Peripheral vestibular disorders

Delayed 3D-FLAIR MRI and vestibular recovery in unilateral acute vestibular syndrome

MRI has traditionally been employed to rule out alternative diagnoses in unilateral acute vestibular syndrome (UAVS), but delayed 3D-FLAIR sequences offer the potential for imaging to contribute to both diagnosis and management. This study aimed to assess abnormalities on delayed 3D-FLAIR MRI in UAVS patients and correlate these findings with clinical outcomes. A retrospective multicenter study was conducted between January 2018 and May 2024 at a university hospital and a private vestibular clinic, representing a diverse clinical setting. It included 92 patients with UAVS (47 women, 45 men; mean age 50.6 years) diagnosed according to Bárány Society guidelines, with acute vertigo lasting at least 24 h, spontaneous horizontal-rotatory nystagmus, and a reduced vestibulo-ocular reflex (VOR) on the affected side, without auditory or neurological symptoms. The MRI findings were blindly assessed to identify potential blood-labyrinth barrier (BLB) impairment, nerve enhancement, or canal fibrosis. These imaging abnormalities were then correlated with initial and follow-up video head impulse test (vHIT) results. BLB impairment was found in 63% of patients and canal fibrosis in 14.1%, with no nerve enhancement detected. BLB impairment significantly correlated with initial VOR deficits and was linked to poorer vHIT recovery, suggesting its role in predicting persistent vestibular dysfunction. These findings suggest that delayed 3D-FLAIR MRI can identify biomarkers, particularly BLB impairment, that are predictive of vestibular recovery, highlighting MRI's role in guiding UAVS treatment.

Developing a Diagnostic Algorithm for Identifying Vestibular Neuronitis in Acute Dizziness: An Overview of Epidemiology, Pathogenesis, and Evidence-Based Guidelines for Diagnostic Approaches

Vestibular neuronitis (VN) is a prevalent peripheral vestibular disorder presenting with sudden unilateral vestibular loss, leading to acute vertigo without associated cochlear or neurological symptoms. Diagnosis remains challenging due to symptom overlap with other vestibular and central disorders. This study reviews the epidemiology, pathogenesis, and diagnostic approaches for VN to propose a streamlined, evidence-based diagnostic algorithm. A comprehensive literature review was conducted, analyzing 114 studies, including randomized controlled trials, systematic reviews, and clinical guidelines. Emphasis is placed on the clinical history and bedside examinations, supported by ancillary tests to confirm the diagnosis and differentiate VN from central and other peripheral causes of vertigo. The proposed algorithm aims to enhance diagnostic precision and support clinical decision-making.

Quality of life, physical symptoms, and psychological symptoms according to the status of chronic vestibulopathy

OBJECTIVES

Symptomatic vestibulopathy impairs patients' lives. However, few studies have explored the lives of patients with compensated or asymptomatic vestibulopathy. This study investigated the quality of life (QOL), psychological health, and physical function of patients with vestibulopathy.

MATERIALS AND METHODS

Using the eighth Korea National Health and Nutrition Examination Survey database, we included individuals with data on demographic factors, diabetes, hypertension, dizziness experiences, pure-tone audiometry, video head impulse test (vHIT), Health-related Quality of Life Instrument with 8 Items, General Anxiety Disorder 7-item scale, stress, and walking and sitting times. Participants were classified into the following groups: an uncompensated group with abnormal vHIT result and chronic dizziness, a compensated group with abnormal vHIT result and a history of dizziness, an asymptomatic group with abnormal vHIT result and no history of dizziness, and a normal group without abnormal vHIT result or a history of dizziness.

RESULTS

Uncompensated vestibulopathy was more common in older individuals and women. The uncompensated group showed impairments in climbing stairs (P < 0.001), pain (P < 0.001), vitality (P = 0.001), working (P < 0.001), depression (P < 0.001), sleep (P = 0.001), happiness (P = 0.002), anxiety (P = 0.006), and stress (P = 0.003). The compensated group showed deficits in pain (P < 0.001), work (P = 0.006), sleep (P = 0.001), and happiness (P = 0.001). The asymptomatic group had no deficits in QOL, psychological health, or physical function. These tendencies were similar after controlling for age and gender.

CONCLUSION

Vestibulopathy with a history of dizziness has a long-lasting impact on QOL and emotional status, even after compensation. Uncompensated vestibulopathy has a significant effect on QOL and mental health. Notably, though, the compensated group also showed a reduction in QOL. Appropriate interventions for each category of patients should be provided based on their impaired functions.

Ocular Movement Examination in Peripheral Vestibular Disorders as a Tool to Improve Diagnosis: A Literature Review

Background and Objectives: This study reviews the current literature on ocular movements, specifically focusing on nystagmus associated with peripheral vestibular disorders, to enhance diagnostic accuracy. The evaluation of ocular movements, particularly nystagmus, provides essential insights into the function and dysfunction of the vestibular system, helping clinicians distinguish between peripheral and central causes of vertigo and imbalance. Materials and Methods: A comprehensive search of PubMed was conducted using key terms such as "ocular movements", "nystagmus", "vestibular nystagmus", and "peripheral vestibular disorders". Results: The search yielded 2739 titles, and after a rigorous selection process, 52 articles were reviewed in full. Discussion: The review highlights different classifications and types of nystagmus, including physiological and pathological forms, and their diagnostic relevance in vestibular disorders such as benign paroxysmal positional vertigo (BPPV), vestibular neuritis, and Meniere's disease. Diagnostic techniques like video/electro-oculography are emphasized for their role in assessing vestibular function and identifying abnormalities. The study underscores the importance of detailed ocular examination in the diagnosis of peripheral vestibular disorders and proposes an algorithm to aid this process. Conclusions: While not a systematic review, this study highlights the importance of detailed ocular examination in diagnosing peripheral vestibular disorders and presents an algorithm to facilitate this process. It also emphasizes the need for continued research and advancements in vestibular medicine to further understand ocular movements and their clinical significance, ultimately contributing to improved patient outcomes.

Consequences of vestibular hypofunction in children with ADHD/DCD

BACKGROUND

Children with Attention Deficit Hyperactivity Disorder (ADHD) demonstrate a heterogeneous sensorimotor, emotional, and cognitive profile. Comorbid sensorimotor imbalance, anxiety, and spatial disorientation are particularly prevalent among their non-core symptoms. Studies in other populations presented these three comorbid dysfunctions in the context of vestibular hypofunction.

OBJECTIVE

To test whether there is a subgroup of children with ADHD who have vestibular hypofunction presenting with concomitant imbalance, anxiety, and spatial disorientation.

METHODS

Children with ADHD-only (n = 28), ADHD + Developmental Coordination Disorder (ADHD + DCD; n = 38), and Typical Development (TD; n = 19) were evaluated for vestibular function by the Dynamic Visual Acuity test (DVA-t), balance by the Bruininks-Oseretsky Test of motor proficiency (BOT-2), panic anxiety by the Screen for Child Anxiety Related Emotional Disorders questionnaire-Child version (SCARED-C), and spatial navigation by the Triangular Completion test (TC-t).

RESULTS

Children with ADHD vs. TD presented with a high rate of vestibular hypofunction (65 vs. 0 %), imbalance (42 vs. 0 %), panic anxiety (27 vs. 11 %), and spatial disorientation (30 vs. 5 %). Children with ADHD + DCD contributed more frequent and severe vestibular hypofunction and imbalance than children with ADHD-only (74 vs. 54 %; 58 vs. 21 %, respectively). A concomitant presence of imbalance, anxiety, and spatial disorientation was observed in 33 % of children with ADHD, all sharing vestibular hypofunction.

CONCLUSIONS

Vestibular hypofunction may be the common pathophysiology of imbalance, anxiety, and spatial disorientation in children. These comorbidities are preferentially present in children with ADHD + DCD rather than ADHD-only, thus likely related to DCD rather than to ADHD disorder. Children with this profile may benefit from a vestibular rehabilitation intervention.

Improvement in Body's Dynamic Adaptation during Walking with Vestibular Rehabilitation Therapy in Patients with Cerebellopontine Angle Tumor Resection

BACKGROUND

Our study aimed to investigate the effects of vestibular rehabilitation therapy on functional gait performance in patients with balance disorders.

METHODS

A total of 40 post-operative patients with balance disorders were included in the study. They were divided into two groups and participated in a vestibular rehabilitation program during their hospital stay. After discharge, the intervention group performed vestibular exercises at home, while the control group did not. Balance was assessed using the Functional Gait Assessment Scale at discharge and three months after surgery.

RESULTS

The intervention group included 15 women and 5 men with an average age of 45 years, while the control group included 7 women and 13 men with an average age of 50 years. Three months after surgery, the change in Functional Gait Assessment (FGA) scores exceeded the clinically significant threshold of 5 points in 17 patients in the intervention group and 14 in the control group. There was a statistically significant difference in FGA progression between the groups (p = 0.034). After three months post-surgery, 7 patients in the intervention group experienced falls compared to 12 in the control group.

CONCLUSION

Three months after surgery, we observed a significant improvement in the performance of balance tasks while walking and a lower risk of falls in the intervention group.

Altered thalamus functional connectivity in patients with acute unilateral vestibulopathy: a resting-state fMRI study

Objective

Acute unilateral vestibulopathy (AUVP) is the second leading cause of peripheral vestibular vertigo. Full recovery of AUVP is related to sufficient central vestibular compensation. It has been confirmed that the vestibular nucleus and vestibular cortex are involved in the process of vestibular compensatory in AUVP patients. However, few studies have focused on the functional compensation of thalamus in patients with AUVP. This study aimed to explore the alterations of resting-state functional connectivity (FC) focused on thalamus using functional magnetic resonance imaging (fMRI) in AUVP patients.

Methods

Data of 3D-T1 and resting-state fMRI were collected from 40 AUVP patients and 35 healthy controls (HC). Seeds-based (bilateral thalamus) FC was analyzed to investigate the changes in FC between the two groups. Furthermore, we evaluated the associations between altered thalamus FC and clinical features in AUVP patients using Pearson's partial correlation.

Results

Compared with HC, AUVP patients showed decreased FC between bilateral thalamus and left insula. We also observed decreased FC between right thalamus and left supramarginal gyrus. Additionally, we found increased FC between left thalamus and right postcentral gyrus (PCG), as well as increased FC between right thalamus and regions of bilateral PCG, right middle frontal gyrus and right middle occipital gyrus in AUVP patients. Furthermore, the FC between left thalamus and left insula was negatively correlated with values of canal paresis in patients with AUVP (p = 0.010, r = -0.434).

Conclusion

Our results provided first evidence for the decreased thalamo-vestibular cortex pathway, as well as increased thalamo-somatosensory and thalamo-visual cortex pathway in AUVP patients. These findings help us better understand the underlying mechanisms of central dynamic compensatory following an acute unilateral peripheral vestibular damage.

Probabilities of Isolated and Co-Occurring Vestibular Disorder Symptom Clusters Identified Using the Dizziness Symptom Profile

OBJECTIVES

Dizziness is among the most common reasons people seek medical care. There are data indicating patients with dizziness, unsteadiness, or vertigo may have multiple underlying vestibular disorders simultaneously contributing to the overall symptoms. Greater awareness of the probability that a patient will present with symptoms of co-occurring vestibular disorders has the potential to improve assessment and management, which could reduce healthcare costs and improve patient quality of life. The purpose of the current investigation was to determine the probabilities that a patient presenting to a clinic for vestibular function testing has symptoms of an isolated vestibular disorder or co-occurring vestibular disorders.

DESIGN

All patients who are seen for vestibular function testing in our center complete the dizziness symptom profile, a validated self-report measure, before evaluation with the clinician. For this retrospective study, patient scores on the dizziness symptom profile, patient age, and patient gender were extracted from the medical record. The dizziness symptom profile includes symptom clusters specific to six disorders that cause vestibular symptoms, specifically: benign paroxysmal positional vertigo, vestibular migraine, vestibular neuritis, superior canal dehiscence, Meniere disease, and persistent postural perceptual dizziness. For the present study, data were collected from 617 participants (mean age = 56 years, 376 women, and 241 men) presenting with complaints of vertigo, dizziness, or imbalance. Patients were evaluated in a tertiary care dizziness specialty clinic from October 2020 to October 2021. Self-report data were analyzed using a Bayesian framework to determine the probabilities of reporting symptom clusters specific to an isolated disorder and co-occurring vestibular disorders.

RESULTS

There was a 42% probability of a participant reporting symptoms that were not consistent with any of the six vestibular disorders represented in the dizziness symptom profile. Participants were nearly as likely to report symptom clusters of co-occurring disorders (28%) as they were to report symptom clusters of an isolated disorder (30%). When in isolation, participants were most likely to report symptom clusters consistent with benign paroxysmal positional vertigo and vestibular migraine, with estimated probabilities of 12% and 10%, respectively. The combination of co-occurring disorders with the highest probability was benign paroxysmal positional vertigo + vestibular migraine (~5%). Probabilities decreased as number of symptom clusters on the dizziness symptom profile increased. The probability of endorsing vestibular migraine increased with the number of symptom clusters reported.

CONCLUSIONS

Many patients reported symptoms of more than one vestibular disorder, suggesting their symptoms were not sufficiently captured by the symptom clusters used to summarize any single vestibular disorder covered by the dizziness symptom profile. Our results indicate that probability of symptom clusters indicated by the dizziness symptom profile is comparable to prior published work on the prevalence of vestibular disorders. These findings support use of this tool by clinicians to assist with identification of symptom clusters consistent with isolated and co-occurring vestibular disorders.

Increased Incidence of Vestibular Disorders in Patients With SARS-CoV-2

Objective

Determine the incidence of vestibular disorders in patients with SARS-CoV-2 compared to the control population.

Study Design

Retrospective.

Setting

Clinical data in the National COVID Cohort Collaborative database (N3C).

Methods

Deidentified patient data from the National COVID Cohort Collaborative database (N3C) were queried based on variant peak prevalence (untyped, alpha, delta, omicron 21K, and omicron 23A) from covariants.org to retrospectively analyze the incidence of vestibular disorders in patients with SARS-CoV-2 compared to control population, consisting of patients without documented evidence of COVID infection during the same period.

Results

Patients testing positive for COVID-19 were significantly more likely to have a vestibular disorder compared to the control population. Compared to control patients, the odds ratio of vestibular disorders was significantly elevated in patients with untyped (odds ratio [OR], 2.39; confidence intervals [CI], 2.29-2.50; P < 0.001), alpha (OR, 3.63; CI, 3.48-3.78; P < 0.001), delta (OR, 3.03; CI, 2.94-3.12; P < 0.001), omicron 21K variant (OR, 2.97; CI, 2.90-3.04; P < 0.001), and omicron 23A variant (OR, 8.80; CI, 8.35-9.27; P < 0.001).

Conclusions

The incidence of vestibular disorders differed between COVID-19 variants and was significantly elevated in COVID-19-positive patients compared to the control population. These findings have implications for patient counseling and further research is needed to discern the long-term effects of these findings.

Vestibular function is associated with immune inflammatory response

Association between vestibular function and immune inflammatory response has garnered increasing interest. Immune responses can lead to anatomical or functional alterations of the vestibular system, and inflammatory reactions may impair hearing and balance. Vestibular disorders comprise a variety of conditions, such as vestibular neuritis, benign paroxysmal positional vertigo, Meniere's disease, vestibular migraine, posterior circulation ischemia, and bilateral vestibular disease. Moreover, some patients with autoimmune diseases develop vestibulocochlear symptom. This paper offers an overview of prevalent vestibular diseases and discusses associations between vestibular dysfunction and immune diseases.

Assessment of functional and structural brain abnormalities with resting-state functional MRI in patients with vestibular neuronitis

BACKGROUND

Vestibular neuritis (VN) is a disorder manifesting as acute, isolated, spontaneous vertigo. There are few comprehensive studies on the changes in related functional and structural brain regions.

PURPOSE

To evaluate alterations in spontaneous neural activity, functional connectivity (FC), and gray matter volume (GMV) in patients with VN.

MATERIAL AND METHODS

A total of 24 patients with VN and 22 age- and sex-matched healthy controls underwent resting-state functional magnetic resonance imaging (rs-fMRI) and three-dimensional T1-weighted anatomical imaging. We calculated the amplitude of low frequency fluctuation (ALFF), regional homogeneity (ReHo), and degree centrality (DC) to discern local brain abnormalities. The most abnormal brain region was selected as the region of interest (ROI) for FC analysis based on ALFF and ReHo values after Bonferroni correction. Voxel-based morphometry (VBM) was used to assess differences in GMV.

RESULTS

Patients with VN, compared to healthy controls, showed increased ALFF (P < 0.001), ReHo values (P = 0.002, <0.001), and DC (P = 0.013) in the left lingual gyrus and right postcentral gyrus. FC analysis demonstrated enhanced connectivity between the left lingual gyrus and the left superior frontal gyrus, and decreased connectivity with the right insula gyrus, right and left supramarginal gyrus (P = 0.012, 0.004, <0.001, 0.014). In addition, GMV was reduced in the bilateral caudate (P = 0.022, 0.014).

CONCLUSIONS

Patients with VN exhibit abnormal spontaneous neural activity and changes in ALFF, ReHo, DC, GMV, and FC. Understanding these functional and structural brain abnormalities may elucidate the underlying mechanisms of VN.

VOR gain of lateral semicircular canal using video head impulse test in acute unilateral vestibular hypofunction: A systematic review

Introduction

Acute unilateral vestibular hypofunction is characterized by sudden onset of vertigo or dizziness, vomiting/nausea, gait instability, and nystagmus. This is commonly described as an acute vestibular syndrome and usually attributed to vestibular neuritis; however, up to 25% of acute vestibular syndrome is caused by a stroke of posterior circulations. The video head impulse test is a recent tool in the vestibular test battery that assesses the vestibule-ocular reflex by measuring the VOR gain and recording overt and covert saccades, these findings have been found to be helpful in the diagnosis of various vestibular disorders.

Method

A literature search was conducted in databases, including PubMed Central, PubMed, and Web of Science. All the articles that define video head impulse test (vHIT), acute vestibular hypofunction, and vestibular neuritis were considered for the preliminary search. No limits were placed on the date of publication. The searches were limited to studies with full-text availability, published in English, and including human subjects. Search words such as "head impulse test," "video head impulse test," "vestibular ocular reflex," "acute vestibular syndrome," "acute vestibular hypofunction," "vestibular neuritis," and "vHIT in central vestibular disorders" were entered into different databases in different combinations using boolean operators such as AND, OR, and NOT.

Results

Searches across different databases, including Web of Science, PubMed Central, and PubMed, resulted in a total of 1,790 articles. Title screening was done for all the articles. Out of the 1,790 articles, we found that 245 articles were related to vestibular hypofunction i.e., 1,545 articles were removed at this stage. A further 56 duplicate articles were removed. This led to a final screening of 189 articles. The exclusion criteria included unavailability of full text, studies reported in languages other than English, case reports, reviews, and articles including participants having other comorbid conditions. This final screening led to 133 articles being excluded, which led to the full-text screening of 56 articles. After screening the full-text articles as per the eligibility criteria, 21 articles were found to be eligible for the systematic review. Among the remaining studies, six articles were excluded due to different specific reasons. A total of 15 articles were included in this systematic review. The mean VOR gain for the patients with vestibular neuritis was 0.48 ± 0.14 for the ipsilesional ear, whereas the mean VOR gain was > 0.80 in the contralesional ear for all the patients with acute vestibular neuritis. In patients with PICA lesions, the VOR gain for the ipsilesional ear was 0.90 (range 0.87-0.94) and for the contralesional ear was 0.88 (range 0.84-0.93). In patients with AICA lesions, the mean VOR gain was variable. Based on the above mean VOR gain findings, the authors propose the following adjective description scale of VOR of the lateral canal using vHIT: normal VOR gain above 0.80, mild VOR gain loss for 0.70-0.79, moderate loss for 0.69-0.4, severe loss for 0.39-0.2, and profound loss for < 0.2.

Can hyperventilation test and duration of spontaneous nystagmus help differentiate between vascular and inflammatory aetiology of acute unilateral vestibular deficit?

Objective

To relate clinically the duration of spontaneous nystagmus and hyperventilation-induced nystagmus (HVIN) to vascular or inflammatory aetiology of acute unilateral vestibulopathy observed in a very early stage.

Methods

This is a retrospective study on 198 patients with acute unilateral vestibulopathy.

Results

In the short-lasting nystagmus group (spontaneous nystagmus < 48 h), mean age and cardiovascular risk were significantly higher; the rates of negative HVIN and paretic HVIN were 41.7% and 58.3%, respectively. In the long-lasting nystagmus group (spontaneous nystagmus > 48 h), mean age and vascular risk were lower; HVIN was absent in 12.6% of the cases, HVIN excitatory patterns were observed in 40.3% of cases and a paretic pattern in 47.1%.

Conclusions

A vascular aetiology should be considered the most likely in patients with spontaneous nystagmus < 48 hours: all patients were > 60 years old, cardiovascular risk was higher and HVIN was always absent or paretic. In the group with nystagmus > 48 hours, similarly, data indicate a higher incidence of paretic HVIN in older patients and higher vascular risk, even if the data does not allow us to lean clearly towards one of the two aetiological hypotheses.

Effectiveness of virtual reality-based vestibular rehabilitation in patients with peripheral vestibular hypofunction

BACKGROUND

The rehabilitation of classical peripheral vestibular disorders is long and costly. Recently, interactive systems based on virtual reality (VR) technology have reduced the cost of vestibular rehabilitation therapy (VRT) and made the process more enjoyable. This study aims to investigate the effects of VR-based VRT in patients diagnosed with peripheral vestibular hypofunction (PVH).

METHODS

In this study, a VR-based VRT program that utilized Sony Playstation®4 VR Head Mounted Display was applied to 25 patients (between 18-60) diagnosed with PVH. PVH was diagnosed by evaluating the patients' clinical histories, the findings in the "Micromedical Technologies VisualEyes Spectrum" videonystagmography (VNG) and the "Micromedical Aqua Stim" model bithermal water caloric tests. VR-based VRT program was applied to the patients for 4 weeks, 2 sessions per week, 8 sessions in total. Each session lasted around 30 to 40 min. All patients underwent the Dizziness Handicap Inventory (DHI), Sensory Organization Test (SOT), Adaptation Test (ADT), Limits of Stability (LOS), and Rhythmic Weight Shift (RWS) before, after, and 8-week follow-up of the VRT program. In addition, the Cybersickness Survey was applied to the patients at the end of the VR-based VRT session every week.

RESULTS

The DHI mean scores of the patients were 54.60, 19.20, and 16.84, respectively, before, just after, and at the 8-week follow-up VRT (p < 0.001). The mean SOT composite score of the patients was obtained as 58.08 before VRT; 77.16 after VRT and 76.40 at 8-week after VRT (p < 0.000). On the other hand, the values in the 'movement velocity' and "direction control" parameters of the patients in LOS and RWS showed a significant improvement after VRT compared to before VRT (p < 0.000). From before VRT to 8 weeks after VRT, the patient's oscillation averages in the 'toes up' and 'toes down' positions in ADT reduced progressively (p < 0.000).

DISCUSSION

This study demonstrates that implementing a VR-based VRT protocol may be an efficient option to improve posture stability and the quality of life in patients with PVH. In addition, VR-based vestibular rehabilitation therapy has shown to be effective for PVH patients in the mid-term.

Recent advancements in bioelectronic devices to interface with the peripheral vestibular system

Balance disorders affect approximately 30% of the population throughout their lives and result in debilitating symptoms, such as spontaneous vertigo, nystagmus, and oscillopsia. The main cause of balance disorders is peripheral vestibular dysfunction, which may occur as a result of hair cell loss, neural dysfunction, or mechanical (and morphological) abnormality. The most common cause of vestibular dysfunction is arguably vestibular hair cell damage, which can result from an array of factors, such as ototoxicity, trauma, genetics, and ageing. One promising therapy is the vestibular prosthesis, which leverages the success of the cochlear implant, and endeavours to electrically integrate the primary vestibular afferents with the vestibular scene. Other translational approaches of interest include stem cell regeneration and gene therapies, which aim to restore or modify inner ear receptor function. However, both of these techniques are in their infancy and are currently undergoing further characterization and development in the laboratory, using animal models. Another promising translational avenue to treating vestibular hair cell dysfunction is the potential development of artificial biocompatible hair cell sensors, aiming to replicate functional hair cells and generate synthetic 'receptor potentials' for sensory coding of vestibular stimuli to the brain. Recently, artificial hair cell sensors have demonstrated significant promise, with improvements in their output, such as sensitivity and frequency selectivity. This article reviews the history and current state of bioelectronic devices to interface with the labyrinth, spanning the vestibular implant and artificial hair cell sensors.

Clinical Study of BPPV and the Effectiveness of Canalolith Repositioning Manoeuvre in Subjects of BPPV

Vertigo is an illusion of motion, either of one self or of the environment. Vertigo in BPPV is a very devastating experience for the patient who experiences it. However, it can be reversible with vestibular rehabilitation, with very good results. A study on 72 patients attending Otoneurology clinic in our hospital, diagnosed as BPPV with history and examination were subjected to DHI (Dizziness Handicap Index) questionnaire prior to and after intervention and results were analyzed. BPPV is more commonly seen in elderly individuals above 45 yrs, females and posterior semi circular canal. A significant improvement was noted in all the three components of DHI index in patients treated with CRM (Canalolith Repositioning Manoeuver) when compared to the patients who received only reassurance. CRM is a very safe and effective treatment of BPPV which has the added advantage of being noninvasive procedure, with excellent results.

The clinical course of vestibular neuritis from the point of view of the ocular vestibular evoked myogenic potential

Background

Studying otolith functions after unilateral vestibular neuritis using ocular vestibular-evoked myogenic potentials and subjective visual vertical tests could give different results.

Method

A total of 39 patients underwent a vestibular assessment that included the Dizziness Handicap Inventory and horizontal and vertical semicircular canal function testing with video head impulse testing, ocular vestibular-evoked myogenic potential testing, cervical vestibular-evoked myogenic potentials and subjective visual vertical testing.

Results

All patients showed a significant alteration (asymmetry ratio more than 40 per cent) for ocular vestibular-evoked myogenic potentials as well as for subjective visual vertical testing (more than −2° to more than +2°) during the acute phase, whereas after 72 hours from the acute vertigo attack normal values (asymmetry ratio less than 40 per cent) were found in 6 out of 39 patients for ocular vestibular-evoked myogenic potentials and 36 out of 39 for the subjective visual vertical (less than −2° to less than +2°).

Conclusion

Ocular vestibular-evoked myogenic potentials are the most suitable test to evaluate otolith functions in patients with unilateral vestibular neuritis in the acute and sub-acute phase.

Effectiveness of the Epley maneuver versus Cawthorne-Cooksey vestibular exercises in the treatment of posterior semicircular canal benign paroxysmal positional vertigo (BPPV): A randomized controlled trial

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo that mainly affects the posterior semicircular canal. Studies suggest that Epley maneuver could improve balance of patients, but Cawthorne-Cooksey vestibular exercises are still scarce. This study aimed to observe the effects of Cawthorne-Cooksey vestibular exercises applied after the Epley maneuver on balance, vertigo symptoms, and quality of life in posterior semicircular canal BPPV.

METHODS

Thirty-six patients with posterior semicircular canal BPPV were randomly assigned into Epley maneuver (EpleyM) and Epley maneuver and exercise (EpleyM&Exe) groups. All patients were treated with the Epley maneuver, while Cawthorne-Cooksey vestibular exercises were given to the EpleyM&Exe group as home exercises for 6 weeks. Their static and dynamic balance, vertigo symptoms, and quality of life were assessed at pre-, post-intervention (1st, 3rd and 6th weeks).

RESULTS

Thirty-two patients completed the study (mean age: 46.91 ± 9.78 years). Epley maneuver applied alone and combined with Cawthorne-Cooksey vestibular exercises, was found to be effective in 25 patients (78.1%), 6 patients (18.8%) and 1 patient (3.1%) at the 1st, 3rd and 6th weeks, respectively. After 6 weeks, both groups had gained significant improvements in balance, vertigo symptoms, and quality of life (p < 0.001); however, there were no significant differences between the groups, except for the static dominant leg balance test (p = 0.022).

CONCLUSIONS

The Epley maneuver can be considered as the first option compared to Cawthorne-Cooksey vestibular exercises. Exercises do not appear to have any additional effects in improving posterior semicircular canal BPPV symptoms.

Vestibular activities and participation measure: Turkish validity and reliability

BACKGROUND

International Classification of Functioning, Disability and Health (ICF) has an important role in rehabilitation in terms of assessments. In the field of vestibular rehabilitation, Vestibular Activities of Participation (VAP) measure is the first assessment developed in a perspective of ICF.

OBJECTIVE

It was aimed to adapt cross-culturally and analyze psychometric properties of VAP into Turkish Language.

METHODS

The VAP was translated into Turkish language by the authors and back translated by a blind native English speaker. The final version was applied to 310 participants. Internal consistency was analyzed with Cronbach's alpha and test-retest reliability analyzed with Intraclass Correlation coefficient (ICC). Validity of the scale investigated with Exploratory and Confirmatory Factor analysis (EFA and CFA).

RESULTS

Cronbach's alpha reliability coefficient was found 0.94, and the reliability of the subscales ranged from 0.75 to 0.95; ICC was found 0.94. VAP resulted 8-factor structure and explained 88%of the total variance. In CFA (χ2) / df ratio shows good agreement with 2.472 and the goodness of fit indices of TLI (0.814), CFI (0.893) and RMSEA (0.075) showed acceptable fit.

CONCLUSIONS

This study showed that VAP-Turkish version is valid and reliable in Turkish speaking populations, and might be used to determine impact of vestibular disorders on activities and participation.

Vestibular paroxysmia: Clinical features and imaging findings; a literature review

According to the definition of neurovascular compression syndromes (NVCS), a vascular structure in direct contact with a cranial nerve is causing mechanical irritation of the neural tissue producing correlating symptoms. Vestibular paroxysmia is an example of a neurovascular compression which is caused by neurovascular contact between the eighth cranial nerve and a vessel. It is crucial to understand the unique anatomy of the vestibulocochlear nerve in order to study the syndrome which is the result of its compression. More specifically, the long transitional zone between central and peripheral myelin plays a central role in clinical significance, as the transitional zone is the structure most prone to mechanical injury. Imaging techniques of the eighth cranial nerve and the surrounding structures are substantial for the demonstration of clinically significant cases and potential surgical decompression. The goal of the current review is to present and study the existing literature on vestibular paroxysmia and to search for the most appropriate imaging technique for the syndrome. An extensive literature search of PubMed database was performed, and the studies were ranked based on evidence-based criteria, followed by descriptive statistics of the data. The present analysis indicates that 3D CISS MRI sequence is superior to any other sequence, in the most studies reviewed, regarding the imaging of neurovascular compression of the eighth cranial nerve.

Clinical value of the video head impulse test in patients with vestibular neuritis: a systematic review

PURPOSE

The aim of this systematic review was to evaluate the clinical application potential of the video head impulse test (vHIT) in diagnosing vestibular neuritis (VN).

METHODS

An electronic search was conducted in the following databases: Embase, MEDLINE, ScienceDirect, Google scholar, and the Cochrane Database of Systematic Reviews. Clinical studies were included in which an evaluation was made using vHIT either alone or in combination with other tests or bedside algorithms. Evaluations that were carried out using unvalidated tools were excluded. Only studies of patients with VN (superior, inferior, or in toto) were included. Screening of titles, abstracts, full texts, and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using a modified version of the Newcastle-Ottawa scale.

RESULTS

Results were reported according to the preferred reporting items for systematic reviews and meta-analyses. Our search yielded 1309 unique records, 21 of which remained after screening titles and abstracts. Sixteen studies were included, i.e., for a total of 933 patients including 474 patients with a diagnosis of VN.

CONCLUSIONS

The diagnostic value of vHIT is high for VN, as it is a high-frequency measurement tool. vHIT is a useful complement or alternative to caloric and rotational tests as an indicator of lesions of vestibular canal functioning, especially at the time of onset. This tool can provide useful clues about the clinical progress of recovery from the lesion through the value of the vestibulo ocular reflex gain and the consequent evolution of the saccade pattern, which allows the patient to stabilize vision on the retina.

Impact of air pollution on benign paroxysmal positional vertigo incidence: a retrospective study of the citizens of Seoul, South Korea

Benign paroxysmal positional vertigo (BPPV) is among the most common inner ear diseases. Although BPPV is one of the most common causes of dizziness, its pathogenesis remains unknown. Air pollutants might reach the middle ear through the eustachian tube and be absorbed into the inner ear through the round window membrane, increasing the risk of BPPV. We investigated the relationship between air pollution and BPPV risk. Data were extracted from the Korean Health Insurance Review and Assessment Service database, which contains health claims information of the entire South Korean population. Variables of interest included the number of patients diagnosed with BPPV in Seoul, South Korea, patients' clinical and demographic characteristics, and osteopenia status. Seoul's daily air pollution indicators, including SO2, CO, O3, NO2, PM10, and PM2.5, were obtained from the Korea Environment Corporation website. Overdispersed Poisson regression analysis was performed. In the multivariable analysis, NO2 air concentration (ppb) was associated with increased incidence of BPPV. In analysis stratified by gender, levels of NO2 were associated with increased incidence of BPPV in both men and women. In the analysis stratified by age, NO2 air concentration was associated with increased incidence of BPPV among all adults over the age of 19 years. In the analysis stratified by osteopenia status, NO2 was associated with increased incidence of BPPV in patients with and without osteopenia. Air levels of NO2 were associated with increased incidence of BPPV in the present study. This finding contributes toward a better understanding of BPPV pathogenesis and improved prevention and management of this condition.

IE-Map: a novel in-vivo atlas and template of the human inner ear

Brain atlases and templates are core tools in scientific research with increasing importance also in clinical applications. Advances in neuroimaging now allowed us to expand the atlas domain to the vestibular and auditory organ, the inner ear. In this study, we present IE-Map, an in-vivo template and atlas of the human labyrinth derived from multi-modal high-resolution magnetic resonance imaging (MRI) data, in a fully non-invasive manner without any contrast agent or radiation. We reconstructed a common template from 126 inner ears (63 normal subjects) and annotated it with 94 established landmarks and semi-automatic segmentations of all relevant macroscopic vestibular and auditory substructures. We validated the atlas by comparing MRI templates to a novel CT/micro-CT atlas, which we reconstructed from 21 publicly available post-mortem images of the bony labyrinth. Templates in MRI and micro-CT have a high overlap, and several key anatomical measures of the bony labyrinth in IE-Map are in line with micro-CT literature of the inner ear. A quantitative substructural analysis based on the new template, revealed a correlation of labyrinth parameters with total intracranial volume. No effects of gender or laterality were found. We provide the validated templates, atlas segmentations, surface meshes and landmark annotations as open-access material, to provide neuroscience researchers and clinicians in neurology, neurosurgery, and otorhinolaryngology with a widely applicable tool for computational neuro-otology.

The effects of climate on the incidence of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders. An investigation into the factors related to BPPV could contribute to its prevention and appropriate management. We investigated the association between climatic factors and incidence of BPPV in this study. A total of 365 patients who were diagnosed with idiopathic BPPV in the emergency room of our hospital in 2015 were included. The number of patients diagnosed with BPPV per week was calculated (every week). Climatic factors, including daily average humidity, temperature, atmospheric pressure, cloud amount, sunshine amount, and daylight time, were documented daily. The weekly mean climatic value in each week was calculated. Simple correlation analysis and multivariate regression analyses were performed to identify climatic factors associated with the number of patients diagnosed with BPPV. Simple correlation analysis revealed a significant association between the humidity (r = 0.276, p = 0.048), temperature (r = 0.275, p = 0.049), and cloud amount (r = 0.293, p = 0.035) and the number of BPPV patients diagnosed per week. Multivariate regression analysis revealed that only the cloud amount was a statistically significant factor associated with the number of BPPV patients diagnosed every week. A significant positive association was discovered between the cloud amount and BPPV incidence. Cloud amount can therefore have an association with the incidence of BPPV.

Investigation of Vestibular Function in Adult Patients with Gitelman Syndrome: Results of an Observational Study

Gitelman syndrome (GS) is a rare salt-losing tubulopathy caused by an inactivating mutation in the SLC12A3 gene, encoding the thiazide-sensitive sodium chloride cotransporter (NCC). Patients with GS frequently complain of vertigo, usually attributed to hypovolemia. Because NCC is also located in the endolymphatic sac, we hypothesized that patients with GS might have vestibular dysfunction. Between April 2013 and September 2016, 20 (22%) out of 90 patients followed at the reference center complained of vertigo in the absence of orthostatic hypotension. Sixteen of them were referred to an otology department for investigation of vestibular function. The vertigo was of short duration and triggered in half of them by head rotation. Seven patients (44%) had a vestibular syndrome. Vestibular syndrome was defined: (1) clinically, as nystagmus triggered by the head shaking test (n = 5); and/or (2) paraclinically, as an abnormal video head impulse test (n = 0), abnormal kinetic test (n = 4) and/or abnormal bithermal caloric test (n = 3). Five patients had associated auditory signs (tinnitus, aural fullness or hearing loss). In conclusion, we found a high frequency of vestibular disorder in GS patients suffering from vertigo, suggesting a role of NCC in the inner ear. Referent physicians of these patients should be aware of this extrarenal manifestation that requires specific investigations and treatment.

Acute consequences of a unilateral VIIIth nerve transection on vestibulo-ocular and optokinetic reflexes in Xenopus laevis tadpoles

Loss of peripheral vestibular function provokes severe impairments of gaze and posture stabilization in humans and animals. However, relatively little is known about the extent of the instantaneous deficits. This is mostly due to the fact that in humans a spontaneous loss often goes unnoticed initially and targeted lesions in animals are performed under deep anesthesia, which prevents immediate evaluation of behavioral deficits. Here, we use isolated preparations of Xenopus laevis tadpoles with functionally intact vestibulo-ocular (VOR) and optokinetic reflexes (OKR) to evaluate the acute consequences of unilateral VIIIth nerve sections. Such in vitro preparations allow lesions to be performed in the absence of anesthetics with the advantage to instantly evaluate behavioral deficits. Eye movements, evoked by horizontal sinusoidal head/table rotation in darkness and in light, became reduced by 30% immediately after the lesion and were diminished by 50% at 1.5 h postlesion. In contrast, the sinusoidal horizontal OKR, evoked by large-field visual scene motion, remained unaltered instantaneously but was reduced by more than 50% from 1.5 h postlesion onwards. The further impairment of the VOR beyond the instantaneous effect, along with the delayed decrease of OKR performance, suggests that the immediate impact of the sensory loss is superseded by secondary consequences. These potentially involve homeostatic neuronal plasticity among shared VOR-OKR neuronal elements that are triggered by the ongoing asymmetric activity. Provided that this assumption is correct, a rehabilitative reduction of the vestibular asymmetry might restrict the extent of the secondary detrimental effect evoked by the principal peripheral impairment.

The Different Stages of Vestibular Neuritis from the Point of View of the Video Head Impulse Test

Vestibular neuritis (VN) is one of the most common causes of acute vestibular syndrome (AVS). Quantifying the vestibulo-ocular reflex (VOR) gain by the video Head Impulse Test (vHIT) could provide useful information to diagnose VN. This study aims to retrospectively evaluate the VOR gain values during the acute and subacute stages of the VN and to correlate these values with the patients’ dizziness-related handicap. Medical record of 28 patients with VN were reviewed. Patients were assigned to two groups according to the time since the acute vestibular syndrome (AVS). One group with patients assessed within seventy-two hours since the AVS (AVSg) and one group with patients evaluated from four days to six weeks since the AVS (PAVSg). VOR gain was evaluated in all selected patients and correlated to Dizziness Handicap Inventory (DHI). Significant differences were found in the between-subjects analysis in DHI score (p = 0.000) and in the ipsilesional hVOR gain values (p = 0.001). The correlation analysis showed significant results (p = 0.017) between DHI score (40 ± 16.08) and ipsilesional VOR gain (0.54 ± 0.09) in the PAVSg. Patients evaluated within 72 h since the AVS showed anticompensatory saccades (AcS) turning the head toward the contralesional side. Patients with unilateral Superior VN (SVN) could have dissimilar hVOR gain values and DHI score according to the damage of the VIII pair of cranial nerves. AcS in the contralesional side is a sign of acute phase in patients with unilateral SVN.

Finding a Balance: A Systematic Review of the Biomechanical Effects of Vestibular Prostheses on Stability in Humans

The vestibular system is located in the inner ear and is responsible for maintaining balance in humans. Bilateral vestibular dysfunction (BVD) is a disorder that adversely affects vestibular function. This results in symptoms such as postural imbalance and vertigo, increasing the incidence of falls and worsening quality of life. Current therapeutic options are often ineffective, with a focus on symptom management. Artificial stimulation of the vestibular system, via a vestibular prosthesis, is a technique being explored to restore vestibular function. This review systematically searched for literature that reported the effect of artificial vestibular stimulation on human behaviours related to balance, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) technique. A total of 21 papers matched the inclusion criteria of the literature search conducted using the PubMed and Web of Science databases (February 2019). The populations for these studies included both healthy adults and patients with BVD. In every paper, artificial vestibular stimulation caused an improvement in certain behaviours related to balance, although the extent of the effect varied greatly. Various behaviours were measured such as the vestibulo-ocular reflex, postural sway and certain gait characteristics. Two classes of prosthesis were evaluated and both showed a significant improvement in at least one aspect of balance-related behaviour in every paper included. No adverse effects were reported for prostheses using noisy galvanic vestibular stimulation, however, prosthetic implantation sometimes caused hearing or vestibular loss. Significant heterogeneity in methodology, study population and disease aetiology were observed. The present study confirms the feasibility of vestibular implants in humans for restoring balance in controlled conditions, but more research needs to be conducted to determine their effects on balance in non-clinical settings.

Video head impulse test in vestibular migraine

Introduction

Vestibular migraine as an entity was described in 1999 and its pathophysiology is still not established. Simultaneously with research to better understand vestibular migraine, there has been an improvement in vestibular function assessment. The video-head impulse test is one of the latest tools to evaluate vestibular function, measuring its vestibular-ocular reflex gain.

Objective

To evaluate vestibular function of vestibular migraine patients using video-head impulse test.

Methods

Cross-sectional case-control study homogeneous by age and gender with vestibular migraine patients according to the 2012–2013 Barany Society/International Headache Society diagnostic criteria submitted to video-head impulse test during intercrisis period.

Results

31 vestibular migraine patients were evaluated with a predominantly female group (90.3%) and mean age of 41 years old. Vestibular function was normal in both patient and control groups. Gain values for horizontal canals were similar between the two groups, but gain values for vertical canals were higher in the group with vestibular migraine (p < 0.05). Patients with vestibular migraine felt more dizziness while performing the video-head impulse test than control subjects (p < 0.001).

Conclusions

Patients with vestibular migraine present normal vestibular function during intercrisis period when evaluated by video-head impulse test. Vertical canals, however, have higher gains in patients with vestibular migraine than in control subjects. Vestibular migraine patients feel dizziness more often while conducting video-head impulse test.

Efficacy and Safety of a Fixed Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg vs Betahistine Dihydrochloride 16 mg in Patients with Peripheral Vestibular Vertigo: A Prospective, Multinational, Multicenter, Double-Blind, Randomized, Non-inferiority Clinical Trial

Background and Objective

Vertigo derived from peripheral vestibular disorders is quite frequently encountered in daily clinical practice and can be a severely disabling symptom associated with substantial impairment of health-related quality of life for the affected patients. Betahistine, a structural analogue of histamine and presumably the most widely prescribed anti-vertigo drug worldwide, has previously been shown to be an effective and safe treatment for these patients. The objective of the present study was to evaluate whether the fixed combination of cinnarizine and dimenhydrinate (Arlevert^®) is non-inferior and thus a potentially useful alternative to betahistine dihydrochloride in the treatment of patients suffering from peripheral vestibular vertigo.

Methods

In this prospective, multicenter, double-blind, randomized, non-inferiority clinical trial, outpatients from 8 ENT clinics in Austria, Bulgaria, the Czech Republic and Russia were randomly assigned to receive three times daily one tablet of either the fixed combination cinnarizine 20 mg/dimenhydrinate 40 mg or betahistine dihydrochloride 16 mg for 4 weeks. Primary endpoint was the reduction of the mean vertigo score (MVS), a validated 12-item composite score defined as the mean of 6 vertigo symptoms (dystasia and walking unsteadiness, staggering, rotary sensation, tendency to fall, lift sensation, blackout) and 6 trigger factors for vertigo (change of position, bowing, getting up, driving by car/train, head movements, eye movement), after 4 weeks of therapy, as judged by the patient on a 5-point visual analogue scale (VAS). The non-inferiority margin was set to 0.3. Secondary outcomes included the patient’s and investigator’s judgment of global efficacy, the patient’s rating of impairment of daily activities, and safety/tolerability of the treatments.

Results

Three hundred and six patients (mean age 53.5 years, approximately 60% female) were enrolled and randomized to the fixed combination cinnarizine/dimenhydrinate (n = 152) or betahistine (n = 154) groups; 297 patients completed the study and 294 (146 and 148, respectively) were valid for the per-protocol analysis, which was used for the non-inferiority analysis. Treatment with cinnarizine/dimenhydrinate led to a stronger reduction of the MVS [least squares mean (LSM)] after 4-week therapy (primary endpoint) in comparison to betahistine (0.395 vs 0.488; difference: − 0.093, 95% CI − 0.180; − 0.007, p = 0.035); since the upper limit of the two-sided 95% confidence interval was not only below the non-inferiority margin of 0.3, but also entirely below 0, superiority of the fixed combination could be demonstrated. The combination preparation was also more effective after 1 week of therapy and received more favorable patient’s ratings on overall efficacy and impairment of daily activities. Both treatments were very well tolerated. Only 12 patients (3.92%) reported 13 non-serious adverse events; 2 cinnarizine/dimenhydrinate-treated patients discontinued the study prematurely due to adverse events as compared to 5 betahistine-treated patients.

Conclusion

The fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg was found to be not only non-inferior, but superior to betahistine 16 mg in the improvement of peripheral vestibular vertigo. Furthermore, taking into account a good and slightly favorable safety profile, the present study provides evidence that the fixed-combination preparation is a potent and even superior alternative to betahistine in the treatment of vertigo related to peripheral vestibular disorders.

Study Registration

EudraCT No. 2011-004025-27.

Effectiveness of Canal Occlusion for Intractable Posterior Canal Benign Paroxysmal Positional Vertigo: A Systematic Review

OBJECTIVES

A last resort for therapy for intractable benign paroxysmal positional vertigo (BPPV) is mechanical occlusion of the posterior semicircular canal. The aim of this review was to assess the effect of posterior canal occlusion for intractable posterior canal BPPV on vertigo and to determine the risk of loss of auditory or vestibular function.

DATA SOURCES

A systematic literature search according to the PRISMA statement was performed on PubMed, the Cochrane Library, Embase, Web of Science, and CINAHL. The last search was conducted in June 2018.

REVIEW METHODS

Cohort studies with original data and case reports describing >5 cases were included if they analyzed the effect of posterior semicircular canal obliteration in adults with intractable posterior BPPV on vertigo. Two authors screened titles and abstracts for eligibility. The first author screened full texts and analyzed the data.

RESULTS

Eight retrospective studies met the eligibility criteria. The quality of all individual studies was rated fair. Canal occlusion was performed on 196 patients. All studies reported complete resolution of BPPV in all patients (100%). Among postoperatively tested patients, total loss of auditory function and vestibular function was reported in 2 of 190 (1%) and 9 of 68 (13%), respectively.

CONCLUSION

Posterior semicircular canal plugging resulted in 100% resolution of BPPV in patients with intractable BPPV in all studies. However, the strength of evidence was weak. Potential serious complications, such as deafness and loss of vestibular function, should be taken into account.

Effect of the novel histamine H4 receptor antagonist SENS-111 on spontaneous nystagmus in a rat model of acute unilateral vestibular loss

BACKGROUND AND PURPOSE

Histamine H₄ receptors are expressed in the peripheral vestibular system, and their selective inhibition improves vertigo symptoms in rats with unilateral vestibular lesions. The effects of SENS-111, a selective oral H₄ receptor antagonist with high affinity to both animal and human receptors, on vertigo symptoms was evaluated in a translational in vivo model of unilateral vestibular loss.

EXPERIMENTAL APPROACH

Pharmacokinetics of SENS-111 in rats was determined to aid dose selection for efficacy testing. Vestibular lesions were induced in rats by unilateral transtympanic injection of kainic acid. The effect of SENS-111 (10 or 20 mg·kg^-1 ) on spontaneous nystagmus was evaluated compared with placebo vehicle using video-nystagmography, and the effective dose was compared with those of similar drugs used clinically, as single agents or combined with SENS-111.

KEY RESULTS

Doses were selected for plasma exposure were consistent with published phase 1 results from healthy volunteers. SENS-111 of 10 mg·kg^-1 gave a 21-22% reduction in nystagmus at 1 hr post-administration, whereas a loss of efficacy was seen with 20 mg·kg^-1 . Compared with SENS-111, meclizine and methylprednisolone had minimal effects on nystagmus as single agents, and meclizine abolished the effect of SENS-111 when combined with SENS-111. All evaluated drugs were well tolerated.

CONCLUSIONS AND IMPLICATIONS

The exposure-efficacy relationship for improved spontaneous nystagmus seen with SENS-111 in this in vivo model is consistent with phase 1 clinical results and provides preclinical support for pharmacokinetic/pharmacodynamic modelling and selection of effective clinical drug concentrations.

LINKED ARTICLES

This article is part of a themed section on New Uses for 21st Century. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.3/issuetoc.

Investigating the vestibular system using modern imaging techniques-A review on the available stimulation and imaging methods

The vestibular organs, located in the inner ear, sense linear and rotational acceleration of the head and its position relative to the gravitational field of the earth. These signals are essential for many fundamental skills such as the coordination of eye and head movements in the three-dimensional space or the bipedal locomotion of humans. Furthermore, the vestibular signals have been shown to contribute to higher cognitive functions such as navigation. As the main aim of the vestibular system is the sensation of motion it is a challenging system to be studied in combination with modern imaging methods. Over the last years various different methods were used for stimulating the vestibular system. These methods range from artificial approaches like galvanic or caloric vestibular stimulation to passive full body accelerations using hexapod motion platforms, or rotatory chairs. In the first section of this review we provide an overview over all methods used in vestibular stimulation in combination with imaging methods (fMRI, PET, E/MEG, fNIRS). The advantages and disadvantages of every method are discussed, and we summarize typical settings and parameters used in previous studies. In the second section the role of the four imaging techniques are discussed in the context of vestibular research and their potential strengths and interactions with the presented stimulation methods are outlined.

Management of peripheral vertigo with antihistamines: New options on the horizon

Vertigo is associated with a wide range of vestibular pathologies. It increasingly affects the elderly, with a high cost to society. Solutions include vestibular suppressants and vestibular rehabilitation, which form the mainstay of therapy. Antihistamines represent the largest class of agents used to combat vestibular vertigo symptoms. Agents targeting the H₁ and H₃ receptors have been in clinical use for several decades as single agents. Nonetheless, effective management of vertigo proves elusive as many treatments largely address only associated symptoms, and with questionable efficacy. Additionally, the primary and limiting side effect of sedation is counterproductive to normal functioning and the natural recovery process occurring via central compensation. To address these issues, the timing of administration of betahistine, the mainstay H₃ antihistamine, can be fine-tuned, while bioavailability is also being improved. Other approaches include antihistamine combination studies, devices, physical therapy and behavioural interventions. Recently demonstrated expression of H₄ receptors in the peripheral vestibular system represents a new potential drug target for treating vestibular disorders. A number of novel selective H₄ antagonists are active in vestibular models in vivo. The preclinical potential of SENS-111 (Seliforant), an oral first-in-class selective H₄ antagonist is the only such molecule to date to be translated into the clinical setting. With an excellent safety profile and notable absence of sedation, encouraging outcomes in an induced vertigo model in healthy volunteers have led to ongoing clinical studies in acute unilateral vestibulopathy, with the hope that H₄ antagonists will offer new effective therapeutic options to patients suffering from vertigo.

Persistent impairment based symptoms post mild traumatic brain injury: Does a standard symptom scale detect them?

AIM

To further explore symptoms in patients beyond the expected recovery period post mild Traumatic Brain Injury (mTBI) that are potentially indicative of impairment.

METHODS

Ninety-four individuals (62 diagnosed with mTBI within the previous 4-24 weeks and 32 healthy controls) participated in the study. Participants in the mTBI group were further grouped as symptomatic (n = 33) or asymptomatic (n = 29) based on their spontaneous report of symptoms at the time of screening. Measures included a demographic questionnaire, 8 impairment specific self-report clinical tools, and a standard post-mTBI self-report symptom scale (Head Injury Scale (HIS)).

RESULTS

Compared to the control group, scores for all instruments (including the HIS) were higher in the symptomatic mTBI group (P < 0.05), and higher for the neck disability and hyperarousal measures in the asymptomatic mTBI group (p < 0.035), but not the HIS (p > 0.093). Overall 94% of the symptomatic and 62% of the asymptomatic participants post-mTBI, recorded scores considered to be clinically relevant on at least one impairment screening tool. In contrast, only 28% of the asymptomatic mTBI group recorded a clinically relevant score for the HIS.

CONCLUSION

Symptoms indicative of persisting impairments beyond the expected recovery period were apparent in a substantial proportion of individuals post mTBI. Furthermore, a high percentage of individuals initially reporting as symptom free demonstrated clinically relevant scores on at least one impairment screening tool. Findings also suggest that a standard post-mTBI self-report symptom scale may often not detect the presence of persisting symptoms.

Recrudescence of Old Stroke Deficits Among Transient Neurological Attacks

Background

Recrudescence of old stroke deficits (ROSD) is a reported cause of transient neurological symptoms, but it is not well characterized.

Objective

We sought to determine the prevalence, potential triggers, and clinical outcome of ROSD in a cohort of patients presenting with acute transient neurological attack (TNA) and absent acute pathology on brain imaging.

Methods

We retrospectively analyzed 340 consecutive patients who presented with TNA and no acute pathology on brain imaging that were included in an institutional stroke registry between February 2013 and April 2015. The presumed TNA cause was categorized as transient ischemic attack (TIA), ROSD, and other cause. Baseline characteristics, triggers, cardiovascular complications within 90 days, and death were recorded.

Results

The prevalence of ROSD in the studied cohort was 10% (34/340). Infectious stressors and acute metabolite derangements were more common in ROSD compared to TIA (P < .05, each). Compared to TIA and the other TNA, ROSD was more likely to have more than 1 acute stressor (P < .001). Patients with ROSD had similar vascular risk factors compared to TIA (P > .05), including hypertension, diabetes mellitus, peripheral vascular disease, hyperlipidemia, and similarly used HMG-CoA reductase inhibitor, antihypertensive, and antiplatelet medications. Among the patients with an available 90-day follow-up (n = 233), cardiovascular events were more frequent in the TIA group as compared to other TNA (P < .05).

Conclusion

ROSD is common and distinct from TIA and is associated with a triggering physiologic reaction leading to transient reemergence of prior neurologic deficits. Further study of the mechanism of this phenomenon is needed to help better identify these patients.

Living with Ménière's disease: an interpretative phenomenological analysis

Purpose: To explore the meanings of Ménière's disease from the perspective of people living with this condition and to understand what was considered significant and important in participants' everyday lives.Materials and methods: Four women with Ménière's disease participated in face-to-face semi-structured interviews. Accounts were recorded, transcribed, and analysed using an iterative process integral to Interpretative Phenomenological Analysis.Results: Three interconnected themes were identified. "You have no control whatsoever" conveys participants' perceptions of vertigo as having a disruptive and ongoing impact on physical and psychosocial function in everyday life. "Ménière's takes away your life completely" describes Ménière's as impinging on participants' most meaningful activities and relationships, and as restricting their ability to live their lives on their own terms. "You get on with life" recounts participants' efforts to refashion their lives whilst living with this condition and manage its most harmful effects. The psychosocial impact of living with Ménière's disease and its relevance to rehabilitation is discussed.Conclusions: Ménière's disease has an enduring physical and psychosocial impact. Clinicians who acknowledge and respond to an individual's subjective experience of their condition may be key to their engagement in therapy. Service users should have a voice in health service design and delivery.Implications for rehabilitationMénière's disease is a long-term disabling condition that not only impacts on physical and psychosocial functioning but also restricts quality of life through stigmatisation.Fear of triggering an attack of vertigo may prevent people with Ménière's disease from engaging with rehabilitation.Therapists who adopt a biopsychosocial approach and who recognise patients' efforts to control their symptoms as a positive form of resistance may be better equipped to empathetically support patients to engage in new activities that may be vital to improving their lives.

Vestibular Rehabilitation for Children

This article focuses on vestibular rehabilitation (VR) for children. Reports of the presence of vestibular dysfunction in infants, young children, and adolescents have increased over the past decade. In addition to being a comorbidity of sensorineural hearing loss, vestibular dysfunction has been noted in children with cytomegalovirus, late prematurity, and concussion, to name a few. Despite ample evidence and reports of VR for adults, the selection and provision of exercises to be included in the VR protocol for children vary, depending on the nature of the lesion, impairments identified, age at the time of lesion, and developmental factors such as critical periods of development and intermodality interdependence. Unlike adults, children with loss of function or hypofunction of the vestibular apparatus since or shortly after birth present with a developmental delay that is progressive. Very young children may not be able to describe symptoms but rather only avoid activities or cry. This report provides a review of vestibular-related impairments in children, determinants of the symptoms and functional impairments of vestibular dysfunction, the mechanisms of recovery in children, the challenges of VR for children, and a summary of research on the efficacy for VR for children.

Bilateral Vestibular Weakness

Bilateral vestibular weakness (BVW) is a rare cause of imbalance. Patients with BVW complain of oscillopsia. In approximately half of the patients with BVW, the cause remains undetermined; in the remainder, the most common etiology by far is gentamicin ototoxicity, followed by much rarer entities such as autoimmune inner ear disease, meningitis, bilateral Ménière’s disease, bilateral vestibular neuritis, and bilateral vestibular schwannomas. While a number of bedside tests may raise the suspicion of BVW, the diagnosis should be confirmed by rotatory chair testing. Treatment of BVW is largely supportive. Medications with the unintended effect of vestibular suppression should be avoided.

Utility of quick oculomotor tests for screening the vestibular system in the subacute and chronic populations

OBJECTIVE

The goal of this study was to determine the sensitivity and specificity of some widely used, easily administered clinical tests.

BACKGROUND

Simple tests of oculomotor function have become widely used for clinical screening of patients suspected of having vestibular disorders despite a paucity of evidence showing good statistical support for their use in this highly variable population.

METHODS

Healthy controls with no history of otologic or neurologic disorders (n = 291) were compared to patients with known vestibular disorders (n = 62). All subjects performed passive and active head shaking, un-instrumented head impulse tests (HT), and video head impulse tests (vHIT) recorded with infrared video-oculography.

RESULTS

For both passive and active head shaking, using presence/absence of vertigo and of nystagmus, sensitivity was low (<0.40). Sensitivity of presence/absence of saccades on HT was even lower (<0.15). On vHIT, gains were all approximately = 1.0, so sensitivity was very low (approximately 0.15-0.35). Sensitivity and specificity for presence/absence of saccades were moderately poor (less than 0.70).

CONCLUSION

None of these tests are adequate for screening patients in the out-patient clinic for vestibular disorders or for screening people in epidemiologic studies to determine the prevalence of vestibular disorders.

Betahistine for symptoms of vertigo

BACKGROUND

Vertigo is a symptom in which individuals experience a false sensation of movement. This type of dizziness is thought to originate in the inner ear labyrinth or its neural connections. It is a commonly experienced symptom and can cause significant problems with carrying out normal activities. Betahistine is a drug that may work by improving blood flow to the inner ear. This review examines whether betahistine is more effective than a placebo at treating symptoms of vertigo from different causes.

OBJECTIVES

To assess the effects of betahistine in patients with symptoms of vertigo from different causes.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 8); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. We also contacted manufacturers and researchers in the field. The date of the search was 21 September 2015.

SELECTION CRITERIA

We included randomised controlled trials of betahistine versus placebo in patients of any age with vertigo from any neurotological diagnosis in any settings.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcome was the proportion of patients with reduction in vertigo symptoms (considering together the intensity, frequency and duration those symptoms).

MAIN RESULTS

We included 17 studies, with a total of 1025 participants; 12 studies were published (567 patients) and five were unpublished (458 patients). Sixteen studies including 953 people compared betahistine with placebo. All studies with analysable data lasted three months or less. The majority were at high risk of bias, but in some the risk of bias was unclear. One study, at high risk of bias, included 72 people with benign paroxysmal positional vertigo (BPPV) and compared betahistine with placebo; all patients also had particle repositioning manoeuvres. The studies varied considerably in terms of types of participants, their diagnoses, the dose of betahistine and the length of time it was taken for, the study methods and the way any improvement in vertigo symptoms was measured. Using the GRADE system, we judged the quality of evidence overall to be low for two outcomes (proportion of patients with improvement and proportion with adverse events).Pooled data showed that the proportion of patients reporting an overall reduction in their vertigo symptoms was higher in the group treated with betahistine than the placebo group: risk ratio (RR) 1.30, 95% confidence interval (CI) 1.05 to 1.60; 606 participants; 11 studies). This result should be interpreted with caution as the test for statistical heterogeneity as measured by the I(2) value was high.Adverse effects (mostly gastrointestinal symptoms and headache) were common but medically serious events in the study were rare and isolated: there was no difference in the frequency of adverse effects between the betahistine and placebo groups, where the rates were 16% and 15% respectively (weighted values, RR 1.03, 95% CI 0.76 to 1.40; 819 participants; 12 studies).Sixteen per cent of patients from both the betahistine and the placebo groups withdrew (dropped out) from the studies (RR 0.96, 95% CI 0.65 to 1.42; 481 participants; eight studies).Three studies looked at objective vestibular function tests as an outcome; the numbers of participants were small, techniques of measurement very diverse and reporting details sparse, so analysis of this outcome was inconclusive.We looked for information on generic quality of life and falls, but none of the studies reported on these outcomes.

AUTHORS' CONCLUSIONS

Low quality evidence suggests that in patients suffering from vertigo from different causes there may be a positive effect of betahistine in terms of reduction in vertigo symptoms. Betahistine is generally well tolerated with a low risk of adverse events. Future research into the management of vertigo symptoms needs to use more rigorous methodology and include outcomes that matter to patients and their families.

Prophylactic treatment of vestibular migraine

Introduction

Vestibular migraine (VM) is now accepted as a common cause of episodic vertigo. Treatment of VM involves two situations: the vestibular symptom attacks and the period between attacks. For the latter, some prophylaxis methods can be used. The current recommendation is to use the same prophylactic drugs used for migraines, including β-blockers, antidepressants and anticonvulsants. The recent diagnostic definition of vestibular migraine makes the number of studies on its treatment scarce.

Objective

To evaluate the efficacy of prophylactic treatment used in patients from a VM outpatient clinic.

Methods

Review of medical records from patients with VM according to the criteria of the Bárány Society/International Headache Society of 2012 criteria. The drugs used in the treatment and treatment response obtained through the visual analog scale (VAS) for dizziness and headache were assessed. The pre and post-treatment VAS scores were compared (the improvement was evaluated together and individually, per drug used). Associations with clinical subgroups of patients were also assessed.

Results

Of the 88 assessed records, 47 were eligible. We included patients that met the diagnostic criteria for VM and excluded those whose medical records were illegible and those of patients with other disorders causing dizziness and/or headache that did not meet the 2012 criteria for VM. 80.9% of the patients showed improvement with prophylaxis (p < 0.001). Amitriptyline, Flunarizine, Propranolol and Topiramate improved vestibular symptoms (p < 0.001) and headache (p < 0.015). The four drugs were effective in a statistically significant manner. There was a positive statistical association between the time of vestibular symptoms and clinical improvement. There was no additional benefit in hypertensive patients who used antihypertensive drugs as prophylaxis or depressed patients who used antidepressants in relation to other prophylactic drugs. Drug association did not show statistically significant results in relation to the use of a single drug.

Conclusions

Prophylactic medications used to treat VM improve the symptoms of this disease, but there is no statistically significant difference between the responses of prophylactic drugs. The time of vestibular symptom seems to increase the benefit with prophylactic treatment.

Meniere's disease

Meniere's disease (MD) is a disorder of the inner ear that causes vertigo attacks, fluctuating hearing loss, tinnitus and aural fullness. The aetiology of MD is multifactorial. A characteristic sign of MD is endolymphatic hydrops (EH), a disorder in which excessive endolymph accumulates in the inner ear and causes damage to the ganglion cells. In most patients, the clinical symptoms of MD present after considerable accumulation of endolymph has occurred. However, some patients develop symptoms in the early stages of EH. The reason for the variability in the symptomatology is unknown and the relationship between EH and the clinical symptoms of MD requires further study. The diagnosis of MD is based on clinical symptoms but can be complemented with functional inner ear tests, including audiometry, vestibular-evoked myogenic potential testing, caloric testing, electrocochleography or head impulse tests. MRI has been optimized to directly visualize EH in the cochlea, vestibule and semicircular canals, and its use is shifting from the research setting to the clinic. The management of MD is mainly aimed at the relief of acute attacks of vertigo and the prevention of recurrent attacks. Therapeutic options are based on empirical evidence and include the management of risk factors and a conservative approach as the first line of treatment. When medical treatment is unable to suppress vertigo attacks, intratympanic gentamicin therapy or endolymphatic sac decompression surgery is usually considered. This Primer covers the pathophysiology, symptomatology, diagnosis, management, quality of life and prevention of MD.

Aspects of cerebral plasticity related to clinical features in acute vestibular neuritis: a "starting point" review from neuroimaging studies

Vestibular neuritis (VN) is one of the most common causes of vertigo and is characterised by a sudden unilateral vestibular failure (UVF). Many neuroimaging studies in the last 10 years have focused on brain changes related to sudden vestibular deafferentation as in VN. However, most of these studies, also due to different possibilities across diverse centres, were based on different times of first acquisition from the onset of VN symptoms, neuroimaging techniques, statistical analysis and correlation with otoneurological and psychological findings. In the present review, the authors aim to merge together the similarities and discrepancies across various investigations that have employed neuroimaging techniques and group analysis with the purpose of better understanding about how the brain changes and what characteristic clinical features may relate to each other in the acute phase of VN. Six studies that strictly met inclusion criteria were analysed to assess cortical-subcortical correlates of acute clinical features related to VN. The present review clearly reveals that sudden UVF may induce a wide variety of cortical and subcortical responses - with changes in different sensory modules - as a result of acute plasticity in the central nervous system.

Efficacy and acceptability of oxcarbazepine vs. carbamazepine with betahistine mesilate tablets in treating vestibular paroxysmia: a retrospective review

OBJECTIVES

Vestibular paroxysmia (VP) is a rare episodic peripheral vestibular disorder that can cause acute short attacks of vertigo. This study aimed to compare the efficacy and acceptability of carbamazepine (CBZ), CBZ plus betahistine mesilate tablets (BMT) and oxcarbazepine (OXC) plus BMT in treating VP within 12 weeks.

METHODS

A retrospective analysis of data from 196 VP patients treated in our hospital was conducted. There were 73 patients receiving CBZ, 65 patients receiving CBZ+BMT and 58 patients receiving OXC+BMT. The frequency of vertigo, vertigo duration, vertigo score, response rate (RR) and side effects were compared between groups to assess efficacy and acceptability at the end of 12(th) week.

RESULTS

After 12 weeks' treatment, the CBZ+BMT group had a greater reduction in the frequency of vertigo, vertigo duration and vertigo score than the other two groups. The RR was highest in the CBZ+BMT group, second in the OXC+BMT group and lowest in the CBZ group. The incidence of side-effects was highest in the CBZ group, second in the CBZ+BMT group and lowest in the OXC+BMT group. Two patients in the CBZ group were withdrawn.

CONCLUSION

These results indicated that using BMT as an augmentation for CBZ or OXC might be a good choice in treating VP.

Sodium channel diversity in the vestibular ganglion: NaV1.5, NaV1.8, and tetrodotoxin-sensitive currents

Firing patterns differ between subpopulations of vestibular primary afferent neurons. The role of sodium (NaV) channels in this diversity has not been investigated because NaV currents in rodent vestibular ganglion neurons (VGNs) were reported to be homogeneous, with the voltage dependence and tetrodotoxin (TTX) sensitivity of most neuronal NaV channels. RT-PCR experiments, however, indicated expression of diverse NaV channel subunits in the vestibular ganglion, motivating a closer look. Whole cell recordings from acutely dissociated postnatal VGNs confirmed that nearly all neurons expressed NaV currents that are TTX-sensitive and have activation midpoints between -30 and -40 mV. In addition, however, many VGNs expressed one of two other NaV currents. Some VGNs had a small current with properties consistent with NaV1.5 channels: low TTX sensitivity, sensitivity to divalent cation block, and a relatively negative voltage range, and some VGNs showed NaV1.5-like immunoreactivity. Other VGNs had a current with the properties of NaV1.8 channels: high TTX resistance, slow time course, and a relatively depolarized voltage range. In two NaV1.8 reporter lines, subsets of VGNs were labeled. VGNs with NaV1.8-like TTX-resistant current also differed from other VGNs in the voltage dependence of their TTX-sensitive currents and in the voltage threshold for spiking and action potential shape. Regulated expression of NaV channels in primary afferent neurons is likely to selectively affect firing properties that contribute to the encoding of vestibular stimuli.

Vestibular migraine: comparative analysis between diagnostic criteria

INTRODUCTION

There is a strong association between vertigo and migraine. Vestibular migraine (VM) was described in 1999, and diagnostic criteria were proposed in 2001 and revised in 2012.

OBJECTIVE

To compare the diagnostic criteria for VM proposed in 2001 with 2012 criteria with respect to their diagnostic power and therapeutic effect of VM prophylaxis.

METHODS

Clinical chart review of patients attended to in a VM clinic.

RESULTS

The 2012 criteria made the diagnosis more specific, restricting the diagnosis of VM to a smaller number of patients, such that 87.7% of patients met 2001 criteria and 77.8% met 2012 criteria. Prophylaxis for VM was effective both for patients diagnosed by either set of criteria and for those who did not meet any of the criteria.

CONCLUSIONS

The 2012 diagnostic criteria for VM limited the diagnosis of the disease to a smaller number of patients, mainly because of the type, intensity, and duration of dizziness. Patients diagnosed with migraine and associated dizziness demonstrated improvement after prophylactic treatment of VM, even when they did not meet diagnostic criteria.