Course of Duration and Trigger Factors of Vertigo Attacks in Patients with Benign Recurrent Vertigo, Menière's Disease, or Vestibular Migraine.

INTRODUCTION: Benign recurrent vertigo (BRV), Menière's disease (MD), and vestibular migraine (VM) show many similarities with regard to the course of vertigo attacks and clinical features. In this paper, we elaborate on the decreasing frequency of vertigo attacks observed in a previous study from our group by exploring changes in the duration and trigger factors of vertigo attacks in patients with BRV, MD, or VM. METHODS: For this 3-year prospective cohort study in our tertiary referral center we recruited patients with a confirmed diagnosis of BRV, MD, or VM by a neurologist and otorhinolaryngologist in our center in 2015-2016. A study-specific questionnaire was used to assess the usual duration of vertigo attacks and their potential triggers every 6 months. Main outcome measures were changes in duration and trigger factors of vertigo attacks in the subgroups of patients with persisting attacks, which were analyzed using repeated measures logistic regression models. RESULTS: 121 patients were included (BRV: n = 44; MD: n = 43; VM: n = 34) of whom 117 completed the 3-year follow-up period and 57 (48.7%) kept reporting vertigo attacks at one more follow-up measurements. None of the diagnosis groups showed statistically significant shortening of attack duration at the subsequent annual follow-up measurements compared to baseline. At baseline, stress and fatigue being reported as triggers for attacks differed significantly between the three groups (stress: BRV 40.9%, MD 62.8%, VM 76.5%, p = 0.005; fatigue: BRV 31.0%, MD 48.8%, VM 68.8%, p = 0.003). In the VM group, a consistent reduction of stress and fatigue as triggers was observed up until the 24- and the 30-month follow-up measurements, respectively, with odds ratios (ORs) ranging from 0.15 to 0.33 (all p < 0.05). In the MD group, a consistent reduction of head movements as trigger was observed from the 24-month measurement onward (ORs ranging from 0.07 to 0.11, all p < 0.05). CONCLUSION: Our study showed no reduction in vertigo attack duration over time in patients with BRV, MD, and VM who remain to have vertigo attacks. In VM and MD patients with persisting vertigo attacks stress, fatigue and head movements became less predominant triggers for vertigo attacks.

Benign Recurrent Vertigo: The Course of Vertigo Attacks Compared to Patients With Menière's Disease and Vestibular Migraine.

Objective: To explore the course of vertigo attacks in patients with benign recurrent vertigo (BRV) as compared to patients with Menière's disease (MD) and vestibular migraine (VM). Study design: Prospective cohort study. Setting: Tertiary referral center. Patients: Adult patients who visited the Apeldoorn Dizziness Center between January 2015 and November 2016 and who were diagnosed with BRV, VM or MD. During 3 years participants were contacted every 6 months by telephone to complete a study-specific questionnaire. Main Outcome Measures: Vertigo attack frequency, use of medication, and Hospital Anxiety and Depression Scale (HADS). Results: The study population (n = 121) consisted of 44 patients with BRV, 34 with VM, and 43 with MD. For the total follow-up period no statistically significant differences between the three diagnosis groups were observed for being attack-free in the past 6 months: OR = 0.86 (95% CI 0.34-2.17; p = 0.745) for VM and OR = 1.06 (95% CI 0.44-2.51; p = 0.902) for MD, compared to BRV. Overall, 19 patients (43.2%) with BRV, 13 (38.2%) with VM, and 35 (81.0%) with MD used medication to prevent vertigo attacks at any point during their 3-year follow-up. Throughout the observation period patients with MD showed an average of 3.37 points (95% CI 0.68-6.07; p = 0.014) higher HADS scores relative to patients with BRV. Conclusion: The course of vertigo attacks was rather favorable in the three groups, as 67-70% of the patients were free of vertigo attacks after 3 years of follow-up. The course of disease in patients with BRV was not distinctive from patients with MD and VM. We assume that BRV is a mild or incomplete variant of VM and MD, rather than a separate disease entity with distinct pathognomonic features.

Dizziness and Driving From a Patient Perspective.

Background: People with dizziness may experience driving-related limitations. Few data are available about the impact of dizziness on driving. Aim: The aim of this study is to investigate the impact of dizziness on driving, factors related to impairment (age, gender, and type of diagnosis), and the potential consequences for patients' ability to work. We also investigated whether the patients expected and actually received information about their dizziness-related fitness to drive from their physician. Methods: A cross-sectional, observational study was conducted in the Apeldoorn Dizziness Centre, a tertiary care referral centre for patients with dizziness. A consecutive cohort of patients was asked to complete a study-specific questionnaire about driving. Results: Between January 1, 2020, and December 20, 2020, 432 patients were included. Fifty-six percent of the patients in this group were female. The average age of patients was 58.3 years (SD 16). Overall, 191 of the 432 patients (44%) experienced limitations related to driving, and 40% of the patients who experienced limitations also experienced limitations to work related to their inability to drive. The subject of fitness to drive had not been discussed with their physician in 92% of the patients, and 24% of the whole patient group indicated that they would have liked to discuss this topic. The following factors, independently from each other, increased the chance of experiencing driving-related limitations: younger age, female sex, and the diagnosis of Meniere's disease. Conclusion: Dizzy patients, especially younger patients, women, and patients with Meniere's disease, regularly experience limitations related to driving, and this often means that they are unable to work. Driving is hardly ever discussed during a medical consultation. In our opinion, the topic of driving and dizziness should always be addressed during medical consultations in dizzy patients.

Physical and Emotional Burden of the Epley Maneuver in the Elderly.

OBJECTIVE: To analyze and compare experiences of anxiety and discomfort caused by the Epley maneuver and the willingness for a potential retreatment between younger (≤70 yr) and older (>70 yr) patients. STUDY DESIGN: Prospective, observational cohort study. SETTING: Tertiary referral center. METHODS: Dutch adults, diagnosed with posterior canal benign paroxysmal positional vertigo, were included. Patients with dementia or subjected to an Epley maneuver ≤4 months before the hospital visit were excluded. Patients were asked about their experiences with the Epley maneuver directly after the maneuver, after 2 weeks and after 2 months. Differences in experiences between the age groups were tested with the Fisher's exact test and subgroup analyses were performed using multivariable logistic regression. RESULTS: Out of 179 included patients, 115 (64%) were aged ≤70 and 134 (75%) were female. In both groups, 25% reported anxiety directly after the Epley maneuver. Two weeks later, 19 and 27%, respectively (p = 0.26) reported anxiety. In the young group, 30% expressed discomfort directly after treatment compared with 45% in the elderly (OR 1.98, 95% CI 1.05-3.75, p = 0.04). Two weeks later, this was 36 and 38%, respectively (p = 0.87). This decreased to 24 and 33%, respectively (p = 0.37), after 2 months. There was no significant difference in willingness for potential retreatment between both groups after 2 weeks (93 and 95%, respectively, p = 0.75) nor after 2 months (97 and 92%, respectively, p = 0.13). CONCLUSION: The Epley maneuver results in little anxiety and discomfort both in young and in elderly patients. Most patients show willingness for potential retreatment in case symptoms recur.

The Dizzy Patient: Consider a Second Diagnosis.

BACKGROUND: Many patients with dizziness complain about >1 type of dizziness and therefore there may be ≥2 coexisting diagnoses. OBJECTIVE: To determine how often a second or third diagnosis is present in a patient with dizziness and to establish what are the most common combinations of diagnoses. STUDY DESIGN: Prospective, observational study in a tertiary center. RESULTS: A consecutive cohort of 621 patients was included in the study. In 187 patients (30.1%) a second diagnosis was present. Within this group a third diagnosis was present in 35 (5.6%) patients. The most common second diagnosis was an anxiety disorder (50.1%). CONCLUSIONS: Patients with dizziness frequently present themselves with >1 type of dizziness caused by 2 or 3 different diseases. In our study 30% of patients with dizziness have >1 diagnosis. Anxiety disorder is the most common second diagnosis.

Intratympanic gentamicin treatment for Ménière's disease: a randomized, double-blind, placebo-controlled trial on dose efficacy - results of a prematurely ended study.

BACKGROUND: Gentamicin is used as a therapeutic agent for Ménière's disease because of its vestibulotoxicity causing chemo-ablation of the vestibular sensory epithelia. Its use has increased in recent years. However, there is still no consensus about the dose regimen of gentamicin in the treatment of Ménière's disease. In this study two different dose regimen treatment protocols are compared in a placebo controlled study design. The primary objective is to quantify the treatment effect on dizziness, the secondary objective is hearing evaluation. METHODS: We performed a randomized, double-blind, placebo-controlled study in adults with unilateral Ménière's disease according to the AAO-HNS guidelines resistant to conservative medication. Three groups received four injections, administered weekly (four intratympanic injections with 40 mg/mL gentamicin solution, two injections gentamicin solution and two injections of placebo in random order, or four injections with placebo). Outcome measures were the score on the Dizziness Handicap Inventory and pure tone audiometry (PTA). Intended follow-up was 2 years. RESULTS: During follow-up one patient exceeded the accepted amount of hearing loss. Further, enrollment was very slow (until 12 months between two patients) and new insights showed an apparent benefit of intratympanic gentamicin treatment (ITG). Therefore we performed an unscheduled interim analysis which showed that PTA threshold shifts reached the stopping criteria in two more patients. Because of this, this study was ended. Of the three patients with the significant PTA threshold shift two were enrolled in the gentamicin group. CONCLUSION: No conclusions can be drawn concerning doses regimens. Now that new publications have shown that ITG treatment can be an effective and safe treatment, a placebo-controlled randomized controlled trial may not pass the ethical committee because of these recent reports in literature. Still, a dose regimen study (without placebo) on ITG treatment needs to be performed. TRIAL REGISTRATION: This trial was registered in The University Medical Center Utrecht/ Gelre hospital Apeldoorn. Protocol ID: 07/343, EudraCT number 2006-005913-37.