Bow and Lean Test for Rare Variants of Vertical Semicircular Canal BPPV.

OBJECTIVE: The objective of this study was to assess the clinical significance of the Bow and Lean Test (BLT) for the diagnosis of different variants of vertical canal Benign Paroxysmal Positional Vertigo (BPPV). BLT is commonly used for diagnoses of lateral semicircular canal (LSC) BPPV. However, vertical nystagmus in the BLT may indicate the presence of other variants such as PSC-BPPV. METHODS: 567 patients with vertical canal BPPV were recruited. Patients with anterior semicircular canal (ASC) or PSC-BPPV were weekly examined until the negativization of BPPV. Nystagmus characteristics during BLT were analyzed. RESULTS: Of 567 patients with vertical canal BPPV, 1.4% had ASC-BPPV. BLT was positive in 155 patients, showing patterns like down-beating nystagmus in bowing and no nystagmus in leaning (15.52% of patients), and down-beating in bowing and up-beating in leaning (6.17%), which was predominantly present in PSC-canalolithiasis. Statistically significant differences were observed in the direction of nystagmus provoked by BLT in PSC-BPPV subtypes. No significant differences were found in nystagmus latency or duration during BLT positions. Among BPPV subtypes, there was a significant difference in nystagmus duration and latency, especially between cupulolithiasis and other variants. BLT's sensitivity was 0.93 in bowing and 1 in a leaning position, while specificity was 0.93 and 0.82 respectively. CONCLUSION: Beyond the LSC, the BLT has expanded to other variants. However, study results differ likely due to variations in patient characteristics and test execution. Currently, no specific features for ASC have been found to differentiate it from PSC-BPPV limiting the test's use for this variant. LEVEL OF EVIDENCE: Level 3, according to Oxford Center for Evidence-Based Medicine Laryngoscope, 2023.

Epidemiología de los trastornos del equilibrio en atención primaria / Epidemiology of balance disorders in primary care

ANTECEDENTES Y OBJETIVO: Actualmente, no existen series de pacientes que hayan descrito la incidencia de cada una de las enfermedades que causan alteraciones del equilibrio (AE) en atención primaria. El objetivo de este estudio es calcular la incidencia de cada una de ellas para proponer medidas formativas específicas. MATERIALES Y MÉTODO: Estudio transversal prospectivo. Se obtuvieron los datos de los pacientes de cinco cupos de médicos en cinco centros diferentes de atención primaria de nuestra área hospitalaria. Durante un año se reclutaron todos los pacientes que acudieron a consultas por cualquier tipo de vértigo, inestabilidad o mareo como motivo principal de consulta. Mediante un algoritmo diagnóstico-terapéutico los pacientes fueron diagnosticados y tratados en atención primaria o derivados para su estudio en atención hospitalaria. RESULTADOS: La población estudiada fue de 7.896 personas. Se detectó una incidencia anual de AE del 2,2%. El 56,1% de los casos pudo ser diagnosticado y tratado en atención primaria. El 53,8% de los pacientes fue diagnosticado de algún tipo de vértigo posicional. Los siguientes tres diagnósticos más frecuentes fueron migraña vestibular, isquemia del sistema nervioso central y efectos secundarios de medicamentos. Estos cuatro grupos sumaron un 87,9% de la población. CONCLUSIONES: La incidencia de las AE en atención primaria requiere un abordaje en el que se incluya formación en el diagnóstico y tratamiento del vértigo posicional paroxístico benigno, la cefalea, los factores de riesgo cardiovascular y de farmacología, no siendo necesario prescribir sedantes vestibulares en la mayoría de los casos

BACKGROUND AND OBJECTIVE: In our country, there are no series of patients that have described the incidence of the different diseases which cause balance disorders (BD) in primary care. The objective of this study is to calculate the incidence of each disease to propose specific training measures. MATERIALS AND METHOD: Prospective cross-sectional study. Patient data of five primary care physicians in five different primary care centres in our hospital area were collected. All patients who attended consultations for any type of vertigo, imbalance or dizziness over one year as the main reason for consultation were recruited. Using a diagnostic-therapeutic algorithm, patients were diagnosed and treated in primary care or referred for study in hospital care. RESULTS: The population studied was 7,896 people. An annual incidence of BD of 2.2% was detected. Of the cases, 56.1% could be diagnosed and treated in primary care. Of the patients, 53.8% were diagnosed with some type of positional vertigo; the next three most frequent diagnoses were vestibular migraine, central nervous system ischaemia and medication side effects. These four groups accounted for 87.9% of the population. CONCLUSIONS: The incidence of BD in primary care requires an approach that includes training in the diagnosis and treatment of benign paroxysmal positional vertigo, headache, cardiovascular risk factors and pharmacology. It is not necessary to prescribe vestibular suppressants in most patients

Epidemiology of balance disorders in primary care. / Epidemiología de los trastornos del equilibrio en atención primaria.

BACKGROUND AND OBJECTIVE: In our country, there are no series of patients that have described the incidence of the different diseases which cause balance disorders (BD) in primary care. The objective of this study is to calculate the incidence of each disease to propose specific training measures. MATERIALS AND METHOD: Prospective cross-sectional study. Patient data of five primary care physicians in five different primary care centres in our hospital area were collected. All patients who attended consultations for any type of vertigo, imbalance or dizziness over one year as the main reason for consultation were recruited. Using a diagnostic-therapeutic algorithm, patients were diagnosed and treated in primary care or referred for study in hospital care. RESULTS: The population studied was 7,896 people. An annual incidence of BD of 2.2% was detected. Of the cases, 56.1% could be diagnosed and treated in primary care. Of the patients, 53.8% were diagnosed with some type of positional vertigo; the next three most frequent diagnoses were vestibular migraine, central nervous system ischaemia and medication side effects. These four groups accounted for 87.9% of the population. CONCLUSIONS: The incidence of BD in primary care requires an approach that includes training in the diagnosis and treatment of benign paroxysmal positional vertigo, headache, cardiovascular risk factors and pharmacology. It is not necessary to prescribe vestibular suppressants in most patients.

Balance disorders as potential confounders associated with an increased risk of acute cerebrovascular accidents.

PURPOSE: There is a higher risk of stroke after suffering from balance disorders (BDs) such as vertigo or dizziness. The causal relationship remains unclear due to the limited scope of the existing studies and the high prevalence of cardiovascular risk factors (CVRFs) in BD patients. The objective of this study is to clarify the role that BDs seem to have in the development of acute cerebrovascular accidents (ACAs). METHODS: This is an observational prospective study. The CVRFs and demographic factors of a sample of our population were noted. Five clusters of patients were tracked over the course of 2 years to detect and diagnose BDs and ACAs. The causal relationships between the CVRFs, BDs and ACAs were analyzed in a univariate analysis. A logistic regression multivariant analysis was performed on those variables that reached statistical significance. RESULTS: The sample included 7886 participants and 31 ACAs were recorded. CVRFs that reached statistical significance included age ≥ 60, hypertension, diabetes mellitus, dyslipidemia, ischemic heart disease, atrial fibrillation and previous ACAs. The relationship between BDs and ACAs always reached statistical significance, regardless of how the BD variable was defined. Five different multivariate analyses were performed, but in none of them did the BD variables significantly reduce the deviance and thus, they were not taken into account when building the final model. CONCLUSION: This study shows that BDs are probably confounders that are closely linked to other CVRFs and they are also useful red flags to identify patients at a higher risk of suffering from ACAs.

Identifying Training, Diagnostic and Therapeutic Needs From a Comparison in the Distribution of Vestibular Disorders in Primary Care and in a Neurotology Unit.

Introduction: Several epidemiological studies in Neurotology have been previously carried out in the general population. This approach is useful for learning about the most common disorders in clinical population, but it may fail when one is trying to help professionals to guide their training, to optimize their resources and to decide on the highest-priority research objectives. Objective: To identify which of the neurotological diseases are most common in two different populations, those who attended a consultation in the Neurotology Unit of a tertiary level hospital and those who did so in Primary Care in order to infer which of them requires more attention in each context and their specific needs. Methods: All the diagnoses made in Hospital Care between October 15, 2017 and October 14, 2018 were reviewed. These diagnoses were coded and classified into syndromes and diseases. Later, the proportions of each category were compared with the proportions of the neurotological diagnoses made in five Primary Care centers over the same period of time. Results: BPPV is the most common cause of vestibular symptoms in both contexts. Vestibular migraine, ischemic vestibular symptoms, orthostatic hypotension and side effects of drugs are common in Primary Care, whereas Ménière's disease and undifferentiated episodic vestibular syndrome are common in specialized centers. Conclusion: The proportion of diagnoses in neurotologic patients is different in the general population and in the specialized center population, and therefore they have different needs. Primary Care professionals would benefit from training on maneuvers for repositioning otoliths, the treatment of headache, the identification of cardiovascular risk factors, the orthostatic hypotension and the side effects of the most commonly used drugs. The professionals who work in specialized centers need strategies for dealing with cases of BPPV associated to other vestibular diseases and refractory cases and their research should focus on the development of new diagnostic tools for the diagnosis of undifferentiated episodic vestibular syndrome and new therapeutic options for Ménière's disease.

Experiencia de uso de fampridina en pacientes con nistagmo vertical inferior / Clinical use of 4-aminopyridine in patients with downbeat nystagmus

OBJETIVO: Presentar los resultados del tratamiento con fampridina de liberación prolongada (4-AP-SR) en pacientes con nistagmo vertical inferior. MATERIAL Y MÉTODO: Serie de casos de nistagmo vertical inferior tratados con 10 mg de 4-AP-SR cada 12h. Se valoraron la mejoría clínica y la variación del nistagmo antes y después del tratamiento, registrando la puntuación en el Dizziness Handicap Inventory, la velocidad de la fase lenta del nistagmo y su frecuencia. RESULTADOS: Se trataron 3 pacientes, ninguno de los cuales notó cambios durante el tratamiento en relación con los síntomas visuales, aunque 2 pacientes notaron mejoría subjetiva de la marcha. No se detectaron diferencias significativas en la puntuación del Dizziness Handicap Inventory ni en las variables videonistagmográficas estudiadas. CONCLUSIÓN: No se han detectado cambios en los síntomas visuales con el tratamiento con 4-AP-SR. La contradicción con estudios previos puede estar producida por un bajo tamaño muestral, la etiología de los casos o la forma de medir los resultado

OBJECTIVE: To present the results of treatment with sustained-release fampridine (4-AP-SR) in patients with downbeat nystagmus. MATERIAL AND METHOD: Series of cases with downbeat nystagmus treated with 10 milligrams of 4-AP-SR every 12 hours. The clinical improvement and the variation of the nystagmus before and after the treatment were evaluated, recording the score in the Dizziness Handicap Inventory, the velocity of the slow phase of the nystagmus and its frequency. RESULTS: Three patients were treated, none of whom reported significant subjective changes during the treatment. No significant differences were detected in the Dizziness Handicap Inventory score or in the studied videonystagmographic variables. CONCLUSION: This communication does not present positive results on the use of 4-AP-SR. The contradiction with previous studies may be caused by a small sample size, by the etiology of the cases or by the way in which the results were measured

Clinical use of 4-aminopyridine in patients with downbeat nystagmus. / Experiencia de uso de fampridina en pacientes con nistagmo vertical inferior.

OBJECTIVE: To present the results of treatment with sustained-release fampridine (4-AP-SR) in patients with downbeat nystagmus. MATERIAL AND METHOD: Series of cases with downbeat nystagmus treated with 10 milligrams of 4-AP-SR every 12hours. The clinical improvement and the variation of the nystagmus before and after the treatment were evaluated, recording the score in the Dizziness Handicap Inventory, the velocity of the slow phase of the nystagmus and its frequency. RESULTS: Three patients were treated, none of whom reported significant subjective changes during the treatment. No significant differences were detected in the Dizziness Handicap Inventory score or in the studied videonystagmographic variables. CONCLUSION: This communication does not present positive results on the use of 4-AP-SR. The contradiction with previous studies may be caused by a small sample size, by the etiology of the cases or by the way in which the results were measured.