A possible mechanism of the formation of endolymphatic hydrops and its associated inner ear disorders

The pathology of Meniere’s disease (MD) is well established to be endolymphatic hydrops. However, the mechanism underlying deafness and vertigo of MD or idiopathic endolymphatic hydrops is still unknown. In order to evaluate the pathogenesis of deafness and vertigo in MD, it seems to be rational to investigate the interrelationship between hydrops and inner ear disorders using animals with experimentally-induced endolymphatic hydrops. In spite of intense efforts by many researchers, the mechanism of vertiginous attack has been unexplained, because animals with experimental hydrops usually did not show vertiginous attack.Recently, there are two reports to succeed to evoke vertiginous attack in animals with experimental hydrops. In the present paper were first surveyed past proposals about underlying mechanism of the development of hydrops and inner ear disorders associated with hydrops, and were discussed the pathogenetic mechanism of vertiginous attack in hydrops. In conclusion, abrupt development of hydrops was thought to play a pivotal role in the onset of vertiginous seizure.     

Therapeutic options in Meniere's disease.

Emphasis on treatment in Meniere's disease has recently shifted from a concentration on the vertiginous component alone to include conservation or improvement of hearing as well. This presentation tabulates the current otological literature's reports of both the medical and surgical options available in the treatment of Meniere's disease. The authors conclude that these more recent reports deemphasize the importance of the vertiginous component, while emphasizing the importance of the hearing component in evaluation of the efficacy of any therapeutic modality. Furthermore, these reports indicate that endolymphatic sac decompression and drainage surgery alone offers a considerable chance for conservation or improvement in hearing, as well as relief of vertigo in early cases of reversible, fluctuating hearing deficits. In nonreversible or nonfluctuating hearing deficits with hearing worth conserving, vestibular neurectomy with excision of Scarpa's ganglion yields the best results.     

Panic disorder in otoneurological experience

The evaluation of cochleovestibular dysfunction in psychiatric patients often causes a difficult problem in neurootological experience. The authors discuss here the neurobiological basis of panic disorders and cochleovestibular dysfunction. In this multicenter study, we examined 63 patients with vertigo and panic disease. Twenty patients with primary panic disease and consecutive vertigo composed group 1, whereas group 2 comprised 43 vertiginous patients with secondary panic disease. The most interesting question is whether the patients have an organic vestibular lesion, which would explain why vertigo alone is the problematic symptom in these panic patients, whereas in other patients, panic disease can cause other severe symptoms that resemble heart attack, dyspnea, or abdominal crisis. Vertigo has a bidirectional connection with psychiatric disorders. The panic disorder can be superimposed on chronic vertigo, and psychiatric patients with a cochleovestibular lesion have diminished chances for complete recovery. The examination of psychiatric patients with vertigo is very time consuming and requires much more empathy than does examination of vertiginous patients with a normal mental state. Anxiety provokes somatic and behavioral symptoms in most such patients. The treatment of vertigo in panic patients and of the panic disorder in vertiginous patients requires cooperation between neurootologist and psychiatrist.     

伴有心血管代谢疾病的眩晕患者的疗效影响因素

目的 探讨伴有心血管代谢性疾病的眩晕/头晕患者的临床特征和近期结局影响因素.方法 本研究纳入了2018年10月至2020年1月之间连续就诊于武汉同济医院眩晕专科门诊的伴有心血管代谢性疾病的眩晕/头晕患者.随访时获得的患者眩晕/头晕症状视觉模拟量表(Visual analogue scale,VAS)评分作为结局指标并按...     

Monothermal air caloric test in children.

We compared the efficacy of bithermal (BAT) and monothermal cold (MCAT) and warm (MWAT) air caloric tests in identifying labyrinthine function anomalies in the child. At first, we established confidence intervals of normality for both monothermal tests in 40 children (22 males, 18 females) aged 6-14 years, clinically healthy and normal as previously shown by BAT. Subsequently, we compared the results of BAT with those of MCAT and MWAT performed in 46 children (22 males, 24 females) aged 6-14 years, affected by multiple labyrinthine diseases. These results confirmed that, as in the adult, MCAT alone should not be used in the evaluation of labyrinthine function in vertiginous patients. As to MWAT, we obtained good sensitivity and specificity with respect to BAT (83% and 90% for 90% probability; 78% and 92.5% for 95% probability). Sensitivity values increased or decreased depending on the disease causing vertiginous symptoms, with decreased or increased number of false negatives. In our opinion, MWAT cannot replace BAT for the study of labyrinthine function in children. MWAT alone can be used when vertigo is ascribable to vestibular neuritis or to endogenous disease (dysmetabolic, dyscrasic, dysendocrine).     

Revision surgery after saccotomy for Meniere's disease: does it make sense?

Saccotomy is an established surgical treatment for Meniere's disease that involves exposing and opening the endolymphatic sac and draining the endolymph. However, in patients experiencing recurrent vertigo after saccotomy, it is questionable whether revision saccotomy should be recommended as opposed to more invasive procedures, such as neurectomy of the vestibular nerve. To determine the utility of revision saccotomy, we conducted a retrospective study of 29 patients undergoing this procedure for recurrent vertigo. Patient charts were reviewed for the re-occurrence of any vertiginous symptoms and outcomes with regard to hearing results and post-operative complications. An attempt was made to correlate vertigo status post-revision with surgical findings at the time of revision. After an average follow-up of 20 months, 18 patients (62%) were free of vertigo, and four patients (14%) had a significant decrease in the frequency and intensity of vertiginous attacks. Two patients (7%) relapsed after a vertigo-free period of 18 months, and five patients (17%) experienced no clinical improvement after revision surgery. In patients with a successful sac revision, a common finding at the time of revision was new bone formation in the endolymphatic sac area (n=11), which may have caused blocking of the endolymphatic drainage. Our results demonstrate that revision saccotomy should be considered for recurrent Meniere disease before other, more invasive, surgical options.     

Migraine-related vertigo: diagnostic criteria and prophylactic treatment

OBJECTIVE/HYPOTHESIS: The objective of this prospective, observational study was to evaluate the efficacy of migraine pharmacologic prophylaxis on a group of vertiginous patients considered affected by migraine-related vertigo on the basis of precise criteria of inclusion. METHODS: Fifty-three patients affected by migraine-related vertigo were selected from a cohort of 652 vertiginous patients referred to our Dizziness Unit from March 2001 to June 2005. Inclusion criteria were at least five vertigo attacks occurred in any period of time or dizziness and/or positional vertigo for at least 6 months; migraine, past or present, and/or a family history of migraine and/or motion intolerance; and exclusion of other causes. Patients were submitted to migraine pharmacologic prophylaxis selected on the basis of the characteristics of the patients and of the drug side effects. The efficacy of the treatment was evaluated after 6 months by questionnaire divided into five outcome categories (resolution, substantial control, moderate control, minimal control, no improvement or worsening) and, for the patients with recurrent vertiginous attacks, also reporting the percentage reduction of the attack frequency. RESULTS: Thirty-six patients completed the study and were submitted to analysis of the results: 10 reported complete resolution of symptoms, 15 substantial control, 7 moderate control, one minimum control and 3 no improvement. Thirty-three of them had recurrent vertigo: 19 reported complete disappearance of the attacks, 8 reduction of the frequency >50%, 5 reduction <50%, and one no reduction. CONCLUSIONS: Migraine prophylactic treatment shows encouraging results in patients with migraine-related vertigo selected with our criteria of inclusion: 69.3% reported satisfactory control of symptoms (sum of complete resolutions and substantial controls) and 81.8% had at least a 50% reduction of the vertiginous episodes frequency.     

Otolith dysfunction during vertiginous attacks in Ménière's disease

OBJECTIVE: Vertiginous attacks of Ménière's disease (MD) are characterized by various types of vertigo, namely rotatory vertigo, dizziness and drop attack. When a patient complains of dizziness without spontaneous nystagmus, otolith dysfunction cannot be ruled out. The purpose of this study was to evaluate otolith dysfunction during vertiginous attacks of MD or delayed endolymphatic hydrops. MATERIAL AND METHODS: Vestibular function tests were carried out daily for several days in 11 patients (MD, n = 9; delayed endolymphatic hydrops, n = 2) during vertiginous attacks. Otolith function was evaluated by means of the static torsional position of both eyes [static ocular torsion (OT)] whilst in an upright position. We defined otolith dysfunction as an abnormal change (range) in OT without spontaneous nystagmus or as an abnormal change in OT without a change in spontaneous nystagmus. RESULTS: Four patients had an abnormal change (range) in OT without spontaneous nystagmus or an abnormal change in OT without a change in spontaneous nystagmus during vertiginous attacks of MD. CONCLUSIONS: Otolith dysfunction occurs in patients during vertiginous attacks of MD. In cases of ataxia without spontaneous nystagmus, otolith dysfunction most likely causes atypical attacks of MD.     

Endolymphatic sac surgery for meniere's disease: A composite study of 339 cases

This paper analyzes 339 consecutively performed endolymphalic mastoid sac shunts. Regardless of the method used, vertigo was controlled and hearing either improved or stabilized in approximately 70% of the cases. Overall, vertigo was controlled in approximately 80% of the cases. Similar results were obtained in cases of Meniere's syndrome and vestibular Meniere's disease. It is suggested here that, regardless of the method employed, there remains a high likelihood that the symptoms will recur, and the question is raised as to whether sac surgery may merely induce a temporary remission of the disease process. Consequently, it is hereby proposed that there is a need to devise a method to permanently drain the endolymph in order to more effectively control the disease on a permanent basis. Until this is achieved, however, sac surgery would appear to be the most appropriate surgical treatment for Meniere's disease.     

Treatment of Ménière's disease by intratympanic gentamicin application

Ménière's disease is a vestibular disorder characterized by episodic vertigo, tinnitus, fluctuant hearing loss, and ear fullness, with vertiginous attacks being the most disabling complaint. The effectiveness of conservative treatment has been variable, while surgical techniques provide more permanent relief from vertigo, but pose possible morbidity and cochlear risk. Intratympanic administration of gentamicin has been proposed as an alternative for patients with debilitating Ménière's disease who have failed to respond to standard medical treatment. The goal of such treatment is to control vertigo by partially or completely destroying the vestibular system, while at the same time maintaining hearing. In this review we present the current medical literature on pathophysiology, pharmacokinetics, administration methods, dosage, treatment protocols, and problems related to intratympanic administration of gentamicin for patients with MD. Intratympanic gentamicin administration is a simple medical modality for treatment of persistent vertigo in patients with Ménière's disease. According to recent world research protocols, we propose the instillation of gentamicin by transtympanic injection, as a quick, easy, well-tolerated, ambulatory and cost-effective technique. Drug solution concentrations should be dependent on the frequency, intensity and duration of vertigo spells, as well as the degree of existing hearing loss, thus providing progressive vertigo relief with a low possibility of secondary deafness.     

Which medication do I need to manage dizzy patients?

Vertigo and dizziness are not independent disease entities, but instead symptoms of various diseases. Accordingly, a variety of treatment approaches are required. Here we review the most relevant drugs for managing dizziness, vertigo, and nystagmus syndromes. It is important to differentiate symptomatic treatment of nausea and vomiting with, for example, dimenhydrinate and benzodiazepines, and prophylactic treatment of motion sickness with scopolamine from a causal therapy of the underlying disorders. Examples of such causal therapy include aminopyridines for downbeat nystagmus and episodic ataxia type 2; carbamazepine for vestibular paroxysmia, paroxsymal dysarthria and ataxia in multiple sclerosis, and superior oblique myokymia; betahistine, dexamethasone, and gentamicin for Menière's disease; gabapentin and memantine for different forms of acquired and congenital nystagmus; corticosteroids for acute vestibular neuritis and Cogan's syndrome; metoprolol and topiramate for vestibular migraine; and selective serotonin reuptake inhibitors such as paroxetine for phobic postural vertigo. The clinical entities are briefly described, the various medications are discussed in alphabetical order, and dosage, major side effects, contraindications, and alternative medications of each drug are displayed in boxes for easy reference.     

Vertigo in a district NHS hospital

Thirteen general ENT clinics are held for a population of 600,000 people. The present study comprises an individual experience in managing patients with dizziness seen in three general ENT clinics. Eighty-six patients with a complaint of dizziness were seen over a period of 10 years from 1974 to 1984. Postural vertigo in elderly patients was the commonest cause of vertigo (50 per cent) in the present study. Most of these patients suffered from momentary dizzy spells with excessive neck movements. Symptomatic relief was achieved with reassurance and advice to avoid precipitating neck movements in most of the cases. Menière's disease was the second commonest cause of dizziness, which was seen in 15.1 per cent of the patients. Most of the cases were managed successfully with firm reassurance and a short course of treatment with either Betahistine or Cinnarizine. Only two patients showed a very moderate deterioration in hearing and only one patient needed saccus decompression surgery for uncontrolled vertiginous spells. Three patients with congenital unilateral total deafness showed a characteristic picture of secondary hydrops. One needed chemical destruction of the labyrinth to control the dizziness. Two cases (2.4 per cent) had posterior fossa lesions, one with an acoustic neuroma and the other with a large subarachnoid cyst. Both these cases were successfully managed by surgery.     

Prevention of vertigo in Ménière's syndrome by means of transtympanic ventilation tubes

The insertion of a transtympanic ventilation tube prevented the occurrence of vertiginous attacks in 82% of a series of 28 patients suffering typical Ménière's syndrome with incapacitating vertigo resistant to medical treatment. The follow-up time exceeds 2 years for all cases. It ranges from 2 to 4 years with an average of 2.5 years. This treatment had no effect on drop attacks. Also, hearing loss does not seem to be influenced. The presence of a transtympanic ventilation tube has not caused any major complications in these patients. Obstruction or loss of the tube was in some cases followed by the reappearance of vertigo. It is therefore important to check the patency of the tube before concluding that treatment has failed. The apparent benefit of ventilation tubes in reducing the occurrence of vertiginous attacks suggests that patients with endolymphatic hydrops are particularly sensitive to middle ear pressure.     

对选择和应用抗眩晕药的理性思考

依据前庭性眩晕的不同病因不同病情及不同愈后结果，合理选择和应用不同的抗眩晕药物，对改善眩晕症状和促进平衡功能康复至关重要。根据各种抗眩晕药的不同药理学效应，针对眩晕症状的大部分西药可被分为促进神经代偿的药物或抑制神经代偿的药物两大类，前者属于多巴胺兴奋剂，而后者属于多巴胺抑制剂，两者的药理学机制却恰好相反。在所有引起眩晕的前庭疾病中，占总数近半的案例属于可逆性病变并可自行恢复，但另外近半病例却因发生了不可逆性前庭损害而难以自愈。对于那些可自愈的眩晕病例，应用多巴胺兴奋剂加速平衡功能的代偿是不必要的甚至是有害的；而对于那些不可逆性单侧前庭永久损害的眩晕病例，应用多巴胺兴奋剂却有助于促进平衡功能的代偿并尽早消除眩晕症状，相反，应用多巴胺抑制剂却会延长平衡障碍的过程并阻碍平衡功能的代偿性恢复。因此，在哪种眩晕条件下需要应用促进平衡代偿的药物，而在哪种眩晕条件下需要应用抑制平衡代偿的药物，以及在哪种眩晕的哪个病程阶段应该积极促进平衡代偿而在哪个病程阶段需要抑制平衡代偿，是眩晕临床工作者应该根据药理学原理和患者的病因病情及病变后果来慎重思考的问题。     

Meniett低压脉冲发生器治疗梅尼埃病的疗效分析

梅尼埃病（Meniere’Sdisease,MD）是一种特发性膜迷路积水内耳病,表现为反复发作的旋转性眩晕、波动性感音神经性听力损失、耳鸣和（或）耳闷胀感。1861年ProsperMeniere首次报告了此种以眩晕、耳聋、耳鸣为主要表现的病症,     

Psychological evaluation in vertiginous patients

Four psychological tests, namely the Cornell Medical Index (CMI), the Manifest Anxiety Scale (MAS), the self-rating depression scale (SDS), and the self-rating anxiety scale (SAS) were performed to investigate the role of psychological factors in vertigo, in a study of 111 vertiginous patients and 81 controls. Vertiginous patients comprised the following three groups: 56 vertebrobasilar insufficiency (VBI group), 29 autonomic nervous dysfunction (AND group), and 26 Ménière's disease (MD group). The incidence of abnormal scores by CMI and SAS in the vertiginous patients was significantly higher than that in the controls (p < 0.01). No significant difference between the vertiginous patients and the controls was observed with respect to MAS and SDS scores. The abnormal rates by CMI in the VBI and AND groups were significantly higher than in controls (p < 0.01). Also, the abnormal rates by SAS in the VBI and MD groups were significantly higher than in controls (VBI group: p < 0.01, MD group: p < 0.05). However, no significant differences between the three groups of vertiginous patients and controls were found with respect to MAS and SDS scores. The average score from other psychological tests in the CMI-abnormal group was significantly higher than that in the CMI-normal group (p < 0.01). There were significant correlations between the MAS and SDS, MAS and SAS, and SDS and SAS scores (r = 0.682-0.688, p < 0.01). The matched data rate between the psychological tests was about 70-80%. Considering the results of MAS and SAS, vertigo induces anxiety forwards vertigo, and thereby initiates a vicious cycle. In vertiginous patients, CMI and SAS are most useful for determining whether or not psychological factors play a role in the onset of and persistence of vertigo. But CMI consist of 195 factors, and therefore, is time concerning. On the other hand, SAS has 20 factors and takes only 5 minutes to complete, thus, SAS is more suitable for screening psychological factors.     

Acoustic neuroma presenting as exercise-induced vertigo

We present two subjects with previously undiagnosed acoustic neuromas who complained of vertigo whenever they ran. One had normal hearing while the other already had a unilateral sensorineural deafness. Hyperventilation for 30 seconds provoked an ipsilateral beating nystagmus and reproduced the vertiginous sensation in both subjects. Hyperventilation is a simple bedside test that should be performed when assessing a subject with vertigo or when there is a clinical suspicion of an acoustic neuroma.     

Meta-analysis of clinical studies with betahistine in Ménière’s disease and vestibular vertigo

We present a meta-analysis of 12 double-blind, randomized, placebo-controlled clinical studies with betahistine in patients suffering from vestibular vertigo or Ménière’s disease, based on both published and unpublished data. The clinical endpoint we used was the investigator’s overall opinion on the response to treatment of the vertigo symptoms, after at least 1 month of treatment. We introduce a new effect parameter, the odds of a favorable treatment outcome, with the odds ratio as measure to compare the responses of betahistine and placebo patients. For each study a separate odds ratio was estimated (the study-specific odds ratio). All but one of the study-specific odds ratios were >1.0, meaning that with the new effect parameter there was evidence of an effect of betahistine on vertigo symptoms in 11 of the 12 studies. Four of the 12 studies showed a statistically significant effect in favor of betahistine compared to placebo. The meta-analytical (i.e., average) odds ratio was 2.58 (95 % confidence interval 1.67–3.99), a statistically significant result. This means that on average, the likelihood of a favorable outcome is almost two times higher for patients treated with betahistine than for placebo-treated patients. Sub-analyses conducted for patients with Ménière’s disease on one hand and with vestibular vertigo on the other hand also yielded statistically significant results. For Ménière’s disease, the meta-analytical odds ratio was 3.37 (95 % CI 2.14–5.29); for vestibular vertigo, the odds ratio was 2.23 (95 % CI 1.20–4.14). Our meta-analysis supports the therapeutic benefit of betahistine on vertiginous symptoms in both Ménière’s disease and vestibular vertigo.     

Vestibulopathy after a modified Blalock–Taussig procedure in a cyanotic congenital heart disease patient

Vestibulopathy is a condition characterized by the onset of vertigo, nausea and vomiting, in the absence of hearing loss or tinnitus. The differential diagnosis includes peripheral otologic disorders and central disorders such as vascular insufficiency. Modified Blalock–Taussig (B–T) shunt, a polytetrafluoroethylene graft from the subclavian artery to the pulmonary artery, has become the palliative procedure of choice in cyanotic congenital heart disease patients. This palliative surgery creates a similar vascular haemodynamic to that seen in the subclavian steal syndrome and when associated with aplasia, hypoplasia or stenosis of the contralateral carotid, vertebral or posterior communicating arteries it may predispose to vascular hypoperfusion and peripheral hypofunctioning of the vestibular system. We report the case of a cyanotic congenital heart disease patient with vertigo and dizziness who underwent a modified B–T fistula on childhood and developed, many years later, a vertiginous syndrome probably of vascular origin.     

Otoneurological Expert System for Vertigo

We have developed an otoneurological expert system (ONE) to aid the diagnostics of vertigo, to assist teaching and to implement a database for research. The ONE database is set to harvest data on patient history, signs and test results necessary for diagnostic work with vertiginous patients. A method based on pattern recognition was used in the reasoning process. Questions about symptoms, signs and test results are weighted and scored for each disease and the most likely disease is recognized from defined disease profiles. Missing information and uncertainties are solved with a method resembling fuzzy logic. ONE was validated by comparing diagnoses assessed by physicians with those provided by the system. It proved to be a valid decision-maker by solving 65% of the cases correctly, while the physicians' mean was 69%. To improve ONE further, a follow-up should be implemented for the patients, since diagnosing sudden deafness and Meniere's disease during the first visit is often impossible. We aim to obtain new information on diseases involving vertigo by applying adaptive computer applications, such as genetic algorithms, to the reasoning process.