Determining vestibular hypofunction: start with the video-head impulse test.

Caloric testing is considered the 'reference standard' in determining vestibular hypofunction. Recently, the video-head impulse test (vHIT) was introduced. In the current study we aimed to assess the diagnostic value of the vHIT as compared to caloric testing in determining vestibular function. In a cross-sectional study between May 2012 and May 2013, we prospectively analysed patients with dizziness who had completed caloric testing and the vHIT. For the left and right vestibular system we calculated the mean vHIT gain. We used a gain cut-off value of 0.8 for the vHIT and presence of correction saccades to define an abnormal vestibular-ocular reflex. An asymmetrical ocular response of 22 % or more (Jongkees formula) or an irrigation response with a velocity below 15°/s was considered abnormal. We calculated sensitivity, specificity, positive and negative predictive values with 95 % confidence intervals for the dichotomous vHIT. Among 324 patients [195 females (60 %), aged 53 ± 17 years], 39 (12 %) had an abnormal vHIT gain and 113 (35 %) had an abnormal caloric test. Sensitivity was 31 % (23-40 %), specificity 98 % (95-99 %), positive predictive value was 88 % (74-95 %), and negative predictive value 73 % (67-77 %). In case of vHIT normality, additional caloric testing remains indicated and the vHIT does not replace the caloric test. However, the high positive predictive value of the vHIT indicates that an abnormal vHIT is strongly related to an abnormal caloric test result; therefore, additional caloric testing is not necessary. We conclude that the vHIT is clinically useful as the first test in determining vestibular hypofunction in dizzy patients.

Prevalence of unrecognized benign paroxysmal positional vertigo in older patients.

Dizziness is a relatively common complaint which occurs more often with increasing age. Benign paroxysmal positional vertigo (BPPV) is an important cause which can easily be treated but is frequently not recognized by professionals. The aim of this study was to assess the prevalence of unrecognized BPPV in older patients. Patients ≥70 years of age (n = 989) indicated whether they experienced dizziness, and if so whether the symptoms were typical for BPPV. If affirmed, a diagnostic maneuver was performed. Positive patients were treated at once. All suspected patients completed quality of life questionnaires and were followed for 3 and 6 months. Positive BPPV patients were compared with negative (but suspected) patients. Almost one quarter of the patients (226 patients, 23 %) suffered from dizziness, among whom 101 were suspected of BPPV. Less than half (n = 45) underwent the diagnostic maneuver, of whom 13 (29 %) were positive for BPPV. At follow-up, one patient developed BPPV, leading to a total of 14 positive patients (overall prevalence 1.4 %). BPPV positive patients did not differ from BPPV negative patients. Among a large group of older patients, one quarter experiences dizziness, and 1.4 % has definite BPPV.

A randomised sham-controlled trial to assess the long-term effect of the Epley manoeuvre for treatment of posterior canal benign paroxysmal positional vertigo.

OBJECTIVE: To evaluate the long-term efficacy of the Epley manoeuvre as a therapeutic procedure for posterior canal benign paroxysmal positional vertigo. DESIGN: Randomised, double-blind, sham-controlled trial. SETTING: A multidisciplinary dizziness unit in a non-academic Hospital. PARTICIPANTS: Forty-four patients with posterior canal benign paroxysmal positional vertigo (BPPV) with a duration of at least 1 month. Participants were randomised in two groups of 22 and treated with either the Epley manoeuvre or a sham manoeuvre and followed up for 1 year after treatment. MAIN OUTCOME MEASURES: Conversion of a 'positive' Dix-Hallpike test to a 'negative' Dix-Hallpike test, impairments perceived by the dizziness assessed by the Dizziness Handicap Inventory (DHI). STATISTICAL ANALYSIS: Absolute and relative risks were computed, and Fisher's exact test was used to compare the treatments. RESULTS: Six patients were lost to follow up (five in the sham group, one in the Epley group). The Epley procedure resulted in a treatment success in 20/22 patients (91%) after 12 months of follow-up, whereas the sham procedure had a positive effect in 10/22 patients (46%; P = 0.001). The DHI was significantly lower in the Epley group at all follow-up assessments (median scores 12 months 0 (0-51) versus 20 (0-76), P = 0.003). CONCLUSION: The Epley manoeuvre provides long-term resolution of symptoms in patients with posterior canal BPPV.

Video-head impulse test results in patients with Menière's disease related to duration and stage of disease.

BACKGROUND: The video-head impulse test employs the vestibulo-ocular reflex (VOR) to assess vestibular function. To this day, no consensus has been reached among scientists in terms of whether or not vHIT results change in MD patients as the disease progresses. OBJECTIVE: To assess whether the vHIT is more often abnormal in later stages of MD compared to earlier stages. METHODS: We retrospectively analyzed patients with 'definite' MD who had undergone a vHIT and caloric test between 2012 and 2015. Patients were evaluated based on duration of disease in years (≤1, >1≤5, >5≤10, >10) and stage of disease (stage I and II versus III and IV). For the vHIT, an abnormal vestibulo-ocular reflex was defined as a gain cut-off value of≤0.8 and presence of correction saccades including subanalyses using a cut-off value of≤0.9. RESULTS: In 89 definite MD patients (42 (47%) male, mean age 55±5 (SD)), data on both the caloric test and the vHIT were available. The risk of an abnormal vHIT was 25% in patients with a duration of disease over 10 years compared to 22% in the patients with a disease duration of 10 years or less (risk difference 3%, 95% CI:- 28% to 35%), p = 0.82). The risk for an abnormal vHIT in the Stage I and Stage II was 17% compared to 26% in Stage III and IV (risk difference 9%, 95% CI:- 30% to 11%). When using a cut-off value of 0.9 we also did not demonstrate a relationship between the duration of disease and the proportion of abnormal vHIT test results. CONCLUSIONS: There is no relationship between the proportion of abnormal vHIT test results in patients with MD in either duration or stage of disease.

Age of onset of Ménière's disease in the Netherlands: data from a specialised dizziness clinic.

OBJECTIVES: To determine the age of onset of Ménière's disease in patients who visited a specialised dizziness clinic, and to verify whether the trend of a delayed onset age of Ménière's disease as reported for the Japanese population also occurs in the Netherlands. METHOD: A retrospective data analysis was performed of patients diagnosed with 'definite' Ménière's disease who visited our clinic between January 2000 and December 2013. RESULTS: Mean onset age of Ménière's disease among the 296 patients was 53.0 ± 14.1 years; 209 patients (71 per cent) were diagnosed between the fifth and seventh decades of life. No trend towards a later onset of Ménière's disease was found (regression beta co-efficient for year of presentation was 0.03; 95 per cent confidence interval = -0.34-0.61; p = 0.58). CONCLUSION: Ménière's disease has a peak incidence between 40 and 69 years of age. No shift towards a later onset age of Ménière's disease was found.