The Relationship Between Paroxysmal Vertigoes and Right-To-Left Shunt: A Large Observational Study

Background The association between paroxysmal vertigo and right-to-left shunt (RLS) is rarely reported. We investigated the incidence and correlation of RLS in patients with different paroxysmal vertigo diseases. Methods This large observational study included patients with paroxysmal vertigo from seven different hospitals in China from 2017 to 2021 (NCT04939922). Migraine patients within the same period were included for comparison. Demographic data and medical history were collected, contrast transthoracic echocardiography (cTTE) was performed, and the clinical features, dizziness handicap inventory, and incidence of RLS in each group were recorded. Results This study used a consecutive sampling of 4536 patients from seven centres, and a total of 2751 patients were enrolled. The proportion of RLS in patients with migraine with aura (MA), migraine without aura (MoA), vestibular migraine (VM) with headache, VM without headache, and benign recurrent vertigo (BRV) was significantly higher than that in patients with benign paroxysmal positional vertigo (BPPV), Meniere’s disease (MD), and vestibular paroxysmia (VP) (P<0.05). There was no statistical difference between the frequency of RLS in patients with BRV and those with MoA (P=0.931), MA (P=0.997), VM with migrainous headache (P=0.787), and VM without migrainous headache (P=0.754). There was a positive correlation between the RLS grade and the dizziness handicap inventory scores of VM and BRV patients (P<0.01). Conclusions RLS was significantly associated with BRV and VM. RLS may be involved in the pathogeneses of BRV and VM and may serve as a reference index for the differential diagnosis of central and peripheral vertigo. Trial registration: CHRS, NCT04939922, registered 14 June 2021- retrospectively registered, https://register.clinicaltrials.gov

Approach of management a patient with vertigo in out-patient practice: case of recurrent benign paroxysmal positional vertigo with vitamin D deficiency

Головокружение является одной из наиболее частых причин обращения к неврологу. С возрастом частота головокружения возрастает. Первой целью невролога является дифференциация между центральным и периферическим головокружением. Вторым этапом необходимо провести детальный дифференциальный диагноз между нозологиями. Для решения этих задач врачу необходимо провести нейровестибулярное обследование, включающее пробу Хальмаги, тест с встряхиванием головы, тест Фукуда и обязательное проведение позиционных проб. Тактика дальнейшего ведения предполагает адекватную вертиголитическую терапию, лечение основного заболевания и создание плана реабилитации, которая включает в себя как вестибулярную гимнастику и другие нелекарственные методы (биологическая обратная связь, занятия на стабилоплатформе), так и препараты, улучшающие вестибулярную компенсацию. Периферическое головокружение встречается значительно чаще центрального, а самой распространенной причиной вращательного головокружения является доброкачественное пароксизмальное позиционное головокружение. По разным оценкам, до 85% случаев доброкачественного пароксизмального позиционного головокружения являются идиопатическими, у 50% наблюдается рецидивирование. В статье приведен клинический случай рецидивирующего доброкачественного пароксизмального позиционного головокружения с поражением нескольких каналов. Особенностью данного случая является его сочетание с дефицитом витамина D. На сегодняшний день накоплены данные, указывающие на то, что недостаточность и дефицит витамина D не просто коморбидное состояние, часто выявляемое у пациентов с доброкачественным пароксизмальным позиционным головокружением, но, вероятнее всего, фактор развития и рецидивирования доброкачественного пароксизмального позиционного головокружения. Однако данные достаточно противоречивы и требуют дальнейшего изучения. Выявление и коррекция метаболических факторов позволят оптимизировать терапию. Dizziness is one of the most frequent causes of appliance to neurologist. The occurrence of dizziness increases in elder groups. The first goal of a neurologist is the differentiation between central and peripherial vertigo. It is necessary for second stage to make detalized differential diagnosis. To realize this purpose doctor should carry out neurovestibular investigation, including HINT test, shaking-test,test Fukuda and mandatory performing of positional tests. The further management includes adequate vertigolytic therapy, treatment of the basic disease and creation of a rehabilitation scheme, which includes both vestibular gymnastics and other non-drug methods (biofeedback, exercises on a stabiloplatform), and drugs that improve vestibular compensation. Peripheral vertigo is much more common than central vertigo and is the most common cause spinning vertigo is a benign paroxysmal positional vertigo. According to various estimates, up to 85% of benign paroxysmal positional vertigo cases have idiopathic origin, frequency of relapse is about 50%. The article presents a clinical case of recurrent benign paroxysmal positional vertigo with multiple canal involvement. A feature of this case is its combination with a vitamin D deficiency. Today, data have been accumulated indicating that vitamin D deficiency and insufficency is not just a comorbid condition often detected in patients with benign paroxysmal positional vertigo, but, most likely, is a factor in the development and recurrence of benign paroxysmal positional vertigo. However, the data are rather contradictory and require further investigation. Identifying and correcting of metabolic factors will optimize therapy.

Comparison of effectiveness of Cawthorne Cooksey exercise with Brandt Daroff exercise in managing post Epley’s residual dizziness in patients with posterior canal benign paroxysmal positional vertigo

<p class="abstract"><strong>Background:</strong> Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo. Vertigo and balance disorders are among the most common symptoms experienced in patients who visit ENT outpatient department. BPPV is a common vestibular disorder leading to significant morbidity and psychosocial impact. Residual dizziness is a common condition that manifests as persistent disabling imbalance after successful repositioning maneuvers for BPPV.</p><p class="abstract"><strong>Methods: </strong>In this study we analysed and compared the effectiveness of Cawthorne Cooksey Exercise with Brandt Daroff Exercise to treat residual dizziness after successful Epley’s maneuver for posterior canal benign paroxysmal positional vertigo. A total of 30 subjects with residual dizziness after successful Epley’s maneuver for posterior canal BPPV were included in our study, 10 were male and 20 were female. The Group A received the Cawthorne Cooksey exercise post Epley’s maneuver and Group B received the Brandt Daroff exercise post Epley’s maneuver. </p><p class="abstract"><strong>Results:</strong> We conclude that both the groups have significant improvement in their symptoms and balance. This was indicated by the results. Despite the significant results within the groups, there was no significant difference between the groups, means both exercises showed almost equal improvement in their respective group.</p><p><strong>Conclusions: </strong>This<strong> </strong>study concludes that both Cawthorne Cooksey exercise and Brandt Daroff exercise are helpful in treating residual dizziness after successful Epley’s maneuver in posterior canal BPPV patients. These exercises are safe and able to reduce subjective symptoms and imbalance hence, any of these can be recommended for treating post Epley’s residual dizziness in patients with posterior canal BPPV. </p>

CENTRAL VERTIGO

Central vertigo is a symptom characterized by a feeling of changes in body position or environment as a result of diseases originating from the central nervous system. Central vertigo is caused by a disease that extend from vestibular nuclei in medulla oblongata to ocular motor nuclei and integration system in mesencephalon to vestibulocerebellum, thalamus and vestibular cortex in temporoparietal and the neuronal pathway which mediate VOR (vestibulo-ocular reflex). The diseases can be vestibular migrain, TIA (Transient Ischemic Attack), Vertebrobasilar ischemic stroke, multiple sclerosis, tumor in cerebelopontine angle and congenital malformation like Dandy Walker Syndrome. Central vertigo can be diagnosed by performing several special tests. This examination can also distinguish central vertigo from its differential diagnosis, namely peripheral vertigo. Management of central vertigo can be in the form of acute attack management and specific management according to the cause.

Incidence of peripheral vestibular disorders in individuals with obstructive sleep apnea

BACKGROUND: Obstructive sleep apnea(OSA) could influence peripheral vestibular function adversely via intermittent hypoxia and its consequences. OBJECTIVE: This study aimed to evaluate the risk of peripheral vestibular disorders in OSA using a nationwide population-based retrospective cohort study. METHODS: The National Health Insurance Service–National Sample Cohort represents the entire Korean population from 2002 to 2015. OSA was defined as individuals who had used medical services twice or more under a diagnosis of OSA(G47.33 in ICD-10). A comparison cohort consisted of socio-demographically matched non-OSA subjects in a ratio of 1:4. The incidences of benign paroxysmal positional vertigo(BPPV), Meniere’s disease, and vestibular neuritis were evaluated in each cohort. RESULTS: A total of 2,082 individuals with OSA and 8,328 matched non-OSA subjects were identified. The incidence rates(IRs) of peripheral vertigo in OSA and non-OSA were 149.86 and 23.88 per 10,000 persons, respectively (Ratio of IR, IRR = 6.28, 95%CI 4.89 to 8.08). In multivariable analysis, the risk of peripheral vertigo was significantly higher in OSA(adjusted HR = 6.64, 95%CI 5.20 to 8.47), old age(adjusted HR = 1.03, 95%CI 1.02 to 1.04), female sex(adjusted HR = 1.92, 95%CI 1.48 to 2.50), and comorbidities(adjusted HR = 1.09, 95%CI 1.003 to 1.19). The IRRs of each vestibular disorder in the two groups were 7.32(95%CI 4.80 to 11.33) for BPPV, 3.61(95%CI 2.24 to 5.81) for Meniere’s disease, and 9.51(95%CI 3.97 to 25.11) for vestibular neuritis. CONCLUSIONS: Subjects diagnosed with OSA had a higher incidence of peripheral vestibular disorders than those without OSA, according to national administrative claims data. It is recommended to take peripheral vertigo into account when counseling OSA.

Vertigo in association with gastro-esophageal reflux disease

<p class="abstract"><strong>Background:</strong> Gastroesophageal reflux (GERD) is a condition which develops when the reflux of stomach contents cause troublesome symptoms. Symptoms of GERD are either esophageal: heartburn and regurgitation, or extra-esophageal: chronic cough, recurrent sinusitis, and globus sensation in the throat. One of the extra-esophageal manifestations of GERD is otitis media with effusion, very common among children. The aim of our study was to find the prevalence of GERD and <em>Helicobacter Pylori</em> (<em>H. Pylori</em>) among patients with peripheral vertigo.</p><p class="abstract"><strong>Methods:</strong> The present descriptive study was conducted on randomly selected patients attending outpatient department (OPD) of in community health center, Chenani for a period of one year from August 2018 to July 2019. Patients were selected without the pathology of central nervous system for the further analysis. </p><p class="abstract"><strong>Results:</strong> 85 (75.89%) patients had gastro-esophageal reflux disease. Tendency of GERD was found higher among females (54.12%). Positive <em>H. pylorus</em> was found for 21 patients (24.71%). 65 (74.71%) patients with vertigo positive had GERD. When acid refluxes into the upper GI system, it can affect the tubes that lead to the inner ear. When these tubes become irritated, swelling can occur, causing a loss of balance and common with GERD that occurs when lying down after a meal.</p><p class="abstract"><strong>Conclusions:</strong> It present data confirms the hypothesis that one of the peripheral vertigo causes could be GERD, by way of a mechanism which may include reflux of gastric acids causing inflammation or local infection. The present study found a definite prevalence of GERD and <em>H. Pylori</em> among patients with peripheral vertigo.</p>