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.

Assessment of inner ear morphology and function in response to local positive pressure for Ménière's disease: a nonrandomized controlled trial.

Ménière's disease (MD) is an inner ear disorder in which the main pathological feature is endolymphatic hydrops (EH). Positive pressure therapy (PPT) using a portable device is now a second-line therapy for intractable MD when initial medical treatment fails. However, it remains unknown whether PPT causes the morphological and functional changes of inner ear in patients with active MD in accordance with reduction of vertigo attacks. In this nonrandomized controlled trial of 52 patients with MD, the volume of EH significantly decreased with reduction of vertigo attacks during 8 months of PPT combined with medications while the volume of that significantly increased with medications alone. There was no difference between Control group (n = 26) and PPT group (n = 26) regarding the vertigo control, however, PPT group achieved a significant functional improvement of vertical semicircular canals. The effect of volume reduction by PPT has been firstly demonstrated and the functional changes of all semicircular canals during PPT have been firstly examined. Morphological and functional changes in the inner ear by administrating local positive pressure are quite different from those caused by medications alone.Clinical trial registration: UMIN-CTR UMIN000041164 (registered on July 20, 2020).

Assessment, diagnosis and management of the dizzy patient.

Dizziness and balance disorders are very common problems. Having a structured approach, including adequate history taking and clinical examination, in a multidisciplinary environment allows for effective management of patients with these complex symptoms. Hearing assessment is an integral part of the assessment of patients with dizziness, along with the occasional need for further testing. Identifying red flags, along with the ability to involve different medical specialties, are prerequisites for safe management and a successful outcome. While surgical intervention has a small role in the management of balance disorders, vestibular rehabilitation remains the cornerstone of treatment, along with different supportive measures. This article outlines the approach used in the authors' centre to manage patients with dizziness and balance disorders.

Cerebellar Dizziness and Vertigo: Etiologies, Diagnostic Assessment, and Treatment.

Cerebellar dizziness and vertigo account for approximately 10% of diagnoses in a tertiary dizziness center. This term summarizes a large group of disorders with chronic (degenerative, hereditary, acquired cerebellar ataxias), recurrent (episodic ataxias), or acute (stroke, inflammation) presentations. Key to the diagnosis is a comprehensive examination of central ocular motor and vestibular function. Patients with cerebellar dizziness and vertigo usually show a pattern of deficits in smooth pursuit, gaze-holding, saccade accuracy, or fixation-suppression of the vestibulo-ocular reflex. Central fixation nystagmus (e.g., downbeat nystagmus), gaze-evoked nystagmus, central positional nystagmus, or head-shaking nystagmus with cross-coupling (i.e., horizontal head shaking causing inappropriate vertical nystagmus) occurs frequently. Overlap syndromes with peripheral vestibular disorders, such as cerebellar ataxia, neuropathy, and vestibular areflexia, exist rarely. Posturography and gait analysis can contribute to diagnostic differentiation, estimation of the risk of falls, as well as quantification of progression and treatment effects. Patients with cerebellar dizziness and vertigo should receive multimodal treatment, including balance training, occupational therapy, and medication.

Vertigo and dizziness cause considerable more health care resource use and costs: results from the KORA FF4 study.

OBJECTIVES: Vertigo is a common reason for primary care consultations, and its diagnosis and treatment consume considerable medical resources. However, limited information on the specific cost of vertigo is currently available. The aim of this study is to analyse the health care costs of vertigo and examine which individual characteristics would affect these costs. STUDY DESIGN: We used cross-sectional data from the German KORA ("Cooperative Health Research in the Augsburg Region") FF4 study in 2013. METHODS: Impact of personal characteristics and other factors was modelled using a two-part model. Information on health care utilisation was collected by self-report. RESULTS: We included 2277 participants with a mean age of 60.8 (SD = 12.4), 48.4% male. Moderate or severe vertigo was reported by 570 (25.0%) participants. People with vertigo spent 818 Euro more than people without vertigo in the last 12 months (2720.9 Euro to 1902.9 Euro, SD = 4873.3 and 5944.1, respectively). Consultation costs at primary care physicians accounted for the largest increase in total health care costs with 177.2 Euro (p < 0.01). After adjusting for covariates, the presence of vertigo increased both the probability of having any health care costs (OR = 1.6, 95% CI =[1.2;2.4]) and the amount of costs (exp(ß) = 1.3, 95% CI = [1.1;1.5]). The analysis of determinants of vertigo showed that private insurance and a medium level of education decreased the probability of any costs, while higher income increased it. CONCLUSIONS: The presence of vertigo and dizziness required considerable health care resources and created significantly more related costs in different health care sectors for both primary and pertinent secondary care.

[Chinese multidisciplinary expert consensus on assessment and management of vestibular migraine].

Vestibular migraine (VM) is a common disorder characterized by recurrent dizziness and/or vertigo, which involves a number of specialites and is easily misdiagnosed. The Stroke and Vertigo Association of Chinese Stroke Association and Vertigo Professional Committee of Neurology Branch of Chinese Physicians Association organized multi-disciplinary experts to discuss clinical issues of VM. The purpose of this consensus is to establish a standard framework for the diagnosis and management of VM in China.

Economic management of vertigo/dizziness disease in a county hospital: video-head-impulse test vs. caloric irrigation.

The video-head-impulse test (vHIT) is an important test for examining unilateral vestibular hypofunction. Alternatively, one can test for vestibular hypofunction with the caloric irrigation test. Various studies have shown that both tests may not always identify vestibular hypofunction; instead, the results of the tests might be contradictory. This retrospective study reproduces those finding in a much larger group of patients at a county hospital. 1063 patients were examined with the vHIT and bithermal caloric irrigation on the same day and analyzed with respect to side differences. Of those patients 13.3% had pathological vHIT and a caloric irrigation test, 4.6% a pathological vHIT only and 24.1% a pathologic caloric test only. As both tests might be necessary, we calculated the optimal sequence of the two examinations based on savings in time for the different disease groups. Especially in vestibular failure using the vHIT first and only applying the caloric irrigation in case of an unremarkable vHIT saves time and optimizes the diagnostic work up. In contrast, in Menière's disease and vestibular migraine testing caloric irrigation first might be more efficient.

Delayed diagnosis and treatment of benign paroxysmal positional vertigo associated with current practice.

The purposes of this study were to demonstrate the current status of benign paroxysmal positional vertigo (BPPV) management and the advantages of repositioning maneuvers as well as to facilitate the accurate and efficient diagnosis and management of BPPV. Of 131 participants with severe dizziness/vertigo who were examined and treated, 31 (23.7%) fulfilled the diagnostic criteria for BPPV. All patients in the study had a diagnosis of BPPV confirmed by their history, typical subjective symptom reports, and characteristic positional nystagmus during the Dix-Hallpike test and/or roll test. All participants were comprehensively interviewed regarding their medical history, characteristics of the first attack of vertigo, associated symptoms, previous financial costs, and number of hospital visits. The average duration from the appearance of the first symptoms until a final diagnostic positional maneuver was >70 months. On average, patients visited hospitals more than eight times before the final diagnosis due to initial visits to inappropriate departments, including neurology, emergency, orthopaedic surgery, and Traditional Chinese Medicine, with a corresponding average financial cost of more than 5,000 RMB. The canalith repositioning procedure (CRP) was effective in 80.65% of patients after the first repositioning maneuver. Our data demonstrated that despite the significant prevalence of BPPV, delays in diagnosis and treatment frequently occur, which have both cost and quality-of-life impacts on both patients and their caregivers. The CRP is very effective for patients with BPPV. It is important for patients to pay more attention to the impact of BPPV on their lives and recognize its nature to ensure compliant follow-up in otolaryngology.

Primary assessment of the vertiginous patient at a pre-ENT balance clinic.

INTRODUCTION: Due to problems with long waiting times for assessment of vertiginous patients (more than 24 weeks), we changed practice and instituted a pre-ENT balance clinic assessment; we then audited the results. In particular, we looked at the subgroup with benign positional paroxysmal vertigo. METHODS: One hundred and fifteen patients were seen at the pre-ENT balance clinic from October 2003 to September 2004. Those diagnosed with benign positional paroxysmal vertigo received particle repositioning therapy at the same clinic and did not subsequently need ENT assessment. RESULTS: By the end of the audit period, waiting times were reduced to three weeks, and more than one-quarter of vertiginous patients (i.e. those diagnosed with benign positional paroxysmal vertigo) did not need to be reviewed at an ENT clinic. CONCLUSION: We believe this to be the first study to present prospective data showing that patients with benign positional paroxysmal vertigo may be safely diagnosed and effectively managed at a pre-ENT balance clinic.

Laboratory-free measurement of gait rhythmicity in the assessment of the degree of impairment and the effectiveness of rehabilitation in patients with vertigo resulting from vestibular hypofunction.

A portable system for measurement of stride time rhythmicity was developed using the technique of Hausdorff et al (2001a Arch. Phys. Med. Rehabil. 82 1050-6). Measurement was performed for an extended period of walking of 256 steps for each foot outside of the laboratory on 18 normal individuals and 20 patients referred with symptomatic vestibular impairment. Ten of the patients were reassessed following vestibular therapy. Gait rhythmicity measured by standard deviation (SD) stride time was found to be significantly higher in patients with vestibular impairment than in normal volunteers (mean +/- SD 60.3 +/- 39.8 ms versus 21.9 +/- 4.9 ms respectively, P < 0.001, t-test). The ten patients who returned following a course of vestibular rehabilitation displayed significant improvement in SD stride time following therapy (mean +/- SD 57.3 +/- 44.6 ms prior to and 40.9 +/- 23 ms following therapy, P = 0.01, Wilcoxon signed rank test). Gait rhythmicity measurement, specifically measurement of stride time variability, appears to be a powerful assessment tool for objective measurement of extent of impairment and response to therapy in patients with vestibular hypofunction.

Do patients with benign paroxysmal positional vertigo receive prompt treatment? Analysis of waiting times and human and financial costs associated with current practice.

This study retrospectively analysed how 20 patients with posterior canal benign paroxysmal positional vertigo (BPPV) were managed from primary care, to treatment in tertiary care. The average time from first referral to treatment was 93 weeks, with an average of 58 weeks within primary care and 40 weeks within hospital care. At least 85% of cases had classical symptoms of BPPV and could have been easily identified by Primary Care Physicians at first referral, had they been trained to recognise and diagnose the condition. It was concluded that patients could be treated more efficiently and at less cost if the condition was identified at first referral in primary care, and treated in either primary care or dedicated BPPV clinics receiving referrals from primary care. A dedicated clinic for BPPV is recommended, which will substantially reduce waiting time for treatment and save primary care and hospitals time and money by avoiding unnecessary appointments and medication.

Dizziness and vertigo: an epidemiological survey and patient management in the emergency room.

Dizziness and vertigo are frequent causes of presentation at the emergency room, with an incidence in the Vimercate district, Italy, close to 3.5%. The basic management of the "dizzy" patients in the emergency room includes a detailed history and an accurate physical/neurological examination, with the aim to identify "at risk" patients who require further diagnostic procedures and/or immediate admission to the hospital.

Outcome measures for assessment of treatment of the dizzy and balance disorder patient.

There are a variety of measurement tools available for assessing the treatment outcomes for patients with dizziness and imbalance. Some of these tools, however, may not be appropriate or valid for the patients in question. In this article, the various outcome measures are described and evaluated in terms of their reliability, validity, and sensitivity. There is no clearly superior outcome measure at this time, and the choice of the measurement tool depends on the patient and the aims of the treatment.

[Effectiveness indices in "Particle Repositioning Maneuver" by Parnes and Price-Jones]. / Indicatori di efficacia nella "Particle Repositioning maneuver" di Parnes e Price-Jones.

The Parnes and Price-Jones "Particle Repositioning Maneuver" (PRM) was used to treat Paroxysmal Positional Vertigo (VPP) in 36 consecutive cases, studying both any induced secondary nystagmus and any persistent Paroxysmal Positional Nystagmus (PPNy) upon repetition of the Hallpike positioning after 15 minutes (re-test). The purpose of the study was to evaluate the ability to use secondary Ny and the retest to predict maneuver effectiveness. Although the PRM was quite effective (PPNy disappeared in 86% of the cases after a single session), the low observation frequency reduced the feasibility of using secondary Ny. On the other hand the systematic introduction of the Hallpike re-test into clinical practice does not offer the desired cost/benefit ratio because of the time required to prevent false negatives due to PPNy fatigue. In fact, secondary Ny was only evoked in 12 out of 36 cases (33%) and of these only 9 out of 36 (25%) presented direction congruous with canalolith release (liberating Ny). The predictive value of evoked liberating Ny appeared further reduced by the persistence of PPNy upon subsequent re-testing in two cases and in one case by the persistence of the disorder upon follow-up. The Hallpike test appears a more reliable indicator of effectiveness as it proved in agreement with subsequent clinical findings in 80% of the cases. The present results lead one to conclude that, when using PRM in cases where no secondary liberating Ny was found (75%), we should rely on the high effectiveness of this procedure (86% of the cases resolved in a single session) rather than perform a Hallpike retest. Thus it is possible to select a small number of patients (22%) still presenting PPNy (positive retest) and requiring repetition of the therapeutic maneuver.