Diagnosis and Treatment of Vestibular Neuritis/Neuronitis or Peripheral Vestibulopathy (PVP)? Open Questions and Possible Answers

Development of NIR photocleavable nanoparticles with BDNF for vestibular neuron regeneration

Among nanoparticle platforms, light or photoresponsive nanoparticles have emerged as a promising drug delivery strategy with spatiotemporal control while minimizing off-target effects. The characteristic absorption spectrum of the photoresponsive moiety dictates the wavelength of light needed to activate bond cleavage. However, the low tissue penetration depth limit and short-wavelength ultraviolet (UV) cellular toxicity are considered disadvantageous. This study developed a vestibular ganglion neuron organoid as a model for vestibulopathy. UV and near-infrared (NIR) radiation targeted the inner ear and neural cells, followed by toxicity evaluation. A significantly smaller toxicity of NIR light was confirmed. The photocleavage release of brain-derived neurotrophic factor (BDNF) was used by applying NIR wavelength. The results indicate that polyethylene glycol octamethylene diamine derivative conjugated with leucomethylene blue with an ethanolamine linker nanoparticle can be effectively disassembled and release BDNF when using the 808 nm laser as a trigger. The findings of the cytotoxicity assay suggest that photocleavable nanoparticles (PCNs) and laser irradiation are safe and biocompatible for human-derived and neural progenitor types of cells. Phototriggered BDNF release by NIR laser supported the growth and differentiation of human neural progenitor cells in culture. In addition, the vestibulopathy organoid exhibited a significant regenerative effect. This study harnesses the full potential of NIR laser PCNs to treat vestibular neuropathies.

Four-hour-delayed 3D-FLAIR MRIs in patients with acute unilateral peripheral vestibulopathy

OBJECTIVE

Conventionally, MRI aids in differentiating acute unilateral peripheral vestibulopathy/vestibular neuritis (AUPV/VN) from mimickers. Meanwhile, the diagnostic utility of MRIs dedicated to the inner ear remains to be elucidated for diagnosing AUPV/VN.

METHODS

We prospectively recruited 53 patients with AUPV/VN (mean age ± SD = 60 ± 15 years, 29 men). Initial MRIs were performed with a standard protocol, and an additional axial 3D-fluid-attenuated inversion recovery (3D-FLAIR) sequence was obtained 4 h after intravenous injection of gadoterate meglumine. Abnormal enhancement was defined as a signal intensity that exceeded the mean + 2SD value on the healthy side. The findings of neurotologic evaluation and MRIs were compared.

RESULTS

Overall, the inter-rater agreement for gadolinium enhancement was 0.886 (Cohen's kappa coefficient). Enhancement was observed in 26 patients (49%), most frequently in the vestibule (n = 20), followed by the anterior (n = 12), horizontal (HC, n = 8), posterior canal (n = 5), and superior (n = 3) and inferior (n = 1) vestibular nerves. In multivariable logistic regression analysis, the enhancement was associated with decreased HC gain in video head-impulse tests (p = 0.036), increased interaural difference in ocular vestibular-evoked myogenic potentials (p = 0.001), and a longer onset-to-MRI time span (p = 0.024). The sensitivity and specificity were 92.3% and 81.5%, respectively, with an area under the curve of 0.90 for predicting gadolinium enhancement.

INTERPRETATION

Robust gadolinium enhancement was observed on 4-hour-delayed 3D-FLAIR images in nearly half of the patients with AUPV/VN, with a good correlation with the results of neurotologic evaluation. The positivity may be determined by the extent of vestibular deficit, timing of imaging acquisition, and possibly by the underlying etiology causing AUPV/VN. MRIs may aid in delineating the involved structures in AUPV/VN.

Pharmacological Treatment of Acute Unilateral Vestibulopathy: A Review

There have been few investigations on the epidemiology, etiology, and medical management of acute unilateral vestibulopathy (AUV). Short-term pharmaceutical resolutions include vestibular symptomatic suppressants, anti-emetics, and some cause-based therapies. Anticholinergics, phenothiazines, antihistamines, antidopaminergics, benzodiazepines, and calcium channel antagonists are examples of vestibular suppressants. Some of these medications may show their effects through multiple mechanisms. In contrast, N-acetyl-L-leucine, Ginkgo biloba, and betahistine improve central vestibular compensation. Currently, AUV pathophysiology is poorly understood. Diverse hypotheses have previously been identified which have brought about some causal treatments presently used. According to some publications, acute administration of anti-inflammatory medications may have a deleterious impact on both post-lesional functional recovery and endogenous adaptive plasticity processes. Thus, some authors do not recommend the use of corticosteroids in AUV. Antivirals are even more contentious in the context of AUV treatment. Although vascular theories have been presented, no verified investigations employing anti-clotting or vasodilator medications have been conducted. There are no standardized treatment protocols for AUV to date, and the pharmacological treatment of AUV is still questionable. This review addresses the most current developments and controversies in AUV medical treatment.

[Demographic and epidemiological risk factors in patients with acute vestibular neuritis]

OBJECTIVE

Vestibular neuritis (VN) is one of the most common peripheral vestibular balance disorder. Demographic and other risk factors associated with VN are insufficiently published. Therefore, the aim of this study is to identify associated risk factors in patients with acute VN.

METHODS

This study evaluated all hospitalized VN cases between 2017-2019. Inclusion criteria was an otoneurologically confirmed diagnosis of acute VN. Patient data was compared with data of the German normal population (Robert Koch Institute, "Gesundheit in Deutschland aktuell").

RESULTS

168 patients (Ø 59.8 years) were included. Compared with the normal German population, the study population was significantly more likely to have preexisting cardiovascular diseases, and the male patients were significantly more likely to have arterial hypertension. No significant differences were measurable between the study population and the normal population for other secondary diseases. Leukocytosis was present in 23% on admission, and 9% of patients reported a history of VZV or HSV-1 disease.

DISCUSSION

Etiology and pathogenesis of VN are poorly understood. Inflammatory and vascular causes are discussed. In this study, patients had increased prevalence of cardiovascular disease compared with the normal population, but the study population had a higher average age. Currently, it is unclear what significance nonspecific elevated leukocyte values could have as a possible sign of VN triggered by an infection. Since the number of inpatient cases with VN is rising, prospective studies should be performed to get a better understanding of the pathogenesis of the disease.

[Animal models of balance pathologies: New tools to study peripheral vestibulopathies]

The different types of peripheral vestibulopathies (PVs) or peripheral vestibular disorders (PVDs) are essentially diagnosed on the basis of their clinical expression. The heterogeneity of vestibular symptoms makes it difficult to stratify patients for therapeutic management. Animal models of PVs are a good mean to search for clinical evaluation criteria allowing to objectively analyze the kinetics of expression of the vertigo syndrome and to evaluate the benefits of therapeutic strategies, whether they are pharmacological or rehabilitative. The question of the predictability of these animal models is therefore crucial for the identification of behavioral and biological biomarkers that could then be used in the human clinic. In this review, we propose an overview of the different animal models of PVs, and discuss their relevance for the understanding of the underlying pathophysiological mechanisms and the development of new and more targeted therapeutic approaches.

Vertigo symptom scores and videonystagmographic examinations in recovered coronavirus disease 2019 patients

OBJECTIVE

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may be among the viral agents that affect the audio-vestibular system. This study aimed to investigate vestibular symptoms and videonystagmographic examinations in recovered coronavirus disease 2019 (Covid-19) patients compared with the control group.

METHOD

The patients were evaluated with Vertigo Symptom Scale questionnaire and audiometric, tympanometric, stapedial reflex and videonystagmographic examinations.

RESULTS

A total of 92 of the patients in the coronavirus disease 2019 patients group and 25 of the volunteers in the control group were included in the study. The mean Vertigo Symptom Scale score was found to be significantly higher (p < 0.001) in the coronavirus disease 2019 group. Furthermore, one of the hospitalised patients was diagnosed with vestibular neuritis.

CONCLUSION

The vestibular system may also be affected in some coronavirus disease 2019 patients. Although this may be seen as dizziness in some patients, in rare cases it can cause severe issues, such as vestibular neuritis.

Acute Vertigo in a Patient Following COVID-19 Infection: A Case Report and Literature Review

COVID-19 has infected millions of people worldwide causing millions of deaths. COVID-19 has many serious effects on organs of the body especially the respiratory system causing pneumonia and acute respiratory distress syndrome (ARDS). The disease also has severe complications on other different organs; kidneys and liver which may end in multi-organ failure. Most common symptoms that have been detected in large section of patients were fever, cough and loss of taste or smell and less commonly sore throat, headache and muscle pain. The incidence of vertigo or dizziness is a rare symptom of COVID-19. In this case report, we introduce a 59-year-old male patient suffering from acute vertigo attack after COVID-19 infection. The patient had negative medical history of vertigo and any ear diseases. The patient received REGEN-COV (casirivimab and imdevimab) for COVID-19 and meclizine for vertigo. Vertigo attacks lasted for the two weeks follow up after disappearance of COVID-19 symptoms despite receiving vertigo medication. In conclusion, vertigo may be the sole neurological manifestation of COVID-19. More observational studies should address this symptom and researchers should also focus on identifying the origin of developing vertigo and the direct or indirect mechanisms that SARS-CoV-2 triggers to develop dizziness in general. This research should deliver a clear message, especially to ER physicians to consider proper referral of these patients without underestimating the risk of developing more serious COVID-19 symptoms as ARDS and multi-organ failure if no proper testing and follow-up are provided.

Vestibular Neuritis as Clinical Presentation of COVID-19

Coronavirus disease 2019 (COVID-19) may lead to many otolaryngological disorders such as loss of smell and taste, sudden sensorineural hearing loss (SSNHL), facial palsy, and parotitis. The involvement of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vestibular neuritis (VN) has been reported in 2 adult patients but not really confirmed through objective testings. We present a case of a 13-year-old girl with left superior vestibular neuritis confirmed by Video Head Impulse Test during a proven COVID-19 infection. To the best of our knowledge, this is the first case associating VN and COVID-19 that was demonstrated with an objective peripheral assessment. Physicians may be aware about the occurrence of VN in patients with COVID-19, keeping in mind that this condition may develop not only in adults. Early detection of SARS-CoV-2 in this pandemic is required to prevent its spread.

What Predictability for Animal Models of Peripheral Vestibular Disorders?

The different clinical entities grouped under the term peripheral vestibulopathies (PVs) or peripheral vestibular disorders (PVDs) are distinguished mainly based on their symptoms/clinical expression. Today, there are very few commonly accepted functional and biological biomarkers that can confirm or refute whether a vestibular disorder belongs to a precise classification. Consequently, there is currently a severe lack of reliable and commonly accepted clinical endpoints, either to precisely follow the course of the vertigo syndrome of vestibular origin or to assess the benefits of therapeutic approaches, whether they are pharmacological or re-educational. Animal models of PV are a good means to identify biomarkers that could subsequently be exploited in human clinical practice. The question of their predictability is therefore crucial. Ten years ago, we had already raised this question. We revisit this concept today in order to take into account the animal models of peripheral vestibular pathology that have emerged over the last decade, and the new technological approaches available for the behavioral assessment of vestibular syndrome in animals and its progression over time. The questions we address in this review are the following: are animal models of PV predictive of the different types and stages of vestibular pathologies, and if so, to what extent? Are the benefits of the pharmacological or reeducational therapeutic approaches achieved on these different models of PV (in particular the effects of attenuation of the acute vertigo, or acceleration of central compensation) predictive of those expected in the vertiginous patient, and if so, to what extent?

Corticosteroids in patients with vestibular neuritis: An updated meta-analysis

Vestibular neuritis is a common neuro-otological entity. Therapeutically, corticosteroids are advised, although the evidence is limited. The objective of this review is to update meta-analyses of clinical trials that address the question of whether patients with vestibular neuritis treated with corticosteroids show better recovery than control patients. The electronic databases Medline, Scopus and Cochrane were searched for clinical trials for the years 1970-2020 without language restriction. Data were extracted, and outcome parameters were subjected to conventional and cumulative meta-analysis using a commercially available software program (www.meta-analysis.com). Finally, 15 trials with 363 participants in the treatment and 489 in the control groups were identified and could be included. Eight studies were judged to be at high risk of bias. The odds ratio (OR) for good outcome in the acute phase was 3.1 (95% CI 1.2-7.8; p = .015) in favour of steroid treatment leading to the number needed to treat (NNT) = 6 (95% CI 4-23). The odds ratio (OR) for restoration of vestibular function in the follow-up was 2.4 (95% CI 1.3-4.4; p = .004) for the benefit of steroid treatment resulting in a NNT = 7 (95% CI 5-18). The results of the cumulative statistics did not differ. The risk of adverse effects was higher in patients treated with steroids with an OR of 10.9 (95% CI 1.3-93.8; p = .015) and an estimated number needed to harm (NNH) = 4 (95% CI 3-19). The advantage for corticosteroids remained when differentiating between patients who participated in randomized or non-randomized clinical trials. Steroid treatment in vestibular neuritis resulted in a statistically significant benefit compared to control therapies. However, broad heterogeneity of the studies, mostly low-grade quality of studies, high risk of bias and broad confidence intervals put the findings into perspective allowing only a careful judgement of some benefit of corticosteroids. The findings, however, support the call for an adequately powered and well-designed randomized controlled trial to re-evaluate the effectiveness of corticosteroids.

Corticosteroids for patients with vestibular neuritis: an evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN.

METHODS

We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids as compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed.

RESULTS

From 149 titles, 5 systematic reviews were selected for quality assessment, and 2 reviews were of higher methodological quality and were included. These 2 reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of 2 RCTs including a total of 50 patients, the use of corticosteroids (as compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% CI 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide confidence interval for the outcome of dizziness handicap score (1 study, 30 patients, 20.9 points in corticosteroids group vs 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low.

CONCLUSIONS

There is limited evidence to support the use of corticosteroids for the treatment of vestibular neuritis in the emergency department.

Monthly and seasonal variations in vestibular neuritis

Seasonal variations in vestibular neuritis (VN) could support the etiology of viral infection. However, several recent studies revealed no significant seasonal variations in VN. Further studies are necessary to determine the etiology of VN. We analyzed patients with VN to evaluate monthly and seasonal variations. Patients with VN who visited our otorhinolaryngology department or were referred to our department from the emergency department between March 2014 and February 2019 were included retrospectively in this study. Differences among the months and seasons of VN visits were analyzed. Patients were divided into 2 groups according to sex and age (65 years or older and younger than 65 years). Differences among the months and seasons of VN visits were analyzed between groups. There were no significant differences in monthly and seasonal distributions in 248 patients with VN. There were also no significant differences in monthly and seasonal distributions in male and female patients or in older and younger patients. There were no significant differences in monthly or seasonal distributions of patients with VN. Factors other than viruses, such as vascular ischemia, should also be considered in the incidence of VN, especially in older patients.

Acute Unilateral Peripheral Vestibulopathy After COVID-19 Vaccination: Initial Experience in a Tertiary Neurotology Center

Objective

The aim of the present study was to identify patients who developed acute unilateral peripheral vestibulopathy (AUPVP) after COVID-19 vaccination.

Methods

For this single-center, retrospective study, we screened the medical records of our tertiary interdisciplinary neurotology center for patients who had presented with AUPVP within 30 days after COVID-19 vaccination (study period: 1 June−31 December 2021). The initial diagnosis of AUPVP was based on a comprehensive bedside neurotological examination. Laboratory vestibular testing (video head impulse test, cervical and ocular vestibular evoked myogenic potentials, dynamic visual acuity, subjective visual vertical, video-oculography, caloric testing) was performed 1–5 months later.

Results

Twenty-six patients were diagnosed with AUPVP within the study period. Of those, n = 8 (31%) had developed acute vestibular symptoms within 30 days after COVID-19 vaccination (mean interval: 11.9 days, SD: 4.8, range: 6–20) and were thus included in the study. The mean age of the patients (two females, six males) was 46 years (SD: 11.7). Seven patients had received the Moderna mRNA vaccine and one the Pfizer/BioNTech mRNA vaccine. All patients displayed a horizontal(-torsional) spontaneous nystagmus toward the unaffected ear and a pathological clinical head impulse test toward the affected ear on initial clinical examination. Receptor-specific laboratory vestibular testing performed 1–5 months later revealed recovery of vestibular function in two patients, and heterogeneous lesion patterns of vestibular endorgans in the remaining six patients.

Discussion and Conclusions

The present study should raise clinicians' awareness for AUPVP after COVID-19 vaccination. The relatively high fraction of such cases among our AUPVP patients may be due to a certain selection bias at a tertiary neurotology center. Patients presenting with acute vestibular symptoms should be questioned about their vaccination status and the date of the last vaccination dose. Furthermore, cases of AUPVP occurring shortly after a COVID-19 vaccination should be reported to the health authorities to help determining a possible causal relationship.

Comparison between caloric and video-head impulse tests in Ménière's disease and vestibular neuritis

OBJECTIVE

To compare the diagnostic accuracies of air caloric testing with electronystagmography and the vHIT (video-head impulse test).

DESIGN

Prospective, controlled study.

STUDY SAMPLE

MD (Ménière's disease), 26; vestibular neuritis, 27; control, 56.

RESULTS

In MD, CP (canal paresis) was pathological in 88.5%, the GA (gain asymmetry) on vHIT was pathological in 65.3%, and the gain was abnormal in only one patient. The GA and CP, were significantly higher in the MD group than in the control group, indicating hypofunction of the horizontal canals in MD, whereas a hyperfunction may also occur. No correlation was observed between the results of the two tests for evaluating MD, suggesting that pathological outcomes of one test do not guarantee abnormalities on the other test. For vestibular neuritis, significantly higher CP (96.3%), GA (81.5%), and gain (51.9%) values were detected. A correlation was identified between the two tests for vestibular neuritis, indicating a similar diagnostic efficiency. The higher percentage of pathological GA versus pathological gain values indicates that the asymmetry may be more informative.

CONCLUSIONS

The vHIT showed a higher specificity, whereas the caloric test a higher sensitivity. No correlation between the two methods was observed; therefore, the tests appear to provide complementary information.

Neuro-otological Symptoms: An Atypical Aspect of COVID-19 Disease

This study aimed to evaluate the various neuro-otological symptoms experienced by patients with COVID-19 disease. This is a retrospective study conducted from September 2020 to August 2021. Patients with positive RTPCR tests for COVID-19, aged between 18 and 60 years were included in the study. The patients were assessed for neuro-otological symptoms, the type, frequency, and character of these symptoms, their relation with age, gender and COVID-19 disease. Of the 286 patients, 64 (22.3%) had neuro-otological symptoms. The mean age of the patients was 36.3 ± 8.1 years. The frequency of neuro-otological symptoms was higher in females than males and was more frequent in the age group of 18–30 years as compared with other age groups. Of these 64 patients, 29 had vertigo (10.1%), 21 (7.3%) tinnitus, 16 (5.5%) experienced hearing loss. Like many viral diseases, apart from its typical prodromal symptoms, COVID-19 can also cause symptoms like tinnitus, hearing loss, and vertigo.

Hearing Loss, Tinnitus, and Dizziness in COVID-19: A Systematic Review and Meta-Analysis

OBJECTIVES

Extensive studies indicate that severe acute respiratory syndrome coronavirus (SARS-CoV-2) involves human sensory systems. A lack of discussion, however, exists given the auditory-vestibular system involvement in CoV disease 2019 (COVID-19). The present systematic review and meta-analysis were performed to determine the event rate (ER) of hearing loss, tinnitus, and dizziness caused by SARS-CoV-2.

METHODS

Databases (PubMed, ScienceDirect, Wiley) and World Health Organization updates were searched using combined keywords: 'COVID-19,' 'SARS-CoV-2,' 'pandemic,' 'auditory dysfunction,' 'hearing loss,' 'tinnitus,' 'vestibular dysfunction,' 'dizziness,' 'vertigo,' and 'otologic symptoms.'

RESULTS

Twelve papers met the eligibility criteria and were included in the study. These papers were single group prospective, cross-sectional, or retrospective studies on otolaryngologic, neurologic, or general clinical symptoms of COVID-19 and had used subjective assessments for data collection (case histories/medical records). The results of the meta-analysis demonstrate that the ER of hearing loss (3.1%, CIs: 0.01-0.09), tinnitus (4.5%, CIs: 0.012-0.153), and dizziness (12.2%, CIs: 0.070-0.204) is statistically significant in patients with COVID-19 (Z ≤ -4.469, p ≤ 0.001).

CONCLUSIONS

COVID-19 can cause hearing loss, tinnitus, and dizziness. These findings, however, should be interpreted with caution given insufficient evidence and heterogeneity among studies. Well-designed studies and follow-up assessments on otologic symptoms of SARS-CoV-2 using standard objective tests are recommended.

Vascular mechanisms in acute unilateral peripheral vestibulopathy: a systematic review

Acute unilateral peripheral vestibulopathy (AUPVP) is a frequent cause of vestibular loss. Several aetiologies have been proposed, but the exact mechanism remains unknown. The aim of this study is a systematic analysis of the literature evaluating the vascular aetiology of AUPVP. A systematic literature search was performed in PubMed, Cochrane Library and Embase, including articles published from January 1^st, 2010 to November 30^th, 2020. Two reviewers independently selected articles investigating a link between AUPVP and vascular disease. The following information was extracted: year of publication, country, level of evidence, assessed vascular risk factors and number of patients. A total of 450 articles was obtained. Eleven articles were retained with 100% agreement between the two reviewers. In a pooled population of 805 patients, the main results were the higher neutrophil to lymphocyte ratio and higher prevalence of vascular risk factors among AUPVP patients. A meta-analysis was not performed because the studies were too heterogeneous in terms of methodology. Indirect arguments for vascular mechanisms in AUPVP were found. These findings indicate that larger prospective well-controlled studies are needed to clarify the vascular aetiology of AUPVP.

Breaking a dogma: acute anti-inflammatory treatment alters both post-lesional functional recovery and endogenous adaptive plasticity mechanisms in a rodent model of acute peripheral vestibulopathy

BACKGROUND

Due to their anti-inflammatory action, corticosteroids are the reference treatment for brain injuries and many inflammatory diseases. However, the benefits of acute corticotherapy are now being questioned, particularly in the case of acute peripheral vestibulopathies (APV), characterized by a vestibular syndrome composed of sustained spinning vertigo, spontaneous ocular nystagmus and oscillopsia, perceptual-cognitive, posturo-locomotor, and vegetative disorders. We assessed the effectiveness of acute corticotherapy, and the functional role of acute inflammation observed after sudden unilateral vestibular loss.

METHODS

We used the rodent model of unilateral vestibular neurectomy, mimicking the syndrome observed in patients with APV. We treated the animals during the acute phase of the vestibular syndrome, either with placebo or methylprednisolone, an anti-inflammatory corticosteroid. At the cellular level, impacts of methylprednisolone on endogenous plasticity mechanisms were assessed through analysis of cell proliferation and survival, glial reactions, neuron's membrane excitability, and stress marker. At the behavioral level, vestibular and posturo-locomotor functions' recovery were assessed with appropriate qualitative and quantitative evaluations.

RESULTS

We observed that acute treatment with methylprednisolone significantly decreases glial reactions, cell proliferation and survival. In addition, stress and excitability markers were significantly impacted by the treatment. Besides, vestibular syndrome's intensity was enhanced, and vestibular compensation delayed under acute methylprednisolone treatment.

CONCLUSIONS

We show here, for the first time, that acute anti-inflammatory treatment alters the expression of the adaptive plasticity mechanisms in the deafferented vestibular nuclei and generates enhanced and prolonged vestibular and postural deficits. These results strongly suggest a beneficial role for acute endogenous neuroinflammation in vestibular compensation. They open the way to a change in dogma for the treatment and therapeutic management of vestibular patients.

Linggui Zhugan Decoction for peripheral vertigo: A protocol for systematic review and meta-analysis

BACKGROUND

Vertigo is a sense of movement or rotation of the patient's own or an external object. At present, western medicine treatment such as vestibular suppressant medications commonly used in clinical practice are ineffective and have adverse reactions. In traditional Chinese medicine, Linggui Zhugan Decoction (LZD) was used by doctors to warm yang for resolving fluid retention, strengthen the spleen and clear away dampness, with significant effect. Recently, some clinical studies have also shown that LZD has reliable effect in treating peripheral vertigo, but there is no systematic evidence. Therefore, this study aims to objectively evaluate the efficacy and safety of LZD in the treatment of peripheral vertigo.

METHODS

Eight electronic databases will be searched from inception to August 2020 by 2 independent researchers, in order to collect qualified randomized controlled trials (RCTs) on the LZD treatment for peripheral vertigo. The therapeutic effects according to Clinical efficacy will be adopted as the primary outcomes. RevMan V.5.3 software will be used for the data synthesis and the Cochrane's risk of bias assessment tool will be used to assess the risk of bias.

RESULTS

This review will conduct a high-quality synthesis on present evidence of LZD for peripheral vertigo.

CONCLUSION

The conclusion of the study will indicate whether LZD is an effective treatment for peripheral vertigo by providing updated evidence.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD 42021238817.

Prognosis after acute unilateral vestibulopathy: Usefulness of the suppression head impulse paradigm (SHIMP)

OBJECTIVES

This cross-sectional study aims to describe the features of the suppression head impulse paradigm (SHIMP) in acute unilateral vestibulopathy (AUV) and to define its role in predicting the recovery of patients.

METHODS

Thirty patients diagnosed with AUV were retrospectively analyzed. The dizziness handicap inventory score and video head impulse test parameters performed 4-8 weeks from the AUV onset constituted the main outcome measures. Patients with a worse recovery (Group 1) and patients who recovered spontaneously (Group 2) were compared.

RESULTS

The SHIMP vestibulo-ocular reflex (VOR) gain was statistically significantly lower than the conventional head impulse paradigm (HIMP) VOR gain (P <  0.001). The SHIMP VOR gain was negatively correlated with the DHI (P <  0.001) and was positively correlated with the HIMP VOR gain (P <  0.001) and the SHIMP overt saccades (%) (P <  0.001). Patients with a worse recovery exhibited the following: higher DHI (P <  0.001), lower SHIMP and HIMP VOR gain (P <  0.001 and P = 0.007, respectively), and lower SHIMP and greater HIMP overt saccade prevalence values (P = 0.007 and P = 0.032, respectively).

CONCLUSIONS

The SHIMP and HIMP help in improving our approach to AUV. SHIMP appears to better identify the extent of the vestibular damage in patient suffering from AUV than HIMP and could provide interesting information about the course of the disease. Particularly, the analysis of SHIMP VOR gain and overt saccade prevalence would provide useful information about the recovery of patients.

COVID-19-Induced Vestibular Neuritis, Hemi-Facial Spasms and Raynaud's Phenomenon: A Case Report

The coronavirus disease 2019 (COVID-19) pandemic has created a global health crisis. Though respiratory symptoms have been the usual manifestations, the presentation in some cases may be atypical with various neurological and cutaneous manifestations. We present a case of a 63-year-old female diagnosed with COVID-19 and associated rare manifestations during her visit to Europe.

Spontaneous Recovery of the Vestibulo-Ocular Reflex After Vestibular Neuritis; Long-Term Monitoring With the Video Head Impulse Test in a Single Patient

Vestibular rehabilitation of patients in whom the level of vestibular function is continuously changing requires different strategies than in those where vestibular function rapidly becomes stable: where it recovers or where it does not and compensation is by catch-up saccades. In order to determine which of these situations apply to a particular patient, it is necessary to monitor the vestibulo-ocular reflex (VOR) gains, rather than just make a single measurement at a given time. The video Head Impulse Test (vHIT) is a simple and practical way to monitor precisely the time course and final level of VOR recovery and is useful when a patient has ongoing vestibular symptoms, such as after acute vestibular neuritis. In this study, we try to show the value of ongoing monitoring of vestibular function in a patient recovering from vestibular neuritis. Acute vestibular neuritis can impair function of any single semicircular canal (SCC). The level of impairment of each SCC, initially anywhere between 0 and 100%, can be accurately measured by the vHIT. In superior vestibular neuritis the anterior and lateral SCCs are the most affected. Unlike after surgical unilateral vestibular deafferentation, SCC function as measured by the VOR can recover spontaneously after acute vestibular neuritis. Here we report monitoring the VOR from all 6 SCCs for 500 days after the second attack in a patient with bilateral sequential vestibular neuritis. Spontaneous recovery of the VOR in response to anterior and lateral SCC impulses showed an exponential recovery with a time to reach stable levels being longer than previously considered or reported. VOR gain in response to low-velocity lateral SCC impulses recovered with a time constant of around 100 days and reached a stable level at about 200 days. However, in response to high-velocity lateral SCC and anterior SCC impulses, VOR gain recovered with a time constant of about 150 days and only reached a stable level toward the end of the 500 days monitoring period.

Electrophysiological and inner ear MRI findings in patients with bilateral vestibulopathy

PURPOSE

Bilateral vestibulopathy (BV) is an uncommon disorder and the etiology remained idiopathic in most cases. Delayed 3D-FLAIR sequences have provided new insights into various inner ear diseases, allowing the evaluation of the endolymphatic space and the permeability of the blood-labyrinthine barrier (BLB). The aim of this study was to assess both the morphology of the endolymphatic space and the permeability of the BLB in patients with BV as evaluated by delayed 3D-FLAIR sequences.

METHODS

In this retrospective study, we performed 3D-FLAIR sequences 4 h after administering contrast media to 42 patients with BV. Two radiologists independently evaluated the morphology of the endolymphatic space (either vestibular atelectasis or endolymphatic hydrops) and the permeability of the BLB.

RESULTS

Morphologic anomalies of the endolymphatic space and vestibular blood-labyrinthine barrier impairment were observed in 59.6% of patients with BV. Bilateral vestibular atelectasis (VA) was found in 21 patients (50%), involving only the utricle and all three ampullas while the saccule was always observed with no sign of collapse: idiopathic BV (n = 19), aminoglycoside administration (n = 1) and few days following abdominal surgery (n = 1). One patient had bilateral vestibular malformation. BLB impairment was observed in five patients (11.9%): paraneoplastic (n = 1), lymphoma (n = 1), autoimmune (n = 1), and vestibular "neuritis" (n = 2). Seventeen patients (40.4%) had normal MRI with no endolymphatic space anomaly or BLB impairment.

CONCLUSION

Patients with BV presented with morphologic anomalies of the endolymphatic space or BLB impairment in 59.6% of patients.

Diagnoses of Dizziness- and Vertigo-related Disorders in ENT Practices in Germany

AIM

The aim of this study was to analyze the prevalence of dizziness- and vertigo-related diagnoses in ear, nose, and throat (ENT) practices in Germany and the associated demographic characteristics based on data from a representative nationwide practice database.

METHOD

The study sample included patients from 138 ENT practices in Germany who received dizziness- and vertigorelated diagnoses (ICD-10 code) between January 2012 and December 2015. Collected parameters included age, sex, insurance status, prescribed medication (anatomical therapeutic chemical [ATC] class), and referrals to other specialists and hospitals.

RESULTS

A total of 107,458 patients were available for analysis. Most common diagnoses were "dizziness and giddiness" (67.7%), "benign paroxysmal vertigo" (10.2%) and "disorder of vestibular function, unspecified" (7.2%). Referrals and admissions were made in 12.8%, mostly to radiologists (7.7%), followed by neurologists (3.7%), and hospitals (1.4%). Most referrals were made for unspecific diagnoses and for "vestibular neuronitis." The rate of medical prescriptions was 37.3%, with the most common prescription being for antivertigo preparations.

CONCLUSIONS

Dizziness- and vertigo-related disorders are frequently diagnosed in ENT practices in Germany. The majority of these diagnoses are unspecific and lead to an increased rate of referrals and hospital admissions. The medical prescription rate, especially of antivertigo preparations, was high, even among patients with benign paroxysmal positioning vertigo. This study reflects a mostly pragmatic approach to a complex diagnostic and therapeutic challenge in daily ENT practice as well as the limited ability of the ICD-10 system to classify the underlying etiology.

Assessment and treatment of dizziness and vertigo

Dizziness is a common patient complaint with multiple etiologies. Many causes are benign, but NPs should consider red flags for serious differential diagnoses. A systematic patient history and physical exam are crucial to accurately diagnosing conditions related to dizziness. This article reviews common etiologies of dizziness and vertigo, assessment techniques, and treatment options.

Morphological and functional correlates of vestibular synaptic deafferentation and repair in a mouse model of acute-onset vertigo

Damage to cochlear primary afferent synapses has been shown to be a key factor in various auditory pathologies. Similarly, the selective lesioning of primary vestibular synapses might be an underlying cause of peripheral vestibulopathies that cause vertigo and dizziness, for which the pathophysiology is currently unknown. To thoroughly address this possibility, we selectively damaged the synaptic contacts between hair cells and primary vestibular neurons in mice through the transtympanic administration of a glutamate receptor agonist. Using a combination of histological and functional approaches, we demonstrated four key findings: (1) selective synaptic deafferentation is sufficient to generate acute vestibular syndrome with characteristics similar to those reported in patients; (2) the reduction of the vestibulo-ocular reflex and posturo-locomotor deficits mainly depends on spared synapses; (3) damaged primary vestibular synapses can be repaired over the days and weeks following deafferentation; and (4) the synaptic repair process occurs through the re-expression and re-pairing of synaptic proteins such as CtBP2 and SHANK-1. Primary synapse repair might contribute to re-establishing the initial sensory network. Deciphering the molecular mechanism that supports synaptic repair could offer a therapeutic opportunity to rescue full vestibular input and restore gait and balance in patients.

Summary: The molecular rearrangements of the synaptic proteins that accompany the deafferentation and subsequent reafferentation of the inner ear sensors following an excitotoxic insult are demonstrated for the first time.

Detection of intralabyrinthine abnormalities using post-contrast delayed 3D-FLAIR MRI sequences in patients with acute vestibular syndrome

PURPOSE

3D-FLAIR sequences with delayed acquisition after contrast medium injection have demonstrated new insights into blood-labyrinthine barrier (BLB) abnormalities in various diseases. The aim of this study was to assess the BLB in patients referred with unilateral acute vestibular syndrome (UAVS).

MATERIALS AND METHODS

In this retrospective multicenter imaging study, we performed 3D-FLAIR and steady-state free precession (SSFP) sequences 4 h after contrast medium administration in 26 healthy volunteers and in 30 patients with UAVS. Two radiologists, blinded to the clinical data, independently assessed the asymmetrical enhancement of the labyrinthine structures and the vestibular nerve on 3D-FLAIR sequences, and the signal of the labyrinthine structures on SSFP sequences. Inter-reader agreement tests were performed.

RESULTS

An asymmetrical enhancement of the semicircular canals was observed in 26 out of 30 ears (86.6%, p < 0.001) and never observed in healthy subjects. An asymmetrical enhancement of the vestibular nerve was never observed in either patients or healthy subjects. An asymmetrical enhancement of the cochlea was observed on the 3D-FLAIR sequence in 6 out of 30 ears only in the patients' group (20%, p = 0.03) and always associated with an enhancement of at least one semicircular canal. A low signal on SSFP sequences was observed only in 11 out of 30 symptomatic ears (36.7%, p < 0.001), involving the utricle in 7 ears and the superior semicircular canal in 4 ears.

CONCLUSION

Patients with typical UAVS presented with semicircular canal enhancement on MRI, while an asymmetrical enhancement of the vestibular nerve was not displayed.

TRIAL REGISTRATION

NCT02529475 KEY POINTS: • Patients with typical vestibular neuronitis presented with semicircular canal enhancement on MRI in 87% of cases. • An enhancement of the vestibular nerve was never displayed.

Reduced Balance Restoration Capacities Following Unilateral Vestibular Insult in Elderly Mice

Acute vestibular syndrome (AVS) is characterized by severe posturo-locomotor and vestibulo-oculomotor impairment and accompanies several types of peripheral vestibulopathies (PVP). We know very little about its etiology, how its various symptoms are expressed and how it evolves with age. Robust repair capabilities of primary vestibular synapses have recently been shown to restore behavioral functionality. In this study, we used a mouse model of an excitotoxically induced unilateral vestibular lesion to compare the ability to restore balance and posture between old and young adult mice. We compared the temporal evolution of the evoked vestibular syndrome using a battery of behavioral tests to follow the evolution of postural-locomotor alterations and equilibrium. For the first time, we show that young adult (3 months) and elderly (22 months) mice are together able to restore normal postural-locomotor function following transient unilateral excitotoxic vestibular insult, though with different time courses. This animal study paves way for future, more detailed studies of how the early postural and locomotor disturbances following a unilateral insult are compensated for by various plasticity mechanisms, and in particular how age influences these mechanisms.

[Management of vertigo and dizziness]

Balance disorders presenting with symptoms of dizziness and vertigo are due to various diseases. Clinical approach gives the opportunity to identify emergency situations and most common causes, among them the first one being the benign paroxysmal positional vertigo. Oculomotor assessment is pertinent as major clinical orientation, particularly between peripheral and central diseases. These clinical findings support the respective indication of modern imaging and/or vestibular tests, focused on the direction of presupposed diagnosis. On elderly the risk of falls and their complications needs a specific evaluation.

[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.

Vestibular impairment in chronic inflammatory demyelinating polyneuropathy

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a common, treatable, autoimmune peripheral neuropathy considered to produce imbalance by weakness and proprioceptive impairment rather than vestibular impairment. We measured semicircular canal vestibular function in 21 CIDP patients (15M/6F) by the video head impulse test and postural stability with a battery comprising the modified Clinical Test of Sensory Integration and Balance, the Berg Balance Scale, the Dynamic Gait Index, the Fall Efficiency Scale, and the International Cooperative Ataxia Rating Scale. Of the 21 patients, 16 had vestibular impairment, ranging from mild-affecting just a single semicircular canal, to severe-affecting all 6 canals. Although the severity of the vestibular impairment did not correlate either with the severity of the postural imbalance or of the peripheral neuropathy, our data show that vestibular impairment is an additional challenge to balance that some CIDP patients will face.