Assessing the impact of migraine on benign paroxysmal positional vertigo symptoms and recovery.

BACKGROUND: During episodes of benign paroxysmal positional vertigo (BPPV), individuals with migraine, compared with individuals without migraine, may experience more severe vestibular symptoms because of their hyperexcitable brain structures, more adverse effects on quality of life, and worse recovery processes from BPPV. METHODS: All patients with BPPV were assigned to the migraine group (MG, n = 64) and without migraine group (BPPV w/o MG, n = 64) and completed the Vertigo Symptom Scale (VSS), Vertigo Dizziness Imbalance Symptom Scale (VDI-SS), VDI Health-Related Quality of Life Scale (VDI-HRQoLS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI) at the time of BPPV diagnosis (baseline) and on the one-month follow-up. Headache Impact Test-6 and Migraine Disability Assessment Scale were used for an assessment of headache. Motion sickness was evaluated based on the statement of each patient as present or absent. RESULTS: Compared with the BPPV w/o MG, the MG had higher VSS scores at baseline [19.5 (10.7) vs. 11.3 (8.5); p < 0.001] and on one-month follow-up [10.9 (9.3) vs. 2.2 (2.7), p < 0.001]; experienced more severe dizziness and imbalance symptoms based on the VDI-SS at baseline (61.9% vs. 77.3%; p < 0.001) and after one month (78.9% vs. 93.7%, p < 0.001); and more significantly impaired quality of life according to the VDI-HRQoLS at baseline (77.4% vs. 91.8%, p < 0.001) and after one month (86.3% vs. 97.6%, p < 0.001). On the one-month follow-up, the subgroups of patients with moderate and severe scores of the BAI were higher in the MG (39.2%, n = 24) than in the BPPV w/o MG (21.8%, n = 14) and the number of patients who had normal scores of the BDI was lower in the MG than in the BPPV w/o MG (67.1% vs. 87.5%, p = 0.038). CONCLUSION: Clinicians are advised to inquire about migraine when evaluating patients with BPPV because it may lead to more intricate and severe clinical presentation. Further studies will be elaborated the genuine nature of the causal relationship between migraine and BPPV.

COVID-19 and Vestibular Symptoms and Assessment: A Review.

BACKGROUND: The current pandemic of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality primarily associated with respiratory failure. However, it has also been reported that COVID-19 can evolve into a nervous system infection. The direct and indirect mechanisms of damage associated with SARS-CoV-2 neuropathogenesis could affect our sensory functionality, including hearing and balance. SUMMARY: In order to investigate a possible association between SARS-CoV-2 viral infection and possible damage to the vestibular system, this review describes the main findings related to diagnosing and evaluating otoneurological pathologies. KEY MESSAGES: The clinical evidence shows that SARS-CoV-2 causes acute damage to the vestibular system that would not leave significant sequelae. Recovery is similar to vestibular pathologies such as vestibular neuronitis and benign paroxysmal positional vertigo. Further basic science, clinical, and translational research is needed to verify and understand the short- and long-term effects of COVID-19 on vestibular function.

Probabilities of Isolated and Co-Occurring Vestibular Disorder Symptom Clusters Identified Using the Dizziness Symptom Profile.

OBJECTIVES: Dizziness is among the most common reasons people seek medical care. There are data indicating patients with dizziness, unsteadiness, or vertigo may have multiple underlying vestibular disorders simultaneously contributing to the overall symptoms. Greater awareness of the probability that a patient will present with symptoms of co-occurring vestibular disorders has the potential to improve assessment and management, which could reduce healthcare costs and improve patient quality of life. The purpose of the current investigation was to determine the probabilities that a patient presenting to a clinic for vestibular function testing has symptoms of an isolated vestibular disorder or co-occurring vestibular disorders. DESIGN: All patients who are seen for vestibular function testing in our center complete the dizziness symptom profile, a validated self-report measure, before evaluation with the clinician. For this retrospective study, patient scores on the dizziness symptom profile, patient age, and patient gender were extracted from the medical record. The dizziness symptom profile includes symptom clusters specific to six disorders that cause vestibular symptoms, specifically: benign paroxysmal positional vertigo, vestibular migraine, vestibular neuritis, superior canal dehiscence, Meniere disease, and persistent postural perceptual dizziness. For the present study, data were collected from 617 participants (mean age = 56 years, 376 women, and 241 men) presenting with complaints of vertigo, dizziness, or imbalance. Patients were evaluated in a tertiary care dizziness specialty clinic from October 2020 to October 2021. Self-report data were analyzed using a Bayesian framework to determine the probabilities of reporting symptom clusters specific to an isolated disorder and co-occurring vestibular disorders. RESULTS: There was a 42% probability of a participant reporting symptoms that were not consistent with any of the six vestibular disorders represented in the dizziness symptom profile. Participants were nearly as likely to report symptom clusters of co-occurring disorders (28%) as they were to report symptom clusters of an isolated disorder (30%). When in isolation, participants were most likely to report symptom clusters consistent with benign paroxysmal positional vertigo and vestibular migraine, with estimated probabilities of 12% and 10%, respectively. The combination of co-occurring disorders with the highest probability was benign paroxysmal positional vertigo + vestibular migraine (~5%). Probabilities decreased as number of symptom clusters on the dizziness symptom profile increased. The probability of endorsing vestibular migraine increased with the number of symptom clusters reported. CONCLUSIONS: Many patients reported symptoms of more than one vestibular disorder, suggesting their symptoms were not sufficiently captured by the symptom clusters used to summarize any single vestibular disorder covered by the dizziness symptom profile. Our results indicate that probability of symptom clusters indicated by the dizziness symptom profile is comparable to prior published work on the prevalence of vestibular disorders. These findings support use of this tool by clinicians to assist with identification of symptom clusters consistent with isolated and co-occurring vestibular disorders.

In BPPV, canalith repositioning maneuver increased symptom resolution vs. vestibular suppressants.

SOURCE CITATION: Sharif S, Khoujah D, Greer A, et al. Vestibular suppressants for benign paroxysmal positional vertigo: a systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med. 2022. [Epub ahead of print.] 36268806.

Clinical characteristics of benign paroxysmal positional vertigo after traumatic brain injury.

INTRODUCTION: The aim of the present study was to evaluate the characteristics of brain injury and to assess the relationship between them and treatment outcomes in patients with traumatic benign paroxysmal positional vertigo (t-BPPV). MATERIALS AND METHODS: Sixty-three consecutive patients who were diagnosed with BPPV within 2 weeks after head trauma were included. RESULTS: Cerebral concussion, intracranial hemorrhages (ICH), skull fracture without ICH, and hemorrhagic contusion were observed in 68%, 24%, 5%, and 3% of t-BPPV patients, respectively. BPPV with single canal involvement was observed in 52 (83%) patients and that with multiple canal involvement was observed in 11 (17%) patients. The number of treatment sessions was not significantly different according to the cause of head trauma (p = 0.252), type of brain injury (p = 0.308) or location of head trauma (p = 0.287). The number of recurrences was not significantly different according to the cause of head trauma (p = 0.308), type of brain injury (p = 0.536) or location of head trauma (p = 0.138). CONCLUSION: The present study demonstrated that there were no significant differences in treatment sessions until resolution and the mean number of recurrences according to the type of brain injury.

Multimodal deep learning-based diagnostic model for BPPV.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is a prevalent form of vertigo that necessitates a skilled physician to diagnose by observing the nystagmus and vertigo resulting from specific changes in the patient's position. In this study, we aim to explore the integration of eye movement video and position information for BPPV diagnosis and apply artificial intelligence (AI) methods to improve the accuracy of BPPV diagnosis. METHODS: We collected eye movement video and diagnostic data from 518 patients with BPPV who visited the hospital for examination from January to March 2021 and developed a BPPV dataset. Based on the characteristics of the dataset, we propose a multimodal deep learning diagnostic model, which combines a video understanding model, self-encoder, and cross-attention mechanism structure. RESULT: Our validation test on the test set showed that the average accuracy of the model reached 81.7%, demonstrating the effectiveness of the proposed multimodal deep learning method for BPPV diagnosis. Furthermore, our study highlights the significance of combining head position information and eye movement information in BPPV diagnosis. We also found that postural and eye movement information plays a critical role in the diagnosis of BPPV, as demonstrated by exploring the necessity of postural information for the diagnostic model and the contribution of cross-attention mechanisms to the fusion of postural and oculomotor information. Our results underscore the potential of AI-based methods for improving the accuracy of BPPV diagnosis and the importance of considering both postural and oculomotor information in BPPV diagnosis.

A new roll test to diagnose posterior semicircular canal benign paroxysmal positional vertigo.

BACKGROUND: The Dix-Hallpike (DH) test is a gold standard for diagnosing benign paroxysmal positional vertigo (BPPV). However, lateral semicircular canal BPPV is not rare. We have been performing the new roll test that begins from the sitting position and contains a head-hanging position, in order not to overlook lateral canal BPPV. We noticed that transient vertical/torsional nystagmus sometimes occurs during the new roll test. OBJECTIVE: To clarify the value of the new roll test in diagnosing posterior canal BPPV and elucidate the position that elicits nystagmus. MATERIALS AND METHODS: The subjects were 100 consecutive patients (79 were female, 21 were male) with posterior canal BPPV. We classified the patients into four types based on a position that induced nystagmus. RESULTS: The patient's position that elicited nystagmus varied. The supine type accounted for 24 %, the lateral type accounted for 62 %, the head-hanging type accounted for 9 %, and the DH type accounted for 5 %. CONCLUSION: The new roll test is valuable for diagnosing posterior canalolithiasis cases. Most patients reveal vertical/torsional nystagmus in the supine or lateral position. Therefore, performing the new roll test first is efficient at the initial visit.

Assessment of vitamin D deficiency in recurrent BPPV patients: A cross-sectional study.

PURPOSE: This study aimed to investigate the vitamin D deficiency of patients with BPPV recurrence and to evaluate the differences of 25-hydroxy vitamin D (25(OH)D) and serum calcium levels among gender and age categories. METHODS: This cross-sectional study enrolled patients with BPPV. The diagnosis of BPPV was based on positional nystagmus and vertigo induced by certain head positions (The Dix-Hallpike maneuver and head roll tests). All patients' age, serum 25(OH)D, calcium measurements and recurrence data were collected and analyzed. RESULTS: The median of 25(OH)D was 15.32 (IQR 10.61, 20.90) ng/ml. The recurrent group showed lower 25(OH)D levels than that of non-recurrent group [13.28 (IQR 9.47, 17.57) ng/ml vs 16.21 (IQR 11.49, 21.13) ng/ml]. There were significant differences of 25(OH)D levels among age categories. The proportion of vitamin D deficiency in patients ≥60 years old was lower than that in the other two groups. CONCLUSION: Our study suggested that BPPV patients had a decreased 25(OH)D level and a high incidence of vitamin D deficiency. The 25(OH)D level of recurrent BPPV patients was lower than that in non-recurrent ones. Among them, the elderly group (≥60 years) took the preponderance, which had the lowest incidence of vitamin D deficiency and the highest incidence of vitamin D sufficiency.

Benign paroxysmal positional vertigo and asymmetric hearing loss: is the worst hearing ear likely to suffer from otoconial displacement?

PURPOSE: Benign paroxysmal positional vertigo (BPPV) may be found in patients complaining of hearing disorders. The aim of our investigation was to describe audiological findings in BPPV patients, focusing on subjects with asymmetric hearing loss (AHL), to better understand whether otoconial displacement may occur preferentially in the worst hearing ear. METHODS: A prospective study was performed on 112 BPPV patients. We divided the sample into subjects who suffered from AHL (G1) and patients with did not (G2). Data regarding vestibular symptoms, tinnitus, migraine, antivertigo drug therapy, and vascular risk factors were collected. RESULTS: Out of 30 AHL subjects, 83.33% of them were affected by sensorineural hearing loss (SNHL) in at least one ear, with a significant difference in the distribution of hearing loss type between groups (p = 0.0006). In 70% of cases, the ear affected by BPPV was the one with the worst hearing threshold (p = 0.02); threshold asymmetry predicted BPPV in the worst hearing ear (p = 0.03). The predictability depended neither on the hearing threshold gap between ears nor the severity of the hearing threshold in the worst ear (p > 0.05). No differences in vascular risk factors between groups were observed (p > 0.05). We evidenced a moderate correlation between age and hearing threshold (ρ = 0.43). Age did not result a predictive factor for residual dizziness or BPPV in the worst ear (p > 0.05). CONCLUSIONS: Our study supports the likelihood of an otoconial displacement in the worse hearing ear in BPPV patients. Clinicians should start testing the worst hearing ear when managing AHL patients with suspected BPPV.

Otolithic and canal functions assessment during the acute phase of benign paroxysmal positional vertigo.

PURPOSE: Assess otolith and canal involvement in patients with Benign Paroxysmal Positional Vertigo (BPPV) during the acute phase. METHODS: Ninety patients with BPPV in the acute phase underwent a vestibular assessment that included an assessment with videonistagmography, video Head Impulse Test (vHIT) to evaluate horizontal and vertical semicircular canals, and ocular vestibular evoked myogenic potentials (oVEMPs) for the otolithic function. RESULTS: Ninety patients had an involvement of the posterior canal, fifty-five out of ninety patients presented a BPPV of the right ear. No asymmetry of the otolithic functions was found for the utricular macula. Furthermore, no reduction of the Vestibular Ocular Reflex gain was found for the examined canal functions. CONCLUSIONS: The lack of asymmetry suggests that during the acute phase of BPPV, the otolithic function is balanced between the affected and unaffected ears. Moreover, the preserved VOR gain for the examined canal functions suggests that the VOR responses for the examined channels were intact.

Positional nystagmus is observed in the vast majority of healthy individuals.

INTRODUCTION: Benign paroxysmal positional vertigo (BPPV) is a vestibular disease characterized by brief  positional vertigo. When examined, characteristic patterns of positional nystagmus (PN) are found with specific head position changes. Previous studies have shown a high prevalence of PN among vestibular healthy subjects. Considering the current diagnostic criteria of BPPV and the potentially high prevalence of PN in healthy individuals, this raises the question of potential over diagnosing BPPV, if diagnostics are based exclusively upon objective findings. This study aims to determine the prevalence of PN within a healthy, adult population and furthermore include a characterization of the PN observed. METHODS: This is a prospective cross-sectional study. 78 subjects were included. The subjects underwent four standardized positional tests for BPPV in a mechanical rotational chair while using a VNG-goggle to monitor and record eye movements. RESULTS: Positional nystagmus was recorded in 70.5% (55/78) of the subjects. Of the 55 subjects, who presented with PN, 81.8% (45/55) had upbeating PN. The 95th percentile of the maximum a-SPV was found to be 10.4 degrees per second, with a median of 4. Five subjects (6.4%) in total presented with PN mimicking BPPV. CONCLUSION: This study found PN to be a common finding within a healthy, adult population based on the high prevalence of PN in the study population. Upbeating PN mimicking posterior canalolithiasis was found in numerous subjects. The authors recommend a cautious approach when diagnosing BPPV, especially in cases of purely vertical PN (without a torsional component) and if no vertiginous symptoms are present during Dix-Hallpike and Supine Roll Test examinations.

Deep Learning-Based Nystagmus Detection for BPPV Diagnosis.

In this study, we propose a deep learning-based nystagmus detection algorithm using video oculography (VOG) data to diagnose benign paroxysmal positional vertigo (BPPV). Various deep learning architectures were utilized to develop and evaluate nystagmus detection models. Among the four deep learning architectures used in this study, the CNN1D model proposed as a nystagmus detection model demonstrated the best performance, exhibiting a sensitivity of 94.06 ± 0.78%, specificity of 86.39 ± 1.31%, precision of 91.34 ± 0.84%, accuracy of 91.02 ± 0.66%, and an F1-score of 92.68 ± 0.55%. These results indicate the high accuracy and generalizability of the proposed nystagmus diagnosis algorithm. In conclusion, this study validates the practicality of deep learning in diagnosing BPPV and offers avenues for numerous potential applications of deep learning in the medical diagnostic sector. The findings of this research underscore its importance in enhancing diagnostic accuracy and efficiency in healthcare.

[Vertigo and dizziness in child: a clinical analysis in 120 cases].

Objective: To investigate the disease composition, clinical features, diagnosis, and treatment characteristics of vertigo in children. Methods: A total of 120 children with vertigo diagnosed and treated in the Department of Otorhinolaryngology, Children's Hospital, Capital Institute of Pediatrics in Beijing from February 2018 to February 2022 were retrospectively analyzed to explore the clinical characteristics of common peripheral vertigo in children and to summarize the experience of diagnosis and treatment. Results: The etiological composition of 120 cases of vertigo in children are as follows: 63 (52.5%) cases of vestibular migraine of childhood (VMC), 19 (15.8%) of recurrent vertigo of childhood (RVC), 11 (9.2%) of probable vestibular migraine of childhood (PVMC), 10 (8.3%) of secretory otitis media (SOM), 6 (5.0%) of persistent postural-perceptual dizziness (PPPD), 4 (3.3%) of benign paroxysmal positional vertigo (BPPV), 2 (1.7%) of vestibular neuritis (VN), 2 (1.7%) of Meniere's disease (MD), 2 (1.7%) of inner ear malformation (IEM), and 1 (0.8%) of vestibular paroxysmal syndrome (VP).The major cause of vertigo in children of different ages was different. SOM was the most important cause in preschool children, followed by RVC and VMC; VMC was the most important cause in school-age children, followed by RVC; and MD and BPPV were exclusive found in adolescents. The incidence rate of PPPD was higher in adolescents than in preschool and school-age children. Children with vertigo had good prognosis in general. Conclusions: VMC, RVC and SOM are the most common causes in vertigo in children, and their proportion was different in different aged children. Transforming abstract feelings into specific information is the skill required for collecting medical history of children with vertigo. Considering the age and cooperation of children, appropriate hearing and vestibular examination techniques are recommended. We should pay more attention to the mental health of children with vertigo and their parents.

[Comparison of efficacy between personalized vestibular rehabilitation and otolith reposition for the treatment of atypical benign paroxysmal positional vertigo].

Objective: To compare the clinical efficacy of personalized vestibular rehabilitation and otolith reposition in treating atypical benign paroxysmal positional vertigo (BPPV). Methods: A randomized controlled trial was carried out. Fifty patients diagnosed with atypical BPPV in the Vertigo Clinic of the First Affiliated Hospital of Shandong First Medical University from October 2022 to September 2023 were recruited and randomly divided into manual reduction group (25 cases) and vestibular rehabilitation group (25 cases) according to the random number table. All patients were given flunarizine. Patients in the manual reduction group were treated by Epley maneuver and (or) Barbecue maneuver, while the vestibular rehabilitation group was given personalized vestibular rehabilitation therapy. After two weeks' treatment, the clinical symptoms (positional vertigo/nystagmus) and total dizziness handicap inventory (DHI) score, DHI physical (DHI-P), DHI emotional (DHI-E), and DHI functional (DHI-F) of the two groups were evaluated and compared. Results: A total of 50 patients diagnosed with atypical BPPV were included, including 23 males and 27 females, with an average age of (48.8±14.5) years. There was no statistically significant difference between the two groups in age, gender, disease severity, Romberg, position test abnormality ratio (Dix-hallpike/Roll test), temperature test, and video head impulse test baseline test results (all P>0.05). After 2 weeks of treatment, the effective rates of the treatment in the manual reduction and vestibular rehabilitation groups were 56.0% (14/25) and 88.0% (22/25), respectively, with a statistically significant difference (P=0.025). The total DHI score, DHI-P, DHI-E, and DHI-F scores in both groups were significantly decreased after treatment (all P<0.001). Compared with the manual reduction group, the total DHI score (23.2±2.7 vs 36.4±15.7, P=0.002), DHI-P (10.2±4.6 vs 13.7±5.3, P=0.016) and DHI-F (6.5±6.4 vs 13.0±7.2, P=0.002) in the vestibular group were lower, however, there was no significant difference in DHI-E score between the two groups (6.6±4.8 vs 9.6±7.3, P=0.087). Conclusion: Compared with otolith reposition, personalized vestibular rehabilitation therapy plays a better role in improving the symptoms and decreasing DHI score for patients with atypical BPPV.

Updates in neuro-otology.

PURPOSE OF REVIEW: Recent updates with clinical implications in the field of neuro-otology are reviewed. RECENT FINDINGS: Important updates relating to several neuro-otologic disorders have been reported in recent years. For benign positional paroxysmal vertigo (BPPV), we provide updates on the characteristics and features of the short arm variant of posterior canal BPPV. For the acute vestibular syndrome, we report important updates on the use of video-oculography in clinical diagnosis. For autoimmune causes of neuro-otologic symptoms, we describe the clinical and paraclinical features of kelch-like protein 11 encephalitis, a newly-identified antibody associated disorder. For cerebellar ataxia, neuropathy, vestibular areflexia syndrome, we report recent genetic insights into this condition. SUMMARY: This review summarizes important recent updates relating to four hot topics in neuro-otology.

Outcomes of Treatment of Multicanal Benign Paroxysmal Positional Vertigo by Means of TRV Chair.

INTRODUCTION: Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of peripheral vertigo and can manifest in different forms. Multicanal BPPV is rare and difficult to treat. TRV Chair is a method that offers diagnosis and treatment at the same time. The aim was to analyze the outcomes of treatment of multicanal BPPV by means of TRV Chair and compare those results with manual maneuvers. METHODS: Forty-nine subjects aged 26-73 and diagnosed with multicanal BPPV were included. Appropriate maneuvers were performed on affected canals either by TRV Chair or manually. The number of maneuvers required by TRV Chair and manual maneuver were analyzed and compared. RESULTS: The mean number of maneuvers performed until the treatment was completed in manual treatment group was 2.57 ± 1.03, and in TRV group, it was 2.25 ± 1.16. No significant difference was observed between the number of maneuvers performed in either group until the end of the treatment (p > 0.05). DISCUSSION/CONCLUSIONS: Neither TRV Chair nor manual maneuvers were superior to the other in the treatment of multicanal BPPV cases.

Temporal Bone Histopathology of Undiagnosed Dizziness in the Elderly.

INTRODUCTION: Dizziness is a common disease. However, approximately 10-40% of patients were diagnosed unknown dizziness even though general, neurological, and otological examinations were performed. The aim of this otopathological study was to investigate the histopathology of the peripheral vestibular system of patients who suffered from undiagnosed dizziness. METHODS: Eighteen temporal bone specimens from 9 patients with undiagnosed dizziness and 20 temporal bone specimens from age-matched 10 normal controls were selected. Cases with a history of dizziness and vertigo caused by particular peripheral vestibular disease and central etiology were excluded. Specimens of the vestibular system were carefully assessed by light microscopy. The basophilic deposits adhered to cupulae of the semicircular canals and the wall of the labyrinth were investigated. Scarpa's ganglion cell counts in the vestibular nerves were performed. RESULTS: Fifteen ears of 9 patients had the findings of vestibular pathology such as a basophilic deposit on cupula (8 ears), on canal wall (7 ears), vestibular nerve loss (8 ears), or vestibular atelectasis (2 ears). Unclear pathological findings such as crista neglecta, subepithelial deposits of the crista ampullaris, and adhesion of the cupula to dark cell area were demonstrated. The mean size of basophilic deposits seen in the patients (mean: 191 µm) was larger than that of latent deposits seen in the normal controls (mean: 101 µm; p = 0.01). CONCLUSIONS: We demonstrated some peripheral vestibular pathological findings such as deposit within the semicircular canal, vestibular nerve loss, and vestibular atelectasis and suggested the possible diagnosis of dizziness (benign paroxysmal positional vertigo, presbyvestibulopathy, vestibular atelectasis). These findings will provide a better insight into the multiple etiologies of the unknown dizziness in the elderly.

Utility of Inter-Frequency Amplitude Ratio of Vestibular-Evoked Myogenic Potentials in Identifying Meniere's Disease: A Systematic Review and Meta-Analysis.

OBJECTIVES: A recently devised parameter of vestibular-evoked myogenic potential (VEMP) based on the principles of frequency tuning is the inter-frequency amplitude ratio (IFAR). It refers to the ratio of the amplitude of 1000 Hz tone burst evoked VEMP to 500 Hz evoked tone burst. A pathology like Meniere's disease changes the frequency response and alters the frequency tuning of the otolith organs. Because IFAR is based on the principle of frequency tuning of VEMP, it is likely to help identify Meniere's disease. Few studies in the last decade have investigated the utility of IFAR in identifying Meniere's disease. However, a systematic review and a meta-analysis on IFAR in Meniere's disease are lacking. The present study investigates whether the IFAR of VEMP helps identify Meniere's disease and differentiates it from healthy ears and other vestibular pathologies. DESIGN: The present study is a systematic review and a meta-analysis. The studies investigating the IFAR of cervical and ocular VEMPs in Meniere's disease, healthy controls, and other vestibular pathologies were searched across research databases such as PubMed, Science Direct, and Scopus. The search strategy was developed using the PICO (population, intervention, comparison, and outcomes) format, and Medical Subject Headings (MeSH) terms and Boolean operators were employed. The systematic review was performed using the Rayyan software, whereas the Review Manager software was used to carry out the meta-analysis. A total of 16,605 articles were retrieved from the databases. After the duplicate removal, 2472 articles remained. These were eliminated using title screening, abstract screening, and full-length inspections. A total of nine articles were found eligible for quality assessment and meta-analysis, and the New Castle-Ottawa Scale was used for quality assessment. After the data extraction, 24 six articles were found to have the desired data format for the meta-analysis. RESULTS: The results showed significantly higher IFAR in the affected ears of individuals in the Meniere's disease group than in the control group's unaffected ears. There was no significant difference between the unaffected ears of individuals in the Meniere's disease group and the ears of the control group. The only study on Meniere's disease and benign paroxysmal positional vertigo found significantly larger ocular VEMP IFAR in ears with Meniere's disease than in benign paroxysmal positional vertigo. CONCLUSIONS: This systematic review and meta-analysis found IFAR efficient in differentiating Meniere's disease from healthy controls. We also found an enhanced IFAR as a potential marker for Meniere's disease. However, more investigations are needed to confirm the utility of an enhanced IFAR value in the exclusive identification of Meniere's disease.

We should be screening for benign paroxysmal positional vertigo (BPPV) in all older adults at risk of falling: a commentary on the World Falls Guidelines.

Benign paroxysmal positional vertigo (BPPV) is amongst the commonest causes of dizziness and falls in older adults. Diagnosing and treating BPPV can reduce falls, and thereby reduce fall-related morbidity and mortality. Recent World Falls Guidelines recommend formal assessment for BPPV in older adults at risk of falling, but only if they report vertigo. However, this recommendation ignores the data that (i) many older adults with BPPV experience dizziness as vague unsteadiness (rather than vertigo), and (ii) others may experience no symptoms of dizziness at all. BPPV without vertigo is due to an impaired vestibular perception of self-motion, termed 'vestibular agnosia'. Vestibular agnosia is found in ageing, neurodegeneration and traumatic brain injury, and results in dramatically increased missed BPPV diagnoses. Patients with BPPV without vertigo are typically the most vulnerable for negative outcomes associated with this disorder. We thus recommend simplifying the World Falls Guidelines: all older adults (>60 years) with objective or subjective balance problems, irrespective of symptomatic complaint, should have positional testing to examine for BPPV.

Correlation of idiopathic benign paroxysmal positional vertigo with cerebral small vessel disease.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is the most prevalent form of peripheral vertigo, with vascular lesions being one of its suspected causes. The older adults are particularly vulnerable to BPPV. Cerebral small vessel disease (CSVD), on the other hand, is a clinical condition that results from damage of cerebral small vessels. Vascular involvement resulting from age-related risk factors and proinflammatory state may act as the underlying factor linking both BPPV and CSVD. AIM: The objective of this study is to explore the potential correlation between BPPV and CSVD by examining whether individuals aged 50 and older with BPPV exhibit a greater burden of CSVD. MATERIALS AND METHODS: This retrospective study included patients aged 50 years and older who had been diagnosed with BPPV. A control group consisting of patients diagnosed with idiopathic facial neuritis (IFN) during the same time period was also included. The burden of cerebral white matter hyperintensities (WMHs) was evaluated using the Fazekas scale. An ordinal regression analysis was conducted to investigate the potential correlation between BPPV and WMHs. RESULTS: The study included a total of 101 patients diagnosed with BPPV and 116 patients with IFN. Patients with BPPV were found to be significantly more likely (OR = 2.37, 95% CI 1.40-4.03, p = 0.001) to have a higher Fazekas score compared to the control group. Brain infarctions, hypertension, and age were all identified as significant predictors of white matter hyperplasia on MRI, with OR of 9.9 (95% CI 4.21-24.84, P<0.001), 2.86 (95% CI 1.67-5.0, P<0.001), and 1.18 (95% CI 1.13-1.22, P<0.001) respectively. CONCLUSION: Our findings suggest that vascular impairment caused by age-related risk factors and proinflammatory status may be contributing factors to the development of BPPV in individuals aged 50 and above, as we observed a correlation between the suffering of BPPV and the severity of WMHs.