Persistent continuous dizziness: pathophysiology and treatment

Persistent blurred vision and oscillopsia have a negative impact on quality of life, and the burden of these symptoms is more severe than that of rotationally vertiginous attack. We doctors should take patients' pain as our own and treat them accordingly. However, because these cases are rather rare in daily clinical experience, in reality we tend to treat these patients as neurosis cases and send the patients home without providing adequate care. We conducted a retrospective study involving 182 recently treated clinical cases and found that "jumbling of objects," which is thought to be caused by bilateral peripheral vestibular lesions, was more often observed in patients with central vestibular lesions. We named this the pseudo-Dandy phenomenon. In this study, we discuss the pathophysiology and treatment of this pseudo-Dandy phenomenon.     

A study of factors influencing intensity and annoyance in vertigo or dizziness

For 74 men and 123 women averaging 52.5 years of age with vertigo and dizziness, we recorded the age, gender, vertigo type, duration of illness, concomitant symptoms, and vestibular and psychological test results and used a 100 mm horizontal visual analog scale (VAS) to quantitatively assess sensation intensity and annoyance in vertigo or dizziness. Factors influencing these 2 quantitative assessment parameters were analyzed by stepwise multiple regression analysis. Factors influencing sensation intensity were nausea or vomiting as a concomitant symptom, duration of vertigo or dizziness (within a day), and first episode onset. Intensity of sensation to vertigo or dizziness, self-rating depression score (SDS), and gender (female) were selected as significantly influencing annoyance. These results suggest that rational care of significant factors that involve the intensity and annoyance in vertigo is essential to treating patients with vertigo or dizziness.     

A study of vertigo and dizziness in the premenstrual period

Twenty-five patients with nausea, vomiting and vertigo or dizziness in the premenstrual period were examined. In the week before menstruation, four of them had spontaneous nystagmus, six had positional nystagmus, and nine of them showed abnormal caloric responses. Most of them showed no abnormality during the week of menstruation. The caloric-induced responses were 'labyrinthine' in type in seven cases, and 'central' in type in two cases, thus denoting that cerebral oedema is not the only factor which may produce vertigo in the premenstrual period; as suggested by the present study, labyrinthine oedema may also play a considerable role in causing such troubles.     

Prevalence of dizziness and vertigo in an urban elderly population

The prevalence of balance symptoms (vertigo, dizziness, and dysequilibrium) was investigated in an epidemiological study of elderly people, the longitudinal and cross-sectional gerontological and geriatric population study from G?teborg, Sweden (H70). Three different age cohorts were studied, one at age 70, one at age 75 and one at ages 79, 82, 85, 88 and 90 years. Altogether 2011 participants answered the questionnaire at 3197 occasions. The overall prevalence of balance problems at age 70 was 36% (women) and 29% (men). Balance symptoms were more common among women than men, and increased with increasing age. At ages 88-90 years the corresponding values were 51-45%. The most common symptom was poor balance/general unsteadiness (11-41%). Rotatory symptoms occurred in 2-17%. Other types of symptoms were less common. Precipitating factors were rising from supine to sitting position in 17-40%. Balance symptoms in a side position were uncommon, but occurred more often when tilting the head backwards (up to 14%). Signs that possibly could indicate neurological involvement were uncommon. Falls in conjuncture to dizziness, vertigo and similar symptoms occurred in 7-15%, in about equal proportions indoors as outdoors.     

Persistent benign paroxysmal positional vertigo: our experience and proposal for an alternative treatment

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Despite the great efficacy of canalith repositioning procedures (CRPs), BPPV may persist (PBPPV). The aim of the study was to evaluate whether a prolonged and self-assessed temporal bone vibration (TBV) could change the outcome of PBPPV after 12 months of repeated treatments, in order to avoid further invasive and/or drug therapies. This evaluation was also conducted with respect to the entire BPPV population treated with CRPs. Seventy-two patients affected by PBPPV were enrolled in the study: 51 and 21 of them suffering from posterior semicircular canal (PSC) and lateral semicircular canal (LSC), respectively. PBPPV patients underwent a twice-a-day self-assessed TBV, using a common low-intensity massaging cushion. Patients were re-tested 1 week later and they were considered free from disease as the results of the positioning tests continued to be negative after 1 month. 70.6 % of PSC PBPPV and 61.9 % of LSC PBPPV patients had positive and statistically significant (P < 0.01) outcomes not biased by “age” and “gender” variables. The recurrence rate of BPPV (RBPPV) was also studied in the BPPV and PBPPV groups after a 12/24-month follow-up and any statistically significant result was found in multiple regression analysis between nuisance variables and RBPPV patients previously treated by CRPs or TBV. The present study suggests that the self-assessed and prolonged TBV could be an alternative treatment in patients affected by PBPPV otherwise addressed to undergo more invasive procedures and pharmacological treatment that are not completely side effects free.     

Residual dizziness after successful treatment of idiopathic benign paroxysmal positional vertigo originates from persistent utricular dysfunction

Objective: We used ocular vestibular evoked myogenic potentials to investigate the relationship between residual dizziness and utricular function following the canalith repositioning procedure for benign paroxysmal positional vertigo.

Methods: Ocular vestibular evoked myogenic potentials were measured in 44 patients (40 included in analyses, four excluded) with successful results from the canalith repositioning procedure. The patients were examined before treatment and again one week after treatment. We analyzed how various general factors and ocular vestibular evoked myogenic potentials related to residual dizziness.

Results: Residual dizziness was not related to gender, affected side, age, duration of symptoms, recurrence, or the results of the initial ocular vestibular evoked myogenic potential test (p?>?.05). However, residual dizziness was significantly associated with the results of the second ocular vestibular evoked myogenic potential test (p?=?.007).

Conclusions: Residual dizziness after a successful canalith repositioning procedure may be caused by persistent utricular dysfunction.     

Surgical treatment of vertigo by utriculostomy: an experimental study in sheep.

The objective of this study was to develop and test an endolabyrinthic microsurgical procedure for treatment of vertigo, the utriculostomy. This involves the application of local heat for obtaining a fistula in the membranous labyrinth, so as to establish communication between the endolymphatic and perilymphatic spaces at the utricle level. Before the procedure, an experimental model using quail eggs was built for pre-evaluation, and macroscopic and histological studies were performed in the temporal bones of three healthy sheep. Following this, the utriculostomy was performed through the oval window in 12 sheep. A microthermocautery was conceived by the first author and developed at Hospital de Clinicas de Porto Alegre. This equipment allows for control of temperature and duration of exposure to heat. Three months after the surgery, the animals were killed. A histological study of the temporal bones was performed to assess whether communication had been created between the endolymphatic and perilymphatic spaces, or whether a neomembrane had developed in the cauterized region. Histological sections of the vestibule of eight animals (three normal, five surgical) were analysed. All non-surgical cases presented a normal utricle wall. Three surgical cases (60%) presented a neomembrane. The absence of identifiable perforations in the utricle wall and the presence of neomembrane areas in 60% of the operated bones suggest that utriculostomy is a promising procedure for the treatment of Meniere's disease.     

Persistent vertigo following particle repositioning maneuvers: an analysis of causes

OBJECTIVE: To analyze the causes of persistent vertigo following treatment with particle repositioning maneuvers (PRMs) in patients with benign paroxysmal positional vertigo. DESIGN: Prospective study of outcomes in patients with benign paroxysmal positional vertigo. STUDY SETTING: Outpatient clinic of a tertiary care referral center. PATIENTS: A sample of 90 consecutive patients with documented benign paroxysmal positional vertigo of the posterior semicircular canal who had persistent vertigo after at least 3 sessions of PRMs during a period of 2 weeks. INTERVENTION: Particle repositioning using a modified Epley maneuver. MAIN OUTCOME MEASURE: Persistent vertigo following at least 3 sessions of PRMs over a period of 2 weeks. RESULTS: Seven patients showed partial or no improvement following treatment. The causes subsequently determined included coincident horizontal canal positional vertigo (2 cases), Ménière's disease (2 cases), persistent posterior canal benign paroxysmal positional vertigo in association with cervical spondylosis (2 cases), and a posterior fossa meningioma (1 case). CONCLUSIONS: Patients with persistent or frequently recurring positional vertigo following treatment with PRMs should undergo detailed investigation to exclude coincidental pathology for which specific treatment is required. In patients in whom no coincident pathology requiring therapy is identified, treatment options other than the PRM already instituted should be considered.     

Danhong enhances recovery from residual dizziness after successful repositioning treatment in patients with benign paroxysmal positional vertigo

ObjectivesAlthough the repositioning maneuvers are usually very effective in patients with BPPV, some patients still complain residual dizziness. Danhong injection (DHI), a traditional Chinese medicine, can effectively dilate blood vessels and improve microcirculation, and has been proven to be effective in improving cervical vertigo and posterior circulation ischemic vertigo. The aim of this study was to evaluate the effects of DHI on residual dizziness after successful repositioning treatment in patients with BPPV.MethodsEighty-six patients with BPPV were randomized into two treatment groups, DHI group and non DHI group. The DHI group received the same repositioning treatment as the non-DHI group, with the addition of DHI therapy. The durations of residual dizziness of DHI group and non-DHI group were compared. In addition, the scores of the dizziness handicap inventory of these two groups were calculated.ResultsThe durations of residual dizziness of DHI group were shorter than that of non-DHI group. There were no significant differences in the scores of dizziness handicap inventory in the first week between these two groups, and there were much significant differences in the second, the fourth, the sixth and eighth weeks.ConclusionsThe results demonstrate that DHI can significantly improve the residual dizziness after successful repositioning treatment in patients with BPPV.     

Common factors in speech-language treatment: An exploratory study of effective clinicians

Research in related fields that employ behavioral interventions indicates that factors common to treatment programs may be more important to successful outcomes than specific components of a treatment. Applying this concept to speech-language pathology, we investigated one hypothesized “common factor,” namely, the clinician who implements treatment. Data were collected from limited samples of speech-language clinicians in two surveys. In Study One, 79 participants responded to open-ended questions about the nature of effective clinicians. A thematic analysis of their responses resulted in three broad categories of characteristics: behaviors, traits, and acquisitions. These themes were incorporated into an online survey for Study Two, in which 158 clinicians rated the importance of 25 clinician qualities. Their ratings suggested that the clinician–client relationship may be particularly important to treatment outcomes. These preliminary findings provide a foundation for further research on the clinician's contribution to treatment efficacy.Learning outcomes: Readers will be able to: (1) understand the concept of Common Factors; (2) describe the impact of clinicians on speech-language therapy outcomes as predicted by the Common Factors model; (3) list important characteristics of effective speech-language clinicians.     

Caloric test and video-head-impulse: a study of vertigo/dizziness patients in a community hospital

The head-impulse test (HIT) is an important test for examining unilateral vestibular hypofunction. The new video-head-impulse test (vHIT) is more sensitive and specific than the clinical bedside-head-impulse test (bHIT). Alternatively, one can test for vestibular hypofunction with the caloric irrigation test. Various studies showed that both tests may not always identify vestibular hypofunction; instead, the results of the tests might be contradictory. To evaluate the diagnostic value of these tests, we routinely measured patients exhibiting vertigo or dizziness at our community hospital with bithermal caloric irrigation, the bHIT and the vHIT. Only those patients (n = 172) with a pathological caloric irrigation test of more than 25 % unilateral weakness in the Jongkee’s formula were included. Out of these patients, 41 % had a pathologic vHIT. Among the subgroup with acute symptoms (symptom onset within 5 days), 63 % had a pathological video-head-impulse, whereas only 33 % of the non-acute group (symptom onset more than 5 days) tested pathological. A pathological HIT depended on the disease stage, the amount of unilateral weakness in caloric examination and on the test itself.     

Type I Tympanoplasty: surgical success and prognostic factors

ObjectivesTo evaluate success rate of type I tympanoplasty in adults and to investigate the importance of selected prognostic factors on graft uptake.Material and methodsRetrospective medical chart review of 155 patients who underwent Type I Tympanoplasty, in our department, from January 2013 to December 2017. Graft uptake rate was evaluated and the effects of prognostic factors on surgical outcome such as sex, smoking and otological surgery history, status of the contralateral ear, size and location of the perforation, middle ear mucosa status, surgical approach and graft material. Preoperative and postoperative audiometric data were collected, and the functional success was determined.ResultsThe overall surgical anatomical success rate was 75%. Analysis of the selected variables, identified as independent prognostic factors of anatomical unsuccess (95% CI): smoking (OR = 3.29, p < .01), middle ear tympanosclerosis (OR = 2.96; p = .04). Perforations above 50% of the tympanic membrane area had a borderline effect on graft uptake (p = .05). There was a significative improvement in the average air conduction thresholds of 7.44 dB and an ABG closure rate at 10 dB and 20 dB was achieved in 47% and 84.5%, respectively. Patients who received temporalis fascia graft had similar hearing gain compared to patients who underwent cartilage tympanoplasty (7.7 vs. 7.3 dB, p = .79).ConclusionType I tympanoplasty is an effective and safe procedure with a high anatomical success rate in the treatment of mucosal COM. Poorer outcomes were found in patients with smoking habits, in those with tympanosclerosis of middle ear mucosa and in larger perforations. These prognostic factors should be considered in surgical planning and patients should be advised to quit smoking. Tympanoplasty with cartilage graft had a hearing outcome comparable to temporalis fascia graft and should be considered in high-risk patients.     

Long-term results in ossiculoplasty: an analysis of prognostic factors.

OBJECTIVES: The aim of the present study is to examine the prognostic factors based on 6-month and 5-year results of ossiculoplasty. STUDY DESIGN: Retrospective analysis was made on the ossiculoplasty cases in a county hospital. The information was extracted from a computer database. METHODS: All patients who had ossiculoplasty were routinely followed up in a dedicated ear audit clinic on a yearly basis. Between 1988 and 1999, 242 ossiculoplasties for chronic otitis media were performed on 197 patients. Only the first ossiculoplasty operation performed on each patient during the study period was included in the analysis. The 6-month and 5-year results were analyzed. Two different statistical methods were used--logistic regression analysis and the analysis of variance (ANOVA). A successful ossiculoplasty is defined as a postoperative air-bone gap (ABG) of 20 dB or better. RESULTS: The overall success rate of ossiculoplasty was 66.5% at 6 months and 50.3% at 5 years. In a multivariate analysis using logistic regression, those with present malleus were 6.36 times more likely to be successful. Using ANOVA, absent malleus and otorrhea were unfavorable factors of the 6-month ABG. Using logistic regression for the 5-year analysis, malleus remained a significant predictor at 5 years. Those with malleus were 2.65 times more likely to be successful. Using ANOVA, absent malleus was the only significant unfavorable factor of postoperative ABG at 5 years. In the univariate analysis, absent stapes and revision surgery are regarded as possible unfavorable factors. CONCLUSION: In the present study, the authors try to define the studied population (chronic otitis media) and the follow-up period (6 months and 5 years), and use logistic regression and ANOVA for statistical analysis. Absent malleus and otorrhea are important unfavorable factors for short-term outcome in ossiculoplasty (6 months), whereas absent malleus is the only important unfavorable factor for long-term outcome in ossiculoplasty (5 years).     

Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo.

OBJECTIVE: The purpose of the study was to determine whether a newly developed subscale of the Dizziness Handicap Inventory (DHI) could assist in the screening of benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Retrospective case review. SETTING: Tertiary balance referral center. PATIENTS: Charts of 383 patients (mean age, 61 yr) with a variety of vestibular diagnoses (peripheral and central) were reviewed. INTERVENTIONS: Patients completed the DHI before the onset of physical therapy intervention. MAIN OUTCOME MEASURES: A newly developed BPPV subscale developed from current DHI items was computed to determine whether the score could assist the practitioner in identifying individuals with BPPV. RESULTS: Individuals with BPPV had significantly higher mean scores on the newly developed BPPV subscale of the DHI (p < 0.01). The five-item BPPV score was a significant predictor of the likelihood of having BPPV (chi2 = 8.35; p < 0.01). On the two-item BPPV scale, individuals who had a score of 8 of 8 were 4.3 times more likely to have BPPV compared with individuals who had a score of 0. CONCLUSION: Items on the DHI appear to be helpful in determining the likelihood of an individual having the diagnosis of BPPV.