Peripheral Vestibular Disease Research Articles

Spatial anxiety contributes to the dizziness-related handicap of adults with peripheral vestibular disease.

In subjects with peripheral vestibular disease and controls, we assessed: 1. The relationship between spatial anxiety and perceived stress, and 2. The combined contribution of spatial anxiety, spatial perspective-taking, and individual cofactors to dizziness-related handicap. 309 adults participated in the study (153 with and 156 without peripheral vestibular disease), including patients with bilateral vestibular deficiency, unilateral deficiency (evolution <3 or ≥3 months), Meniere's disease, and Benign Paroxysmal Positional Vertigo. Assessments included: general health, personal habits, spatial anxiety (3-domains), perceived stress, spatial perspective-taking, dizziness-related handicap (3-domains), unsteadiness, sleep quality, motion sickness susceptibility, trait anxiety/depression, state anxiety, depersonalization/derealization. After bivariate analyses, analysis of covariance was performed (p ≤ 0.05). Spatial anxiety was related to unsteadiness and perceived stress, with an inverse relationship with trait anxiety (ANCoVA, adjusted R2 = 0.27-0.30, F = 17.945-20.086, p < 0.00001). Variability on perspective-taking was related to vestibular disease, trait and state anxiety, motion sickness susceptibility, and age (ANCoVA, adjusted R2 = 0.18, F = 5.834, p < 0.00001). All domains of spatial anxiety contributed to the Physical domain of dizziness-related handicap, while the Navigation domain contributed to the Functional domain of handicap. Handicap variability was also related to unsteadiness, spatial perspective-taking, quality of sleep, and trait anxiety/depression (ANCoVA, adjusted R2 = 0.66, F = 39.07, p < 0.00001). Spatial anxiety is related to perceived stress in adults both with and without vestibular disease, subjects with trait anxiety rated lower on spatial anxiety. State anxiety and acute stress could be helpful for recovery after peripheral vestibular lesion. Spatial anxiety and perspective-taking contribute to the Physical and Functional domains of dizziness-related handicap, possibly because it discourages behavior beneficial to adaptation.

Application of bedside HINTS, ABCD2 score and truncal ataxia to differentiate cerebellar–brainstem stroke from vestibular neuritis in the emergency room

Background and purposeAcute vestibular syndrome (AVS) typically manifests as isolated dizziness or vertigo with no apparent neurological impairments. However, distinguishing life-threatening stroke from innocuous peripheral vestibular lesions in the emergency...

Advances in the video head impulse test in acute unilateral peripheral vestibular hypofunction disease

Advances in the video head impulse test in acute unilateral peripheral vestibular hypofunction disease

Turkish validity and reliability study of the benign paroxysmal positional vertigo diagnostic scale

Objectives: The study aimed to evaluate the Turkish validity and reliability of the benign paroxysmal positional vertigo (BPPV) diagnostic scale. Patients and Methods: One hundred seventeen patients (67 females, 50 males; mean age: 49.3±12.3 years; range 18 to 74 years) over the age of 18 who were diagnosed or suspected of BPPV, Meniere's disease, vestibular neuritis, or other peripheral vestibular disease were included. Participants filled out the BPPV diagnostic scale. The affected canal and the ear side were determined by performing positional maneuvers to confirm the diagnosis of BPPV. The final version of the scale was created by performing language and content validity, construct validity, reliability, and test-retest analyses of the BPPV diagnostic scale in the given order. Results: Of the 117 patients, 70 were diagnosed with BPPV, 26 with Meniere’s disease, 16 with vestibular neuritis, and five participants with other peripheral vestibular disease. Kendal W for content validity was 0.060 (p=0.700&gt;0.05), and expert opinions showed good agreement. The factor load of the BPPV diagnostic scale was found within the normal range (0.364 to 0.807). Goodness of fit index values were obtained above 0.90. According to this result, the model fit well. The internal consistency Cronbach's alpha (a) coefficient of the scale was 0.716. This value showed that the scale had good reliability. According to the results of the scale, a statistically significant difference was found between the responses of the BPPV group and the other diagnostic groups (p&lt;0.05). Conclusion: The Turkish version of the BPPV diagnostic scale was found to be valid and reliable. This scale is useful in detecting BPPV and establishing the differential diagnosis. The use of the scale is thought to be beneficial in patients with suspected BPPV but who have difficulties in diagnosis and to support objective tests.

Suppression of inner ear signal intensity on fluid-attenuated inversion recovery magnetic resonance imaging in cats with vestibular disease.

Otitis media/interna (OMI) is the most common cause of peripheral vestibular disease in cats. The inner ear contains endolymph and perilymph, with perilymph being very similar in composition to cerebrospinal fluid (CSF). As a very-low-protein fluid, it would be expected that normal perilymph should suppress on fluid-attenuated inversion recovery (FLAIR) MRI sequences. Based on this, we hypothesized that MRI FLAIR sequences should provide a non-invasive way of diagnosing inflammatory/infectious diseases such as OMI in cats, something that has previously been demonstrated in humans and, more recently, in dogs. This was a retrospective cohort study in which 41 cats met the inclusion criteria. They were placed into one of four groups, based on presenting complaint: clinical OMI (group A); inflammatory central nervous system (CNS) disease (group B); non-inflammatory structural disease (group C); and normal brain MRI (control group; group D). Transverse T2-weighted and FLAIR MRI sequences at the level of the inner ears bilaterally were compared in each group. The inner ear was selected as a region of interest using Horos, with a FLAIR suppression ratio calculated to account for variability in signal intensity between MRIs. This FLAIR suppression ratio was then compared between groups. Statistical analyses were performed by an experienced statistician, with a general linear model used to compare mean FLAIR suppression ratio, CSF nucleated cell count and CSF protein concentration between groups. The OMI group (group A) had significantly lower FLAIR suppression scores compared with all other groups. The CSF cell count was also significantly increased in the OMI (group A) and inflammatory CNS disease (group B) groups compared with the control group (group D). This study demonstrates the utility of MRI FLAIR sequences in diagnosing presumptive OMI in cats, similarly to in humans and dogs. This study is relevant to practicing veterinary neurologists and radiologists in interpreting MRI findings in cats with suspected OMI.

Recurrence Rate of Benign Paroxysmal Positional Vertigo – A Multicenter Survey

Background: Benign paroxysmal positional vertigo (BPPV) is a common peripheral vestibular disease. However, the data on the recurrence rate of this condition is lacking. The objectives of this study were to estimate the recurrence rate and factors for the recurrence of BPPV. Methods: This multicenter survey was conducted at the Otorhinolaryngology Clinic, Mahasarakham Hospital, and Srinagarind Hospital, Khon Kaen University in Thailand. From 2016 to 2021, patients with evidence of remission indicated by no nystagmus during an otolaryngologist examination at the last outpatient visit were recruited. The survey was conducted to assess the recurrence, severity, and risk factors of the recurrence. Results: 84 patients participated in this study. All of the patients were followed up after the resolution of the disease to evaluate for the recurrence rate of BPPV. The recurrence rate of BPPV was 27.38%. The mean time to the first recurrence event was 4.47 months. The dizziness handicap index score and visual analog scale score were significantly decreased between baseline and the first recurrence event (p &lt; 0.05). Factors such as age, gender, and comorbidities including diabetes mellitus, hypertension, and hyperlipidemia were not significantly different between the recurrence group and control group (p = 0.248, 0.128, 0.369, 0.651, 0.537). Conclusions: Around 1 in 3 BPPV patients can suffer from a relapse. There was no significant risk factor for the recurrence of BPPV in this study.

Insights into Benign Paroxysmal Positional Vertigo in the Elderly

Vertigo, the illusion of movement of oneself or one’s surroundings in the absence of actual movement, is a common symptom in older adults and, as such, is commonly regarded as an age-related normal or part of the aging process itself, as its incidence increases with age. In neurology and otorhinolaryngology, benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. BPPV is a brief, recurrent episode of vertigo caused by changes in head position relative to the direction of gravity. The symptoms of peripheral vestibular disease are vertigo and characteristic nystagmus. The prevalence of undiagnosed BPPV is high due to the fact that many elderlies tolerate vertigo symptoms. According to etiology, it can be subdivided into idiopathic BPPV and secondary BPPV, and according to location, it can be subdivided into posterior semicircular canal BPPV, horizontal semicircular canal BPPV, and anterior semicircular canal BPPV.

Temporal Bone Histopathology of Undiagnosed Dizziness in the Elderly

Introduction: Dizziness is a common disease. However, approximately 10–40% of patients were diagnosed unknown dizziness even though general, neurological, and otological examinations were performed. The aim of this otopathological study was to investigate the histopathology of the peripheral vestibular system of patients who suffered from undiagnosed dizziness. Methods: Eighteen temporal bone specimens from 9 patients with undiagnosed dizziness and 20 temporal bone specimens from age-matched 10 normal controls were selected. Cases with a history of dizziness and vertigo caused by particular peripheral vestibular disease and central etiology were excluded. Specimens of the vestibular system were carefully assessed by light microscopy. The basophilic deposits adhered to cupulae of the semicircular canals and the wall of the labyrinth were investigated. Scarpa’s ganglion cell counts in the vestibular nerves were performed. Results: Fifteen ears of 9 patients had the findings of vestibular pathology such as a basophilic deposit on cupula (8 ears), on canal wall (7 ears), vestibular nerve loss (8 ears), or vestibular atelectasis (2 ears). Unclear pathological findings such as crista neglecta, subepithelial deposits of the crista ampullaris, and adhesion of the cupula to dark cell area were demonstrated. The mean size of basophilic deposits seen in the patients (mean: 191 µm) was larger than that of latent deposits seen in the normal controls (mean: 101 µm; p = 0.01). Conclusions: We demonstrated some peripheral vestibular pathological findings such as deposit within the semicircular canal, vestibular nerve loss, and vestibular atelectasis and suggested the possible diagnosis of dizziness (benign paroxysmal positional vertigo, presbyvestibulopathy, vestibular atelectasis). These findings will provide a better insight into the multiple etiologies of the unknown dizziness in the elderly.

Using magnetic resonance imaging to improve diagnosis of peripheral vestibular disorders

Peripheral vestibular disorders are caused by pathology of the inner ear. The majority of these disorders are diagnosed with a detailed history and vestibular physical exam. Imaging is rarely a part of diagnostic work up as the pathologies of these disorders are “invisible,” or undetectable on imaging. However, these “invisible” diagnoses are becoming increasingly visible with advancements in imaging technology. Developments in magnetic resonance imaging are allowing for increased spatial resolution and better image contrast, improving our ability to see soft tissue structures including the membranous labyrinth, sensory epithelia and nerves. With these improvements in imaging, clinicians will be able to understand better atypical presentations of peripheral vestibular disorders, disease intractable to traditional therapy, disorders with unclear pathoetiology and disease only seen on histopathological studies. This review assesses the current state of imaging in the neurotology clinic with a special focus on magnetic resonance imaging and then gathers diseases identified by vestibular testing and histopathological studies that could be better understood with developments in imaging. In doing so, we hope to guide advancement in neurotologic imaging and apprise clinicians of the utility of imaging in peripheral vestibular disease diagnosis.

Agreement Between Caloric and Horizontal Video Head Impulse Testing in School-Aged Children Presenting With Dizziness.

The purpose of this investigation was to determine the relationship between the horizontal semicircular canal video head impulse test (hvHIT) and the caloric test in a sample of school-age children evaluated due to complaints of dizziness or imbalance. In adults, these two tests provide different but complementary information regarding vestibular function and/or pathology. However, the most common causes of vestibular loss in children are different than those in adults, and it is not clear how these two tests of horizontal semicircular canal function are related in a pediatric population. This is a retrospective study of electronic records of pediatric patients (< 18 years old) who were referred for vestibular function testing and completed both hvHIT and caloric testing. Agreement between both test results was evaluated by examining measures of sensitivity, specificity, and calculating Cohen's kappa. Results from 117 patients (mean age = 13.7 years, age range: 8-17 years, 37 males) were analyzed. Most patients (97/115 [84.3%]) demonstrated both normal hvHIT and caloric test results. Compared to caloric testing, the hvHIT had poor sensitivity (38.9%) and excellent specificity (98.0%). Cohen's kappa analysis revealed moderate agreement between the methods (coefficient = 0.49 [0.24, 0.73]). Where disagreement between the two tests occurred, the final diagnosis was not contingent on either test result. There is a moderate agreement between the hvHIT and the caloric test in pediatric patients presenting to a tertiary care medical center for a vestibular evaluation. Most patients in this cohort presented with normal findings. The specificity of hvHIT was excellent, although the sensitivity was low. This may be related to the low prevalence of peripheral vestibular system disease in this study cohort, and these results do not generalize to centers that serve populations of children where vestibular disorders are more prevalent (e.g., children with sensorineural hearing loss).

The research progress of residual dizziness after reduction of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo（BPPV） is the most common peripheral vestibular disease that causes vertigo. Manual reduction can be used for treatment, but even after successful reduction, some patients still have residual dizziness, which severely affects the physical and mental health and quality of life of patients, especially those elderly patients with mental and psychological disorders. This article reviews the possible pathogenesis and related risk factors of residual dizziness, and summarizes the prevention and treatment of residual dizziness, in order to provide reference for standardized treatment of residual dizziness.

Magnetic resonance imaging of the endolymphatic space in patients with benign paroxysmal positional vertigo: volume ratio and distribution rate of the endolymphatic space

Background Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disease. It is characterised by sudden onset short lived vertigo triggered by sudden changes in head position relative to gravity. Aims/Objectives We aimed to perform a quantitative volumetric analysis of the inner ear endolymphatic space in patients with BPPV. Material and Methods This study included 67 patients with BPPV and 50 control subjects (CS). The endolymphatic space/total fluid space volume ratio (%) and the distribution rate of the inner ear components in the endolymphatic space (%) were measured using three-dimensional magnetic resonance imaging. Results Differences in the endolymphatic space/total fluid space volume ratio of the inner ear, cochlea, vestibule, and semi-circular canals (SCCs) between the CS and BPPV groups were not significant. The endolymphatic space distribution rate of the vestibule in the BPPV group was significantly lower than that in the CS group, and the endolymphatic space distribution rate of SCCs in the BPPV group was significantly higher than that in the CS group. Conclusions and Significance Extended endolymphatic space in patients with BPPV did not exist. The otoconia released from the damaged utricles were considered to move with the endolymphatic flow toward SCCs.

Research progress on the screening questionnaire related to benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo（BPPV） is the most common peripheral vestibular disease in clinical practice, which can easily lead to missed diagnosis and misdiagnosis. Many guidelines have emphasized that detailed medical history and Dix-Hallpike test are sufficient to complete the diagnosis of BPPV. However, when the patient is unable or refused to undergo the displacement test due to obesity, physical weakness, cervical or lumbar dysfunction, fear of dizziness, and the displacement test does not induce nystagmus or weak nystagmus, the detailed medical history provides a supplementary basis for the diagnosis of BPPV, and compulsive posture therapy and drug treatment can be carried out accordingly. In order to standardize consultations, shorten the time for patients to visit, and help clinicians make more accurate diagnoses, many scholars at home and abroad have designed relevant screening questionnaires based on the history of BPPV, which has achieved good results.This article is summarized as follows, in order to provide ideas and references for clinical inquiry.

Drug-Drug Interactions in Vestibular Diseases, Clinical Problems, and Medico-Legal Implications.

Peripheral vestibular disease can be treated with several approaches (e.g., maneuvers, surgery, or medical approach). Comorbidity is common in elderly patients, so polytherapy is used, but it can generate the development of drug–drug interactions (DDIs) that play a role in both adverse drug reactions and reduced adherence. For this reason, they need a complex kind of approach, considering all their individual characteristics. Physicians must be able to prescribe and deprescribe drugs based on a solid knowledge of pharmacokinetics, pharmacodynamics, and clinical indications. Moreover, full information is required to reach a real therapeutic alliance, to improve the safety of care and reduce possible malpractice claims related to drug–drug interactions. In this review, using PubMed, Embase, and Cochrane library, we searched articles published until 30 August 2021, and described both pharmacokinetic and pharmacodynamic DDIs in patients with vestibular disorders, focusing the interest on their clinical implications and on risk management strategies.

The human vestibular cortex: Functional anatomy, connectivity and the effect of peripheral vestibular disease

The human vestibular cortex: Functional anatomy, connectivity and the effect of peripheral vestibular disease

Peripheral vestibular disease caused by Raillietia auris in a Barzona bull in the USA

AbstractA 2.5‐year‐old Barzona bull presented for right‐sided head tilt and decreased libido of three‐week duration. Video otoscopy of the external ear canal revealed severe erythema, stenosis, purulent debris, necrosis and numerous live Raillietia auris mites. Decontamination via saline lavages, injectable ceftiofur and dexamethasone treatments failed. Topical 10% permethrin solution in mineral oil proved efficacious at killing R. auris mites, and injectable tulathromycin and dexamethasone were administered until resolution of the bacterial otitis; however, the head tilt persisted, and the bull was slaughtered. Systemic administration of ceftiofur was not effective as a sole treatment, and topical antimicrobial treatments were significantly limited per Food Animal Residue Avoidance Databank regulations. Video otoscopy was a useful tool in the rapid diagnosis and management of the otitis. This case highlights the long‐lasting impact of otitis secondary to R. auris mite infestation and the importance of ectoparasite control and rapid treatment of otitis in bovids.

Analysis of the Skew Deviation to Evaluate the Period of Onset of a Canalolithiasis After Macular Damage.

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular end-organ disease, and it is one of the first causes of access to the emergency room. The moment of migration of the otoconial debris in a semicircular canal does not necessarily coincide with the moment of detachment of the debris themselves. Consequently, the paroxysmal positional vertigo could arise with a variable delay with respect to the mechanical damage suffered by the macula. The aim of this work is to try to identify objective criteria to establish whether a canalolithiasis is synchronous or diachronic to the damage. The analysis of skew deviation in the context of ocular tilt reaction in patients with canalolithiasis could provide useful information to understand if macular damage occurred at the origin of the disease and when the damage may have occurred. In this study, 38 patients with BPPV were analyzed based on the type of skew deviation that was presented. We found that if the eye on the side of the canalolithiasis is hypotropic the damage of the utriculus is likely recent (last 10 days), if it is hypertropic the damage is not recent (20 days before) and finally if the eyes are at the same height it could be an utricular damage in compensation (occurring the last 10–20 days) or a secondary labyrinth canalolithiasis, without associated utricular damage. Our results show that the evaluation of skew deviation in patients suffering from BPPV could be useful to evaluate: (a) if a positional paroxysmal nystagmus can be related to an previous relevant injury event (for example a head injury that occurred days before the crisis); (b) if it is a BPPV of recent onset or a re-entry of the debris into the canal.

Clinical Profiles of Elderly Patients Presenting with Persistent Dizziness

BackgroundDizziness among elderly patients is primarily treated in emergency and primary care centers. However, the causes and comorbidities responsible for dizziness in the elderly may differ in tertiary health care centers. ObjectiveTo determine the subtypes of persistent dizziness and to evaluate the number of contributory causes of dizziness among elderly patients. Methods and materialsThis observational cross-sectional study comprised of 130 patients aged >60 years. A detailed history of existing comorbidities was obtained. A standardized comprehensive evaluation of all patients was done using an International Delphi procedure. Data from each patient was independently reviewed for major and contributory causes of dizziness. Chi square test was used to find the association between dizziness and various contributing factors. ResultsPresyncope was the most frequent dizziness subtype (71.5%). Majority of patients showed one dizziness subtype (54.6%) and three contributory causes of dizziness (40.6%). An adverse effect of drug was the most common contributory cause for dizziness (20%). The most frequent underlying cause of dizziness was noted to be cardiovascular disease (40%), followed by peripheral vestibular disease (22.3%) and neurological disease (19%). Sixty six percent of the patients were identified with more than one contributing cause for dizziness. ConclusionPrimary care physicians need to anticipate that many elderly dizzy patients can have more than one cause of dizziness. A systematic and planned approach can help the clinician to effectively treat dizziness in the elderly.

Clinical signs, MRI findings and outcome in dogs with peripheral vestibular disease: a retrospective study

BackgroundVestibular dysfunction is relatively common in dogs, with a prevalence of 0.08% reported in primary veterinary care in the UK. There are several studies investigating how to differentiate between peripheral and central vestibular disease but only limited information regarding the possible underlying causes for peripheral vestibular dysfunction in dogs. This study therefore aimed to describe the clinical signs, magnetic resonance imaging findings (MRI), underlying causes and outcome in a large population of dogs diagnosed with peripheral vestibular disease.ResultsOne hundred eighty-eight patients were included in the study with a median age of 6.9 years (range 3 months to 14.6 years). Neurological abnormalities included head tilt (n = 185), ataxia (n = 123), facial paralysis (n = 103), nystagmus (n = 97), positional strabismus (n = 93) and Horner syndrome (n = 7). The most prevalent diagnosis was idiopathic vestibular disease (n = 128), followed by otitis media and/or interna (n = 49), hypothyroidism (n = 7), suspected congenital vestibular disease (n = 2), neoplasia (n = 1) and cholesteatoma (n = 1). Long-term follow-up revealed persistence of head tilt (n = 50), facial paresis (n = 41) and ataxia (n = 6) in some cases. Recurrence of clinical signs was observed in 26 dogs. Increasing age was associated with a mild increased chance of diagnosis of idiopathic vestibular syndrome rather than otitis media and/or interna (P = 0.022, OR = 0.866; CI 0.765–0.980). History of previous vestibular episodes (P = 0.017, OR = 3.533; CI 1.251–9.981) was associated with an increased likelihood of resolution of the clinical signs whilst contrast enhancement of cranial nerves VII and/or VIII on MRI (P = 0.018, OR = 0.432; CI 0.251–0.868) was associated with a decreased chance of resolution of the clinical signs.ConclusionsIdiopathic vestibular disease is the most common cause of peripheral vestibular dysfunction in dogs and it is associated with advanced age. Incomplete recovery from peripheral vestibular disease is common, especially in dogs presenting with cranial nerve enhancement on MRI but less so if there is previous history of vestibular episodes.

Effect of Midazolam on Vestibular Signs in Two Geriatric Dogs with Vestibular Disease.

An abrupt balance impairment, including leaning, falling, and rolling, occurred after IV administration of 0.2 mg/kg midazolam as a preanesthetic medication in two geriatric dogs with a history of nystagmus and head tilt. In the second case, leaning, falling, and rolling recurred after recovery from general anesthesia but gradually ceased after IV administration of 0.01 mg/kg flumazenil. These two cases suggest that the IV administration of midazolam was responsible for the balance impairment in dogs who were suspected to have idiopathic peripheral vestibular disease.