Psychological manifestations of vertigo: a pilot prospective observational study in a Portuguese population

We sought to ascertain the importance of psychological manifestations of vertigo and psychogenic vertigo among a Portuguese population. Sixty patients complaining of vertigo and imbalance were studied over a 2-year period. At each assessment, the patients underwent a general examination, a neurootological evaluation, psychiatric interviews, and psychopathological assessments conducted by a multidisciplinary team. Overall, 38 patients (63.4%) were given diagnoses of some form of psychopathological complaint. A more detailed analysis revealed panic disorder in 9, moderate depressive episode in 42, and mixed anxiety and depressive disorder in 7, whereas the remaining patients (2) suffered from subclinical symptoms of anxiety or depression. Patients with vertigo demonstrate a high incidence of psychopathological complaints, the most common being anxiety disorders. Somatization, obsessive-compulsive behaviors, and depression tend to lessen over time, whereas few changes are seen in anxiety.     

Cochleovestibular dysfunction caused by cerebrovascular diseases

When a vascular disorder of the cochleovestibular system is considered, the diagnosis is based on exclusion of other diseases. As arteries of the cochleovestibular system cannot be directly visualized, physicians must deduce vascular cochleovestibular disease from the vascular risk factors and vascular lesions of other territories. With my colleagues at Semmelweis University, I analyzed neurootological and audiological examination results in 65 patients with vascular vertigo. Cochleovestibular system disorders can be considered to be of vascular origin if the examinations exclude other diseases, if the patients have vascular risk factors, and if other territories of the brain accessible for imaging methods show vascular disorders.     

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...     

The beneficial effect of methylprednisolone in acute vestibular vertigo

To assess the efficacy of corticosteroids in acute vestibular vertigo, we randomly selected 20 patients so that half took methylprednisolone and half took placebo. Extensive neurotologic examination confirmed the diagnosis. If no significant reduction of vertigo occurred within the first 24 hours of treatment, patients were instructed to switch medications. Patients were followed up prospectively for 1 month. Of the 10 patients receiving methylprednisolone, 9 had a marked reduction of vertiginous symptoms and 1 switched to the placebo medication. Of the 10 patients receiving placebo, 3 had relief of vertiginous symptoms, while the 7 with persistent symptoms switched to methylprednisolone and had subsequent effective reduction of vertigo within 24 hours. The electronystagmogram returned to normal within 1 month in all 16 patients taking methylprednisolone, but remained abnormal in 2 of the 4 patients treated with placebo. One patient receiving methylprednisolone had a relapse of symptoms when the dosage was tapered, but symptoms again remitted when the dosage was increased to 32 mg/d. From this double-blind, prospective, placebo-controlled, crossover study, we conclude that methylprednisolone is much more effective than placebo in reducing vertiginous symptoms in patients with acute vestibular vertigo.     

Peripheral vestibular vertigo and functional disorders of the craniovertebral joint

Some vertiginous lesions producing nystagmus (e.g. acute vestibulopathy, benign paroxysmal postural vertigo and Ménière's disease) are well-defined diseases of purely labyrinthine origin. The possible place of a functional disorder of the vertebral joints on their etiology and pathogenesis, has been discussed, but is purely hypothetical. Since the lesion almost always reaches with reduced function of the vestibular apparatus, the course of the disease depends crucially on central compensation of the peripheral disorder of vestibular function. Investigations of the effect of a functional disorder of the vertebral joints on the central compensation of vestibular functional disorders have not been described previously. Our own observations show that a functional disorder of the vertebral joints can crucially impair central compensation of peripheral vestibular vertigo. The pathological mechanism of the impaired compensation is discussed, and diagnostic and therapeutic consequences explained.     

Schwindel bei Kindern und Jugendlichen

Migraine equivalents are the most common cause of vertigo in children and adolescents. Vertigo and balance disorders occur frequently in children during the course of otitis media, middle ear effusion and viral infections. If otitis media is associated with reduced hearing and vertigo, labyrinthitis must be considered. Craniocerebral injury is another important cause of vertigo in children. In contrast, spontaneous benign paroxysmal positional vertigo is rare among children. The isolated cases of endolymphatic hydrops that occur in children are usually secondary. Perilymph fistula can have congenital, infectious or trauma-related causes. The following characteristics are useful for differentiating between different vertiginous syndromes: type and duration of vertigo, triggering/aggravating/alleviating factors and accompanying symptoms. A neuro-ophthalmologic examination is essential to rule out central vestibular disorders.     

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.     

Vestibular disorders in childhood and adolescents

The aim and objective of the study is to analyze the data of 145 vertiginous patients aged up to 18 years, which were examined at the Otoneurological Department of the Semmelweis University during the last 5 years. The study design for the analysis: the group of children (66 patients, aged up to 14 years) and group of adolescents (79 patients, ages between 14 and 18 years). Children and adolescents, who sent by otolaryngologists or pediatric neurologists, were examined. The detailed case history and routine physical examinations were followed by cochlear function tests. The vestibular test contained statokinetic test, spontaneous nystagmus with electronystagmographical (ENG) registration, positional and positioning nystagmus with Frenzel’s glasses, smooth pursuit eye movement test and caloric test with computer-based ENG. Most of the patients experienced true rotatory vertigo. The ratio of the dizziness (vertigo without direction) was 38% in the children’s and 44% in the adolescent group; 21 children and 31 adolescents had headache. Nausea and vomiting were frequent in both the groups: normal hearing was measured in 62% of children and in 82% of adolescents. The vestibular system was normal in 36% of the children’s group, and in 39% of the adolescents. In conclusion, it is important to realize that 64% of the children and 61% of the adolescents do have certain vestibular abnormalities. The most frequent cause of dizziness (24%) in the adolescent group is the extravestibular disorder-like panic disease and the anxiety disorder. At younger age, the most frequent disease that can cause vestibular symptoms is the migraine.     

Somatoform disorders in vertiginous children and adolescents

Objective

To investigate the frequency and characteristics of psychiatric co morbidity in a group of vertiginous children.

Methods

A retrospective review of patient notes between years 2000 and 2006 in the ENT clinic of Helsinki University Hospital. Patients were identified from the clinic database, based on hospital discharge codes.

Results

119 children were examined because of vertigo. Nine vertiginous children had purely psychogenic vertigo. The main psychiatric diagnosis was depression. The prevalence of somatoform disorders was 2.5%. According to our study the main predictors of a psychogenic vertigo were constant or frequent vertigo usually with coexisting headaches, absence from school and problems with relationships at school or home.

Conclusion

Somatisation should always be kept in mind while dealing with vertiginous children. A thorough clinical work-up is needed to rule out potential illnesses, but as soon as the possibility of somatisation comes to mind, psychiatric consultation is recommended.     

Cochleovestibular nerve compression syndrome. I. Clinical features and audiovestibular findings.

Cochleovestibular nerve compression syndrome (CNCS) is the term used to describe a group of audiovestibular symptoms thought to be due to a vessel compressing the cochleovestibular nerve. These symptoms include recurrent vertigo, continuous disequilibrium and acquired motion intolerance. Recently, Moller reported that CNCS can be diagnosed based on abnormalities in the auditory brainstem response (ABR). After specifically excluding all other vestibular disorders, 63 patients with symptoms suggestive of CNCS were identified. These patients were systematically evaluated with a standard neurotologic test battery, and the results were reviewed retrospectively. Hearing loss was found in 51 (81%) of 63 cases, including 33 cases of unilateral high-frequency loss and 14 cases of middle-frequency loss. ABR data were interpreted with respect to Moller's criteria, and abnormal studies were found in 42 (75%) of 56 cases. Abnormal electronystagmograms were found in 57 (93%) of 61 cases. Thirteen of the patients subsequently underwent a posterior fossa procedure for vertigo and, vessels were found in contact with the cochleovestibular nerve in 11 of 13 cases. The results of this study suggest that the majority of CNCS patients have neurotologic test findings that suggest an abnormality of the cochleovestibular nerve. The results and their implications are discussed.     

The role of neurovisualization methods in diagnosis and verification of vertigo etiology

Roentgen computed tomography (RCT) and MR-imaging (MRI) were used in investigation of vertigo etiology and affection of the cochleovestibular analyzer in 130 patients aged 28 to 74 years with recurrent systemic rotatory vertigo or its other symptoms. All the patients have undergone comprehensive otoneurological examination, RCT and MRI which showed that peripheral cochleovestibular syndromes (PCVS) caused by arterial hypertension (AH), atherosclerosis (AS), vascular dystonia (VD) are rarely characterized by focal alterations in the brain. PCVS comparison with blood flow in the vertebral arteries (VA) detected most frequently anomalies and asymmetries of the diameters. MR-angiography plays an important role in verification of pathology of intracranial VA. In central cochleovestibular syndrome (CCVS) with AH, AS, VD, principal pathological changes were registered in the brain trunk and cerebellum by MRI. Vestibulometry and otoneurological method detect not only vascular cochleovestibular peripheral and central syndromes but also to make differential diagnosis. RCT and MRI verify cochleovestibular syndromes in patients with multiple encephalomyelitis, VIII nerve neurinoma and tumors of the posterior cranial fossa.     

Barotrauma and decompression illness of the inner ear: 46 cases during treatment and follow-up.

INTRODUCTION: Diving accidents affecting the inner ear are much more common than was once thought. Among the 319 patients treated in our clinic between January 2002 and November 2005, 46 cases involved 44 divers with symptoms of acute inner ear disorders. The objective of the present article is to investigate the symptoms of the acute disorders and assess any residual damage. STUDY DESIGN: Retrospective case analysis. MATERIALS AND METHODS: The medical records were used to study the cases of 18 divers treated for inner ear decompression illness on 20 occasions and 26 divers who had inner ear barotrauma. The symptoms of the disorder at the beginning of treatment, latency period before the first therapeutic measures, kind of initial therapy, symptoms after the accident, and hearing and balance functions at the last examination in our clinic were assessed. Divers with inner ear decompression illness were examined via means of transcranial or carotid Doppler ultrasonography for the presence of a vascular right-to-left (R/L) shunt. RESULTS: Of 18 divers with inner ear decompression illness, 17 reported vertigo as the main symptom. In one diver, the inner ear decompression illness was manifested bilaterally. The divers with inner ear decompression illness had been treated with hyperbaric oxygen therapy in 14 of 20 cases; the average latency period before the start of therapy was 40 hours (median, 10 h). In 15 (83%) of 18 patients, a large R/L shunt was detected, and in 14 (78%) of 18 patients, residual cochleovestibular damage was detected. Only 9 of 26 patients with inner ear barotrauma mentioned feeling dizzy, and in no patient was vertigo the main symptom. Twenty-one patients complained of tinnitus, whereas 20 complained of hearing loss. The hearing loss ranged from an unobtrusive difference of 10 dB between the ears up to complete deafness. Three patients were subjected to tympanoscopy because of suspected rupture of the round window membrane. Of patients with inner ear barotrauma, 78% had residual cochleovestibular damage. CONCLUSION: We describe for the first time a patient with bilateral manifestation of inner ear decompression illness. Inner ear decompression illness is frequently associated with a R/L shunt; therefore, after a diving accident, the patient's fitness to dive should be assessed via a specialist in diving medicine. Both decompression illness and barotrauma of the inner ear result in residual cochleovestibular damage in more than three of four patients.     

Utricular paresis and semicircular canal hyperactivity: a distinct otolith syndrome

Conclusions: Although combined utricular and canal paresis has been described previously, this is the first report of canal hyperactivity associated with utricular hypofunction. Unsteadiness and swaying were the most common symptoms, and patients with shorter duration of symptoms also had positional vertigo. We propose that this syndrome is a variant of utricular dysfunction and should be considered in the differential diagnosis of peripheral vestibular disorders. Objective: To describe a syndrome of instability associated with utricular dysfunction and hyperactive caloric responses. Methods: The study comprised 11 consecutive patients exhibiting abnormalities of the eccentric subjective visual vertical test (e-SVV) and high responses during the caloric test of the videonystagmography (VNG). We carried out a review of symptoms, physical examination, and vestibular tests. Results: There was no gender predilection or obvious etiology. The patients’ main complaint included instability with linear symptoms (i.e., tilting, rocking, and swaying), with positional vertigo as a secondary symptom. Oculomotor testing, visual fixation index, and brain MRI were normal, excluding a central nervous system disorder. VNG was essentially normal except for hyperactive responses during the caloric testing in all patients. Abnormal e-SVV was found in 10 patients unilaterally and bilaterally in 1 patient. Abnormal oVEMP was found in seven of seven patients, further supporting a utricular site of lesion.     

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.     

Surgical treatment of peripheral vertigo and vertiginous diseases

Although our understanding of the mechanisms of vertigo and pathophysiology of vertiginous disorders has increased, diagnosis and treatment of various vertiginous diseases is challenging. The objective for the treatment of a vertiginous disease is to eliminate the underlying pathology either with maneuvers or drugs. In vertiginous diseases, surgery is performed either to eliminate the underlying pathologic event or to create stability in the incoming vestibular signals. It is not always possible to treat the underlying disease. Therefore, surgery is usually performed for the relief of vertigo. There are various surgical approaches used to treat a variety of vertiginous diseases. Selection of the approach depends on the type of vertiginous disease. This review mainly focuses on the current status and outcome of the surgeries used in the treatment of a variety of vertiginous diseases.     

Fabry's disease: otoneurologic findings in twelve members of one family

Fabry's disease corresponds to an inherited disorder transmitted by an X-linked recessive gene. It generates a dysfunction of glycosphingolipid metabolism due to an enzymatic deficiency of alpha-galactosidase activity, resulting in glycosphingolipid deposits in all areas of the body. The clinical (heart, kidney, and central nervous system) manifestations are more severe in hemizygous boys than in heterozygous girls. They appear during childhood or adolescence: acroparesthesia, joint pain, angiokeratoma, corneal dystrophy, hypohydrosis or anhydrosis, and renal failure. The otoneurologic symptoms consist of hearing fluctuation, progressive unilateral or bilateral hearing loss, and episodes of vertigo or dizziness. Otoneurologic findings in 12 of 26 members of the same family are presented: the mother and 9 of her 12 children, as well as 2 of her 14 grandchildren: 4 healthy persons, 4 heterozygous female carriers, and 4 hemizygous male patients. Three of the male patients had fluctuation of hearing, sudden hearing loss, and episodes of vertigo and dizziness. The otoneurologic examinations showed a bilateral cochleovestibular deficit (n = 1), a right cochleovestibular deficit (n = 1), and a bilateral hearing loss combined with a right vestibular deficit (n = 1). Histopathologic evidence of glycosphingolipid accumulation in vascular endothelial and ganglion cells, as well as atrophy of the stria and spiral ligament, might explain the otoneurologic symptoms and findings.     

Cochleovestibular nerve sections in labyrinthectomized patients

Labyrinthectomy is indicated for a patient who has unilateral peripheral labyrinthine disease with unserviceable hearing loss. For most patients, labyrinthectomy provides complete relief from intractable vertigo. Some patients continue to have persistent vertigo, however, even after a complete destructive labyrinthectomy. Only after cochleovestibular nerve sections were these patients relieved of intractable vertigo. Representative cases of cochleovestibular nerve sections in labyrinthectomized patients are presented. The reason why the cochleovestibular nerve section relieves the symptom of vertigo in labyrinthectomized patients is not clear. Labyrinthectomy destroys vestibular sense organs, while cochleovestibular nerve section eliminates spontaneous activity and prevents the possibility of nerve regeneration by excision of the ganglion. For those patients who required vestibular nerve sections, there may have been abnormal excitation of vestibular nerve fibers. This might be explained by incomplete labyrinthectomy, regeneration of vestibular nerve fibers, contribution from vestibular ganglia or nonfunctioning cochlea, and vascular loop syndrome.     

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.     

Clinical investigation on hypotensive patients with vertigo

The aim of this study was to investigate the characteristic of hypotensive patients with vertigo. Twenty hypotensive patients with rotatory vertigo, 15 hypotensive subjects without vertigo, and 15 mitral valve prolapse subjects without vertigo underwent a battery of tests including audiometry, electronystagmography (ENG), and vestibular evoked myogenic potential (VEMP) test. The abnormal rates in terms of audiometry, eye tracking, optokinetic nystagmus, visual suppression, and caloric tests were 15, 35, 35, 10, and 42% for the first group; 13, 20, 33, 0, and 0% for the second group; and 7, 13, 60, 0, and 3% for the third group, respectively. Comparison of the first group with the other two control groups revealed that significant difference existed only in the abnormality of caloric responses. Fifteen (75%) of 20 hypotensive patients with vertigo having abnormal ENG results, asymmetric caloric responses, or delayed VEMPs were attributed to vertigo of central origin, possibly from ischemic disorder. In contrast, five patients (25%) had neither central signs in ENG nor abnormal VEMPs, but showing bilateral normal or hyperactive caloric responses were classified as autonomic dysfunction. After 3 months of medication, all patients with autonomic dysfunction had their vertigo and autonomic symptoms subsided, whereas 27% of the patients with ischemic disorder had vertigo persisted, showing a significant difference. In conclusion, hypotensive patients with vertigo could be due to either direct autonomic dysfunction or ischemic disorder mediated by autonomic deficits.     

Investigation of the vertebrobasilar arterial system in vertigo by vestibulocochlear test, SPECT and angiography

OBJECTIVE: Perfusion of the areas of cochleovestibular structures was investigated using Tc-99m HMPAO single photon emission computerized tomography (SPECT) in the young patients with vertigo presumed to have peripheral vestibular abnormalities and compared the results with cochleovestibular test results, and vertebrobasilar angiography findings. METHODS AND PATIENTS: The study was performed on 20 patients with vertigo and 17 control subjects who had performed vertebral arteriography due to another disease. The patients with vertigo presumed to be on peripheral vestibular disorder were included in the study. Systemic and otorhinolaryngological examination were carried out. Audiovestibular function was evaluated in all patients and control subjects. Brain SPECT was performed with a one-head rotating gamma camera system from 64 projections into a 64x64 matrix, using low energy and high-resolution fan beam collimators with a sampling time of 30 s. The images taken from cerebellum, temporal, parietal and occipital lobes which are supplied by a vertebrobasilar system were compared visually with the other side and asymmetry in the perfusion was searched. After cochleovestibular tests and laboratory had been completed, vertebral arteriography was performed bilaterally in all patients. Results of digital subtraction angiography (DSA) and the vestibulocochlear test were compared with images of SPECT. Data analysis was done with Yates Chi(2) and percentages of sensitivity and specificity were calculated. RESULTS: There was vestibular test and cochlear test abnormalities in eight and ten of the patients with vertigo, respectively. SPECT imaging showed hypoperfusion and decreased regional blood flow in 12 of the patients. There was statistically significant differences between the study and control groups in SPECT (P<0.05). Five patients showed abnormal findings in DSA examinations. CONCLUSION: It is believed that SPECT may be helpful in the detection of vascular pathology in the patients with vertigo.