Visually Evoked Postural Responses (VEPRs) in Children with Vestibular Migraine

Vestibular migraine (VM) is the most common cause of episodic vertigo in children. Vertigo, nausea, dizziness and unsteadiness are often complained of by children with migraine, which can precede, follow or be present simultaneously with headache. The aim of this study was to use posturography to investigate the visually evoked postural responses (VEPRs) of children with VM and compare them to data obtained from children with primary headache (M) and controls (C). Twenty children diagnosed as affected by VM, nineteen children with M without aura and twenty healthy subjects were recruited in this cross-sectional study. Posturography was performed by a standardized stabilometric force-platform (Svep-Politecnica) in the following conditions: open eyes (OE), closed eyes (CE) and during full-field horizontal optokinetic stimulation (OKN-S). Electronystagmography was performed simultaneously to analyze optokinetic reflex parameters. In the OE condition, no difference was found between groups with respect to body sway area. In contrast, this parameter increased in the two pathological groups with respect to controls in the CE condition. The optokinetic stimulations also induced a similar increase of body sway area in the M group relative to controls, but a further increase was elicited in the VM group. Electronystagmographic recording also revealed different optokinetic reflex parameters in the latter groups. This study disclosed an abnormal sensitivity of children with M and VM to full-field moving scenes and a consequent destabilization of posture, as documented by the abnormal VEPRs. Children with VM were particularly exposed to this risk. Possible clinical implications of these findings are discussed.

USE OF FLUNARIZINE AS A PREVENTIVE FOR VESTIBULAR MIGRAINE CRISES IN COMPARISON WITH OTHER DRUGS: SYSTEMATIC LITERATURE REVIEW

INTRODUCTION: Vestibular migraine is the main cause of episodic vertigo and the second most common cause of dizziness in adults. Treatment for vestibular migraine encompasses the prevention of crises and the control of acute symptoms. Flunarizine works by preventing the contraction of labyrinthine vessels and altering blood flow, thus preventing symptoms. Due to the high prevalence of the disease, its negative impacts on individual health and increased expenditure on public health, preventive pharmacological and non-pharmacological treatment must be implemented early. PURPOSE: To evaluate the efficacy of Flunarizine as a preventive for migraine and vestibular crises compared to other preventive drugs. MATERIAL AND METHODS: Scientific articles were searched in the databases using the terms (vestibular migraine OR migrainous vertigo) AND (flunarizine) AND (prophylaxis). Subsequently, a systematic literature review and meta-analysis was performed, including 3 randomized clinical trials comparing flunarizine and other preventive drugs in terms of efficacy and safety for preventing migraine vertigo attacks. The studies were analyzed using a ROB table, analysis using the GRADE method and meta-analysis. RESULTS: Qualitatively, the analysis showed that flunariniza was positive for decreasing the frequency of vertigo in cases of vestibular migraine, with a moderate degree of evidence, a relative risk of 0.34 and a confidence interval of 0.15 to 0.76. CONCLUSIONS: There are few studies available in the scientific literature on the use of flunarizine in vestibular migraine, many of which are heterogeneous among themselves, mainly in the way of evaluating and monitoring patients, carried out mainly through subjective methods. The meta-analysis showed a positive result for flunarizine as a preventive drug for the studied population. Furthermore, in all the studies analyzed, no serious side effects resulting from the use of the medication were reported, which makes it safe for patients to use. Flunarizine is a good drug for the prevention of vestibular migraine, especially in reducing the number of attacks, with a good level of evidence.

Treatment response of Epley’s manoeuvre in the management of posterior semicircular canal benign paroxysmal positional vertigo

<p class="abstract"><strong>Background:</strong> Benign paroxysmal positional vertigo (BPPV) is the most common reason for vertigo. Most common site of BPPV is posterior semicircular canal. The commonest symptom is episodic vertigo. This study aimed at the treatment response of Epley’s manoeuvre for posterior semicircular canal BPPV.</p><p class="abstract"><strong>Methods:</strong> 87 patients out of 114 were enrolled for the study from 2020 to 2021. After proper history and examination, Dix-Hallpike test (DHT) was done for diagnosis. Epley’s manoeuvre was done at first visit and was repeated at subsequent visits.</p><p class="abstract"><strong>Results:</strong> The mean age of the patients was 54 years. In this study, out of total 87 patients, there were 59 females (67.82%) and 28 males (32.18%). The male to female ratio was 1:2.11. Out of 87 patients, 53 patients (60.92%) recovered in the first visit, 18 patients (20.69%) recovered in second visit, 11 patients (12.64%) recovered in the third visit and remaining 5 patients (5.75%) recovered in fourth visit. In 3 out of 87 cases, that is, in 3.45%, recurrence was seen with return of the BPPV symptoms.</p><p class="abstract"><strong>Conclusions:</strong> Treatment response of Epley’s manoeuvre in posterior semicircular canal BPPV is good. Maximum number of patients’ recovered in the first visit.</p>

Skull Vibration-Induced Nystagmus Test (SVINT) in Vestibular Migraine and Menière’s Disease

Background: Vestibular migraine (VM) and Menière’s disease (MD) are the two most frequent episodic vertigo apart from Benign Paroxysmal Positional Vertigo (BPPV) differential diagnosis for them may be troublesome in the early stages. SVINT is a newly proposed vestibular test, which demonstrated to be fast and reliable in diagnoses above all of peripheral vestibular deficits. Methods: We retrieved clinical data from two groups of subjects (200 VM and 605 MD), enrolled between 2010 and 2020. Among others, these subjects were included when performing a SVINT. The purpose of the study is to assess if SVINT can be useful to differentiate the two episodic disorders. Results: 59.2% of MD subjects presented as positive with SVINT while only 6% did so with VM; among other tests, only video HIT demonstrated a different frequency in the two groups (13.1% and 0.5%, respectively), but the low sensitivity in these subjects makes the test unaffordable for diagnostic purposes. Conclusions: Since SVINT demonstrated to be positive in a peripheral vestibular deficit in previous works, we think that our data are consistent with the hypothesis that, in the pathophysiology of VM attacks, the central vestibular pathways are mainly involved.

Posterior petrous face meningiomas presenting with Ménière’s-like syndrome: a case series and review of the literature

OBJECTIVE Ménière’s disease is an inner ear disorder classically characterized by fluctuating hearing loss, tinnitus, and aural fullness accompanied by episodic vertigo. While the pathogenesis of Ménière’s remains under debate, histopathological analyses implicate endolymphatic sac dysfunction with inner ear fluid homeostatic dysregulation. Little is known about whether external impingement of the endolymphatic sac by tumors may present with Ménière’s-like symptoms. The authors present a case series of 7 patients with posterior fossa meningiomas that involved the endolymphatic sac and new onset of Ménière’s-like symptoms and review the literature on this rare clinical entity. METHODS A retrospective review of patients undergoing resection of a posterior petrous meningioma was performed at the authors’ institution. Inclusion criteria were age older than 18 years; patients presenting with Ménière’s-like symptoms, including episodic vertigo, aural fullness, tinnitus, and/or hearing loss; and tumor location overlying the endolymphatic sac. RESULTS There were 7 cases of posterior petrous face meningiomas involving the vestibular aperture presenting with Ménière’s-like symptoms. Imaging and intraoperative examination confirmed no cranial nerve VIII compression or labyrinthine artery involvement accounting for audiovestibular symptoms. Of the 7 patients in the series, 6 experienced significant improvement or resolution of their vertigo, and all 7 had improvement or resolution of their tinnitus after resection. Of the 5 patients who had preoperative hearing loss, 2 experienced improvement or resolution of their ipsilateral preoperative hearing deficit, whereas the other 3 had unchanged hearing loss compared to preoperative evaluation. CONCLUSIONS Petrous face meningiomas overlying the endolymphatic sac can present with a Ménière’s syndrome. Early recognition and microsurgical excision of these tumors is critical for resolution of most symptoms and stabilization of hearing loss.

Case Study: Depersonalization and Vestibular Impairment

Background We describe herein the case of a patient whose primary complaints were episodic vertigo and “depersonalization,” a sensation of detachment from his own body. Purpose This case study aims to further clinical knowledge and insight into the clinical evaluation of vertiginous patients with complaints of depersonalization. Research Design This is a case study. Data Collection and Analysis A retrospective chart review of vestibular function testing done on a vertiginous patient with complaints of depersonalization was performed. Results Vestibular function testing revealed absent cervical and ocular vestibular evoked myogenic potentials on the left side with normal vHIT or video Head Impulse Test, videonystagmography, and rotational chair results, suggesting peripheral vestibular impairment isolated to the left saccule and utricle. Conclusion The otolith end organ impairment explains the patient's postural deviation to the left side during attempts to ambulate. We recommend that clinicians should be attentive to patient complaints of depersonalization and perform vestibular evoked myogenic potential testing to determine whether evidence of at least a unilateral peripheral otolith end organ impairment exists.

MENIERE’S DISEASE

Meniere’s disease is a disorder of the inner ear resulting in symptoms of episodic vertigo, tinnitus, hearing loss and aural pressure. Although the exact etiology is uncertain, it is associated with raised pressure in the endolymph of the inner ear (endolymphatic hydrops). The diagnosis of Meniere's disease is based on the clinical setting of the patient. This disease usually presents with unilateral ear symptoms but can be also bilateral. Meniere's disease attacks are usually random and episodic (approximately 6-11 per year), with periods of remission that can last from months to years. Investigations are audiometry, electronystagmogram, vestibular evoked myogenic potentials (VEMPs) and imaging.The management consist pharmacological and non pharmacological. Meniere's disease is initially progressive but fluctuates unexpectedly. It is difficult to distinguish natural resolutions from treatment effects.

Meniere Disease: A Case Report

Background: Meniere’s disease is a clinical disorder defined as the idiopathic syndrome of endolymphatic hydrops. Meniere’s disease has a prevalence of about 200 cases per 100,000 people in the United States. Prevalence increases linearly with increasing age, especially over 60 years. Men and women are estimated to be proportional in the number of cases. The etiology of Meniere’s disease is currently known to be caused by intrinsic factors and extrinsic factors. Symptoms of Meniere’s disease include recurrent spontaneous episodic vertigo, fluctuating hearing loss, ear fullness, and tinnitus. Treatment of Meniere’s disease can be divided into pharmacological therapy and non-pharmacological therapy. In some cases, complaints can be reduced to 80-90 percent. Case Report: A woman, aged 65 years, complained of constant ringing in her right ear, feeling full and accompanied by decreased hearing in the right ear, spinning dizziness that is not related to changing position, especially when she is tired, ringing in the ear, a feeling of fullness in the ear since 3 months ago. Head MRI results were normal. The patient was treated with HCT 1×50 mg, prednisone 1×80 mg for 7 days, KSR 3×1 tablet, betahistine 2×24 mg. Patients experience improvement in complaints even though the complaints do not disappear completely Conclusion: The diagnosis of Meniere’s disease is established by clinical symptoms, namely recurrent spontaneous episodic vertigo, fluctuating hearing loss, ear fullness, and tinnitus. Appropriate therapy in Meniere’s disease can reduce complaints and improve the patient’s quality of life.

A Systematic Review on the Association of Acquired Human Cytomegalovirus Infection with Hearing Loss

Congenital cytomegalovirus (CMV) infection induces a clinical syndrome usually associated with hearing loss. However, the effect of acquired CVM infection in adults and children has not been clearly defined. The objective of this review is to critically appraise scientific evidence regarding the association of acquired CMV infection with postnatal hearing loss or tinnitus. A systematic review of records reporting sensorineural hearing loss (SNHL) or tinnitus and acquired CMV infection including articles published in English was performed. Search strategy was limited to human studies with acquired CMV infection. After screening and quality assessment, nine studies involving 1528 individuals fulfilled the inclusion criteria. A total of 14% of patients with SNHL showed evidence of previous exposure to CMV, while in individuals without SNHL (controls) the percentage rose up to 19.3%. SNHL was reported as unilateral or bilateral in 15.3%, and not specified in 84.7% of cases. The degree of SNHL ranged from mild to profound for both children and adults. None of the records reported tinnitus. The prevalence of children or adults with acquired SNHL with a confirmed acquired CMV infection by Polymerase Chain Reaction (PCR) or IgM anti-CMV antibodies is low. Phenotyping of patients with acquired CMV infection was limited to hearing loss by pure tone audiometry and no additional audiological testing was performed in most of the studies. Additional symptoms deserve more attention, including episodic vertigo or tinnitus, since some patients with the clinical spectrum of Meniere Disease could result from a CMV latent infection.

Systematic Review of Sequencing Studies and Gene Expression Profiling in Familial Meniere Disease

Familial Meniere Disease (FMD) is a rare inner ear disorder characterized by episodic vertigo associated with sensorineural hearing loss, tinnitus and/or aural fullness. We conducted a systematic review to find sequencing studies segregating rare variants in FMD to obtain evidence to support candidate genes for MD. After evaluating the quality of the retrieved records, eight studies were selected to carry out a quantitative synthesis. These articles described 20 single nucleotide variants (SNVs) in 11 genes (FAM136A, DTNA, PRKCB, COCH, DPT, SEMA3D, STRC, HMX2, TMEM55B, OTOG and LSAMP), most of them in singular families—the exception being the OTOG gene. Furthermore, we analyzed the pathogenicity of each SNV and compared its allelic frequency with reference datasets to evaluate its role in the pathogenesis of FMD. By retrieving gene expression data in these genes from different databases, we could classify them according to their gene expression in neural or inner ear tissues. Finally, we evaluated the pattern of inheritance to conclude which genes show an autosomal dominant (AD) or autosomal recessive (AR) inheritance in FMD.