BPPC was 50 to 70 years and mostly in female. According to the different parts of the lesions, it is divided into anterior canal BPPV (AC-BPPV), posterior canal BPPV (PC-BPPV), horizontal canal BPPV (HC-BPPV). Studies have shown that the incidence of PC-BPPV was 86.36%, the incidence of HC-BPPV was 11.37%, the incidence rate of AC-BPPV was 2.27%. Treatment for PC-BPPV includes manual reduction, drug treatment, psychological treatment, and surgical treatment. Repositioning is the preferred method for the treatment of PC-BPPV with high effective rate and low risk. The mechanism is through the different changes of head position to make the otolith back to utricle. Many manual reduction methods have been reported in clinical treatment of PC-BPPV. With the increasing emphasis on the BPPV, a variety of new methods are being developed and designed.

Practical diagnosis and management of peripheral vertigo

Practical diagnosis and management of peripheral vertigo

The impact of opioid medications on subsequent fractures in discharged emergency department patients with peripheral vertigo.

Vertigo is common in the emergency department (ED). Most aetiologies are peripheral and do not require hospitalization, but many patients still fear falling. Some patients may be taking opioid analgesic medications (for other reasons); the risk of falls leading to fractures among patients with vertigo could be potentiated by the simultaneous use of opioids. To examine the risk of fractures in discharged ED patients with peripheral vertigo who were being prescribed opioids during the same time period. Linked administrative databases from Ontario were used to compare discharged ED patients aged ≥65 with peripheral vertigo to patients with urinary tract infection (UTI) from 2006 to 2011. We used Cox regression analysis with an interaction term to estimate the modifying effect of an opioid prescription on the hazard of fracture within 90 days. There were 13,012 patients with a peripheral vertigo syndrome and 76,885 with a UTI. Thirteen percent of the vertigo cohort and 25% of the UTI cohort had access to a filled opioid prescription. Compared to vertigo patients who did not fill an opioid prescription, the adjusted hazard of fracture among vertigo patients who did fill a prescription was 3.59 (95% CI 1.97-6.13). Among UTI patients who filled an opioid prescription the hazard ratio was 1.68 (95% CI 1.43-1.97) compared to UTI patients who did not. Patients discharged from the ED with peripheral vertigo who were also being prescribed opioids had a higher hazard of subsequent fracture compared to those who were not, and the effect was much greater than among UTI patients. These results suggest that in the acutely vertiginous older patient, opioid analgesic medications should be modified, where possible.

Increase in the Admission of Stroke Mimics after Change in Emergency Shifts

Background: In 2010, changes were made to the shift pattern of neurology residents for cover in the Emergency Department at a university hospital. This resulted in a decrease in the number of emergency hours worked by neurology specialists and allowed for a natural quasi-experiment. Aim: We aimed to evaluate if changes to the number of emergency hours worked by neurology residents and specialist neurologists, (intervention) altered the number or pattern of admitted stroke mimics (SMs). Methods: Observational retrospective study from January 2007 to December 2013. Time of intervention was set as August 2010. We used a segmented linear regression - ARIMA - to evaluate changes in the temporal pattern of admitted SMs. A statistical correlation between the number of emergency hours worked by neurology residents and the number of admitted SMs was calculated using the Pearson Correlation Coefficient. Results: Of the 2,552 patients admitted to the stroke unit, 290 were SMs (11.4%). After August 2010, there was an increase in the number of admitted SMs (p = 0.003). After 2010, the most frequent SM diagnosis changed from a psychiatric condition to peripheral vertigo. A positive correlation was found between the number of hours worked primarily by neurology residents and the number of admitted SMs (Pearson correlation coefficient = 0.94; p = 0.002). Conclusions: Changes in the pattern of Emergency Department shifts were associated with an increase in the rate of admitted SMs and with a higher number of mimics with a final diagnosis of peripheral vertigo.

Cinnarizine: A Contemporary Review.

Cinnarizine, is approved for nausea, vomiting, motion sickness, inner ear disorders and is considered as first-line pharmacotherapy for management of vertigo. It acts by anti-vasoconstrictor activity, reducing blood viscosity and reducing nystagmus in labyrinth. Lack of adequate literature on clinical evidence of cinnarizine and its combination (dimenhydrinate) in vertigo management prompted this review. A specific MEDLINE literature search strategy was designed combining Medical Subject Headings, free-text keywords (like cinnarizine and vertigo) using Boolean operators (1970-2016) for clinical studies, clinical reviews and meta-analyses of cinnarizine. Analyses of studies validated cinnarizine's efficacy in peripheral and central vertigo versus placebo or other therapies, and was well-tolerated by the patients recruited across different studies. Cinnarizineand/ or its combinations are favorable in management of vestibular disorders wherein cinnarizine acts predominantly peripherally on labyrinth and dimenhydrinate acts centrally on vestibular nuclei and associated centers in brainstem. Combination therapy of cinnarizineand/ or its combinations demonstrated a better safety profile than either of the mono-components, offering a viable therapeutic option in vertigo management.

The diagnosis, treatment and aviation medicine identification of vestibular neuronitis

estibular neuronitis is one of the leading causes of peripheral vertigo. Inflammation confined to the vestibular system, and the cochlear, central nervous system and hearing are normal. The disease may be associated with viral infections, but the virus serological positive rate is not high. Vestibular-evoked myogenic potential and head impulse test can be used for sub-type diagnosis, and improve the detection rate of inferior vestibular neuronitis.Corticosteroids therapy is still controversial, and had not been included in VN conventional treatment. Vestibular rehabilitation is helpful in building central compensatory earlier for VN patients, and if the compensate for VN completely was the final basis of aviation medicine evaluation. This review focuses on the clinical manifestation, etiology, diagnosis, differential diagnosis，corticosteroids and rehabilitation therapy, and aviation medicine identification of VN.

Abstract TP260: Causes of Delayed Diagnosis of Vertebrobasilar Stroke Patients After Arrival at Emergency Room

Introduction: Dizziness is a main symptom caused by ischemic insult to vertebrobasilar vessels as well as peripheral vertigo. So, proper diagnosis and management is often delayed in the vertebrobasilar ischemic patients. The present study was to evaluate factors related with the delayed diagnosis among vertebrobasilar infarction patients suffered from dizziness as initial main symptom. Methods: We reviewed clinical and radiologic data of 166 patients, who suffered from dizziness and/or vertigo as initial symptom and diagnosed finally as acute infarction on cerebellum and/or brainstem. First, we classified patients by incorrect triage as peripheral vertigo for the patients by first triage doctor of emergency room. Then, we evaluated time intervals from arrival at emergency room to first examination by a neurologist, to first brain image, and to final diagnosis as ischemic stroke of each group of patients. Type of initial symptoms including dizziness only or dizziness plus focal neurologic deficits were also compared between the groups. Finally, factors related with the incorrect triage of the included patients were analyzed using multivariate analysis. Results: The time from ER arrival to examination by a neurologist (221.0±158.7 vs. 56.0±76.8 min, p &lt;0.001), to first image (232.4±182.1 vs. 58.2±77.0 min, p &lt;0.001), and to final diagnosis (367.2±179.7 vs. 151.3±94.1 min, p &lt;0.001) were significantly delayed in incorrect triage group. More patients in incorrect triage group showed dizziness only at presenting ER (52% vs. 13%, p &lt;0.001). Among the focal neurologic signs defined by neurologists in incorrect triage group, Tandem abnormality was most frequently observed (29%). On multiple regression analysis, presence of chronic kidney disease (Odd ratio (OR) 15.7, 95% CI 1.4-175.6, p =0.026), isolated dizziness symptom (OR 13.5, 95% CI 3.3-55.3, p &lt;0.001). Conclusions: In the present study, presence of chronic kidney disease and initial presenting symptom were the main cause of delaying diagnosis of vertebrobasilar infarction patients in ER. Additionally, Tandem gait should be performed for the dizzy patients to avoid delaying diagnosis of ischemic stroke.

Main directions of differential diagnosis optimization and rational treatment of an acute vertigo attack

To develop and assess the validity of the clinical algorithm VERTIGO for the differential diagnosis of central and peripheral vertigo and optimization of treatment of patients with vertigo. Sixty-five patients with an acute attack of vertigo, aged from 18 to 75 years (53±6.7 years), were studied. All patients underwent standard neurological examination. In case of signs of central vertigo, patients underwent neuroimaging. Diagnostic accuracy, sensitivity and specificity of the VERTIGO algorithm as well as its positive and negative prognostic values were calculated. The sensitivity of VERTIGO for the diagnosis of central vertigo was 100% (95% CI: 78.2-100%), specificity 94.0% (95% CI: 83.5-98.8%), positive prognostic value 83.3% (95% CI: 58.6-96.4%); negative prognostic value 100% (95% CI: 92.5-100%). Cohen's kappa estimated by the results of final diagnosis was 0.88. Differential treatment of patients with acute vertigo should be performed according to the current recommendations and include multimodal pharmacological medications, e.g. cavinton forte, to restore the vestibular control by the stimulation of neuroplasticity. The VERTIGO algorithm allows the increase of the efficacy of clinical differential diagnosis of central and peripheral vertigo.

A Comparison of the Effects and Side Effects of Oral Betahistine with Injectable Promethazine in the Treatment of Acute Peripheral Vertigo in Emergency.

BackgroundVertigo is an illusion of rotation that is caused by the asymmetry of neurological function of the right and left vestibular nuclei. The aim of this study was to compare the efficacy and side effects of oral betahistine with injectable promethazine in treatment of acute peripheral vertigo.MethodsIn this double-blind clinical trial study, the patients with acute peripheral vertigo were assigned in the two groups: receiving promethazine intramuscularly at a dose of 25 mg (group A) and receiving 8 mg betahistine tablets (group B) and the severity of their vertigo was evaluated on the visual analog scale (VAS) scoring system. In addition, adverse events in both groups of patients were compared and evaluated.ResultsA total of 162 patients (82 subjects in group A) participated in this study. The mean age, gender distribution, intensity and symptoms of vertigo were similar in both groups before the intervention. At 2 and 3 h after the intervention, the score of VAS in patients taking betahistine was significantly higher than promethazine. In addition, the clinical symptoms after taking betahistine were significantly less. Side effects seen in patients taking the promethazine include mainly drowsiness. After taking betahistine, the most common complication was abdominal problems (nausea and vomiting).ConclusionThe results of this study show that betahistine is a safe and effective drug in controlling patients with acute vertigo and its impact is more than promethazine.

良性発作性頭位めまい症

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo and is characterized by brief attacks of rotatory vertigo associated with positional and/or positioning nystagmus, which are elicited by specific head positions or changes in head position relative to gravity. The pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula. In the canalolithiasis theory, when patients with BPPV move their head, free-floating otoconial debris in the canal creates the endolymph flow, the flow of the fluid causes deflection of the cupula of the canal, and as a result, the canal is stimulated or inhibited and nystagmus and vertigo are induced. In the cupulolithiasis theory, when patients with BPPV move their head, the cupula, with its adherent otoconial debris, deviates in the direction of gravity, and as a result, the canal is stimulated or inhibited and nystagmus and vertigo are induced.

A case of the cerebellar infarction appears findings of peripheral vertigo in the HINTS plus

A case of the cerebellar infarction appears findings of peripheral vertigo in the HINTS plus