Statistical observation of vertigo and dizziness patients]

Subjects visiting the Department of Otolaryngology at Suita Municipal Hospital reporting vertigo or dizziness numbered 664 women and 343 men from April 1999 to December 2000. As a city hospital, we play an important role in the diagnosis and treatment of acute vertigo or dizziness. The frequency of diagnosis of these cases was divided almost equally into 5 groups: (1) benign paroxysmal positional vertigo (BPPV) 23%; (2) suspected BPPV, 18%; (3) peripheral vestibular disorders other than BPPV, 22%; (4) disorders other than peripheral origin, 18%; and (5) undiagnosed, 19%. Based on our results, BPPV, other peripheral vestibular disorders, and disorders of other origins should be differentiated from the first screening. BPPV was most frequent and diagnosed by typical positioning nystagmus. Many other peripheral vestibular disorders were accompanied by nystagmus. It is also important to differentiate serious illnesses such as cerebrovascular disease (7%), space-occupying lesions in the posterior fossa (1.2%), and cardio-circulatory disease (3.6%).     

Incidence of vertigo and dizziness disorders at a university hospital

Subjects were 626 patients reporting vertigo or dizziness seen at the University Hospital Department of Otolaryngology from April 2001 to September 2003. Patients were diagnosed based on diagnostic criteria prescribed by the Japan Society for Equilibrium Research. The most common peripheral vestibular disorder was benign paroxysmal positional vertigo (32%), followed by Meniere's disease (12%). All peripheral vestibular disorders accounted for 65%. Central vestibular disorder accounted for 7%, of which space-occupying lesions in the posterior fossa accounted for 1.0% and cerebral infarction 1.9%. Dizziness due to orthostatic hypotension accounted for 4.0%. Among past reports on clinical statistics of vertigo, the incidence of vertigo and dizziness disorders differed greatly, but our research and the past 2 reports based on diagnostic criteria prescribed by the Japan Society for Equilibrium Research showed almost the same incidence, i.e., BPPV of 30-40%, Meniere's disease of 7-10%, other peripheral vestibular disorders of 15-20%, and central vestibular disorder of 6-8%. Unified diagnostic criteria are thus important in the statistical analysis of vertigo disorders.     

Diagnosis of common causes of vertigo using a structured clinical history

The structured clinical history is the most sensitive test for diagnosing vertigo. Its diagnostic effectiveness on the first visit was analyzed and key signs and symptoms with high predictive value for common causes of vertigo were identified. One hundred outpatients who complained of dizziness or loss of balance were evaluated using a structured clinical interview. Each questionnaire was examined independently by three blinded investigators, who assigned a diagnosis and identified the elements of the history that figured most prominently in the diagnosis. The gold standard was defined as independent selection of the same diagnostic category by all three investigators. A first-visit diagnosis was obtained in 40% of patients (95% confidence interval 30-50%): 38% women and 42% men. Causes included benign positional paroxysmal vertigo (BPPV, 13 patients), headache-associated vertigo (9), Meniere disease (7), cervical vertigo (3), psychiatric dizziness (2), post-traumatic vertigo (2), vertebro-basilar transient ischemic attack (1), vestibular neuritis (1), convulsive seizure (1), and presyncope (1). The best predictors of BPPV were the precipitating mechanism (specificity [SP] 100%), positional nystagmus (sensitivity [SE] 90%, SP 63%), and the Dix-Hallpike test (SE 82%, SP 71%). Elements predictive of headache-associated vertigo were duration of the attack (minutes) and a personal history of headache (both, SP 100%). Other predictors were facial hypoesthesia (SE 92%, SP 47%) and associated neurological disease (SE 82%, SP 58%).     

内耳病变并发良性阵发性位置性眩晕

目的了解继发于几种内耳疾病的良性阵发性位置性眩晕（benign paroxysmal positional vertigo，BPPV）的发病情况，进一步了解BPPV的可能发病机制。方法观察眩晕诊疗中心2004年1月至2006年11月53例前庭神经炎、90例突发性聋（包括伴眩晕的突发性聋）、381例梅尼埃病BPPV等的发病情况，并与同期183例原发性BPPV比较。结果4种内耳疾病后可以出现BPPV，分别是前庭神经炎、突发性聋、梅尼埃病和Bell麻痹。前庭神经炎后出现BPPV为9．4％（5／53）；突发性聋后出现BPPV为38．9％（35／90）；梅尼埃病后出现BPPV为0．3％（1／381）；1例Bell麻痹后出现BPPV。其中外半规管BPPV5例；后半规管37例，其中1例后半规管BPPV在复位过程中出现同侧前半规管BPPV。管结石症39例，外半规管嵴顶结石症3例。内耳病变后出现BPPV在发病后半年内出现者占75．0％（27／36）。继发性BPPV的手法复位效果与原发性BPPV相似，大多都可1、2次就诊后治愈。结论内耳病突发性聋、前庭神经炎和梅尼埃病后可以出现BPPV。这种类型的BPPV主要表现为后半规管管结石，偶见外半规管嵴帽结石。原发性BPPV与内耳病变后出现的BPPV手法复位疗效相似。     

Results of subjective visual vertical tests in patients with vertigo/dizziness

ObjectiveWe previously established the head-tilt subjective visual vertical (HT-SVV) test to evaluate head-tilt perception gain (HTPG) in addition to the original head-upright SVV (HU-SVV) test (Wada-Y et al.: Laryngoscope Investig Otolaryngol, 2020). In this study, we aimed to investigate the HU-SVV and HT-SVV abnormality rates among patients with vertigo/dizziness.MethodsBetween July 2014 and December 2020, 357 patients were hospitalized for examining the HU-SVV and HT-SVV at our vertigo/dizziness center. Among these patients, 120 had Meniere's disease (MD), 99 had unilateral vestibular disease (UVD), 76 had benign paroxysmal positional vertigo (BPPV), 14 had vestibular migraine (VM), 13 had orthostatic dysfunction (OD), 12 had bilateral vestibular disease (BVD), 12 had central dizziness (CD), 7 had vestibular schwannoma (VS), and 4 had psychogenic dizziness (PD). We determined the reference values of the absolute HU-SVV (<2.5°) and HTPG (0.80–1.25) for the sitting position and used these for calculating the HU-SVV and HT-SVV abnormality rates in each type of vertigo/dizziness.ResultsAmong the 357 patients, 111 had abnormal HU-SVV results (31.1%), 132 had abnormal HT-SVV results (37.0%), and 185 had abnormal HU-SVV and/or HT-SVV results (51.8%). The modified HT-SVV test in combination with the original HU-SVV test could detect gravity perception disturbance in patients with vertigo/dizziness significantly better than the original test alone (chi-square: p=0.00019). The HU-SVV, HT-SVV, and HU-SVV and/or HT-SVV abnormality rates were significantly higher in patients with peripheral vestibular diseases, i.e., MD, UVD, BPPV, and BVD than in those with other types of vertigo/dizziness, i.e., VM, OD, CD, VS, and PD (chi-square: p=0.010, p=0.020, and p=0.0025, respectively).ConclusionThese findings suggest that the combined HT-SVV and HU-SVV test could be a powerful neuro-otologic examination for detecting pathologies in the vestibular otolithic pathway.     

The results of vestibular evoked myogenic potentials, with consideration of age-related changes, in vestibular neuritis, benign paroxysmal positional vertigo, and Meniere's disease

CONCLUSION: We interpreted VEMP findings in patients with the three major peripheral vertigo diseases, taking age-related changes into consideration. We found different abnormal VEMP rates among the three diseases, as well as differences in the proportion of parameters that were abnormal, according to the type of disease. OBJECTIVES: Vestibular neuritis, benign paroxysmal positional vertigo (BPPV), and Meniere's disease, common diseases that cause peripheral vertigo, often affect the saccule or inferior vestibular nerve, which are pathways of vestibular evoked myogenic potential (VEMP). Also, aging could have a primary effect on diminished VEMP responses. Our study investigated VEMP the findings in patients with the diseases in relation to their age. PATIENTS AND METHODS: A total of 134 patients with vestibular neuritis, 62 with BPPV, and 29 with Meniere's disease were enrolled in this study. The VEMP findings in patients within the three disease groups were interpreted using our own normative ranges according to age. RESULTS: Abnormal VEMP rates in the vestibular neuritis, BPPV, and Meniere's disease groups were 36.6%, 25.8%, and 69%, respectively. The proportion of prolonged p13 latency in BPPV patients with abnormal VEMP responses was relatively high compared with the other two diseases. VEMP asymmetry in the patients with Meniere's disease was relatively high.     

Patients with vertigo/dizziness of unknown origin during follow-ups by general otolaryngologists at outpatient town clinic

ObjectivesThe purpose of this study was to access the contribution of vertigo/dizziness-related patients’ interview and examinations during short-term hospitalization in determining the accurate final diagnosis of vertigo/dizziness of unknown origin.MethodsWe reviewed 1905 successive vertigo/dizziness patients at the Vertigo/Dizziness Center of Nara Medical University, who were introduced from general otolaryngologists at outpatient town clinic from May 2014 to April 2020. However, 244 patients were diagnosed with vertigo/dizziness of unknown origin (244/1905; 12.8%). Of these patients, 240 were hospitalized and underwent various examinations, including caloric test (C-test), video head impulse test (vHIT), vestibular evoked cervical myogenic potentials (cVEMP), subjective visual vertical (SVV), inner ear magnetic resonance imaging (ieMRI), Schellong test (S-test), and self-rating questionnaires of depression score (SDS).ResultsAccording to the examination data, together with interviewed vertigo/dizziness characteristics and daily changeable nystagmus findings, the final diagnoses were as follows: benign paroxysmal positional vertigo (BPPV: 107/240; 44.6%), orthostatic dysregulation (OD: 56/240; 23.3%), vestibular peripheral disease (VPD: 25/240; 10.4%), vestibular migraine (VM: 14/240; 5.8%), Meniere's disease (MD: 12/240; 5.0%), gravity perception disturbance (GPD: 10/240; 4.2%), psychogenic vertigo (Psycho: 10/240; 4.2%), and unknown (Unknown: 6/240; 2.5%). Supporting factors of final diagnosis was seen in gender, evoked dizziness, and positional nystagmus as BPPV; in evoked dizziness, S-test, and hypertension as OD; in evoked dizziness, head shaking after nystagmus, C-test, and vHIT as VPD; in gender, headache, and S-test as VM; in ear fullness and ieMRI as MD; in gender, evoked dizziness, and SVV as GPD; and in SDS as Psycho. To sum up, the ratios of Unknown were significantly reduced by this short-term hospitalization (244/1905→6/240).ConclusionsThe answer lists for vertigo/dizziness of unknown origin obtained in the present study may be helpful for future general otolaryngologists at outpatient town clinic to better attain an accurate final diagnosis.     

前庭性眩晕疾病患者焦虑和抑郁状况研究

目的 研究临床上常见的四种前庭性眩晕患者的焦虑/抑郁状况及其眩晕残障程度等相关因素并进行分析,为临床诊治四种前庭性眩晕提供依据。 方法 搜集确诊为前庭性眩晕的患者,分别为良性阵发性位置性眩晕(BPPV)、前庭性偏头痛(VM)、梅尼埃病(MD)及前庭神经炎(VN)四种疾病,记录患者的病程、持续时间等一般资料,完善耳科学检查并进行医院焦虑抑郁量表(HAD)、眩晕残障量表(DHI)测定。 结果 纳入前庭性眩晕患者121例,其中BPPV47例,VM31例,MD29例,VN14例,四组患者焦虑/抑郁阳性率分别为BPPV 31.9%、VM 71.0%、MD 75.9%、VN 42.9%;轻度、中度及重度眩晕残障程度分别为BPPV 58.9%、19.8%、21.3%,VM 19.4%、25.8%、54.8%,MD 6.9%、24.1%、69.0%,VN 38.6%、21.4%、40.0%。焦虑与抑郁评分之间线性相关(r=0.570,P<0.05);DHI与HAD评分之间线性相关(r=0.804;P<0.05)。 结论 前庭性眩晕患者存在不同程度的焦虑/抑郁,且焦虑和抑郁有一定的相关性;VM和MD患者焦虑/抑郁的发生率较高;VM、MD及VN患者眩晕残障程度高于BPPV患者。因此在临床上诊治前庭性眩晕疾病的时候要重视患者的焦虑/抑郁状态,特别是VM、MD患者,以便更好的治疗前庭性眩晕。     

Benign paroxysmal positional vertigo in older women may be related to osteoporosis and osteopenia

Benign paroxysmal positional vertigo (BPPV), so-called canalolithiasis and cupulolithiasis, usually occurs after head trauma or viral vestibular neuritis. In many cases, the cause remains obscure, and it often affects women more than 50 years old. The goal of this work was to study a possible relationship between BPPV and osteopenia or osteoporosis. Thirty-two women, whose ages ranged from 50 to 85 years (median age, 69 years), who had BPPV and were free of any other otoneurologic history, were selected. The diagnosis of osteopenia or osteoporosis was confirmed by a bone mineral density measurement made with dual x-ray absorptiometry of spine and hip (T-score). The BPPV was unilateral in 26 patients and bilateral in 6 patients. Our results showed osteopenia or osteoporosis in 24 of the 32 patients (75%) with BPPV. The T-scores were compared in 3 age groups to those of 83 healthy women. The patients with BPPV had a significantly lower (p < .026) T-score in all groups. Possible pathophysiological mechanisms are discussed to explain the apparent correlation between BPPV and osteopenia or osteoporosis.     

Intractable and atypical benign paroxysmal vertigo. Pathological results of high-resolution three-dimensional MR-tomography of the vestibular organ

Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder and a most common cause of dizziness and vertigo. The modern canalolithiasis theory postulates the existence of free-floating dense otolithic particles in the endolymph of the posterior semicircular canal. The symptoms were exactly described by Dix and Hallpike; BPPV is normally a self-limited disease with spontaneous recovery. There is however a small number of patients who do not respond to any treatment or who present with otolithic vertigo which does not fit all Dix-Hallpike criteria (atypical BPPV). While BPPV in its typical appearance cannot be diagnosed with radiologic imaging, the authors succeeded in identifying structural changes in the vestibular organs of patients suffering from intractable or atypical BPPV using three-dimensional magnetic resonance imaging.     

Inkurabler und atypischer benigner paroxysmaler Lagerungsschwindel

Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder and a most common cause of dizziness and vertigo. The modern canalolithiasis theory postulates the existence of free-floating dense otolithic particles in the endolymph of the posterior semicircular canal. The symptoms were exactly described by Dix and Hallpike; BPPV is normally a self-limited disease with spontaneous recovery. There is however a small number of patients who do not respond to any treatment or who present with otolithic vertigo which does not fit all Dix-Hallpike criteria (atypical BPPV). While BPPV in its typical appearance cannot be diagnosed with radiologic imaging, the authors succeeded in identifying structural changes in the vestibular organs of patients suffering from intractable or atypical BPPV using three-dimensional magnetic resonance imaging.     

Factors influencing long-term progress in patients with vestibular neuritis

We previously reported that platform stabilometry was effective in evaluating the condition of patients with vestibular neuritis. In the present study, we increased the patient population (n = 31) and followed them up for long-term (253.5 +/- 36.5 days after admission) to determine factors influencing prognosis. We examined the stability of patients with vestibular neuritis using platform stabilometry at 5 time points: P1, (5.3 +/- 0.7 days after admission); P2, (22.2 +/- 1.2 days); P3, (73.2 +/- 2.5 days); P4, (159.2 +/- 9.2 days); and P5, (258.3 +/- 23.5 days). For some elements--the total length of locus and the area of surroundings with open or closed eyes--the total length of locus with open eyes decreased significantly (P<0.05) following disease amelioration. Important factors for improving elements of platform stabilometry in patients with vestibular neuritis were age, presence of upper respiratory infection, and the duration of nystagmus.     

Residual dizziness after successful repositioning maneuvers for idiopathic benign paroxysmal positional vertigo in the elderly

Even after successful repositioning maneuvers for benign paroxysmal positional vertigo (BPPV), some patients report dizziness lasting for a certain period afterwards. We studied the prevalence and clinical factors associated with residual dizziness in a sample of elderly patients. Sixty outpatients over 65 years of age, affected by idiopathic BPPV were recruited; the exclusion criterion was a history of previous episodes of vertigo, including positional. The patients were asked to describe their self-perceived anxiety for vertigo on a Visual Analogue Scale (VAS) and successively treated with appropriate maneuvers till resolution of nystagmus. Data concerning the demographic and clinical features of BPPV were collected. Patients were followed until complete resolution of subjective dizziness and imbalance without positional nystagmus. Data about residual dizziness were collected from the second day from resolution of BPPV. Clinical and demographic factors related to residual dizziness were analyzed. Twenty-two subjects (37%) reported residual dizziness. In these subjects, the mean duration of residual dizziness was 13.4 ± 7.5 days. No association was observed between residual dizziness and gender, involved canal and the number of repositioning maneuvers before resolution. On the other hand, age older than 72 years, symptom duration greater than 9 days and VAS scale for anxiety greater than 10/100 were associated with an increased risk of residual dizziness. The odds ratio were respectively 6.5 (age—residual dizziness, Confidence Interval 95%), 6.5 (duration of vertigo—residual dizziness, Confidence Interval 95%) and 15.5 (anxiety levels—residual dizziness, Confidence Interval 95%). Longer symptom duration before diagnosis was associated with higher anxiety levels. The results underline the necessity for an early and correct diagnosis of BPPV, especially in the elderly.     

The test and treatment methods of benign paroxysmal positional vertigo and an addition to the management of vertigo due to the superior vestibular canal (BPPV‐SC)

A review of the tests and treatment manoeuvres for benign paroxysmal positional vertigo of the posterior, horizontal and superior vestibular canals is presented. Additionally, a new way to test and treat positional vertigo of the superior vestibular canal is presented. In a prospective study, 57 out of 305 patients' visits are reported. They had residual symptoms and dizziness after the test and the treatment of benign paroxysmal positional vertigo of the horizontal canal (BPPV‐HC) and posterior canal (PC). They were tested with a new test and treated with a new manoeuvre for superior canal benign paroxysmal positional vertigo (BPPV‐SC). Results for vertigo in 53 patients were good; motion sickness and acrophobia disappeared. Reactive neck tension to BPPV was relieved. Older people were numerous among patients and their quality of life (QOL) improved.     

伴有眩晕的突发性聋眩晕的临床特点分析

目的 分析突发性聋伴发的眩晕的临床特点.方法 回顾性分析2005年1月至2009年7月就诊于解放军总医院眩晕中心的伴发作性眩晕的突发性聋患者96例的临床资料,突发性聋及良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)的诊断根据中华医学会颁布的指南.分析其前庭功能特点及前庭与耳蜗症状出现的时间关系.结果 96例患者中BPPV23例(24.O%);余73例患者中一侧前庭功能低下者58例(60.4%),前庭功能正常者15例(15.6%).96例患者中46例患者可以提供准确的耳蜗症状与眩晕出现的时间:其中6例(13.0%)耳蜗症状与眩晕同时出现;耳蜗症状与眩晕出现的间隔时间＜1 h者4例(8.7%);1 h≤间隔时间＜24 h者21例(45.7%);13例(28.3%)在耳蜗症状出现数天后出现眩晕,最长为10 d;仅有2例(4.3%)眩晕的出现早于耳蜗症状.结论 突发性聋伴发的眩晕可以表现为前庭功能正常或低下,部分患者可以表现为BPPV,且耳蜗症状一般早于前庭症状出现.     

The predominant forms of vertigo in children and their associated findings on balance function testing

This article reports vestibular laboratory findings from the most common disorders known to cause dizziness and vertigo in children. Specific information regarding migraine, trauma, benign paroxysmal vertigo of childhood, vestibular neuritis, and otitis media is reviewed, along with indications for balance function testing in children.     

Assessment of sensory organization testing in benign paroxysmal positional vertigo patients before and after repositioning manoeuvre

Introduction and objectiveBenign paroxysmal positioning vertigo is considered the most common disorder of the peripheral vestibular system. After successful physical manoeuvres for BPPV, a number of patients complain of non-positional sustained imbalance of variable duration called residual dizziness lasting for several days. The objective of this study was to compare the posturographic changes before and one week after successful repositioning manoeuvres in patients with idiopathic BPPV.Materials and methodsThis study was a case–control study, where the first group was composed of 20 patients with confirmed BPPV diagnosis regardless of the affected canal or pathology. Twenty age and gender matched normal subjects constituted the control group. The sensory organization test was performed before and one week after a repositioning manoeuvre in BPPV patients.ResultsAll 20 BPPV patients, except 6 who had no significant improvement of symptoms even after disappearance of classic vertigo and nystagmus, had substantial improvement in sensory scores after CRPs in the antero-posterior visual and vestibular scores and the medio-lateral visual and global scores. All antero-posterior and medio-lateral scores before and after CRPs, except for the AP preferential score, were considerably poorer in BPPV patients than healthy subjects. The 6 patients, who showed no improvement after CRPs, presented with a history of non-specific symptoms i.e., light-headedness or sense of floating.ConclusionsSensory organization test might have a role in the assessment of residual dizziness in patients with BPPV after CRPs.     

Head-tilting stabilometry in patients with benign paroxysmal positional vertigo

OBJECTIVE: One of the pathologic conditions underlying benign paroxysmal positional vertigo (BPPV) is degeneration of the otolith organs. In this study, we examined changes in the parameters of stabilometry under an upright condition and head-tilt conditions in patients with BPPV. METHODS: We performed stabilometry on 21 patients with right BPPV, on 21 patients with left BPPV and on 21 controls. First, the subject stood barefoot in an upright position with both feet together on the platform with eyes closed. Next, tilting of the head about 30 degrees to the left was added. Then, tilting about 30 degrees to the right was performed. RESULTS: In right BPPV patients, the total length of velocity vectors in the right or left direction on right or left head-tilt were significantly smaller than those in an upright position. The enveloped area and total length of velocity vectors in the right or left direction were significantly larger than those in controls. In left BPPV patients, there were no parameters that showed any significant difference. CONCLUSIONS: In this study, lesions of right BPPV patients were coincidentally more severe than those in left BPPV patients, and velocity vectors with head-tilts were significantly smaller than in an upright position. Using the total length of the velocity vectors, head-tilting stabilometry has the potential to become a reliable otolith function examination method.     

Bilateral multicanal benign paroxysmal positional vertigo coexisting with a vestibular schwannoma: case report

We describe a rarely encountered case of coexisting bilateral multicanal benign paroxysmal positional vertigo (BPPV) and vestibular schwannoma in a 56-year-old woman. The patient had presented with a 10-year history of dizziness and imbalance, and her vestibular findings were perplexing. We decided on a working diagnosis of BPPV and began treatment. After several months of canalith repositioning maneuvers had failed to resolve her symptoms, we obtained magnetic resonance imaging, which revealed the presence of the vestibular schwannoma. This case serves as a reminder of the importance of differentiating between central and peripheral vestibular disorders, as well as central and anterior canal BPPV-induced down-beating nystagmus in order to establish the correct diagnosis and initiate appropriate treatment.