Vestibular Causes Research Articles

Sensitivity and specificity of the ocular movements test (HINTS) in the detection of central acute vestibular syndrome

BackgroundAcute vestibular syndrome may seem intimidating due to the large overlap of symptoms between vestibular and non-vestibular causes, including serious and benign causes. In addition, there is no diagnostic method to differentiate between central and peripheral causes early. ObjectiveThis study aimed to evaluate the sensitivity and specificity of the ocular movements test (HINTS) in the detection of central acute vestibular syndrome. Materials and methodsA prospective cross-sectional study was conducted, which included (n=58) patients admitted with a complaint of acute vestibular syndrome to Tishreen University Hospital in Latakia during the period from April 14, 2021 to July 1, 2022. Patients with acute vestibular syndrome (according to the definition of the International Classification of Vestibular Disorders) who were admitted to the hospital and who had at least one risk factor for stroke were included. Patients with a history of recurrent vertigo, those with diseases that would preclude HINTS testing, such as cervical or ocular diseases, and those for whom MRI was contraindicated were excluded. HINTS testing and brain CT were performed on admission. A brain MRI was performed 48 h after the onset of symptoms. The central lesion was diagnosed with a positive CT scan or MRI. ResultsOut of the 58 patients, 23 were diagnosed with a central lesion and 35 with a peripheral lesion. We found that in patients with a central lesion, with ischemic stroke being the most common cause. Cerebellar infarction was the most common, with a rate of 34.78%. We found bulbar infarction in 5 patients with a rate of 21.74%, pontine infarction in 4 with a rate of 17.39%, cerebellar metastasis in 3 with a rate of 13.04%, cerebellar peduncle infarction in 2 with a rate of 8.70%, and cerebellar hemorrhage in 1 with a rate of 4.35%. The HINTS test was positive (i.e., indicated a central lesion) in 22 patients with a central lesion and negative (i.e., indicated a peripheral lesion) in 33 patients with a peripheral lesion. Thus, the sensitivity of the HINTS test in detecting central acute vestibular syndrome was found to be 95.65%, and its specificity was 94.29%. ConclusionThe HINTS test is a simple and cost-effective clinical tool that can be used to accurately diagnose central acute vestibular syndrome.

A diagnostic framework to identify vestibular involvement in multi-sensory neurological disease.

Identifying vestibular causes of dizziness and unsteadiness in multi-sensory neurological disease can be challenging, with problems typically attributed to central or peripheral nerve involvement. Acknowledging vestibular dysfunction as part of the presentation provides an opportunity to access targeted vestibular rehabilitation, for which extensive evidence exists. A diagnostic framework was developed and validated to detect vestibular dysfunction, benign paroxysmal positional vertigo or vestibular migraine. The specificity and sensitivity of the diagnostic framework was tested in patients with primary mitochondrial disease. Adults with a confirmed diagnosis of primary mitochondrial disease were consented, between September 2020 and February 2022. Participants with and without dizziness or unsteadiness underwent remote physiotherapy assessment and had in-person detailed neuro-otological assessment. The six framework question responses were compared against objective neuro-otological assessment or medical notes. The output was binary, with sensitivity and specificity calculated. Seventy-four adults completed the study: age range 20-81 years (mean 48 years, ±SD 15.05 years); ratio 2:1 female to male. The framework identified a vestibular diagnosis in 35 participants, with seven having two diagnoses. The framework was able to identify vestibular diagnoses in adults with primary mitochondrial disease, with a moderate (40-59) to very high (90-100) sensitivity and positive predictive value, and moderate to high (60-74) to very high (90-100) specificity and negative predictive value. Overall, the clinical framework identified common vestibular diagnoses with a moderate to very high specificity and sensitivity. This presents an opportunity for patients to access effective treatment in a timely manner, to reduce falls and improve quality of life.

"Vertigo, likely peripheral": the dizzying rise of ChatGPT.

The use of artificial intelligence (AI) in medical decision-making has once again come to the forefront with the prevalence of Natural Language Processing (NLP). In this exploratory article, we tested one such model, ChatGPT, for its ability to identify vestibular causes of dizziness METHODS: Eight hypothetical scenarios were presented to ChatGPT, which included varying clinical pictures and types of prompts. The responses given by ChatGPT were evaluated for coherence, clarity, consistency, accuracy, appropriateness, and recognition of limitations. ChatGPT provided coherent and logical responses. The model accurately provided differentials for both vestibular and non-vestibular causes of dizziness, with the correct diagnosis presented first in six of the cases, with important limitations CONCLUSION: Being an AI tool, ChatGPT lacks the ability to process certain nuances in clinical decision making, in both identifying atypical dizziness, as well as in recommending further examination steps to elucidate a clearer diagnosis. We believe that AI will continue to forge ahead in the medical field. Merging the immense knowledge base of AI programming with the nuances of clinical assessment and knowledge integration will surely enhance patient care in the years to come.

Assessment of the Cost Burden of Episodic Recurrent Vestibular Vertigo in the US

Understanding of the economic burden of recurrent vestibular causes of vertigo and areas contributing to the cost is needed. To analyze and identify the factors contributing to the direct medical costs associated with Ménière disease (MD), vestibular migraine (VM), and benign paroxysmal positional vertigo (BPPV). This economic evaluation used MarketScan Commercial Database claims data from 2018 to identify the non-Medicare patient population with the diagnoses of MD, VM, or BPPV. Data were analyzed January 1 to December 31, 2018. The total direct medical costs associated with MD, VM, and BPPV. A total of 53 210 patients (mean [SD] age, 47.8 [11.8] years; 67.6% female) were included in this study, with 34 738 normal comparisons. There were 5783 (10.9%) patients with MD, 3526 (6.6%) patients with VM, and 43 901 (82.5%) patients with BPPV in the data set. Mean age and sex were different across the different vestibular disorders. Across the different groups, patients with no comorbidities or with a Charlson Comorbidity Index score of zero ranged from 98.4% to 98.8%. Around 5% of patients were hospitalized with inpatient stay lasting between 4.6 and 5.2 days. After adjusting for age, sex, and comorbidities, there were large differences in mean adjusted annual payments/direct costs across the different groups (MD, $9579; VM, $11 371; and BPPV, $8247). This equated to a total incremental estimated cost of $60 billion compared with the normal population. The number of outpatient brain magnetic resonance imaging or computed tomography scans per patient ranged anywhere from 1 to 20, while the number of inpatient brain magnetic resonance imaging or computed tomography scans per patient ranged anywhere from 1 to 6. A heat map of the total cost expenditure indicated that the costs were concentrated around the Midwest, Lake Michigan, and the East Coast. In this economic evaluation, the 3 most common causes of recurrent vertigo-MD, VM, and BPPV-had considerable medical costs associated with them. Extraneous imaging orders and vestibular testing are factors to consider for cost reduction. However, further research and widespread education is needed to optimize the diagnosis, treatment, and care of patients presenting with vestibular disorders or dizziness.

Indicators of pediatric peripheral vestibular disorder: A retrospective study in a tertiary referral center

ObjectivesThis study aims to present characteristics of pediatric patients with peripheral vertigo and dizziness and their clinical workup results in the tertiary otorhinolaryngology center. We wanted to investigate whether the detailed history could replace the extensive vestibular testing and whether the clinical presentation could guide the first contact physician to appropriately directed specialist referral. MethodsRetrospective case review of consecutive pediatric vertigo and dizziness patients referred to the tertiary otorhinolaryngology center from 2015 to 2020. The data about the signs and symptoms of vertigo and dizziness and the results of audiological and vestibular tests were collected. ResultsOf 257 children aged 10.9±4.3 years (R: 1–17 years), 32 (12.5%) had peripheral, and 49 (19%) had central vertigo and dizziness. Acute vestibulopathy was diagnosed in 22/257 (8.5%) children, sudden sensorineural hearing loss and benign paroxysmal positional vertigo in 5/257 (2%) children each. 60% of children with peripheral vertigo and dizziness had emesis, and 55.6% had nausea. 8% of children had spontaneous horizontal-rotatory nystagmus that followed Alexander's law. Goodman and Kruskal's л for determining whether the type of nystagmus could predict the type of vertigo and dizziness (central or peripheral) was 0.481 (p = 0.001). 12/26 (60%) of children with peripheral vertigo and dizziness had emesis compared to 14 (30.04%) children without emesis, a difference in proportions of 0.296 (p = 0.024, chi-square test of homogeneity). Binomial logistic regression to ascertain the effects of duration, nausea and emesis on the likelihood of the presence of peripheral vertigo was statistically significant (χ2(3) = 10.626, p = 0.014). ConclusionUnlike adults, peripheral vestibular causes of vertigo and dizziness in children may be rare but have the same typical signs and symptoms. The detailed history and careful clinical examination are crucial in differentiating between peripheral and central causes. This guides the first contact physician for further referral to appropriate specialists included in a multidisciplinary workup. Namely, nausea, emesis, horizontal nystagmus and a longer duration of symptoms in a child with vertigo and dizziness indicate a peripheral etiology. Therefore, a referral to an otorhinolaryngologist is reasonable.

Can “HINTS” aid the Diagnosis of Posterior Circulation Stroke among patients with Acute Vestibular Syndrome?

Introduction:
 Identifying posterior circulation stroke in patients with AVS without obvious focal neurological deficits poses a difficult diagnostic challenge. It is estimated that about 10% to 20% of patients who present with acute dizziness to the Emergency department have AVS7. Most AVS patients have a benign peripheral vestibular cause (vestibular neuritis or nonbacterial labyrinthitis), but about 25% have brainstem or cerebellar strokes7, 9-10. Rapid, accurate diagnosis of posterior stroke is important for early management as well as prevention of devastating complications. HINTS is a clinical three-step bedside oculomotor exam, that has been suggested of high diagnostic accuracy in identifying posterior circulation stroke in patients with isolated continuous vertigo.
 Methods:
 A comprehensive systematic search of literature was done using the NHS Evidence healthcare databases Medline, EMBASE, CLINIL, Google scholar and Cochrane.
 Results:
 10 relevant articles were identified, combining the results of all six prospective studies showed a total of 338 patients on which Clinical HINTS exam was performed. The overall Hints exam sensitivity was 96.86% 95%CI (92.8-99), specificity 96.09% 95%CI (92.1-98.4) and negative predictive value was 0.03 95%CI (0.01-0.08). ROC analysis was done in which area under curve was found to be 0.965.
 Conclusion:
 Delay in diagnosis of posterior stroke can result in 8-fold increase in mortality7. HINTS is a useful clinical bed side oculomotor exam, which if done appropriately by trained ED doctors, could aid in the early recognition of a subtly presenting posterior stroke with “acute isolated continuous vertigo”. Hence, will improve the overall diagnostic evaluation of acute vestibular syndrome.

Outcome of Manual Traction in Patients with Cervicogenic Dizziness and Neck Pain

Objective: Symptoms of cervicogenic dizziness include instability, unsteadiness, confusion, neck soreness, and limited cervical range of motion (ROM). We evaluated the outcome of manual traction in patients presenting with dizziness and neck pain.
 Materials and Methods: 50 patients included who had dizziness and neck pain with a reduced range of cervical motion. Patients had sessions of manual traction after pre-treatment evaluation. Patients included in the study after history and physical examination were sent to the otorhinology department to rule out the vestibular cause of dizziness. Patients were sent to the Physiotherapy department for manual traction. Pain and dizziness were assessed from VAS and DHI scores.
 Results: There were 28 male and 22 female patients. The mean age of the patients was 23.92 ± 11.39 years. The mean VAS scores (dizziness) were 46, 31, and 14 before treatment, at one week, and at one month, respectively. The mean VAS scores (pain) were 40, 21, and 8 before treatment, at one week, and at one month, respectively. The mean DHI scores (for dizziness disability) were 47.5, 34, and 21, at one week and at one month, respectively. There existed a significant difference (p < 0.00001) between the VAS and DHI scores before the treatment and post-treatment of follow-up at one week and at one month.
 Conclusion: Patients with cervicogenic dizziness who were treated with manual traction improved considerably in terms of dizziness severity, pain relief, and a low score on the dizziness handicap index, indicating better psychological and functional well-being.
 Keywords: Cervicogenic Dizziness (CGD), Dizziness Handicap Inventory (DHI), Manual Traction Protocol.

Identification of Stroke and TIA in Patients With Acute Dizziness, Vertigo or Imbalance in Emergency Departments of Primary Care Hospitals: Early Experiences With a Network-Based Telemedical Approach.

BackgroundAcute dizziness, vertigo, and imbalance are frequent and difficult to interpret symptoms in the emergency department (ED). Primary care hospitals often lack the expertise to identify stroke or TIA as underlying causes. A telemedical approach based on telestroke networks may offer adequate diagnostics and treatment.AimThe aim of this study is to evaluate the accuracy of a novel ED algorithm in differentiating between peripheral and central vestibular causes.MethodsWithin the Telemedical Project for Integrative Stroke Care (TEMPiS), a telemedical application including a videooculography (VOG) system was introduced in 2018 in 19 primary care spoke hospitals. An ED triage algorithm was established for all patients with acute dizziness, vertigo, or imbalance of unknown cause (ADVIUC) as a leading complaint. In three predefined months, all ADVIUC cases were prospectively registered and discharge letters analyzed. Accuracy of the ED triage algorithm in differentiation between central and peripheral vestibular cases was analyzed by comparison of ED diagnoses to final discharge diagnoses. The rate of missed strokes was calculated in relation to all cases with a suitable brain imaging. Acceptance of teleconsultants and physicians in spoke hospitals was assessed by surveys.ResultsA total number of 388 ADVIUC cases were collected, with a median of 12 cases per months and hospital (IQR 8–14.5). The most frequent hospital discharge diagnoses are vestibular neuritis (22%), stroke/TIA (18%), benign paroxysmal positioning vertigo (18%), and dizziness due to internal medicine causes (15%). Detection of a central vestibular cause by the ED triage algorithm has a high sensitivity (98.6%), albeit poor specificity (45.9%). One stroke out of 32 verified by brain scan was missed (3.1%). User satisfaction, helpfulness of the project, improvement of care, personal competence, and satisfaction about handling of the VOG systems were rated consistently positive.DiscussionThe concept shows good acceptance for a telemedical and network-based approach to manage ADVIUC cases in the ED of primary care hospitals. Identification of stroke cases is accurate, while specificity needs further improvement. The concept could be a major step toward a broadly available state of the art diagnostics and therapy for patients with ADVIUC in primary care hospitals.

Post-concussive Dizziness: A Review and Clinical Approach to the Patient.

Dizziness is a frequent complaint after head trauma. Among patients who suffer a concussion (mild traumatic brain injury or mTBI), dizziness is second only to headache in symptom frequency. The differential diagnosis of post-concussive dizziness (PCD) can be divided into non-vestibular, central vestibular and peripheral vestibular causes with growing recognition that patients frequently exhibit both central and peripheral findings on vestibular testing. Symptoms that traditionally have been ascribed to central vestibular dysfunction may be due to peripheral dysfunction. Further, our ability to test peripheral vestibular function has improved and has allowed us to identify peripheral disorders that in the past would have remained unnoticed. The importance of the identification of the peripheral component in PCD lies in our ability to remedy the peripheral vestibular component to a much greater extent than the central component. Unfortunately, many patients are not adequately evaluated for vestibular disorders until long after the onset of their symptoms. Among the diagnoses seen as causes for PCD are (1) Central vestibular disorders, (2) Benign Paroxysmal Positional Vertigo (BPPV), (3) Labyrinthine dehiscence/perilymph fistula syndrome, (4) labyrinthine concussion, (5) secondary endolymphatic hydrops, (6) Temporal bone fracture, and (7) Malingering (particularly when litigation is pending). These diagnoses are not mutually exclusive and PCD patients frequently exhibit a combination of these disorders. A review of the literature and a general approach to the patient with post-concussive dizziness will be detailed as well as a review of the above-mentioned diagnostic categories.

An Audiologist’s Approach to Chronic Dizziness

An Audiologist’s Approach to Chronic Dizziness

Dizziness in the elderly: The role of hemispheric small vessel disease

Imaging and neurophysiological work has advanced our understanding of cortical vestibular topography. Here, we will concentrate on one of the final frontiers in neuro-otology – the cause of “presbyvestibulopathy” or, more correctly, unexplained dizziness of the elderly (UDE). Retrospective imaging assessment suggested that UDE patients had increased small vessel disease (SVD) in brain scans compared to patients with vestibular causes of dizziness (Ahmad et al. 2015-doi:https://doi.org/10.1016/j.jns.2015.09.006).

Prevalence of Vestibular Disorders in Independent People Over 50 That Experience Dizziness.

People aged over 50 are the most likely to present to a physician for dizziness. It is important to identify the main cause of dizziness in order to develop the best treatment approach. Our goal was to determine the prevalence of benign paroxysmal positional vertigo (BPPV), and peripheral and central vestibular function in people that had experienced dizziness within the past year aged over 50. One hundred and ninety three community-dwelling participants aged 51–92 (68 ± 8.7 years; 117 females) were tested using the clinical and video head impulse test (cHIT and vHIT) to test high-frequency vestibular organ function; the head thrust dynamic visual acuity (htDVA) test to test high-frequency visual-stability; the dizziness handicap inventory (DHI) to measure the impact of dizziness; as well as sinusoidal and unidirectional rotational chair testing to test low- to mid-frequency peripheral and central vestibular function. From these assessments we computed the following measures: HIT gain; htDVA score; DHI score; sinusoidal (whole-body; 0.1–2 Hz with 30°/s peak-velocity) vestibulo-ocular reflex (VOR) gain and phase; transient (whole-body, 150°/s2 acceleration to 50°/s constant velocity) VOR gain and time constant; optokinetic nystagmus (OKN) gain and time constant (whole-body, 50°/s constant velocity rotation). Our study showed that BPPV, and peripheral or central vestibular hypofunction were present in 34% of participants, suggesting a vestibular cause to their dizziness. Over half (57%) of these with a likely vestibular cause had BPPV, which is more than twice the percentage reported in other dizzy clinic studies. Our findings suggest that the physical DHI score and VOR time constant were best at detecting those with non-BPPV vestibular loss, but should always be used in conjunction with cHIT or vHIT, and that the htDVA score and vHIT gain were best at detecting differences between ipsilesional and contralesional sides.

Clinicoepidemiological profile and practices to manage dizziness in primary care setting: results from an Indian registry

<p class="abstract"><strong>Background:</strong> Dizziness is a common symptom encountered in primary care settings by general physicians and specialists. This study evaluated the clinicoepidemiological profile and management practices in patients with dizziness in an Indian primary care setting.</p><p class="abstract"><strong>Methods:</strong> This prospective, multicentric, observational study was conducted between November 2018 and June 2019. Patients aged≥18 years presenting with clinical features of dizziness were eligible. The study data included demographics and socioeconomic details, complete medical history, medication and concomitant medication use, and the cause and pattern of dizziness. Patients had a baseline visit and two follow-up visits at weeks 1 and 4. </p><p class="abstract"><strong>Results:</strong> Overall, 1000 patients with a mean age of 45.1 years were included (women: 51.5%; men: 48.5%). Of these, 762 reported dizziness as a primary complaint; whereas, 238 reported it as a complaint associated with nausea, vomiting and light-headedness on visit 1, which reduced on subsequent visits. Around 34% of the patients were unemployed and 59% belonged to the upper-middle class. The most common co-morbidities were hypertension and diabetes mellitus (n=132, each). More than 50% of the patients presented with vestibular cause (n=577), followed by neurologic (n=179), metabolic (n=84) and psychiatric (n=61) etiologies. Betahistine (n=581) and prochlorperazine (n=312) were the commonly prescribed medicines for primary and associated complaints. The most commonly used concomitant medications were telmisartan (n=53), glimepiride plus metformin (n=40), metformin (n=32) and ondansetron (n=29). </p><p class="abstract"><strong>Conclusions:</strong> Dizziness has a multifactorial origin necessitating a multifactorial treatment approach. Betahistine and prochlorperazine were the most commonly prescribed drugs in the primary care setting (CTRI/2018/11/016408). </p>

Sudden-onset dizziness and vertigo symptoms: assessment and management of vestibular causes.

Approximately 2% of adults seek medical attention annually for symptoms of moderate to severe dizziness, with a third of consultations attributable to a vestibular cause.1 Aside from the healthcare burden, there are significant socioeconomic implications for patients presenting with these symptoms. The diagnosis can be challenging given the wide range of possible causes — both vestibular and non-vestibular (see this graphically online at www.balancedisorderspectrum.info).2 The four most common vestibular diagnoses causing sudden-onset dizziness will be reviewed in detail. These are vestibular neuritis (or neuronitis) (VN), benign paroxysmal positional vertigo (BPPV), vestibular migraine (VM), and Meniere’s disease. Both vestibular and non-vestibular causes of dizziness are listed (Supplementary Table 1) but this is not exhaustive. A detailed history (Supplementary Table 1) can diagnose the majority of both vestibular and non-vestibular causes. A detailed neuro-otological examination should be undertaken including otoscopy, cranial nerve examination, HINTS examination (Supplementary Table 2), Romberg’s (test of proprioception and dorsal column function) and Unterberger’s test (as per Romberg’s but with the patient marching on the spot, rotating towards side of vestibular hypofunction), and a lying and standing blood pressure reading. Dix–Hallpike testing can be used to diagnose BPPV. Presence of geotropic (beating towards the ground), torsional nystagmus on Dix–Hallpike testing supports a diagnosis of BPPV and can be followed by a therapeutic Epley manoeuvre. The main concern here is not missing a cerebellar vascular event involving the anterior or …

Ocular movement and nystagmus: basics and clinical diagnosis

Eye movements are one of the most complex motor functions of the central nervous system (CNS). Eye movement disorders including nystagmus occur in diseases of the CNS and the vestibular system. Asystematic clinical examination often allows atopodiagnostic classification of the lesion. The basics of eye movements, the role of the cerebellum, the clinical examination of the oculomotor system, and the most important forms of nystagmus and their diagnostic implications are described. A literature analysis assessing eye movements, cerebellar control of eye movements, clinical examination of eye movement, and nystagmus was performed. In disorders of eye movement, diseases of the oculomotor cranial nerves and the central nervous structures are to be distinguished from diseases of the orbit, eye muscles, and motor end plates. The former result in cranial nerve-related paralysis of extraocular muscles, disturbances of saccadic and smooth pursuit eye movements, vertical or horizontal gaze palsy, internuclear ophthalmoplegia, or impaired gaze holding. Nystagmus in combination with other disturbances of ocular movement is highly related to alesion within the CNS. Intense nystagmus with arotatory component that decreases during fixation usually has aperipheral vestibular cause. Clinical examination of eye movements and nystagmus enables the diagnosis of typical eye movement disorders with astrong relation to distinct lesions of the CNS or the peripheral vestibular pathway.

Vertigo in children: Our experiences at a tertiary care teaching hospital of eastern India

Objective: The aim of this study is to evaluate the vertigo among pediatric age presenting to the vertigo clinic at the department of otorhinolaryngology of a tertiary care teaching hospital. Materials and Methods: Patient records of 108 children under the age of 18 years with vertigo as the chief complaint examined at vertigo clinic, the department of otorhinolaryngology of tertiary care teaching hospital between January 2015 and March 2020. All the data were retrospectively reviewed. The clinical presentations, laboratory tests including audiological and vestibular tests were analyzed. Results: This study consisted 108 children with 66 girls (61.11%) and 42 boys (38.88%) between the age of 4 and 18 years (mean age, 12.4 years). The most common etiology for pediatric vertigo in this study was vestibular migraine (VM) followed by benign paroxysmal vertigo of children and vestibular neuritis. The duration of vertigo attacks occurred in seconds in 29 children (26.85%), min in 45 children (41.66%), hours in 27 children (25%), and more than 24 h in 7 children (6.48%). Conclusion: VM was found to be a more common diagnosis in pediatric vertigo, although several peripheral vestibular causes were diagnosed. Proper evaluation of vertigo in children should be done with thorough neuro-otologic examination. Other multidisciplinary team members should be there during evaluation of vertigo in children to avoid unnecessary delay in diagnosis and treatment.

Bedside examination of the vestibular and ocular motor system in patients with acute vertigo or dizziness

In the initial assessment of the patient with acute vertigo or dizziness, both structured history-taking and a targeted bedside neuro-otological examination are essential for distinguishing potentially life-threatening central vestibular causes from those of benign, self-limited peripheral labyrinthine origin and thus for deciding on further diagnostic testing. In this article, the key elements of the vestibular and ocular motor examination, which should be obtained at the bedside in these acutely dizzy patients, will be discussed. Specifically, this will include the following five domains: ocular stability for (I) nystagmus and for (II) eye position (skew deviation), (III) the head-impulse test (HIT), (IV) postural stability, and (V) ocular motor deficits of saccades, smooth pursuit eye movements, and optokinetic nystagmus. We will also discuss the diagnostic accuracy of specific combinations of these bedside tests (i.e. HIT, testing for nystagmus and vertical divergence, referred to as the H.I.N.T.S. three-step examination), emphasizing that the targeted neuro-otological bedside examination is more sensitive for identifying central causes in acute prolonged vertigo and dizziness than early MRI of the brain.

Symptoms in cervical vertigo.

ObjectiveTo use a unique, 41‐question survey to identify patient features distinguishing cervical vertigo from vestibular causes of vertigo and vestibular migraine.MethodsIn this study, a unique, 41‐question survey was administered to 48 patients diagnosed with cervical vertigo (n = 16), migraine (n = 16), and vestibular vertigo (eg, unilateral vestibular paresis, Meniere's disease) (n = 16) to test the hypothesis that a set of distinct symptoms can characterize cervical vertigo. Responses between the three diagnostic groups were compared to identify questions which differentiated patients based on their symptoms.ResultsEight questions were successful in differentiating vestibular vertigo from migraine and cervical vertigo. Symptoms endorsed by subjects with cervical vertigo overlapped substantially with subjects with well‐established vestibular disturbances as well as symptoms of subjects with migraine. Twenty‐seven percent of cervical vertigo subjects reported having true vertigo, 50% having headache, and 94% having neck pain.ConclusionLacking knowledge of neck disturbance, the symptoms we elicited in our questionnaire suggest that cervical vertigo subjects may resemble migraine subjects who also have evidence of neck injury. Whether or not subjects with “cervical vertigo” also overlap with other diagnoses defined by a combination of symptoms and exclusion of objective findings such as chronic subjective dizziness and other variants of psychogenic dizziness remain to be established.Level of EvidenceIV

Role of Electronystagmography in Diagnosis of Secondary BPPV in Elderly Patients with Vertigo: A Retrospective Study.

Elderly population is frequently affected by vertigo which affects their mobility and makes them vulnerable to fall and other morbidities. Often these patient visit neurologist and are often subjected to CT scan, MRI brain etc. to rule out a central cause of vertigo; whereas majority of these patients suffer from vestibular cause of vertigo. A schematic approach by detailed history, simple tests for vestibular functions like Dix Hallpike, supine roll and head impulse test give important clue to diagnosis. Often the diagnosis is benign paroxysmal positional vertigo (BPPV) which is treated by repositioning maneuver. There are often other vestibular causes which may be diagnosed by Electronystagmography (ENG), electrocochleography and other tests. This study was undertaken to study occurrence of secondary BPPV utilizing various parameters of ENG. The study group comprised of 131 patients from the neuro-otology proforma data base at ENT centre and vertigo clinic from January 2015 to December 2017. Inclusion criterion was male and female aged 51years and above presenting with dizziness, imbalance, rotational vertigo, unsteadiness as the chief complaint. Exclusion criterion was BPPV relieved after Epley's maneuver, Otitis externa, acute Otitis media, Suppurative Otitis media, pre existing neurological condition and history of ear surgery. Neuro-otology Data obtained and the ENG findings were tabulated in the master chart and the observations interpreted and transferred to Claussen's butterfly chart. The study group comprised of 58 male (44.27%) and 73 female (55.73%) with a male female ratio of 1:1.25. ENG exhibited 36 patients (27.49) to have recurrent BPPV, 53 (40.45%) were found to have unilateral/bilateral canal paresis. Meniere's disease was diagnosed in 39 (29.77%) patients and brain stem pathology identified in 3 (2.29%) cases.

Evaluation of giddiness: a peripheral hospital experience

<p class="abstract"><strong>Background:</strong> Giddiness remains one of the most common reasons to consult an ENT specialist. There are multiple causes for giddiness, both peripheral and central. It takes a careful, dedicated and committed history taking as well as examination to establish the cause for giddiness. Vascular effects of metabolic diseases can prepone the onset of vestibular symptoms. This study was undertaken to see the proportions of different types of giddiness among patients who presented with dizziness.</p><p class="abstract"><strong>Methods:</strong> A descriptive study was done in the ENT Outpatient settings for all the patients who presented with dizziness and/or vertigo. Careful history elicitation and examination was done to establish the cause. </p><p class="abstract"><strong>Results:</strong> There was a female preponderance with female to male ratio 13:7. Giddiness due to non-peripheral causes were seen in 150 (69%) and peripheral and migrainous vertigo accounted for dizziness in 33 (15.2%) and 34 (15.7%) patients. Diabetes mellitus was seen in 143 (65.8%) patients.</p><p class="abstract"><strong>Conclusions:</strong> Comprehensive examination and assessment of patients is required for reasonable evaluation of vertigo. Though vestibular causes are important, it is essential to have a broad understanding of the various causes of vertigo so that serious and life threatening non peripheral causes is not missed out. Growing geriatric population, increasing lifestyle diseases and iatrogenic causes should be kept in mind while evaluation protocols of vertigo are standardized through the country.</p>