Diagnostic indices for vertiginous diseases

Prospective diagnostic accuracy study of history taking and physical examination for adults with vertigo in general practice: study protocol

INTRODUCTION

Vertigo is a prevalent and burdensome symptom. More than 80% of patients with vertigo are primarily treated by their general practitioner (GP) and are never referred to a medical specialist. Despite this therapeutic responsibility, the GP's diagnostic toolkit has serious limitations. All recommended tests lack empirical evidence, because a diagnostic accuracy study on vestibular disorders ('How well does test x discriminate between patients with or without target condition y?') has never been performed in general practice. The VERtigo DIagnosis study aims to fill this gap.

METHODS AND ANALYSIS

We will perform a diagnostic accuracy study on vertigo of primary vestibular origin in general practice to assess the discriminative ability of history taking and physical examination. We will compare all index tests with a respective reference standard. We will focus on five target conditions that account for more than 95% of vertigo diagnoses in general practice: (1) benign paroxysmal positional vertigo, (2) vestibular neuritis, (3) Ménière's disease, (4) vestibular migraine (VM) and (5) central causes other than VM. As these five target conditions have a different pathophysiology and lack one generally accepted gold standard, we will use consensus diagnosis as a construct reference standard. Data for each patient, including history, physical examination and additional tests as recommended by experts in an international Delphi procedure, will be recorded on a standardised form and independently reviewed by a neurologist and otorhinolaryngologist. For each patient, the reviewers have to decide about the presence/absence of each target condition. We will calculate sensitivity, specificity, predictive values, likelihood ratios and diagnostic ORs, followed by decision rules for each target condition.

ETHICS AND DISSEMINATION

The study obtained approval from the Vrije Universiteit Medical Center Medical Ethical Review Committee (reference: 2022.0817-NL83111.029.22). We will publish our findings in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

ISRCTN97250704.

A Questionnaire-Based Ensemble Learning Model to Predict the Diagnosis of Vertigo: Model Development and Validation Study

Background

Questionnaires have been used in the past 2 decades to predict the diagnosis of vertigo and assist clinical decision-making. A questionnaire-based machine learning model is expected to improve the efficiency of diagnosis of vestibular disorders.

Objective

This study aims to develop and validate a questionnaire-based machine learning model that predicts the diagnosis of vertigo.

Methods

In this multicenter prospective study, patients presenting with vertigo entered a consecutive cohort at their first visit to the ENT and vertigo clinics of 7 tertiary referral centers from August 2019 to March 2021, with a follow-up period of 2 months. All participants completed a diagnostic questionnaire after eligibility screening. Patients who received only 1 final diagnosis by their treating specialists for their primary complaint were included in model development and validation. The data of patients enrolled before February 1, 2021 were used for modeling and cross-validation, while patients enrolled afterward entered external validation.

Results

A total of 1693 patients were enrolled, with a response rate of 96.2% (1693/1760). The median age was 51 (IQR 38-61) years, with 991 (58.5%) females; 1041 (61.5%) patients received the final diagnosis during the study period. Among them, 928 (54.8%) patients were included in model development and validation, and 113 (6.7%) patients who enrolled later were used as a test set for external validation. They were classified into 5 diagnostic categories. We compared 9 candidate machine learning methods, and the recalibrated model of light gradient boosting machine achieved the best performance, with an area under the curve of 0.937 (95% CI 0.917-0.962) in cross-validation and 0.954 (95% CI 0.944-0.967) in external validation.

Conclusions

The questionnaire-based light gradient boosting machine was able to predict common vestibular disorders and assist decision-making in ENT and vertigo clinics. Further studies with a larger sample size and the participation of neurologists will help assess the generalization and robustness of this machine learning method.

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

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

A Systematic Review of Clinical Vestibular Symptom Triage, Tools, and Algorithms

OBJECTIVE

The evaluation of peripheral vestibular disorders in clinical practice is an especially difficult endeavor, particularly for the inexperienced clinician. The goal of this systematic review is thus to evaluate the design, approaches, and outcomes for clinical vestibular symptom triage and decision support tools reported in contemporary published literature.

DATA SOURCES

A comprehensive search of existing literature in August 2020 was conducted using MEDLINE, CINAHL, and EMBASE using terms of desired diagnostic tools such as algorithm, protocol, and questionnaire as well as an exhaustive set of terms to encompass vestibular disorders.

REVIEW METHODS

Study characteristics, tool metrics, and performance were extracted using a standardized form. Quality assessment was conducted using a modified version of the Quality of Diagnostic Accuracy Studies 2 (QUADAS-2) assessment tool.

RESULTS

A total of 18 articles each reporting a novel tool for the evaluation of vestibular disorders were identified. Tools were organized into 3 discrete categories, including self-administered questionnaires, health care professional administered tools, and decision support systems. Most tools could differentiate between specific vestibular pathologies, with outcome measures including sensitivity, specificity, and accuracy.

CONCLUSION

A multitude of tools have been published to aid with the evaluation of vertiginous patients. Our systematic review identified several low-evidence reports of triage and decision support tools for the evaluation of vestibular disorders.

Development and validation of the dizziness symptoms questionnaire in Thai-outpatients

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History taking plays an essential part in evaluating patients with dizziness.

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The algorithm of the SAQ-1 had been developed based on timing-trigger approach.

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The SAQ-1 might be used to triage the cause of dizziness of outpatients.

Introduction

“Dizziness” is a common complaint in clinical practice that can occur with anyone. However, since the symptom is caused by a wide range of disorders, a general clinician usually faces some difficulty to detect the cause.

Objective

This study aimed to formulate and validate a simple instrument that can be used to screen and predict the most likely cause of dizziness in Thai outpatients.

Methods

This study was divided into two phases. Phase I included 41 patients diagnosed with common causes of dizziness to determine the algorithm and construct the “structural algorithm questionnaire version 1”. In addition, to test and retest its content validity and reliability until the instrument had an acceptable level of both. Phase II of the study pertained to evaluating its accuracy in clinical trials, 150 patients with dizziness had a face-to-face interview while they were waiting for their medical appointment.

Results

The degree of agreement between the algorithm results and clinical diagnoses was within an acceptable level (κ = 0.69). Therefore, this algorithm was used to construct the structural algorithm questionnaire version 1. The content validity of the structural algorithm questionnaire version 1 evaluated by seven experts. The content validity index values of the questionnaire ranged from 0.71 to 1.0. The Cohen’s kappa coefficient (κ) of intra-rater reliability of the structural algorithm questionnaire version 1 was 0.71. In clinical trials, 150 patients with dizziness had a face-to-face interview while they were waiting for their appointment. The overall agreement between their questionnaire responses and final diagnoses by specialists showed a moderate degree of clinical accuracy (κ = 0.55).

Conclusions

The structural algorithm questionnaire version 1 had a well-developed design and acceptable quality pertaining to both validity and reliability. It might be used to differentiate the cause of dizziness between vestibular and non-vestibular disorders, especially of outpatients with dizziness symptoms.

Vestibular migraine with Wallenberg syndrome: a case report

BACKGROUND

Vestibular migraine, a kind of acute vestibular syndrome, leads to both migraines and vertigo symptoms in a single patient. The occurrence of vestibular migraine has shown an obvious increase in female groups based on age. Though it is recognized that migraines may cause ischemic lesions in some brain regions, the relationship between vestibular migraine and cerebral infarction has seldom been reported, especially with no known research reports about vestibular migraine with Wallenberg syndrome. Based on this, the connection of the two diseases needs to be the focus of more research.

CASE PRESENTATION

The patient, a 35-year-old lady, came to our department with severe vertigo and headaches for approximately two years. She suffered from migraines which attacked about twice yearly for nearly a decade. The diffusive weighted imaging showed a subacute infarction in the right lateral medullar. The clinical characteristics and MRI findings supported the diagnosis of vestibular migraine with Wallenberg syndrome. Along with the normal routine medication for vestibular migraine with Wallenberg syndrome, we also prescribed migraine therapy at the same time. In a 3-month follow-up, the patient had suffered only one vertigo attack and she reported that the migraines were less common and less intense than she was previously experiencing.

CONCLUSIONS

Due to the fact that vestibular migraine is one of the risk factors of cerebral ischemia, we need to pay more attention to this phenomenon. The current case suggests that both routine medication on ischemic stroke as well as treatment for migraines should be used concurrently in vestibular migraine with Wallenberg syndrome.

Vestibular Nerve Atrophy After Vestibular Neuritis - Results from a Prospective High-Resolution MRI Study

PURPOSE

 Sudden unilateral peripheral vestibular deficit is mostly termed vestibular neuritis (VN), even if its cause or the exact location of the lesion remains unclear. Thus, therapy is mostly symptomatic. We aimed to prove if there is peripheral atrophy after VN with persistent canal paresis.

METHODS

 After approval by the ethics committee and according to the declaration of Helsinki and with informed consent, ten patients with persistent canal paresis after VN and ten age-matched healthy controls were included. High-resolution measurement (in-plane resolution 0.2 mm) of the internal auditory canal (IAC) using a 3 D CISS sequence at 3 Tesla was performed. The course of the pertaining nerves was reconstructed in the 3 D dataset and the measurement was performed at 60 % of the length of the IAC. The cross-sectional areas of the superior (SVN) and inferior vestibular nerve (IVN) were taken independently by two blinded readers.

RESULTS

 The interrater difference regarding the area was 22 %. We found significant atrophy of the SVN with a 24 % smaller area (p = 0.026) and found a smaller ratio of SVN/IVN on the symptomatic side (p = 0.017). Concerning single subject data, only 5 patients showed extensive atrophy of the NVS, while 5 patients did not. The time since symptom onset did not significantly influence the atrophy.

CONCLUSION

 MRI measuring of the area of the NVS after VN could detect atrophy after VN. However, only 5 patients exhibited marked atrophy, while the other 5 patients did not. With the background of stringent inclusion criteria (more than 6 months of symptom duration and proven persistent canal paresis), one has to wonder if there might be different etiologies behind the apparently identical symptoms.

KEY POINTS

  · MRI measuring of the area of the NVS after VN could detect atrophy after VN. · Only half of the 10 researched patients showed atrophy, while the other patients did not. · There are different etiologies to be suspected for VN.

CITATION FORMAT

· Freund W, Weber F, Schneider D et al. Vestibular Nerve Atrophy After Vestibular Neuritis - Results from a Prospective High-Resolution MRI Study. Fortschr Röntgenstr 2020; 192: 854 - 861.

Neurotology symptoms at referral to vestibular evaluation

Background

Dizziness-vertigo is common in adults, but clinical providers may rarely diagnose vestibular impairment and referral could be delayed. To assess neurotology symptoms (including triggers) reported by patients with peripheral vestibular disease, during the year just before their referral to vestibular evaluation.

Methods

282 patients with peripheral vestibular disease and 282 control subjects accepted to participate. They had no middle ear, retinal, neurological, psychiatric, autoimmune or autonomic disorders. They reported their symptoms by a standardized questionnaire along with their anxiety/depression symptoms.

Results

Patients were referred after months or years from the onset of their symptoms, 24% of them reported frequent falls with a long clinical evolution; 10% of them reported no vertigo but instability related to specific triggers; 86% patients and 12% control subjects reported instability when moving the head rapidly and 79% patients and 6% control subjects reported instability when changing posture. Seven out of the 9 symptoms explored by the questionnaire allowed the correct classification of circa 95% of the participants (Discriminant function analysis, p < 0.001). High blood pressure, dyslipidemia and anxiety/depression symptoms showed a mild correlation with the total score of symptoms (multiple R² =0.18, p < 0.001).

Conclusions

Late referral to vestibular evaluation may underlie a history of frequent falls; some patients may not report vertigo, but instability related to specific triggers, which could be useful to prompt vestibular evaluation. High blood pressure, dyslipidemia and anxiety/depression symptoms may have a mild influence on the report of symptoms of vestibular disease in both, patients and control subjects.

Diagnosis of the subtype and affected ear of benign paroxysmal positional vertigo using a questionnaire

CONCLUSION

The prediction of subtype and the affected ear of benign paroxysmal positional vertigo (BPPV) derived from the answers to our questionnaire can support the definitive diagnosis of BPPV.

OBJECTIVES

We examined to what extent the diagnosis of subtype and the affected ear of BPPV judged from answers to a questionnaire agreed with the diagnosis decided by the results of the positional nystagmus test.

METHODS

We asked the following questions: 'What kind of head movements induce vertigo?' and 'How long does the vertigo continue?'. As for the affected ear, we asked which ear was lower during stronger vertigo when induced in a supine position or during sleep.

RESULTS

The percentages of correct diagnosis speculated by the combined answers were 69% in posterior canal-type BPPV, 48% in BPPV with geotropic nystagmus, and 39% in BPPV with apogeotropic nystagmus. The percentage of correct diagnoses of the affected ear was more than 80%.