[Chinese multidisciplinary expert consensus on assessment and management of vestibular migraine]

Vestibular migraine (VM) is a common disorder characterized by recurrent dizziness and/or vertigo, which involves a number of specialites and is easily misdiagnosed. The Stroke and Vertigo Association of Chinese Stroke Association and Vertigo Professional Committee of Neurology Branch of Chinese Physicians Association organized multi-disciplinary experts to discuss clinical issues of VM. The purpose of this consensus is to establish a standard framework for the diagnosis and management of VM in China.

Migraine Associated Vertigo

This chapter is a brief overview of migraine associated vertigo (MAV), focusing on the points most relevant to the practicing clinician. We review the definition of MAV, theories regarding its underlying pathophysiology, clinical presentation, epidemiology, findings on physical examination and oto vestibular testing, differential diagnosis, management and prognosis.

Vertigo caused by longus colli tendonitis: A case report and literature review

RATIONALE

Tendinitis of the longus colli muscle is an aseptic inflammatory process leading to acute posterior neck pain, neck stiffness, and dysphagia or odynophagia. We present a patient exhibiting an infrequent symptom, vertigo. This is the first description of the occurrence of vertigo symptoms caused by longus colli tendinitis.

PATIENT CONCERNS

A 38-year-old man was diagnosed with vertigo, presenting with a 1-month history of dizziness, palpitations, and numbness in the hands.

DIAGNOSIS

Longus colli tendinitis. The diagnosis was established using magnetic resonance imaging fat-suppression sequences.

INTERVENTIONS

Treatment with corticosteroid injections and acupotomy.

OUTCOMES

The symptoms relieved immediately after the treatment and complete resolution of the symptoms was observed after 1 week.

LESSONS

Longus colli tendinitis with vertigo is an under-reported condition in the literature and physicians should be aware of its existence. A lack of familiarity with the anatomy of the prevertebral space and its variable radiographic appearance makes the diagnosis of longus colli tendinitis clinically difficult. Misdiagnosis of this condition may lead to unnecessary interventions in vertigo.

Pilot cluster randomized controlled trial of a complex intervention to improve management of vertigo in primary care (PRIMA-Vertigo): study protocol

OBJECTIVES

Vertigo and dizziness are highly prevalent symptoms in primary care, frequently misdiagnosed. Based on a thorough need assessment, INDICORE (INform, DIagnose, COmmunicate, REfer), an evidence-based complex intervention has been developed to transfer knowledge of specialized tertiary clinics to primary care providers (PCPs), improve the referral process and, ultimately, improve the functioning and quality of life of patients with vertigo/dizziness. The main objective of the PRIMA-Vertigo pilot study is to examine whether the INDICORE intervention is feasible and sufficiently promising to warrant a larger trial.

METHODS

We plan to perform a single-blind, pragmatic cluster-randomized controlled pilot study with an accompanying process evaluation. PCPs will be the cluster units of randomization. Patients who consult these PCPs because of vertigo/dizziness symptoms will be included consecutively and considered the units of analysis. The intervention will be multi-faceted training on diagnostics targeted at the PCPs, supported by patient education material and a newly developed tool to structure the referral process. To balance the influence of non-specific effects, all clusters will receive generic communication training.

EXPECTED RESULTS

The process evaluation aims to provide results on the acceptability and feasibility of the INDICORE intervention components to PCPs and patients. Additionally, this study will provide a first estimate of the likely effectiveness of the intervention on patients' quality of life, functioning and participation.

CONCLUSIONS

The PRIMA-Vertigo pilot study will allow further tailoring of the INDICORE intervention to stakeholder needs before its effectiveness is evaluated in a large-scale main study.

Update on Vertigo in Autoimmune Disorders, from Diagnosis to Treatment

The prevalence of autoimmune diseases has been increasing over the last 20 years. The clinical presentation of this large and heterogeneous group of disorders depends on whether the involvement is organ-specific or non-organ-specific. Dizziness, vertigo, and disequilibrium are common symptoms reported by patients with vestibulocochlear involvement. The association of vertigo and autoimmune diseases has been largely documented, suggesting that autoimmune disorders could be overrepresented in patients with vertigo in comparison to the general population. The aim of this review is to present the recent literature findings in the field of autoimmune-mediated diseases with cochleovestibular involvement, focusing on the clinical presentation, diagnosis, and treatment of immune-mediated inner ear diseases including autoimmune inner ear disease (AIED), Meniere's disease, and bilateral vestibulopathy, as well as of systemic autoimmune diseases with audiovestibular disorders, namely, Behçet's disease, Cogan's syndrome, sarcoidosis, autoimmune thyroid disease, Vogt-Koyanagi-Harada syndrome, relapsing polychondritis, systemic lupus erythematosus, antiphospholipid syndrome, IgG4-related disease, and ANCA-associated vasculitides.

Standardizing your approach to dizziness and vertigo

First, determine whether the sensation the patient is experiencing is dizziness or true vertigo. Then eliminate ominous causes from the array of benign ones.

[Dizziness and vertigo associated with vestibular neuronitis: the approaches to the diagnostics and treatment]

This article is focused on the peculiar features of diagnostics and treatment of dizziness and vertigo in the patients presenting with vestibular neuronitis. The authors present the detailed overview of various theories concerning etiology and pathogenesis of this condition, describe the methods for its clinical and instrumental diagnostics (including its differential diagnostics from other diseases associated with acute dizziness and vertigo). Special attention is given to the methods of pharmacological and physical rehabilitation of the patients suffering from vestibular neuronitis.

[Approach to patients with vertigo]

Vertigo is defined as an abnormal sensation of body motion or of its surrounding objects. It is a common chief complaint in emergency departments comprising 2 to 3% of these consultations worldwide. Vertigo is classified as peripheral or central, according to its origin, and can also be occasionally mixed, the most common cause of peripheral involvement being benign paroxysmal positional vertigo. The initial findings on clinical evaluation of patients are the clues for making a correct diagnosis. The differentiation between central and peripheral vertigo can be optimized by analysing nystagmus, by using the skew test and the head impulse test (HINTS), as also by performing the appropriate tests to evaluate the integrity of the vestibular-cerebellar pathway. In addition, tonal threshold audiometry could raise the diagnostic sensibility from 71 to 89% on initial approach. Appropriate diagnosis is the principal key for managing this clinical condition.

Alternobaric vertigo and facial baroparesis caused by scuba diving and relieved by chewing pineapple: a case report

Equalization of middle ear pressure is an important consideration for scuba divers. When middle ear pressure is asymmetric, a diver may experience alternobaric vertigo. Moreover, individuals with an underlying temporal bone dehiscence are predisposed to facial baroparesis. An understanding on behalf of fellow divers and emergency responders to recognize and differentiate facial baroparesis from decompression illness is critical. Misdiagnosis may lead to inappropriate treatment or unwarranted stoppage of diving. There have been a few dozen reported cases of facial baroparesis in the literature, but few have included firsthand accounts. This report describes an incidence of unilateral facial baroparesis preceded by alternobaric vertigo, with commentary from divers who witnessed the individual experiencing the facial paresis. The facial weakness in this case resolved within 15 minutes after the diver chewed on fresh pineapple. This report suggests that alternobaric vertigo may be a harbinger of facial baroparesis. Upon resurfacing divers should consider prophylactic measures that help to dilate the Eustachian tube such as chewing, yawning and swallowing in order to minimize the risk of middle ear pressure-induced vertigo or facial paresis.

Health-related quality of life and disability in patients with acute unilateral peripheral vestibular disorders

Introduction

Health-related quality of life is used to denote that portion of the quality of life that is influenced by the person's health.

Objectives

To compare the health-related quality of life of individuals with vestibular disorders of peripheral origin by analyzing functional, emotional and physical disabilities before and after vestibular treatment.

Methods

A prospective, non randomized case-controlled study was conduced in the ENT Department, between January 2015 and December 2015. All patients were submitted to customize a 36 item of health survey on quality of life, short form 36 health survey questionnaire (SF-36) and the Dizziness Handicap Inventory for assessing the disability. Individuals were diagnosed with acute unilateral vestibular peripheral disorders classified in 5 groups: vestibular neuritis, Ménière Disease, Benign Paroxysmal Positional Vertigo, cochlear-vestibular dysfunction (other than Ménière Disease), or other type of acute peripheral vertigo (as vestibular migraine).

Results

There was a statistical significant difference for each parameter of Dizziness Handicap Inventory score (the emotional, functional and physical) between the baseline and one month both in men and women, but with any statistical significant difference between 7 days and 14 days. It was found a statistical significant difference for all eight parameters of SF-36 score between the baseline and one month later both in men and women; the exception was the men mental health perception. The correlation between the Dizziness Handicap Inventory and the SF-36 scores according to diagnostics type pointed out that the Spearman's correlation coefficient was moderate correlated with the total scores of these instruments.

Conclusion

The Dizziness Handicap Inventory and the SF-36 are useful, proved practical and valid instruments for assessing the impact of dizziness on the quality of life of patients with unilateral peripheral vestibular disorders.

[Clinical Observation of the Proprioceptive Sensibility Reflexotherapy by Tendon Acupuncture at Trigger Points for Cervical Vertigo]

OBJECTIVE

To evaluate the efficacy of the proprioceptive sensibility reflexotherapy by tendon acupuncture needling at trigger points for patients with proprioceptive disorder of cervical vertigo.

METHODS

Seventy-nine patients with proprioceptive disorder of cervical vertigo were randomly assigned into a treatment group (42 cases) and a control group (37 cases). Patients in the treatment group received the proprioceptive sensibility reflexotherapy with tendon acupuncture at trigger points in the neck. And those in the control group were given traditional traction, massage and intermediate frequency electro therapy. All the treatment was given for 2 courses, once a day and 10 days as a course. The cervical vertigo symptom and function, the joint position error (JPE) and stability index (ST) before and after treatment were observed in the two groups and the effects were evaluated.

RESULTS

The cervical vertigo symptom and function were improved, JPE and ST decreased after treatment in the two groups (all P<0.05), with better results in the treatment group (all P<0.05).

CONCLUSIONS

The proprioceptive sensibility reflexotherapy with tendon acupuncture at trigger points is effective for proprioceptive disorder of cervical vertigo.

Schnitzler Syndrome With Delirium and Vertigo: The Utility of Neurologic Manifestations in Diagnosis

<p>Schnitzler syndrome (SS) is an autoinflammatory dermatosis that often goes undiagnosed for 5-6 years. Patients typically carry a diagnosis of urticaria; however, their cutaneous symptoms fail to respond to typical urticaria therapies and lack symptoms such as pruritus. Additionally, patients with SS may see multiple providers for nonspecific complaints of fever, lymphadenopathy, arthralgias, and bone pain. A correct diagnosis is paramount, as close to 20% of patients may develop a lymphoproliferative disorder and appropriate treatment may ameliorate all symptoms.1 We report 2 cases of SS misdiagnosed as urticaria for years in order to illuminate diagnostic pearls, histopathological findings, and treatment modalities. Additionally, we highlight the importance of neurologic disturbances in this rare but important differential diagnosis of urticaria.</p> <p><em>J Drugs Dermatol. 2017;16(6):625-627.</em></p>.

Use of canalith repositioning manoeuvres and vestibular rehabilitation: a GP survey

OBJECTIVE

To investigate the use of canalith repositioning manoeuvres and vestibular rehabilitation (VR) by GPs and to assess reasons for not using these techniques in patients with vertigo.

DESIGN

Online survey.

SETTING

GPs in the western and central part of the Netherlands.

SUBJECTS AND METHOD

Of GPs, 1169 were approached to participate in the survey. A sample of 426 GPs filled out the questionnaire (36.4% response rate). The 22-item questionnaire contained both multiple choice and free-text questions on the Epley manoeuvre, the Brandt-Daroff exercises and VR. Results of the survey were descriptively analyzed.

MAIN OUTCOME MEASURES

The use of the Epley manoeuvre, the Brandt-Daroff exercises and VR by GPs; reasons that deter GPs from using these techniques.

RESULTS

The repositioning manoeuvres (Epley manoeuvre and Brandt-Daroff exercises) were used by approximately half of all GPs (57.3 and 50.2%), while only a small group of GPs applied VR (6.8%). The most important reason for GPs not to use the Epley manoeuvre, Brandt-Daroff exercises and VR was that they did not know how to perform the technique (49.5, 89.6 and 92.4%).

CONCLUSIONS

Despite the proven effectiveness, repositioning manoeuvres and VR are remarkably underused by Dutch GPs. Not knowing how to perform the technique is the most important reason for GPs not to use these techniques. Efforts should be made to increase the knowledge and skills of GPs regarding canalith repositioning manoeuvres and VR. Key points Dizziness is a common symptom with limited therapeutic options.   • Canalith repositioning manoeuvres and vestibular rehabilitation represent the best treatment options currently available for vertigo.   • Canalith repositioning manoeuvres and vestibular rehabilitation are still widely underused by GPs.   • The most important reason for GPs not to use these techniques is that they do not know how to perform them.   • Efforts should be made to increase the knowledge and skills of GPs regarding canalith repositioning manoeuvres and vestibular rehabilitation.

Evalution of the effectiveness of multimodal approach to the management of cervical vertigo

INTRODUCTION

Vertigo is one of the most common complaints among patients consulting neurologists and general practitioners - family medicine. A special form of dizziness is cervical vertigo. However, the presence of chronic vertigo and imbalance in this group of patients makes it possible to include the treatment of vestibular rehabilitation in the program.

AIM

Evalution of the effectiveness of multimodal approach to the management of cervical vertigo.

MATERIAL AND METHODS

109 patients aged from 18 to 45 with vertigo together with myofascial pain syndrome of neck and shoulder area were examined. The survey included a sample of Dix-Hallpike, neurological and otoneurological examinations, Doppler ultrasound of the main arteries of the head and neck, brain MRI, functional spondylography of the cervical spine. For quantitive evaluation of the impact of vertigo on daily life the questionnaire DHI (Dizziness Handicap Inventory) was used. Testing was performed in two stages - before treatment and in 2 weeks' time. Patients were randomly divided into 3 groups which differ in their therapeutic tactics.

RESULTS

In all three groups the normalization of the biomechanical pattern and elimination of musculo-tonic disorders accompanied by a decrease of a pain syndrome and a decrease in the severity or complete regression of dizziness and postural instability. At the same time, in groups 2 and 3, in which in addition to manual therapy, patients received acupuncture, there was a distinct positive dynamics of a pain syndrome according to VAS, Neck Disability Index and the Dizziness Handicap Inventory. A marked regression of vertigo and postural instability can be observed in patients in which the treatment along with manual therapy and acupuncture, a complex of vestibular rehabilitation was used.

CONCLUSIONS

The multimodal approach using manual therapy in combination with acupuncture and vestibular rehabilitation showed the maximum therapeutic effect on elimination of musculo-tonic disorders, reduction of a pain syndrome with a complete regression of vertigo and postural instability.

Natural History of Benign Paroxysmal Positional Vertigo and Efficacy of Epley and Lempert Maneuvers

We assessed the efficacy of Epley maneuver in patients with posterior canal benign paroxysmal positional vertigo (P-BPPV) and Lempert maneuver in patients with horizontal canal BPPV (H-BPPV). In patients with P-BPPV, positional vertigo in patients treated by Epley maneuver was significantly resolved more quickly than that in untreated patients. But in patients with H-BPPV, there were no significant differences of time course in remission of positional vertigo between untreated patients and patients treated by Lempert maneuver. Among the untreated patients, the positional vertigo in patients with H-BPPV was significantly resolved more quickly than that in patients with P-BPPV. Epley maneuver was effective for the treatment of patients with P-BPPV, whereas the efficacy of Lempert maneuver for the treatment of patients with H-BPPV was limited. The natural courses in remission of positional vertigo in untreated patients with H-BPPV showed significantly faster resolution than that in patients with P-BPPV.

[Update on the evaluation and management of dizziness in older people]

This article provides an update on the evaluation and management of dizziness in older people. It is based on a recent literature review. Indeed, it is a frequent reason to consult a general practitioner. Its clinical presentation is not very specific and its treatment is often challenging. Although dizziness is often benign it can have serious physical, functional and psychological consequences. Thanks to a careful medical history and simple clinical examination tools, general practitioners can make a correct diagnosis and provide early multidisciplinary care that can greatly improve the quality of life of elderly people who suffer from dizziness.

Horizontal Canal Benign Positional Vertigo

The existence of horizontal canal benign positional vertigo (BPV) was predicted from temporal bone studies in 1973, but was not clinically confirmed until later. In this series of 300 patients with BPV, 35 (12%) were identified as having the horizontal canal variant. The essential features are the onset of vertigo when the patient assumes a supine position and bidirectional horizontal nystagmus as the head is turned from side to side. In one third it appeared as a canal “conversion” in patients undergoing repositioning treatment for posterior canal BPV. The mechanism can be canalithiasis or cupulolithiasis. Repositioning treatment is a 360° horizontal head and body rotation that has a high success rate if the symptomatic ear is correctly identified.

Benign Positional Vertigo: Prognostic Factors

OBJECTIVE/HYPOTHESIS: We sought to assess prognostic factors associated with initial successful treatment and recurrence of benign paroxysmal positional vertigo (BPPV) with the canalith repositioning (CRP) maneuver with mastoid vibration. STUDY DESIGN AND SETTING: We conducted a retrospective chart review of 104 consecutive BPPV patients at a tertiary care referral center during 1999.

METHODS: The main outcome measures were resolution of BPPV and absence of nystagmus on Hallpike maneuver.

RESULTS: Ninety-three patients (89.4%) experienced initial symptom resolution, and 21 of the initially successful patients had a recurrence (recurrence rate of 22.6%). Prior trauma or labyrinthitis was found to predict the lowest initial CRP success. Endolymphatic hydrops and central nervous system-related dizziness as cofactors with BPPV were associated with the highest recurrence rates.

CONCLUSION AND SIGNIFICANCE: Specific concurrent otologic conditions are associated with different outcomes in BPPV. (Otolaryngol Head Neck Surg 2004;130:426-9.)

BPPV and Variants: Improved Treatment Results with Automated, Nystagmus-Based Repositioning

OBJECTIVE: Although classical benign paroxysmal positional vertigo has generally been resolvable by routine manual repositioning maneuvers, nevertheless resistant cases and variants remain a significant problem. We investigated the efficacy of analyzing and treating positional vertigo with a system that provides unlimited, automated maneuverability of the patient while maintaining constant electronic monitoring of nystagmus.

STUDY DESIGN AND SETTING: A power-driven, multi-axial positioning chair combined with ongoing infrared video-oculography was used to manage 986 subjects in a tertiary clinical setting with complaints of positional vertigo. A nystagmus-based strategy and condition-specific protocols were used.

RESULTS: Significantly enhanced treatment outcomes were achieved, especially regarding intransigent and variant forms. Pertinent correlations were noted.

CONCLUSION: This multi-axial positioning chair combination provided enhanced diagnostic and treatment capabilities for managing positional vertigo, apparently due to improved analytical capability, precision repeatability, and unlimited 360-degree maneuverability.

SIGNIFICANCE: This advancement should be considered for tertiary management of complicated labyrinthine lithiasis.

Diagnostic, Pathophysiologic, and Therapeutic Aspects of Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo is the most common peripheral vestibular disorder. It can be defined as transient vertigo induced by a rapid head position change, associated with a characteristic paroxysmal positional nystagmus. Canalolithiasis of the posterior semicircular canal is considered the most convincing theory of its pathogenesis and the development of appropriate therapeutic maneuvers resulted in its effective treatment. However, involvement of the horizontal or the anterior canal has been found in a significant rate and the recognition and treatment of these variants completed the clinical picture of the disease. This paper describes the advances in understanding how this disease is generated and discusses the current therapeutic modalities.

[A clinical study into the vestibular function and therapy of patients with chronic positional symptoms after acute vestibular syndrome]

Objective:To investigate the status of the vestibular function of the patients with chronic positional symptoms after peripheral acute vestibular syndrome (AVS) and the curative effect of the vestibular rehabilitation therapy (VRT). Method:Using caloric test (CT), head shaking nystagmus test (HST), cervical vestibular evoked myogenic potentials as well as ocular vestibular evoked myogenic potentials to estimate the function of semicircular canal and otolith organs. The patients with normal VEMPs are divided as Group A. Otherwise are as Group B. Both groups are treated with VRT. The curative effect is estimated by vestibular symptom index (VSI) and Berg balance scale (BBS). Result:Thirty-three of 37 patients (86.5%) had an abnormal result of CT and HST, with 23 of these patients (65.7%) had an abnormal of both test. Twenty-two patients (59.5%) were in Group A and 15 (40.5%) in Group B. Before the therapy, Group B had a higher score of the balance and dizziness symptoms of VSI (P<0.05), and Group A had a higher score of the BBS (P<0.05). After the therapy, the VSI scores of both groups dropped and scores of the BBS raised. Conclusion:Patients with chronic positional symptoms after peripheral AVS have dynamic vestibular lesions to different extents. Those with otolith organs lesions tend to have a worse function of balance. Nevertheless, patients have a better off after VRT.

[Study of BPPV precise manipulation treatment]

Objective:To explore the effect of the BPPV precision manipulation treatment. Method:With 3D SLICER software we segment structure such as semicircular canal, eye ball, orbital and ear rod from MRI or CT volume data of patients which underwent MRI or CT scaning of inner ear, for measuring the spatial direction of semicircular canals and building semicircular canal modules with standard space coordinate system and embedding into 3D PDF files. Result:With the slice that divide the semicircular canal equally as the semicircular canal plane and the eyeball as reference object to determine whether it is symmetric, it is not only intuitive but also reliable for measuring the angle between the posterior semicircular canal. 3D PDF is intuitive, rotation angle can be adjusted according to the individual differences in the process of manipulation treatment, to observe and demonstrate the theoretical reduction effect before the actual operation. Conclusion:By reconstruction the three-dimensional semicircular canal structure from the inner ear image data of patients and measurement of the semicircular canal space direction, it is of a certain significance for BPPV precision manipulation treatment.

An approach to vertigo in general practice

BACKGROUND

Dizziness is a common and very distressing presentation in general practice. In more than half of these cases, the dizziness is due to vertigo, which is the illusion of movement of the body or its surroundings. It can have central or peripheral causes, and determining the cause can be difficult.

OBJECTIVE

The aim of this article is to provide a clear framework for approaching patients who present with vertigo. A suggested approach to the assessment of vertigo is outlined.

DISCUSSION

The causes of vertigo may be central (involving the brainstem or cerebellum) or peripheral (involving the inner ear). A careful history and physical examination can distinguish between these causes. The most common causes of vertigo seen in primary care are benign paroxysmal positional vertigo (BPPV), vestibular neuronitis (VN) and Ménière's disease. These peripheral causes of vertigo are benign, and treatment involves reassurance and management of symptoms.

10 years of Vertigo Clinic at National Hospital Abuja, Nigeria: what have we learned?

The clinician's major role in management of the dizzy patient involves determining what dizziness is vertigo, and what vertigo is of central or peripheral origin. These demand attention to details of history, otolaryngological workup including vestibular assessment, and often use of diagnostic and management algorithms. There is paucity of published reports of the management outcomes of peripheral vestibular diseases from Africa. Two tertiary care otologist-led dedicated vertigo clinics are located in Abuja, Nigeria. A prospective, non-randomized study of patients presenting with features of peripheral vestibular diseases attending the National Hospital Abuja Nigeria (between May 2005 and April 2014) and CSR Otologics Specialist Clinics (May 2010 to April 2014) was carried out. Both institutions adopted the same diagnostic and management protocols. Data extracted from anonymized databases created for this study include age, sex, vertigo duration (acute <12 weeks, chronic >12 weeks), dizziness handicap inventory score at presentation and at subsequent visits, otological and vestibular findings, ice-water caloric testing results, other investigation outcomes, treatments offered and outcomes. 561/575 (97.5 %) of the cases recorded had peripheral vestibular disease. The male-to-female ratio was 290:271. The mean age of the subjects was 44.7 years. Duration of vertigo at presentation was acute in 278 subjects and chronic in 283 subjects. Identifiable clinical diagnostic groups include BPPV (n = 200), Meniere's disease (n = 189), cervicogenic vertigo (n = 35), labyrinthitis (n = 32), Migraine-associated vertigo (MAV) (n = 32), cholesteatoma/perilymph Fistula (n = 10), climacteric vertigo (n = 8) and unclassified vertigo (n = 55). Migraine-associated vertigo recorded the highest DHI score (95 % CI 75 ± 4.3), followed by cholesteatoma/perilymph fistula (95 % CI 72 ± 6.1) and labyrinthitis (95 % CI 62 ± 1.9). Pure tone audiometry (95 % CI 67.3 ± 3.43), followed by thyroid function tests (95 % CI 66.7 ± 23.55) and ice-water caloric testing (95 % CI 59.7 ± 2.69) were investigations with the highest yields. 86.5 % of cases were treated by either vestibular suppressant medications alone (n = 285) and/or particle repositioning maneuver (n = 200) with improvement in vertigo control (95 % CI 63.63 to 74.37 % and 62.59 to 75.41 %, respectively). Peripheral vestibular diseases constitute majority of cases of self-reported vertigo seen in our setting. Migraine-associated vertigo seen in our setting all have peripheral vestibular signs. Dedicated vertigo clinics could significantly improve the diagnostic and treatment yield in a resource-constrained setting like ours. Most cases can be managed using non-operative measures.

Vertigo and dizziness in children

Vertigo and dizziness of at least moderate severity occur in >5% of school-aged children and cause considerable restrictions in participation in school and leisure activity. More than 50% of dizzy children also have headache. Vestibular migraine and benign paroxysmal vertigo as a migraine precursor are the most common diagnoses in dizziness clinics for children and adolescents. They account for 30-60% of diagnoses. Other common causes are somatoform, orthostatic, or posttraumatic dizziness. All other disorders that are known to cause vertigo and dizziness in adults also occur in children, but incidence rates are usually lower. The vestibular and balance systems are largely developed after 1 year of age. Therefore, clinical and laboratory testing is reliable. Brain magnetic resonance imaging to exclude severe conditions, such as a brainstem tumor, is necessary only if clinical - in particular, ocular motor - testing is abnormal. Most conditions causing vertigo and dizziness in childhood and adolescence are treatable. Nonpharmacologic prophylaxis should always be recommended in vestibular migraine. Behavioral support is useful in somatization. Evidence for the effectiveness of drug therapy is largely based on experience in adult populations. High-quality controlled studies in childhood cohorts are sparse. It is important to make a correct diagnosis early on, as counseling and appropriate treatment may avoid chronic illness.

[Vestibular migraine]

Dizziness caused by migraine, vestibular migraine (VM), has been highly debated over the last three decades. The co-morbidity of migraine and dizziness is higher than a random concurrence. One third of the patients with migraine and dizziness have VM. Recently, The International Headache Society approved VM as a diagnostic entity and the diagnostic criteria for VM appear in the appendix for The International Classification of Headache Disorders. VM is common but often underdiagnosed. Treatment follows migraine management guidelines although evidence is sparse.

Faints, fits and funny turns for the physician

The diagnosis and management of the dizzy patient presents the physician with significant challenges. Dizziness and imbalance are common complaints among the general population, affecting around one-third of people over the age of 65 years, and can result from a range of causes spanning many medical disciplines. The ability to take a thorough, accurate history with a logical framework for formulating a differential diagnosis is essential given the many ways that symptoms of dizziness can present. An understanding of the key features of the vestibular examination, and consideration of other pathologies including neurological and cardiac, are important. This conference was held with the aim of demystifying the dizzy patient by providing physicians with a practical approach to the assessment and management of dizziness, imbalance and 'funny turns'.

Sudden hearing loss and vertigo after tooth extraction successfully treated with combined therapy including HBO2: a case report

Sudden sensorineural hearing loss (SSNHL) is a decrease in hearing of at least 30 dB that occurs within three days and which affects at least three consecutive frequencies in either ear or both ears. This case report describes a woman who had sudden hearing loss and vertigo in the right ear after tooth extraction. As the first-line therapy, systemic and intratympanic steroid injections were used this led to a slight improvement; however, the majority of improvement in hearing was not observed until hyperbaric oxygen (HBO2) therapy was instituted on the 20th day of hearing loss. Sudden hearing loss and vertigo after tooth extraction is an otologic emergency and early evaluation and treatment are effective. HBO2, although employed beyond the Undersea and Hyperbaric Medical Society's recommended initial 14 days of symptom onset, very was effective for this particular case.

[Diseases of the peripheral vestibular system: contribution of ENT medical diagnostics and therapy]

The most common types of vertigo caused by diseases of the peripheral vestibular system are benign paroxysmal positional vertigo (BPPV), Meniere's disease and vestibular neuritis. A thorough examination of the medical history and clinical examination are usually sufficient for the differential diagnostics. Treatment includes differentiated repositioning maneuvers, medicinal treatment and physiotherapy.

[Long-term efficacy of triple semicircular canal occlusion in the treatment of intractable Meniere's disease]

OBJECTIVE

To explore the long-term efficacy and safety of triple semicircular canal occlusion (TSCO) in the treatment of intractable Meniere's disease (MD) so as to provide an alternative surgical procedure for treating this disorder.

METHODS

Data from Forty-nine patients, who were referred to our hospital and diagnosed with unilateral MD strictly meeting the criteria issued by Chinese Academy of Otolaryngology-Head and Neck Surgery Committee (2006) from Dec. 2010 to Jul. 2012, were retrospectively analyzed in this work. Forty-nine patients, in whom the standardized conservative treatment was given at least one year and frequent vertigo still occurred, received TSCO. Vertigo control and auditory function were measured. Pure tone audiometry, caloric test, and cervical vestibular evoked myogenic potential (cVEMP) were performed for evaluation of audiological and vestibular function. Magnetic resonance hydrograph of inner ear was performed in patients received TSCO after 2 years for the observation of morphology of membranous labyrinth. Postoperative follow-up period was more than 2 years.

RESULTS

According to the preoperative staging of hearing, among these 49 patients, there were 2 cases in stage II (with an average hearing threshold of 25-40 dBHL), 40 in stage III (41-70 dBHL) and 7 in stage IV (over 70 dBHL). Vertigo was controlled effectively in all 49 cases in two-year follow-up, of which 40 cases (81.6%) were completely controlled and 9 cases (18.4%) were substantially controlled after surgery. The rate of hearing preservation was 69.4% and the rate of hearing loss was 30.6%. Post-operatively, all patients suffered from temporary vertigo and balance disorders. Vertigo was disappeared in all patients within 3-5 days, while averagely recovered after 13.5 days. Two years afer treatment, loss of semicircular canal function by caloric test was found in the operation side of all patients and no change in cVEMP test was noted. All patients had no facial paralysis, cerebrospinal fluid leakage, and other complications. Magnetic resonance hydrograph of inner ear showed that endolymph fluid in the position of plugging had no water after 2-years of TSCO.

CONCLUSIONS

TSCO, which can reduce vertiginous symptoms effectively in patients with intractable MD in long-term follow-up, represents an effective and safe therapy for this disorder. TSCO is expected to be used as an alternative procedure for the treatment of MD in selected patients suffering from severe hearing loss or recurrence after endolymphatic sac surgery.

Postural stability in patients with decompression sickness evaluated by means of Quantitative Romberg testing

OBJECTIVE

The present study was designed to retrospectively evaluate the use of quantitative Romberg's testing on postural stability during the course of hyperbaric oxygen (HBO2) therapy in patients presenting with decompression sickness (DCS).

METHODS

The Quantitative Romberg test was used to evaluate postural stability in 33 patients with DCS treated between May 2009 and August 2014. Postural stability was assessed before and after each session of HBO2 therapy. Patients were allocated into groups according to whether they presented with vertigo or not.

RESULTS

Significantly higher sway values obtained with the Quantitative Romberg test were observed in the group of DCS with vertigo relative to DCS without vertigo and healthy controls. A stepwise improvement in postural instability for DCS patients with vertigo was found following HBO2 therapy. After three treatments of HBO2, postural stability was found to be within the normal range of healthy controls.

CONCLUSIONS

The Quantitative Romberg test offers the the clinician a fast, reliable and objective set of parametrical data to document postural instability in patients with either confirmed or suspected DCS.

[Efficacy of endolymphatic sac-mastoid shunt surgery for intractable Meniere's disease]

OBJECTIVE

To investigate the effect and mechanism of endolymphatic sac-mastoid shunt surgery for intractable Meniere's disease of different stages according to hearing level.

METHODS

Data from 240 patients diagnosed with unilateral MD strictly meeting the criteria issued by Chinese Academy of Otolaryngology-Head and Neck Surgery Committee (2006) from January 1983 to January 2012 were analyzed in this study. Endolymphatic sac-mastoid shunt surgery was performed in affected ear for each patient. The evaluation of therapy followed the guidelines issued by Chinese Academy of Otolaryngology Head and Neck Surgery Committe. Vertigo control and auditory function were measured in two-year's follow-up.

RESULTS

According to the preoperative staging of hearing, among these 240 patients, there were 12 cases in stage I (with an average hearing threshold < 25 dB), 130 cases in stage II (with an average hearing threshold of 25-40 dB), 85 in stage III (41-70 dB) and 13 cases in stage IV(with an average hearing threshold > 70 dB). Overall control rate of vertigo was 77.9% (187/240) in two-year's follow-up, with total control 49.2% (118/240) and substantial control 28.7% (69/240). The hearing was improved in 25.0% (60/240) of cases, no change in 59.2% (142/240) of cases, and worse in 15.8% (38/240) of cases. According to different stages, vertigo control rate was 83.3% (10/12) in stage I, 82.3% (107/130) in stage II, 75.3% (64/85) in stage III and 46.2% (6/13) in stage IV. Vertigo control rate of stage IV patients was significantly lower than that of stage II and III patients (χ(2) = 9.318 and 4.692, P < 0.05), while vertigo control rate of stage I, II, III patients had no significant difference with each other (P > 0.05).

CONCLUSION

Endolymphatic sac-mastoid shunt operation is an effective method in the treatment of intractable Meniere's disease, but the effect was poor in stage IV patients.

[Analyses of clinical features and efficacy of sudden deafness with vertigo and dizziness]

OBJECTIVE

To investigate the clinical characteristics and the effect of drug treatment for sudden hearing loss with vertigo or dizziness.

METHODS

In a prospective, randomized, single blinded randomized multicenter clinical study, patients with sudden deafness, ranging in age from 18 to 65 years old, with a duration less than 2 weeks, and with no any medical treatments were collected. In accordance with the hearing curve, those patients were divided into four types, i.e., low and intermediate frequency descent type; high frequency descent type; fall flat type; and total deafness type. Each type was treated by four different treatment options, according to the unified design of the random table, and randomly selected one of the options for treatment. The efficacy of the patients with sudden deafness with vertigo and dizziness was analyzed statistically after the follow-up for 4 weeks. SPSS 13.0 software was used to analyze the data.

RESULTS

In August 2007 to October 2011, 33 hospitals in the country included 1 024 patients with sudden deafness in line with the inclusion criteria, of whom 296 (28.91%) were accompanied by vertigo/dizziness symptoms, 126 were males and 170 were females, with an average age of (41.2 ± 13.5) years old. types of the different audiometric curves of sudden deafness, the occurrence of complete deafness with vertigo/dizziness was the highest (44.93%), followed by flat down type (25.87%), high frequency descent type (21.28%) and low intermediate frequency descent type (18.54%). After the standard treatment, the vertigo and dizziness symptoms of the sudden deafness patients could disappear, and the hearing in each group was obviously improved. The hearing curative effect on patients accompanied by vertigo/dizziness of low frequency and intermediate frequency descent type was the best, and the total efficiency can reach up to 94.74%, with the cure rate of 68.42%; followed by flat type, in which the total effective rate was 80.76%, with the recovery rate of 22.12%; and the effects on patients in high frequency descent type and total deafness type effect were relatively poor, in which the total effective rates were 70.00% (recovery rate of 10.00%) and 65.32% (recovery rate of 5.65%), respectively. The total effective rate of patients with sudden deafness associated with halo had no statistical significance (P > 0.05), in comparison to that of patients without halo; but, the cure rate of patients with no vertigo/dizziness of total deafness and the high frequency decreased patients with sudden deafness was significantly higher than that of vertigo/dizziness patients, with a statistical difference (P < 0.05).

CONCLUSIONS

The patients with sudden deafness in each type have a certain proportion of vertigo/dizziness, especially the deaf type. The possibility of hearing complete recovery in patients with vertigo/dizziness was significantly lower than that without vertigo/dizziness.

[Vertigo/dizziness and syncope from a neurological perspective]

Vertigo/dizziness and syncope are among the most frequent clinical entities encountered in neurology. In patients with presumed syncope, it is important to distinguish it from neurological and psychiatric diseases causing a transient loss of consciousness due to another etiology. Moreover, central nervous disorders of autonomic blood pressure regulation as well as affections of the peripheral autonomic nerves can be responsible for the onset of real syncope. This is particularly relevant in recurrent syncope. Vertigo occurs in the context of temporary disorders, relatively harmless diseases associated with chronic impairment, as well as in acute life-threatening states. Patient history and clinical examination play an important role in classifying these symptoms. It is of crucial importance in this context, e.g., to establish whether the patient is experiencing an initial manifestation or whether such episodes have been known to occur recurrently over a longer period of time, as well as how long the episodes last. Clinical investigations include a differential examination of the oculomotor system with particular regard to nystagmus. The present article outlines the main underlying neurological diseases associated with syncope and vertigo, their relevant differential diagnoses as well as practical approaches to their treatment.