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Van Laer L, Nogi A, Serrador J, Schubert MC. Effect of viewing distance on dynamic visual acuity. J Vestib Res 2025:9574271251327957. [PMID: 40103311 DOI: 10.1177/09574271251327957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2025]
Abstract
BackgroundPatients with dizziness and unsteadiness are commonly prescribed gaze stability exercises at varying target distances to manage vestibular impairments but lack objective tools to monitor progress. Maintaining gaze stability during head motion at near distances demands greater eye velocity relative to head velocity due to vergence and increased translational eye rotation demands.ObjectivesThis study compared dynamic visual acuity (DVA) during yaw and pitch at both near and far distances in patients and healthy controls.MethodsThis study includes individuals with unilateral vestibular deafferentation (UVD), veterans with dizziness yet healthy vestibular function, and healthy controls. The computerized DVA at near (50 cm) and far (200 cm) distances were collected. Data analysis included comparisons of near and far DVA in yaw and pitch planes.ResultsA total of 94 participants (34 UVD, 24 veterans with dizziness, 36 controls) were included. Near-distance DVA was significantly worse than far-distance DVA for the entire sample and within each group (p < 0.001).ConclusionsNear-distance DVA is more challenging than far-distance DVA across populations and planes of head rotation. Near-distance DVA may serve as a robust measure of vestibulo-ocular reflex function and offers a practical means for patients to self-monitor the effects of gaze stability training.
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Affiliation(s)
- Lien Van Laer
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allison Nogi
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jorge Serrador
- MARCS Institute for Brain, Behaviour and Development, Western Sydney University, Sydney, NSW, Australia
| | - Michael C Schubert
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kirazli G, Balayeva F, Kacan Yilmaz M, Kaya I, Kirazli T, Gokcay F, Celebisoy N. vHIT and fHIT in Patients With Migraine, Vestibular Migraine, and Persistent Postural-Perceptual Dizziness. Laryngoscope 2025; 135:857-863. [PMID: 39268858 PMCID: PMC11725681 DOI: 10.1002/lary.31758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 08/06/2024] [Accepted: 08/23/2024] [Indexed: 09/15/2024]
Abstract
OBJECTIVE Impairment in the integration of different vestibular stimuli is the proposed mechanisms in vestibular migraine (VM). In this study, it was aimed to assess the vestibulo-ocular reflex (VOR) and dynamic visual acuity (DVA) in patients with VM and to compare the results with migraine without vestibular symptoms (MwoV), and persistent postural-perceptual dizziness (PPPD) to find out if there are discriminative differences and search for a correlation with the levels of anxiety. METHODS Twenty-two patients with MwoV, 23 patients with VM, 22 patients with PPPD, and 23 healthy controls (HC) were studied. Video head impulse test (vHIT) and functional head impulse test (fHIT) without and with an optokinetic background (OB) were performed. Percentage of correctly identified optotypes (CA%) was considered for the fHIT test. Beck anxiety inventory (BAI) was used to assess anxiety. RESULTS Lateral canal vHIT gain of the patient groups were not different from the healthy controls (p > 0.05). fHIT and fHIT/OB CA% results of all patient groups were lower than the HC (p < 0.005), and VM patients had the lowest scores for both tests. BAI scores of the PPPD patients were the highest and a correlation between anxiety levels, and fHIT results could not be identified (p > 0.05). CONCLUSION Prominent CA% drop by the use of an OB was the main finding in patients with VM. This discriminative feature was not correlated with anxiety scores. Difficulty in resolving the conflict between visual and vestibular inputs seem to be the underlying mechanism. LEVEL OF EVIDENCE 3 Laryngoscope, 135:857-863, 2025.
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Affiliation(s)
- Gulce Kirazli
- Department of AudiologyEge University Faculty of Health SciencesIzmirTurkey
| | - Fidan Balayeva
- Department of NeurologyEge University Medical SchoolIzmirTurkey
| | - Melis Kacan Yilmaz
- Department of Clinical NeuroscienceEge University Institute of Health SciencesIzmirTurkey
| | - Isa Kaya
- Department of Otorhinolaryngology Head & Neck SurgeryEge University Medical SchoolIzmirTurkey
| | - Tayfun Kirazli
- Department of Otorhinolaryngology Head & Neck SurgeryEge University Medical SchoolIzmirTurkey
| | - Figen Gokcay
- Department of NeurologyEge University Medical SchoolIzmirTurkey
| | - Nese Celebisoy
- Department of NeurologyEge University Medical SchoolIzmirTurkey
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Van Laer L, Hallemans A, De Somer C, Janssens de Varebeke S, Fransen E, Schubert M, Van Rompaey V, Vereeck L. Predictors of Chronic Dizziness in Acute Unilateral Vestibulopathy: A Longitudinal Prospective Cohort Study. Otolaryngol Head Neck Surg 2025; 172:262-272. [PMID: 39224036 DOI: 10.1002/ohn.964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/25/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE Chronic dizziness after acute unilateral vestibulopathy (AUVP) causes significant social and economic burdens. This study aims to identify predictors of chronic dizziness. STUDY DESIGN Prospective, longitudinal cohort study. SETTING ENT departments from secondary and tertiary hospitals. METHODS Participants meeting the Barany Society's diagnostic criteria for AUVP were included. Evaluations occurred within 0 to 21 days (T1), and at 4 (T2) and 10 weeks (T3) postonset. The primary outcome measure was the Dizziness Handicap Inventory (DHI) at 6 months, with a score >30 indicating chronic dizziness. Five clusters of predictors were assessed at T1-3: central vestibular compensation, visual dependence, movement exposure, psychological factors, and balance performance. Separate linear regression models for T1, T2, and T3 were constructed to explain the variability in the 6-month DHI score. Receiver operating characteristics analyses were conducted to predict chronic dizziness. RESULTS From June 2021 to January 2024, 103 participants (55.2 ± 16.6 years old, 49 women) were included. The regression models explained the variability in the 6-month DHI score by 33.0% at T1, 47.6% at T2, and 64.0% at T3 (P < .001), including psychological factors (T1, T2, T3), visual dependence (T2, T3), and static balance performance (T3). Cutoff values for the Vestibular Activities Avoidance Instrument (23/54), Visual Vertigo Analog Scale (33.5/100), and Hospital Anxiety and Depression Scale-Anxiety (7.5/21) at 10 weeks postonset predicted chronic dizziness. CONCLUSION Higher psychological burden, increased visual dependence, and poorer static balance performance were associated with chronic dizziness. Cutoff values were determined to identify individuals with AUVP at risk for chronic dizziness.
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Affiliation(s)
- Lien Van Laer
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Science, Multidisciplinary Motor Centre Antwerp (M²OCEAN), University of Antwerp, Antwerp, Belgium
| | - Ann Hallemans
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Science, Multidisciplinary Motor Centre Antwerp (M²OCEAN), University of Antwerp, Antwerp, Belgium
| | - Clara De Somer
- Vzw Sint-Lievenspoort, Centrum voor Ambulante Revalidatie, Ghent, Belgium
| | | | - Erik Fransen
- Center of Medical Genetics, Faculty of Medicine and Health Science, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Michael Schubert
- Department of Otolaryngology-Head and Neck Surgery, Laboratory of Vestibular NeuroAdaptation, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vincent Van Rompaey
- Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Luc Vereeck
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Science, Multidisciplinary Motor Centre Antwerp (M²OCEAN), University of Antwerp, Antwerp, Belgium
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Yang Y, Zhao T, Mi F, Li H, Huang P, Chen F. Photodynamic therapy-induced precise attenuation of light-targeted semicircular canals for treating intractable vertigo. SMART MEDICINE 2024; 3:e20230044. [PMID: 39776590 PMCID: PMC11669792 DOI: 10.1002/smmd.20230044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 07/09/2024] [Indexed: 01/11/2025]
Abstract
Vertigo is a common symptom of various diseases that affects a large number of people worldwide. Current leading treatments for intractable peripheral vertigo are to intratympanically inject ototoxic drugs such as gentamicin to attenuate the semicircular canal function but inevitably cause hearing injury. Photodynamic therapy (PDT) is a noninvasive therapeutic approach by precisely targeting the diseased tissue. Here, we developed a PDT-based method for treating intractable peripheral vertigo in a mouse model using a polymer-coated photosensitizer chlorin e6 excited by red light. We found that a high dose of PDT attenuated the function of both semicircular canals and otolith organs and damaged their hair cells. Conversely, the PDT exerted no effect on hearing function or cochlear hair-cell viability. These results suggest the therapeutic potential of PDT for treating intractable peripheral vertigo without hurting hearing. Besides, the attenuation level and affected area can be precisely controlled by adjusting the light exposure time. Furthermore, we demonstrated the potential of this therapeutic approach to be minimally invasive with light irradiation through bone results. Thus, our PDT-based approach for attenuating the function of the semicircular canals offers a basis for developing a less-invasive and targeted therapeutic option for treating vertigo.
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Affiliation(s)
- Yingkun Yang
- Department of Biomedical EngineeringSouthern University of Science and TechnologyShenzhenGuangdongChina
- Division of Life ScienceHong Kong University of Science and TechnologyHong KongChina
- Department of Otolaryngology‐Head and Neck SurgeryStanford UniversityStanfordCaliforniaUSA
| | - Tong Zhao
- Department of Biomedical EngineeringSouthern University of Science and TechnologyShenzhenGuangdongChina
| | - Feixue Mi
- Department of Biomedical EngineeringSouthern University of Science and TechnologyShenzhenGuangdongChina
| | - Hongzhe Li
- Research ServiceVA Loma Linda Healthcare SystemLoma LindaCaliforniaUSA
- Department of Otolaryngology‐Head and Neck SurgeryLoma Linda University HealthLoma LindaCaliforniaUSA
| | - Pingbo Huang
- Division of Life ScienceHong Kong University of Science and TechnologyHong KongChina
- State Key Laboratory of Molecular NeuroscienceHong Kong University of Science and TechnologyHong KongChina
- Hong Kong Branch of Guangdong Southern Marine Science and Engineering Laboratory (Guangzhou)Hong Kong University of Science and TechnologyHong KongChina
| | - Fangyi Chen
- Department of Biomedical EngineeringSouthern University of Science and TechnologyShenzhenGuangdongChina
- Guangdong Provincial Key Laboratory of Advanced BiomaterialsSouthern University of Science and TechnologyShenzhenChina
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Jáuregui-Renaud K, Cabrera-Pereyra R, Miguel-Puga JA, Alcántara-Thome M. Graviception Uncertainty, Spatial Anxiety, and Derealization in Patients with Persistent Postural-Perceptual Dizziness. J Clin Med 2024; 13:6665. [PMID: 39597808 PMCID: PMC11594595 DOI: 10.3390/jcm13226665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Revised: 10/30/2024] [Accepted: 10/31/2024] [Indexed: 11/29/2024] Open
Abstract
Objectives: Persistent Postural-Perceptual Dizziness (PPPD) is a frequent diagnosis in patients with chronic dizziness, ineffective postural control, visual dependence, and emotional symptoms. Methods: 53 patients with PPPD (25-84 years old) and 53 adults (29-84 years old) with no vestibular disease agreed to participate in this study. Assessments included: vestibular function tests (sinusoidal yaw rotation and vestibular-evoked myogenic potentials); accuracy and precision of Subjective Visual Vertical (SVV) estimation while static and during on-axis yaw rotation; static posturography with open/closed eyes and 30° neck extension, while standing on hard/soft surface; questionnaires on symptoms of unsteadiness, spatial anxiety, dizziness-related handicap, anxiety/depression, depersonalization/derealization, and perceived stress. After preliminary bivariate analyses, analysis of covariance was performed on the measurements of postural sway, spatial anxiety, and dizziness-related handicap (p < 0.05). Results: Higher intraindividual variability (reduced precision) on SVV estimations was evident in patients with PPPD compared to adults with no vestibular disease, which was related to the length of postural sway, to velocity displacement in the sagittal plane, as well as to spatial anxiety and common mental symptoms (including depersonalization/derealization symptoms). Covariance analysis showed contribution of these factors to the dizziness-related handicap reported by the patients. Conclusions: Unprecise graviception could be a contributing factor to the postural instability and mental symptoms reported by patients with PPPD, which in turn contribute to their dizziness-related handicap.
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Affiliation(s)
- Kathrine Jáuregui-Renaud
- Unidad de Investigación Médica en Otoneurología, Instituto Mexicano del Seguro Social, Ciudad de México 06720, Mexico; (R.C.-P.); (J.A.M.-P.)
| | - Rodrigo Cabrera-Pereyra
- Unidad de Investigación Médica en Otoneurología, Instituto Mexicano del Seguro Social, Ciudad de México 06720, Mexico; (R.C.-P.); (J.A.M.-P.)
- Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México 06720, Mexico;
| | - José Adán Miguel-Puga
- Unidad de Investigación Médica en Otoneurología, Instituto Mexicano del Seguro Social, Ciudad de México 06720, Mexico; (R.C.-P.); (J.A.M.-P.)
| | - Mónica Alcántara-Thome
- Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México 06720, Mexico;
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Karabulut M, Viechtbauer W, Van Laer L, Mohamad A, Van Rompaey V, Guinand N, Perez Fornos A, Gerards MC, van de Berg R. Chronic Unilateral Vestibular Hypofunction: Insights into Etiologies, Clinical Subtypes, Diagnostics and Quality of Life. J Clin Med 2024; 13:5381. [PMID: 39336868 PMCID: PMC11432443 DOI: 10.3390/jcm13185381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 09/06/2024] [Accepted: 09/09/2024] [Indexed: 09/30/2024] Open
Abstract
Background/Objectives: Chronic unilateral vestibular hypofunction (UVH) can lead to disabling vestibular symptoms and a decrease in quality of life. The aim of this study was to investigate etiologies, clinical subtypes, symptoms, and quality of life (QoL) in patients with chronic UVH. Methods: A retrospective study was performed on 251 UVH patients in a tertiary referral center. Inclusion criteria comprised reduced or absent caloric responses, with a caloric asymmetry ratio ≥25%. Patients with central vestibular pathology, symptom duration <3 months, and incomplete responses to questionnaires were excluded. Patient records were assessed for etiologies, secondary vestibular diagnoses, clinical subtypes, and questionnaires related to QoL. Additionally, multiple linear regression analysis was performed to evaluate factors influencing QoL. Results: Thirteen different etiologies were identified, with Menière's Disease as the most prevalent (31%, n = 79). The most frequently reported secondary vestibular diagnoses were benign paroxysmal positional vertigo (BPPV) (21%, n = 54) and persistent postural perceptual dizziness (PPPD) (19%, n = 47). Five distinct clinical subtypes were identified: recurrent vertigo with UVH (47%), rapidly progressive UVH (25%), idiopathic/unknown UVH (18%), slowly progressive UVH (8%), and congenital UVH (2%). Over 80% of UVH patients experienced moderate-to-severe handicap, as indicated by the Dizziness Handicap Inventory. Approximately 20-25% of UVH patients exhibited moderate-to-severe depression and anxiety, based on the Hospital Anxiety and Depression Scale. Multiple linear regression analyses demonstrated that the presence of PPPD significantly reduced QoL in chronic UVH patients. Conclusions: Chronic UVH is a heterogeneous disorder. Secondary vestibular diagnoses like BPPV and PPPD often co-exist and can significantly impact QoL. A structured diagnostic approach and tailored interventions are crucial to address the diverse needs of UVH patients.
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Affiliation(s)
- Mustafa Karabulut
- Division of Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, 6229HX Maastricht, The Netherlands
| | - Wolfgang Viechtbauer
- Department of Psychiatry and Neuropsychology, Maastricht University, 6229HX Maastricht, The Netherlands
| | - Lien Van Laer
- Department of Rehabilitation Sciences and Physiotherapy/Movant, Faculty of Medicine and Health Science, University of Antwerp, 2000 Antwerp, Belgium
- Multidisciplinary Motor Centre Antwerp (M2OCEAN), University of Antwerp, 2000 Antwerp, Belgium
| | - Alfarghal Mohamad
- Department of Ear Nose Throat, King Abdul Aziz Medical City, Jeddah 22384, Saudi Arabia
| | - Vincent Van Rompaey
- Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, Faculty of Medicine and Health Sciences, University of Antwerp, 2000 Antwerp, Belgium
| | - Nils Guinand
- Service of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Angélica Perez Fornos
- Service of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Marie-Cecile Gerards
- Division of Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, 6229HX Maastricht, The Netherlands
| | - Raymond van de Berg
- Division of Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, 6229HX Maastricht, The Netherlands
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Meletaki V, Gobinet M, Léonard J, Elzière M, Lopez C. French adaptation and validation of the Niigata PPPD Questionnaire: measure of severity of Persistent Postural-Perceptual Dizziness and its association with psychiatric comorbidities and perceived handicap. Front Neurol 2024; 15:1388805. [PMID: 39139768 PMCID: PMC11319117 DOI: 10.3389/fneur.2024.1388805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024] Open
Abstract
Persistent Postural-Perceptual Dizziness (PPPD) is a functional vestibular condition. Despite being the most common chronic neuro-otologic disorder, it remains undertreated. The Niigata PPPD Questionnaire (NPQ), developed by Yagi et al. in 2019 to assess the severity of PPPD, could be a useful tool to help in the screening and diagnosis of this condition. This study aimed to validate a French version of the NPQ and make it an available assessment tool. Moreover, we aimed to understand the characteristics of PPPD patients better. The NPQ was translated and adapted into French. 50 PPPD patients, 50 patients with vestibular disorders without PPPD, and 50 healthy controls were included. They answered the adapted NPQ and additional questionnaires assessing trait (STAI) and state anxiety (HADS-A), depression (HADS-D) and handicap related to dizziness (DHI). The NPQ's reliability was assessed by Cronbach's alpha. Intergroup comparisons and multiple linear regressions were conducted to examine the characteristics of PPPD patients compared to vestibular patients and healthy controls, to validate NPQ's reliability, and to explore the effect of clinical parameters and treatment with selective serotonin reuptake inhibitors. Receiver operating characteristic (ROC) curves were carried out to determine the diagnostic values of the NPQ total score and sub-scores. Relations between NPQ and reported handicap, depression and anxiety were evaluated by correlations between questionnaire scores. The internal consistency was high (>0.8) for all NPQ subscales and the total score. Intergroup comparisons showed a significantly higher NPQ total score and sub-scores in the PPPD group compared to the two others. The ROC curve analysis showed a significant, but poor, discrimination of NPQ (AUC = 0.664) and its subscales. DHI scores, depressive symptoms and trait anxiety were significantly higher in PPPD patients than in vestibular patients and healthy controls. State anxiety did not differ between patients with PPPD and vestibular patients without PPPD. Finally, there was a significant correlation between the NPQ and the DHI. Our study provides a better understanding of PPPD symptomatology and its assessment. It showed that the NPQ is a reliable tool that can assist in symptom assessment for a French-speaking population.
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Affiliation(s)
- Vasiliki Meletaki
- Aix Marseille Univ, CNRS, Centre de Recherche en Psychologie et Neurosciences (CRPN), Marseille, France
| | - Maélis Gobinet
- Aix Marseille Univ, CNRS, Centre de Recherche en Psychologie et Neurosciences (CRPN), Marseille, France
| | - Jacques Léonard
- Aix Marseille Univ, CNRS, Centre de Recherche en Psychologie et Neurosciences (CRPN), Marseille, France
| | - Maya Elzière
- Aix Marseille Univ, CNRS, Centre de Recherche en Psychologie et Neurosciences (CRPN), Marseille, France
- Centre des Vertiges, European Hospital, Marseille, France
| | - Christophe Lopez
- Aix Marseille Univ, CNRS, Centre de Recherche en Psychologie et Neurosciences (CRPN), Marseille, France
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Lennox-Bowley A, Dasgupta S. Modernising vestibular assessment. J Laryngol Otol 2024; 138:S3-S7. [PMID: 38247298 DOI: 10.1017/s0022215123002128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
BACKGROUND There is a high prevalence of dizziness, vertigo and balance symptoms in the general population. Symptoms can be generated by many inner-ear vestibular disorders and there are several diagnostic tests available that can help identify the site of the vestibular lesion. There is little consensus on what diagnostic tests are appropriate, with diagnostics either not completed or minimally performed, leading to missed diagnosis, unsatisfactory results for patients and costs to healthcare systems. METHODS This study explored the literature for different neuro-vestibular diagnostic tests not currently considered in the traditional standard vestibular test battery, and examined how they fit effectively into a patient care pathway to help quickly and succinctly identify vestibular function. RESULTS A vestibular patient care pathway is presented for acute and subacute presentation of vestibular disorders. CONCLUSION An accurate diagnosis following a rigorous anamnesis and vestibular testing is paramount for successful management and favourable outcomes.
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Affiliation(s)
- Amy Lennox-Bowley
- Audio-Vestibular Clinic, Hypatia Dizziness and Balance Clinic, Liverpool, UK
| | - Soumit Dasgupta
- Audio-Vestibular Medicine, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Fukushima A, Kabaya K, Minakata T, Katsumi S, Esaki S, Iwasaki S. Age-related differences in the characteristics of persistent postural-perceptual dizziness. Front Neurol 2024; 15:1378206. [PMID: 38708003 PMCID: PMC11066216 DOI: 10.3389/fneur.2024.1378206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Objective To investigate differences in the clinical characteristics of patients with persistent postural-perceptual dizziness (PPPD) according to age. Methods We retrospectively reviewed 143 patients diagnosed with PPPD. Patients were classified into three groups by age: young group (19 to 44 years, n = 60), middle-age group (45 to 64 years, n = 56), old group (65 to 85 years, n = 27). Demographic data, scores of the Dizziness Handicap Inventory (DHI), the Niigata PPPD Questionnaire (NPQ), the Hospital Anxiety and Depression Scale (HADS), precipitating conditions, and the results of vestibular function tests including caloric testing, video head impulse test (vHIT), cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs), and posturography, were compared among the three groups. Results While there were no significant differences in the scores of the DHI or NPQ, the total score and anxiety score in HADS in the young group were significantly higher than in the old group (p < 0.05, each). On the other hand, for precipitating conditions, the rate of peripheral vestibular diseases was significantly greater in the old group (77.8%) compared to the young group (41.7%, p < 0.01). There was no significant difference in the results of caloric testing, vHIT, cVEMPs, or oVEMPs among the three groups. For posturography, the velocity of the center of pressure with eyes-open as well as with eyes-closed was significantly greater in the old group compared to the young group and the middle-age group (p < 0.005, respectively). Conclusion The clinical characteristics of PPPD were different according to age. Young patients tended to have stronger anxiety than old patients whereas the old patients had a higher proportion of peripheral vestibular diseases among the precipitating conditions compared to young patients.
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Affiliation(s)
| | - Kayoko Kabaya
- Department of Otolaryngology, Head and Neck Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Murofushi T, Goto F, Ushio M. Habituation disorders in auditory middle latency response of persistent postural-perceptual dizziness patients. Front Neurol 2024; 15:1366420. [PMID: 38510380 PMCID: PMC10951051 DOI: 10.3389/fneur.2024.1366420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/22/2024] [Indexed: 03/22/2024] Open
Abstract
Objectives To study habituation disorders in auditory middle latency response (AMLR) to repetitive stimuli of persistent postural-perceptual dizziness (PPPD) patients. Subjects Twenty-eight PPPD (10 men and 18 women, mean 59.5 years of age, 26-81 years of age) were enrolled. For comparison, data of 13 definite vestibular migraine (VM) patients (3 men, 10 women, mean age 45.5), 13 definite unilateral Meniere's disease (MD) patients (2 men, 11 women, mean age 50.6), and 8 healthy control (HC) subjects (2 men, 6 women, mean age 37.1) in the previous study were utilized. Methods The electrodes were placed on the vertex and the spinal process of the fifth cervical vertebra. Clicks (0.1 msec, 70 dB nHL) were binaurally presented and averaged (800 times). Averaged responses were divided into 4 sets (S1 to S4) according to the temporal order. As peaks, Na, and Pa were identified, and relative Na-Pa amplitudes in S2-S4 to S1 were analyzed. Results The mean relative amplitude of PPPD patients showed lack of habituation (potentiation) as shown in VM patients, although the extent of potentiation was weaker than VM. Comparison of relative S4 amplitudes showed significant differences among the 4 groups (p = 0.0013 one-way ANOVA), Multiple comparison revealed significant differences between PPPD and MD (p = 0.0337 Dunnet's test). Conclusion PPPD patients showed lack of habituation (potentiation) of Na-Pa amplitude in AMLR to repetitive stimuli. Lack of habituation (potentiation) might be associated with sensory processing disorders in PPPD.
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Affiliation(s)
- Toshihisa Murofushi
- Department of Otolaryngology, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki, Japan
| | - Fumiyuki Goto
- Department of Otolaryngology-Head and Neck Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Munetaka Ushio
- Department of Otolaryngology, Toho University Medical Center Sakura Hospital, Sakura, Japan
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Casani AP, Ducci N, Lazzerini F, Vernassa N, Bruschini L. Preceding Benign Paroxysmal Positional Vertigo as a Trigger for Persistent Postural-Perceptual Dizziness: Which Clinical Predictors? Audiol Res 2023; 13:942-951. [PMID: 38131807 PMCID: PMC10740490 DOI: 10.3390/audiolres13060082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/01/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE Persistent postural-perceptual dizziness (PPPD) is a syndrome described as secondary, when it is the consequence of an organic disorder (s-PPPD), or primary, when no somatic triggers can be identified. We evaluated a group of patients diagnosed as s-PPPD, with Benign Positional Paroxysmal Vertigo (BPPV) as the main somatic trigger, with the aim of identifying the predictive clinical elements of evolution towards PPPD. STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS We evaluated 126 patients diagnosed with PPPD; 54 patients were classified as p-PPPD (43%) and 72 as s-PPPD (57%). Of these, 51 patients had BPPV as a somatic trigger of PPPD, and in this group, we evaluated the prevalence of some clinical features (age, sex, latency between the onset of BPPV and the final diagnosis, recurrence of BPPV and the presence of migraine headache) for comparison with a group of patients who suffered from BPPV without an evolution towards PPPD (control group). RESULTS In the group with PPPD secondary to BPPV, we found a significantly higher mean age and a longer latency between the onset of BPPV and the final diagnosis compared to the control group. No difference between the two groups was found regarding sex, recurrence rate and the presence of migraine headache. CONCLUSIONS The parameters most involved as potential precipitants of PPPD after BPPV were the age of the patients and a long latency between the onset of BPPV and the final diagnosis; the mean age of the subjects who developed PPPD following BPPV was significantly higher. These findings lead us to emphasize the importance of the early identification and treatment of BPPV, especially in older patients.
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Affiliation(s)
- Augusto Pietro Casani
- Department of Surgical and Medical Pathology, ENT Section, Pisa University Hospital, 56122 Pisa, Italy; (N.D.); (F.L.); (N.V.); (L.B.)
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Castillejos-Carrasco-Muñoz R, Peinado-Rubia AB, Lérida-Ortega MÁ, Ibáñez-Vera AJ, Tapia-Toca MC, Lomas-Vega R. Validity and reliability of the Niigata PPPD Questionnaire in a Western population. Eur Arch Otorhinolaryngol 2023; 280:5267-5276. [PMID: 37266755 PMCID: PMC10620260 DOI: 10.1007/s00405-023-08038-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE To analyze the psychometric properties of the Niigata Questionnaire (NPQ) for use in a European population with persistent postural-perceptual dizziness (PPPD). METHODS Observational study included 140 patients with different vestibular conditions. Construct validity, internal consistency and concurrent validity were analyzed. Intra-class correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were calculated. Receiver operating characteristic (ROC) curve was used to test diagnostic values. RESULTS Of the 140 patients, 47 had a diagnosis of PPPD. Factorial analysis showed a single-factor structure and concurrent validity analysis showed strong correlations with other instruments. Cronbach alpha coefficients of 0.938 for the total score, 0.869 for the standing and gait subscale, 0.803 for the subscale of movements and 0.852 for the visual stimulation subscale were obtained. The reproducibility was substantial except for the standing subscale, which could be considered moderate. For the standing, movement and visual stimulation subscales and for the total score, the SEM was 3.27, 2.41, 2.50 and 6.63, respectively, and the MDC was 6.40, 4.72, 4.91 and 12.99, respectively. The NPQ total score showed an area under the curve (AUC) of 0.661, a sensitivity of 72.34 and a specificity of 55.91 for discriminating between PPPD and other vestibular disorders. CONCLUSIONS The NPQ is feasible for use in a Western population and presents a uni-factorial structure, high internal consistency and strong correlation with other instruments. The reliability can be considered substantial. The NPQ has low accuracy in discriminating between subjects with or without PPPD.
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Affiliation(s)
| | - Ana Belén Peinado-Rubia
- Department of Health Sciences, University of Jaen, Campus Las Lagunillas, S/N, Building B3, Office 212, 23071, Jaen, Spain
| | - Miguel Ángel Lérida-Ortega
- Department of Health Sciences, University of Jaen, Campus Las Lagunillas, S/N, Building B3, Office 212, 23071, Jaen, Spain
- Sanitary Management Area North of Jaen, San Agustin Hospital, Linares, Spain
| | - Alfonso Javier Ibáñez-Vera
- Department of Health Sciences, University of Jaen, Campus Las Lagunillas, S/N, Building B3, Office 212, 23071, Jaen, Spain.
| | | | - Rafael Lomas-Vega
- Department of Health Sciences, University of Jaen, Campus Las Lagunillas, S/N, Building B3, Office 212, 23071, Jaen, Spain
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Trinidade A, Cabreira V, Goebel JA, Staab JP, Kaski D, Stone J. Predictors of persistent postural-perceptual dizziness (PPPD) and similar forms of chronic dizziness precipitated by peripheral vestibular disorders: a systematic review. J Neurol Neurosurg Psychiatry 2023; 94:904-915. [PMID: 36941047 DOI: 10.1136/jnnp-2022-330196] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/23/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND The literature on predictors of persistent postural-perceptual dizziness (PPPD) following peripheral vestibular insults has not been systematically reviewed. METHODS We systematically reviewed studies on predictors of PPPD and its four predecessors (phobic postural vertigo, space-motion discomfort, chronic subjective dizziness and visual vertigo). Investigations focused on new onset chronic dizziness following peripheral vestibular insults, with a minimum follow-up of 3 months. Precipitating events, promoting factors, initial symptoms, physical and psychological comorbidities and results of vestibular testing and neuroimaging were extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS We identified 13 studies examining predictors of PPPD or PPPD-like chronic dizziness. Anxiety following vestibular injury, dependent personality traits, autonomic arousal and increased body vigilance following precipitating events and visual dependence, but not the severity of initial or subsequent structural vestibular deficits or compensation status, were the most important predictors of chronic dizziness. Disease-related abnormalities of the otolithic organs and semi-circular canals and age-related brain changes seem to be important only in a minority of patients. Data on pre-existing anxiety were mixed. CONCLUSIONS After acute vestibular events, psychological and behavioural responses and brain maladaptation are the most likely predictors of PPPD, rather than the severity of changes on vestibular testing. Age-related brain changes appear to have a smaller role and require further study. Premorbid psychiatric comorbidities, other than dependent personality traits, are not relevant for the development of PPPD.
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Affiliation(s)
- Aaron Trinidade
- Department of Otolaryngology, Southend University Hospital, Southend-on-Sea, UK
- Faculty of Medicine, Anglia Ruskin University Medical School, Chelmsford, UK
| | - Verónica Cabreira
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joel A Goebel
- Department of Neuro-otology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Diego Kaski
- Department of Neuro-otology, University College London, London, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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El Medany NM, Kolkaila EA, El Mehallawi TH, Lasheen RM. A study of otolith function in patients with orthostatic dizziness. Eur Arch Otorhinolaryngol 2023; 280:4803-4810. [PMID: 37106133 PMCID: PMC10562266 DOI: 10.1007/s00405-023-07985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Orthostatic dizziness (OD) is the dizziness that occurs when moving from a sitting or a supine to a standing position. It is typically thought to be connected to orthostatic hypotension (OH). The otolithic control of respiratory and cardiovascular system through vestibulosympathetic reflex has been the focus of considerable recent interest. This study aimed to evaluate the relationship between the orthostatic dizziness and otolith organ function. METHODS This study was carried on 50 adults aged from 18 to 50 years with normal peripheral hearing. Subjects were divided into two groups: controls (GI): 20 healthy adults and study group (GII): 30 patients who were complaining of OD. Patients were submitted to; blood pressure measurement in sitting and standing positions, combined vestibular-evoked myogenic potentials (VEMPs) and subjective visual vertical and horizontal tests (SVV) and (SVH). RESULTS The study group showed abnormal absent cVEMP, oVEMP. There were also statistically significant differences of P13 and N23 latencies and (P13N23) amplitudes between the two groups in the left ears. Both groups differed significantly in SVH values deviated to the left side. Study group were further subdivided into ten patients with OH and 20 patients with OD without OH. The both study subgroups showed abnormal absent cVEMP, oVEMP and abnormal SVH. OH patients showed statistically significant differences of cVEMP waves P13, N23 latencies in the left ears when compared with the control. CONCLUSIONS Otolith malfunction may be the cause of orthostatic dizziness (OD) in patients with and without orthostatic hypotension.
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Affiliation(s)
- Nada Medhat El Medany
- Audio-Vestibular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Enaas Ahmad Kolkaila
- Audio-Vestibular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Reham Mamdouh Lasheen
- Audio-Vestibular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
- Audiovestibular Unit, Department of Otolaryngology/Head and Neck Surgery, Tanta University Hospital, El-Geish Street, Tanta, 31511 El-Gharbia Egypt
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Murofushi T, Monobe H, Ushio M. Isolated bilateral posterior semicircular canal hypofunction: comparison with bilateral vestibulopathy. Acta Otolaryngol 2023; 143:687-691. [PMID: 37682576 DOI: 10.1080/00016489.2023.2253270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Chronic unsteadiness is a common complaint at vestibular clinics. Bilateral vestibulopathy (BVP) is a major cause of chronic unsteadiness but is often overlooked. Although diagnostic criteria for BVP have been established by the Barany Society, isolated vertical canal hypofunction can remain undiagnosed. Recently, the video head-impulse test has enabled clinicians to assess vertical semicircular canal function at clinics. OBJECTIVE This study aimed to compare the features of isolated bilateral posterior semicircular canal hypofunction (IBPH) with those of BVP diagnosed based on the Barany criteria. METHODS The clinical data of 8 IBPH patients that had been diagnosed using our diagnostic criteria (sex, age, subjective symptoms, questionnaire, video head-impulse test and stabilometry) were analyzed and compared with those of 6 BVP patients diagnosed using the Barany criteria. RESULTS The IBPH patients were all aged >70 years, while the age range of the BVP patients was wider. While the BVP patients complained of both oscillopsia during body movement and unsteadiness in darkness, the IBPH patients complained of unsteadiness in darkness without oscillopsia during body movement. The IBPH patients exhibited milder clinical findings than the BVP patients. CONCLUSION IBPH can cause mild unsteadiness in the elderly. SIGNIFICANCE Clinicians should be aware that IBPH can cause unsteadiness in the elderly.
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Affiliation(s)
- Toshihisa Murofushi
- Department of Otolaryngology, Teikyo University School of Medicine Mizonokuchi Hospital, Kasasaki, Japan
| | - Hiroko Monobe
- Department of Otolaryngology, Japan Red Cross Medical Center, Tokyo, Japan
| | - Munetaka Ushio
- Department of Otolaryngology, Toho University School of Medicine Sakura Medical Center, Sakura, Japan
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Wu Z, Liu B. [Expert consensus on the diagnosis of isolated otolith dysfunction]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2023; 37:409-414. [PMID: 37253512 PMCID: PMC10495805 DOI: 10.13201/j.issn.2096-7993.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 05/15/2023] [Indexed: 06/01/2023]
Abstract
Isolated otolith dysfunction(iOD) involves a group of unexplained vestibular syndromes that manifest clinically as a sense of translation, tilting or floating, and blurred vision with head movement, with normal semicircular canal function but abnormal otolith function on laboratory vestibular testing. As vestibular medicine has gained widespread popularity in recent years, increasing attention has also been paid to iOD and case reports, clinical studies and diagnostic criteria have been published. However, there is no consensus document to guide the diagnosis of this disease in China. In this context, the Special Committee on Vertigo of China Medical Education Association organized a group of domestic experts in vestibular medicine and formulated this diagnostic consensus after thorough discussion based on the latest evidence in China and abroad, in order to promote the best clinical practice for iOD.
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Azami M, Fushiki H, Tsunoda R, Kamo T, Ogihara H, Tanaka R, Kato T. Clinical features of persistent postural-perceptual dizziness with isolated otolith dysfunction as revealed by VEMP and vHIT findings. Front Neurol 2023; 14:1129569. [PMID: 37006499 PMCID: PMC10060848 DOI: 10.3389/fneur.2023.1129569] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundPersistent postural-perceptual dizziness (PPPD) is a relatively new disease entity, with diagnostic criteria published by the Bárány Society. PPPD is often preceded by a peripheral or central vestibular disorder. It is not clear how coexisting deficits due to preceding vestibular disorders affect PPPD symptoms.ObjectiveThis study aimed to characterize the clinical features of PPPD with or without isolated otolith dysfunction using vestibular function tests.MethodsThe study included 43 patients (12 males and 31 females) who were diagnosed with PPPD and completed oculomotor-vestibular function tests. The Dizziness Handicap Inventory (DHI), Hospital Anxiety and Depression Scale (HADS), Niigata PPPD Questionnaire (NPQ), and Romberg test for stabilometry were examined. The 43 patients with PPPD were classified into four categories based on vestibular evoked myogenic potential (VEMP) and video head impulse test (vHIT) results: normal function for both semicircular canals and otoliths (normal), isolated otolith dysfunction (iOtoDys), isolated semicircular canal dysfunction (iCanalDys), and dysfunction of both otoliths and semicircular canals (OtoCanalDys).ResultsAmong the 43 patients with PPPD, the iOtoDys group was the largest (44.2%), followed by the normal group (37.2%), iCanalDys group (9.3%), and OtoCanalDys group (9.3%). Eight of the 19 iOtoDys patients showed both abnormal cVEMP and oVEMP responses unilaterally or bilaterally (both sacculus and utriculus damage type), whereas 11 showed either an abnormal cVEMP or an abnormal oVEMP response (either sacculus or utriculus damage type). In a three-group comparison of the both sacculus and utriculus damage type, the either sacculus or utriculus damage type, and the normal group, the mean total, functional, and emotional DHI scores were significantly higher for the both sacculus and utriculus damage type than for the either sacculus or utriculus damage type. The Romberg ratio, a measure of stabilometry, was significantly higher for the normal group than for the both sacculus and utriculus damage type and the sacculus or utriculus damage type in the iOtoDys group.ConclusionsThe coexistence of sacculus and utriculus damage may exacerbate dizziness symptoms in patients with PPPD. Determining the presence and extent of otolith damage in PPPD may provide useful information on the pathophysiology and treatment strategies of PPPD.
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Affiliation(s)
- Masato Azami
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
- Department of Physical Therapy, Faculty of Health Sciences, Japan University of Health Sciences, Satte, Japan
| | - Hiroaki Fushiki
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
- *Correspondence: Hiroaki Fushiki
| | - Reiko Tsunoda
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
| | - Tomohiko Kamo
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
- Department of Physical Therapy, Faculty of Rehabilitation, Gunma Paz University, Takasaki, Japan
| | - Hirofumi Ogihara
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
- Division of Physical Therapy, Department of Rehabilitation, Faculty of Health Sciences, Nagano University of Health and Medicine, Nagano, Japan
| | - Ryozo Tanaka
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
- Department of Physical Therapy, Faculty of Health Sciences, Mejiro University, Saitama, Japan
| | - Takumi Kato
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
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