Persistent Postural Perceptual Dizziness In The Neurology Clinic.

Aim: To determine the proportion of referrals to a General Neurology New Patient Clinic which meet the diagnostic criteria of Persistent Postural Perceptual Dizziness (PPPD) and to gauge patient-perceived response to treatment. Methods: Referral letters, n=1315, to a General Neurology New Patient Clinic from 2021-2023 were screened for terms 'dizziness', 'vertigo', 'unsteadiness' and 'vestibular'. A chart review was performed to establish study outcomes. Results: 202 (15.4%) patients were referred with 'dizziness', 'vertigo' or 'unsteadiness', 22 (11%) of which fulfilled the diagnostic criteria. Venlafaxine was offered in 10 (45.5%) patients and conferred ≥50% benefit in 8 (80%). Vestibular physiotherapy improved symptoms by ≥25% in all 7 (100%) patients with access to the intervention. Cognitive behavioural therapy and effective communication of the diagnosis alleviated symptoms by 50% in 3 (14%) patients respectively. Discussion: PPPD is increasingly recognised in patients with chronic vestibular symptoms and can cause significant functional morbidity. Venlafaxine may independently improve symptoms1.

Effectiveness of vestibular rehabilitation therapy and yoga in the management of chronic peripheral vertigo: A randomized controlled trial.

Background: The purpose of the study was to compare the effectiveness of yoga as a form of Vestibular Rehabilitation (VR) to standard VR for managing patients with symptoms such as dizziness, disequilibrium and gait instability. Methods: 150 participants based on 18-point difference in the DHI score were randomly assigned to group 1- Yoga, group 2- VR and group 3- control group using block randomization. The intervention was provided for 12 weeks. The participants were assessed for Dizziness Handicap Inventory (DHI) at baseline, 4 th, 8 th and 12 th week. Results: The mean DHI for group 1(41.12±7.13) group 2 (42.96±10.54) group 3 (50.84±10.78), p<0.001 decreased significantly in group 1 and 2 when compared to baseline. There was no statistically significant difference in overall Dizziness Handicap Inventory (DHI) scores between the Yoga and Physiotherapy groups after one month; however, both groups resulted in a significant decrease in scores when compared to the control group. Similarly, by the end of the second and third months, there was no significant distinction between the Yoga and Physiotherapy groups, even though both had a considerable decrease in DHI scores when compared to the control group. Furthermore, an examination of the functional, emotional, and physical components of DHI demonstrated persistent trends of significant improvement in both the Yoga and Physiotherapy groups as compared to the control group over a three-month period. Conclusions: In addition to VR, Yoga and medications administered concurrently can provide effective therapeutic effects. Yoga has an advantage over VR since it offers a customized cure for giddiness in addition to symptom relief. Yoga might be a great alternative to the conventional VR because along with enhancing overall body relaxation, it is affordable and is easy to learn.

Evaluating diagnostic and management agreement between physiotherapists and ear, nose and throat specialist in a primary contact physiotherapy-led vestibular clinic: A prospective blinded inter-rater agreement pilot study.

BACKGROUND: Dizziness and vertigo are common referrals to Ear Nose Throat (ENT) outpatient services however these services have long waitlists for assessment. Primary contact physiotherapy-led vestibular clinics are recognized as improving access to care. This pilot study investigated agreement between physiotherapists and an ENT medical practitioner for diagnostic and management decisions in patients attending a primary contact physiotherapy-led vestibular clinic. METHODS: Prospective blinded inter-rater agreement study undertaken in an ENT primary contact physiotherapy-led vestibular clinic. Participants were adults referred to ENT from general practitioners, triaged (Category 2 or 3) to the primary contact physiotherapy-led vestibular clinic with clinical symptoms consistent with vestibular disorder. Primary outcome measures included agreement of diagnoses and management decisions made by an ENT medical practitioner and Physiotherapist based on a vestibular physiotherapy assessment. Adverse events were reviewed 11 months post data collection. Gwet's first order agreement co-efficient (AC1) calculated inter-rater reliability between physiotherapy and ENT. RESULTS: Fifty-one participants were recruited consecutively from the primary contact physiotherapy-led vestibular clinic. Physiotherapy and ENT had a substantial agreement (AC1 0.613) on diagnosis. AC1 between physiotherapy and ENT for recommending Magnetic resonance imaging (0.810) and computerized tomography (0.935) both indicated near perfect agreement. There was moderate to near-perfect agreement regarding management recommendations between physiotherapy and ENT. Substantial agreement (AC1 0.720) was found for recommendations for ENT input, near perfect agreement (AC1 0.933) for neurology input and moderate agreement (AC1 0.574) for physiotherapy input. There were no adverse events from physiotherapist's management decision, based on final recommendations undertaken 11-months post data collection. CONCLUSIONS: Physiotherapists and ENT medical practitioner made comparable diagnostic and management decisions, based on physiotherapy and audiology hearing assessment, for adults with signs of vestibular dysfunction, within an ENT primary contact physiotherapy-led vestibular clinic. This study provides support for this type of Physiotherapy-led service in managing patients referred to an ENT service with vestibular dysfunction.

Approach to Acute Dizziness/Vertigo in the Emergency Department: Selected Controversies Regarding Specialty Consultation.

Acute dizziness and vertigo are common emergency department presentations (≈4% of annual visits) and sometimes, a life-threatening diagnosis like stroke is missed. Recent literature reviews the challenges in evaluation of these symptoms and offers guidelines for diagnostic approaches. Strong evidence indicates that when well-trained providers perform a high-quality bedside neurovestibular examination, accurate diagnosis of peripheral vestibular disorders and stroke increases. However, it is less clear who can and should be performing these assessments on a routine basis. This article offers a focused debate for and against routine specialty consultation for patients with acute dizziness or vertigo in the emergency department as well as a potential path forward utilizing new portable technologies to quantify eye movements.

Evaluation of the audiovestibular system before and after treatment in patients with Idiopathic intracranial hypertension.

BACKGROUND: Idiopathic intracranial hypertension (IIH) can affect both hearing and balance due to increased inner ear pressure. AIMS/OBJECTIVES: This study aimed to evaluate the impact of increased inner ear pressure on hearing and balance in patients with IIH using auditory and vestibular tests. MATERIAL AND METHODS: Twenty-four IIH patients and 28 healthy controls underwent oVEMP, pure tone audiometry, tympanometry, and acoustic reflex tests pre-lumbar punctures. IIH patients received acetazolamide. Pre- and post-treatment results, tinnitus, and vertigo scores were compared. Post-treatment oVEMP and audiometry results were compared between groups. RESULTS: Pre-treatment oVEMP showed a significant left N1 latency difference (p = 0.049). Post-treatment, left ear amplitude (p = 0.035) and both ear amplitude ratios (p = 0.044 and p = 0.047) increased significantly. Audiometry had no significant changes (p < 0.05). Tinnitus and vertigo scores decreased significantly (p ≤ 0.001). CONCLUSION: Prolonged oVEMP latency suggests IIH may impact the brain stem and vestibular nerve, while increased amplitude values indicate peripheral vestibular involvement. IIH affects hearing across all frequencies, especially at 4000 Hz, impacting both hearing and balance. SIGNIFICANCE: Understanding the effects of IIH on auditory and vestibular functions can guide effective treatments, improving quality of life for patients by addressing both hearing and balance issues.

Feasibility of gamified visual desensitisation for visually-induced dizziness.

Visually-induced dizziness (visual vertigo) is a core symptom of Persistent Perceptual Postural Dizziness (PPPD) and occurs in other conditions and general populations. It is difficult to treat and lacks new treatments and research. We incorporated the existing rehabilitation approach of visual desensitisation into an online game environment to enhance control over visual motion and complexity. We report a mixed-methods feasibility trial assessing: Usage and adherence; rehabilitation potential; system usability and enjoyment; relationship with daily dizziness. Participants played online with (intervention, N = 37) or without (control, N = 39) the visual desensitisation component for up to 5-10 min, twice daily for 6 weeks. Dropout was 45%. In the intervention group, N = 17 played for the recommended time while N = 20 played less. Decreases in visual vertigo symptoms, anxiety and depression correlated with playtime for the intervention but not control. System usability was high. Daily symptoms predicted playtime. Qualitative responses broadly supported the gamified approach. The data suggest gamified visual desensitisation is accessible, acceptable and, if adherence challenges can be overcome, could become a useful addition to rehabilitation schedules for visually-induced dizziness and associated anxiety. Further trials are needed.

[Application of the holism of body-qi-spirit in needle knife treatment for cervical vertigo].

This paper introduces Professor WANG Haidong's approach to treat cervical vertigo with needle knife based on the holism of body-qi-spirit. Professor WANG Haidong, considering the etiology and pathogenesis of cervical vertigo, starting from the holism of body-qi-spirit, based on the anatomical structure, employs the "seven-neck points" technique to improve local blood supply and address the physical issue; guided by the Jingjin theory, he utilizes the "knot releasing technique" to disperse knots and relax sinews, thereby regulating qi. In addition, he uses the "bone puncturing technique at governor vessel" to uplift yang-qi and nourish the brain, thereby nurturing the spirit.

The First 100 Children Treated in a Newly Established Pediatric Vertigo Center.

BACKGROUND: Correctly diagnosing dizziness in children is essential for appropriate management; nevertheless, healthcare professionals face challenges due to children's limited ability to describe their symptoms and their cooperation during physical examination. The objective of this study is to describe the first 100 patients seen at a newly established pediatric vertigo center. METHODS: This is a retrospective review of a consecutive series of 100 patients seen at our pediatric vertigo clinic in a tertiary referral center from August 2019 until June 2022. Comprehensive clinical data were collected. The diagnoses were established by 2 pediatric otolaryngologists based on validated diagnostic criteria. Trends in diagnosis, investigation, and treatment of these patients were analyzed. RESULTS: A total of 100 children were included in the study. Vestibular migraine was the most common diagnosis (20%) followed by benign paroxysmal vertigo of childhood (14%). Eleven patients had combined pathologies. Fifteen out of 70 children (21%) had abnormal audiograms, 30 out of 48 children (62.5%) had abnormal vestibular testing, and 6 out of 31 (19%) patients had abnormal imaging. Fifty-one children received medical treatment, 23 received vestibular physiotherapy, and 9 patients had particle repositioning maneuvers; moreover, 17 of these patients received multimodal treatment. CONCLUSIONS: Our analysis suggests that imaging and audiology testing have relatively low yield in the assessment of pediatric vertigo. On the other hand, vestibular testing detected a high proportion of abnormalities, such as saccadic pursuit, vertical nystagmus, central positional nystagmus, and abnormal directional preponderance, particularly associated with vestibular migraine. Given the complexity of diagnosing vertigo in children, it is critical to establish multidisciplinary specialized centers capable of providing accurate diagnosis and treatment for these children.

Cervical vertigo due to rotational fixation of atlantoaxial joint combined with benign paroxysmal positional vertigo: A case report and literature review.

INTRODUCTION: Vertigo is the most common clinical complaint, misdiagnosed patients are not rare, so it is very important to exclude and identify vertigo. For vertigo caused by multiple causes, including cervical vertigo with atlantoaxial rotation fixation combined with benign paroxysmal positional vertigo (BPPV), tuina can correct joint misalignment. The reduction technique will return the fallen otolith to the correct position. The use of massage and reduction can improve clinical symptoms and improve quality of life and may be a simple, safe, and effective treatment strategy for this disease. PATIENT CONCERNS: We report on a patient with both cervical vertigo due to atlantoaxial rotational fixation and BPPV, including his imaging examination, clinical manifestations, and treatment methods. DIAGNOSIS: Cervical vertigo (atlantoaxial rotatory fixation) and BPPV. INTERVENTION: Tuina combined with atlantoaxial directional inverted reduction technique and reduction manipulation. OUTCOMES: The patient's vertigo symptoms improved significantly, nystagmus disappeared, cervical occipital pain, nausea, head distension, and other symptoms disappeared, and cervical motion rotation reached 60°. CONCLUSION: This study proved the effectiveness of massage combined with a reduction in the treatment of cervical vertigo and BPPV, as well as the importance of vertigo diagnosis and differential diagnosis, and provided a new treatment idea for the future diagnosis and treatment of vertigo caused by a variety of causes.

Otology: Vertigo.

Vertigo, an unexpected feeling of self-motion, is no longer characterized simply by symptom quality but by using triggers and timing. Evaluating vertigo by triggers and timing not only distinguishes serious central causes from benign peripheral causes, but also narrows the differential diagnosis by further classifying vertigo as spontaneous episodic vestibular syndrome, triggered episodic vestibular syndrome, or acute vestibular syndrome. A targeted physical examination can then be used to further delineate the cause within each of these three vestibular categories. Neuroimaging and vestibular testing are not routinely recommended. In the management of vertigo, vestibular hypofunction can be treated with vestibular rehabilitation, which can be self-administered or directed by a physical therapist. Pharmacotherapy sometimes is indicated for vertigo based on triggers, timing, and the specific condition, but it is not always beneficial and is used more often for symptom reduction than as a cure. Transtympanic corticosteroid or gentamicin injections are recommended for patients who do not benefit from nonablative therapy. Surgical ablative therapy is reserved for patients who have not benefited from less definitive therapy and have nonusable hearing.

[Nape seven needles combined with pressing moxibustion for cervical vertigo: a randomized controlled trial].

OBJECTIVE: To observe the clinical effect of nape seven needles combined with pressing moxibustion for cervical vertigo (CV). METHODS: A total of 70 patients with CV were randomized into an observation group and a control group, 35 cases in each group. In the observation group, nape seven needles combined with pressing moxibustion was delivered, once a day, 6 times a week, for consecutive 2 weeks. In the control group, betahistine hydrochloride tablet and aceclofenac dispersible tablet were given orally, for 2 weeks and 3 days respectively. Before and after treatment, the evaluation scale for cervical vertigo (ESCV) score was observed, the plasma levels of neuropeptide Y (NPY), endothelin-1 (ET-1) and calcitonin gene related peptide (CGRP) were detected, the hemorheologic and hemodynamic indexes were measured, and the clinical efficacy was evaluated after treatment in the two groups. RESULTS: After treatment, the scores of dizziness, daily life and work ability, psychological and social adaptability, and headache, as well as the total scores of ESCV were increased compared with those before treatment (P<0.01, P<0.05) in the two groups, and the score and total score of neck and shoulder pain of ESCV was increased compared with that before treatment (P<0.01) in the observation group; each sub-item score and total score of ESCV in the observation group were higher than those in the control group (P<0.01, P<0.05). After treatment, the plasma levels of NPY and ET-1 were decreased compared with those before treatment (P<0.01), while the plasma levels of CGRP were increased compared with those before treatment (P<0.01, P<0.05) in the two groups; the plasma levels of NPY and ET-1 in the observation group were lower than those in the control group (P<0.01), the plasma level of CGRP in the observation group was higher than that in the control group (P<0.01). After treatment, the whole blood high shear viscosity, plasma viscosity and whole blood low shear viscosity were decreased compared with those before treatment (P<0.01, P<0.05), the mean velocity of basilar artery (BA), left vertebral artery (LVA) and right vertebral artery (RVA) were increased compared with those before treatment (P<0.05) in the two groups; the whole blood high shear viscosity, plasma viscosity and whole blood low shear viscosity in the observation group were lower than those in the control group (P<0.01), and the mean velocity of BA, LVA and RVA in the observation group were higher than those in the control group (P<0.05). The total effective rate in the observation group was 91.4% (32/35), which was superior to 71.4% (25/35) in the control group (P<0.05). CONCLUSION: Nape seven needles combined with pressing moxibustion can effectively alleviate the clinical symptoms, and improve the hemorheology and hemodynamics in CV patients.

Consensus paper on the management of acute isolated vertigo in the emergency department.

Acute vertigo is defined as the perception of movement of oneself or the surroundings in the absence of actual motion and it is a frequent cause for emergency department admissions. The utilization of medical resources and the duration of hospital stay for this kind of symptom is high. Furthermore, the efficiency of brain imaging in the acute phase is low, considering the limited sensitivity of both CT and MRI for diagnosing diseases that are the causes of central type of vertigo. Relying on imaging tests can provide false reassurance in the event of negative results or prolong the in-hospital work-up improperly. On the other hand, clinical examinations, notably the assessment of nystagmus' features, have proven to be highly accurate and efficient when performed by experts. Literature data point out that emergency physicians often do not employ these skills or use them incorrectly. Several clinical algorithms have been introduced in recent years with the aim of enhancing the diagnostic accuracy of emergency physicians when evaluating this specific pathology. Both the 'HINTS and 'STANDING' algorithms have undergone external validation in emergency physician hands, showing good diagnostic accuracy. The objective of this consensus document is to provide scientific evidence supporting the clinical decisions made by physicians assessing adult patients with acute vertigo in the emergency department, particularly in cases without clear associated neurological signs. The document aims to offer a straightforward and multidisciplinary approach. At the same time, it tries to delineate benchmarks for the formulation of local diagnostic and therapeutic pathways, as well as provide a base for the development of training and research initiatives.

Advances in diagnosis and treatment of vestibular migraine and the vestibular disorders it mimics.

Dizziness is one of the most common chief complaints in both the ambulatory care setting and the emergency department. These symptoms may be representative of a broad range of entities. Therefore, any attempt at treatment must first start with determining the etiology. In this current perspective, we focus specifically on the diagnosis of and treatment of vestibular migraine, which is common and overlaps clinically with a variety of other diagnoses. We discuss the traditional treatments for vestibular migraine in addition to the recent explosion of novel migraine therapeutics. Because vestibular migraine can mimic, or co-exist with, a variety of other vestibular diseases, we discuss several of these disorders including persistent postural-perceptual dizziness, benign paroxysmal positional vertigo, post-concussive syndrome, Ménière's disease, and cerebrovascular etiologies. We discuss the diagnosis of each, as well as overlapping and distinguishing clinical features of which the reader should be aware. Finally, we conclude with evidence based as well as expert commentary on management, with a particular emphasis on vestibular migraine.

Advances in the diagnosis and management of acute vertigo.

BACKGROUND: Patients presenting to the emergency department with acute vertigo pose a diagnostic challenge. While 'benign' peripheral vestibulopathy is the most common cause, the possibility of a posterior circulation stroke is paradoxically the most feared and missed diagnosis in the emergency department. OBJECTIVES: This review will attempt to cover the significant advances in the ability to diagnose acute vertigo that have occurred in the last two decades. The review discusses the role of neurological examinations, imaging and specific oculomotor examinations. The review then discusses the relative attributes of the Head Impulse-Nystagmus-Test of Skew plus hearing ('HINTS+') examination, the timing, triggers and targeted bedside eye examinations ('TiTrATE'), the associated symptoms, timing and triggers, examination signs and testing ('ATTEST') algorithm, and the spontaneous nystagmus, direction, head impulse testing and standing ('STANDING') algorithm. The most recent technological advancements in video-oculography guided care are discussed, as well as other potential advances for clinicians to look out for.

Beyond Vertigo: Vestibular, Aural, and Perceptual Symptoms in Vestibular Migraine.

PURPOSE: To review the vestibular, aural, and perceptual symptoms of vestibular migraine (VM) that may present alongside vertigo. RECENT FINDINGS: Increased research attention to the wide spectrum of symptoms presenting in VM patients has improved understanding of this disorder, with recent identification of five different VM phenotypes. Research into the clinical overlap between VM and other chronic vestibular syndromes such as persistent postural-perceptual dizziness and mal-de-debarquement syndrome reveals a range of vestibular symptoms and hints at pathophysiological connections between migraine and vestibular dysfunction. Studies of migraine treatment for hearing loss suggest patients presenting with aural symptoms may have an underlying diagnosis of migraine and deserve a trial of migraine preventives. Research into the neurologic basis of the perceptual disorder Alice in Wonderland syndrome has revealed brain areas that are likely involved and may help explain its prevalence in VM patients. VM is a sensory processing disorder that presents with more than just vertigo. Understanding the range of potential symptoms improves diagnosis and treatment for migraine patients whose diagnosis may be missed when only the symptoms identified in the diagnostic criteria are considered.

Focused Update on Migraine and Vertigo Comorbidity.

PURPOSE OF REVIEW: To provide an update on comorbidity of vestibular symptoms and migraine. RECENT FINDINGS: Multisensory processing and integration is a key concept for understanding mixed presentation of migraine and vestibular symptoms. Here, we discuss how vestibular migraine should be distinguished from a secondary migraine phenomenon in which migraine symptoms may coincide with or triggered by another vestibular disorder. We also have some updates on the diagnostic criteria of vestibular migraine, its pathophysiology, and common approaches used for its treatment. As a common clinical presentation of migraine and vestibular symptoms, vestibular migraine should be distinguished from a secondary migraine phenomenon, in which migraine symptoms may be triggered by or coincide with another vestibular disorder. Recent experimental evidence suggests vestibular symptoms in vestibular migraine are linked to multisensory mechanisms that control body motion and orientation in space.

Vestibular migraine: an update.

PURPOSE OF REVIEW: We performed a narrative review of the recent findings in epidemiology, clinical presentation, mechanisms and treatment of vestibular migraine. RECENT FINDINGS: Vestibular migraine is an underdiagnosed condition that has a high prevalence among general, headache and neuro-otology clinics. Vestibular migraine has a bimodal presentation probably associated with a hormonal component in women. These patients could have a complex clinical phenotype including concomitant autonomic, inflammatory or connective tissue conditions that have a higher prevalence of psychological symptoms, which may mistakenly lead to a diagnosis of a functional neurological disorder. A high proportion of patients with postural perceptual persistent dizziness have a migraine phenotype. Independently of the clinical presentation and past medical history, patients with the vestibular migraine phenotype can respond to regular migraine preventive treatments, including those targeting the calcitonin gene-related peptide pathways. SUMMARY: Vestibular migraine is an underdiagnosed migraine phenotype that shares the pathophysiological mechanisms of migraine, with growing interest in recent years. A thorough anamnesis is essential to increase sensitivity in patients with unknown cause of dizziness and migraine treatment should be considered (see supplemental video-abstract).

[Preliminary observation of wearable balance diagnosis and treatment system in evaluating dynamic and static balance function in patients with vestibular vertigo].

A newly developed wearable balance diagnosis and treatment system was studied to evaluate the indexes of the abnormal balance function in patients with vestibular vertigo. A cross-sectional study was carried out. A total of 30 patients diagnosed with non-acute vestibular vertigo in the outpatient department of Eye, Ear, Nose and Throat Hospital Affiliated to Fudan University from July 2022 to May 2023 were selected as the vertigo group, including 13 males and 17 females, and aged (45.7±13.9) years. Meanwhile, 20 healthy controls (8 males and 12 females) were included as the control group, with a mean age of (43.6±8.0) years. The static balance and limits of stability (LOS) function of all subjects were assessed with wearable balance diagnosis and treatment system developed under the leadership of Eye & ENT Hospital of Fudan University. In the static balance test, the ratio of eyes open with cushions to eyes open without cushions in the vertigo group was less than that of the control group[1.20% (0.92%, 1.53%) vs 1.49% (1.22%, 1.81%), P=0.008], indicating that patients with non-acute vestibular vertigo may compensate static balance ability earlier. In vertigo group, the directional control in 8 directions, the maximum excursion in anterior, posterior, right anterior and right posterior directions, the endpoint excursion in the posterior, right posterior, and left posterior directions were all smaller than those of the control group (all P<0.05). The reaction time in the left posterior direction of vertigo group was longer than that of the control group (all P<0.05). Those results indicated that the directional control, maximum excursion and endpoint excursion of LOS could be considered as important reference indexes for dynamic balance function.

Assessment and management of vestibular migraine within ENT.

OBJECTIVE: Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic. METHOD: Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine. RESULTS: A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging. CONCLUSION: This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.