Vestibular Rehabilitation

Vestibular rehabilitation (VR) is a therapeutic approach prepared specifically for each individual who has a vestibular and balance disorder. VR helps in the treatment of unilateral or bilateral vestibular hypofunction and vestibular problems such as labyrinthitis and vestibular neuronitis. Individuals who have inner ear problems which have not been solved for a long time or have received medical treatment benefit from VR. In addition, VR helps to alleviate the complaints of individuals who have undergone surgery due to vestibular problems. With the VR program, regulative activities are carried out to decrease the duration, intensity, and frequency of vertigo; the symptoms of vertigo; increase independency in daily life activities; and to make it possible for patients to deal with the feelings of dizziness, imbalance, and anxiety, in addition to training patients about this issue and regulating the general conditions. The aim is to increase the life quality of patients.

Risk of Vestibulocochlear Disorders in Patients with Migraine or Non-Migraine Headache

Headaches, especially migraines, have been associated with various vestibular symptoms and syndromes. Tinnitus and hearing loss have also been reported to be more prevalent among migraineurs. However, whether headaches, including migraine or non-migraine headaches (nMH), are associated with vestibular and cochlear disorders remains unclear. Thus, we sought to investigate possible associations between headache and vestibulocochlear disorders. We analyzed 10 years of data from the Smart Clinical Data Warehouse. In patients with migraines and nMH, meniere’s disease (MD), BPPV, vestibular neuronitis (VN) and cochlear disorders, such as sensorineural hearing loss (SNHL) and tinnitus, were collected and compared to clinical data from controls who had health check-ups without headache. Participants included 15,128 with migraines, 76,773 patients with nMH and controls were identified based on propensity score matching (PSM). After PSM, the odds ratios (OR) in subjects with migraine versus controls were 2.59 for MD, 2.05 for BPPV, 2.98 for VN, 1.74 for SNHL, and 1.97 for tinnitus, respectively (p < 0.001). The OR for MD (1.77), BPPV (1.73), VN (2.05), SNHL (1.40), and tinnitus (1.70) in patients with nMH was also high after matching (p < 0.001). Our findings suggest that migraines and nMH are associated with an increased risk of cochlear disorders in addition to vestibular disorders.

Current aspects of the treatment of different types of vertigo

Dizziness is one of the most frequent complaints of patients in daily clinical practice. The prevalence of vertigo increases significantly in older patients. In most cases, vertigo is caused by pathology of the peripheral vestibular system: benign paroxysmal positional vertigo, vestibular neuronitis, Meniere’s disease. Episodes of recurrent vestibular vertigo without hearing loss can be associated with vestibular migraine, a diagnosis of which remains low in our country. Modern treatment regimens have been developed for patients with various causes of vertigo and unsteadiness. High effectiveness is achieved with a comprehensive approach to the management of patients with vertigo, which includes vestibular exercises, psychological training, and medications that help to reduce the severity and frequency of vertigo attacks and improve vestibular compensation. Many studies have shown high efficacy of the low-dose combination drug cinnarizine 20 mg + dimenhydrinate 40 mg for the treatment of peripheral and central vertigo, which is well tolerated and does not delay vestibular compensation. The efficacy of the low-dose combination drug cinnarizine + dimenhydrinate and betahistine dihydrochloride was compared in the treatment of patients with unilateral vestibular neuronitis, Meniere’s disease, and other diseases of the peripheral and central vestibular system. Studies have shown no less efficacy of the combined drug cinnarizine + dimenhydrinate in the treatment of Meniere’s disease than of betahistine, a more pronounced improvement in vestibular function in the treatment of vestibular neuronitis with the combined drug than with betahistine. For patients with peripheral vestibulopathy of various etiologies, treatment with the combination drug was more effective than therapy with betahistine.

Risk of vestibulocochlear disorders in patients with migraine or non-migraine headache

Background Headache, especially migraine, has been associated with various vestibular symptoms and several vestibular syndromes. In addition, cochlear disorders, such as tinnitus and hearing loss, have recently been reported to be more prevalent among migraine patients. However, whether headaches, including migraine or non-migraine headaches, are associated with vestibular and cochlear disorders remains unclear. Thus, the possible associations between headaches, including migraine and non-migraine headaches, and vestibulocochlear disorders were investigated in the present study. Methods Clinical data were analyzed from the Smart Clinical Data Warehouse of Hallym University Medical Center from 2011–2021. In patients with migraine and non-migraine headaches, data on Meniere`s disease (MD), benign paroxysmal positional vertigo (BPPV), vestibular neuronitis (VN), and cochlear disorders such as sensorineural hearing loss (SNHL) and tinnitus, were collected and compared with clinical data from controls without headache who had health check-ups. In addition, the presence of comorbidities were defined according to the International Classification of Diseases, tenth revision codes in the database and analyzed. Results The study included 15,128 participants with migraines and 76,773 with non-migraine headaches. Controls were identified based on propensity score matching (PSM). After PSM, the adjusted odds ratios (ORs) in subjects with migraine versus controls were 2.597 for MD (95% CI, 2.047–3.295; p < 0.001), 2.045 for BPPV (95% CI, 1.816–2.302; p < 0.001), 2.976 for VN (95% CI, 2.636–3.360; p < 0.001), 1.739 for SNHL (95% CI, 1.404–2.156; p < 0.001), and 1.970 for tinnitus (95% CI, 1.658–2.341; p < 0.001). The adjusted ORs for MD (1.771; 95% CI, 1.560–2.011; p < 0.001)), BPPV (1.731; 95% CI, 1.637–1.831; p < 0.001), VN (2.048; 95% CI, 1.935–2.168; p < 0.001), SNHL (1.396; 95% CI, 1.273–1.531; p < 0.001), and tinnitus (1.693; 95% CI, 1.569–1.826; p < 0.001) in patients with non-migraine headache versus controls were also high after PSM. Conclusion The present study findings indicated that migraine and non-migraine headaches are associated with an increased risk of cochlear disorders, such as SNHL and tinnitus, in addition to vestibular disorders.

VESTIBULAR NEURONITIS

Vestibular neuronitis is an acute vestibular syndrome due to inflammation of the vestibular nerve characterized by the typical symptoms of acute rotatory vertigo accompanied by nausea, vomiting, and symptoms of balance disorders. The incidence of vestibular neuronitis is about 3.5 per 100,000 people. The exact etiology of this vestibular neuronitis is unknown. However, based on existing evidence, vestibular neuronitis is associated with viral infections of the upper respiratory tract and herpes zoster infection. The clinical manifestations of vestibular neuronitis are persistent rotatory vertigo accompanied by oscillopsia, horizontal-rotatory peripheral vestibular spontaneous nystagmus on the healthy side, and a tendency to fall on the affected side. Diagnosis of vestibular neuronitis can be made by clinical diagnosis, through history, physical examination, and special examinations. Through these examinations, the differential diagnosis of vestibular neuronitis should be excluded, such as Meniere's disease, labyrinthitis, benign paroxysmal positional vertigo, and vertigo due to central lesions such as cerebellar infarction. Management of vestibular neuronitis is in the form of symptomatic therapy with vestibular suppressants, antivertigo, and redirect to relieve the symptoms that arise, then causative therapy can be done by administering corticosteroids, and in patients, physiotherapy can be done to improve vestibular function.

Vestibular vertigo in emergency neurology

The review deals with approaches to the differential diagnosis of the causes of vertigo in emergency neurology. The main causes of episodic and acute vestibular syndrome are discussed. Clinical diagnostic methods for acute vestibular syndrome (evaluation of nystagmus, test of skew, head-impulse test and neurological status) are considered. Clinical signs of “benign” acute vestibular syndrome and symptoms indicating a stroke in the vertebrobasilar system are presented. Differential diagnostic criteria for peripheral and central vestibular disorders are presented. Transient ischemic attacks, features of the otoneurologic status in vestibular neuronitis and different localizations of cerebral infarction focus are considered. Errors in the diagnosis of the vertigo causes are discussed.

Vestibular neuronitis of idiopathi origin: a case report

Vestibular Neuronitis is a neuronal condition characterized by spontaneous and unilateral vestibular loss suddenly with preserved hearing and no signs of brain stem dysfunction. According to large population studies, it is the sixth cause of vertigo with an incidence of 8%. Here is the case report of VN which was observed in a super speciality hospital. A 42 years old male patient was admitted in a private super speciality hospital with the chief complaints of history of vomiting 4 episodes, neck pain, mild headache and gaint imbalance since 5 days. Complete analysis of diagnostic reports was done and appropriate treatment given. This case emphasizes the importance of periodic evaluation and reporting of vestibular neuritis cases accumulating clinical knowledge. In this particular type of cases it is difficult to identify the etiology and pathophysiology, hence it is vitally important to conduct such studies.

Vestibular neuronitis

Vestibular neuronitis occurs as a result of damage to the vestibular nerve and is manifested by a sudden and prolonged attack of vestibular vertigo, accompanied by nausea, vomiting and imbalance. Questions of etiology, pathogenesis, clinical picture, diagnosis and treatment of VN are discussed. The disease is associated with selective inflammation (viral or infectious-allergic genesis) of the vestibular nerve. The role of herpes simplex virus type 1 is confirmed by cases of herpetic encephalitis in VN. In 2020, cases of VN development in patients with COVID-19 are described. VN usually affects the upper branch of the vestibular nerve, which innervates the horizontal and anterior semicircular canals. The duration of vertigo with VN ranges from several hours to several days. The timing of the restoration of vestibular function depends on the degree of damage to the vestibular nerve, the speed of central vestibular compensation and the patient’s performance of vestibular gymnastics. Some patients, months and even years after VN, experience significant instability. The diagnosis of VL is based on the clinical picture of the disease, the results of an otoneurological examination, and the exclusion of other diseases. VN treatment is aimed at reducing dizziness, nausea and vomiting and accelerating vestibular compensation. In our country VN is rarely diagnosed, which is associated with poor awareness of doctors about this disease. The article presents the observation of a 46-year-old patient with VN, who was mistakenly diagnosed with vertebrobasilar insufficiency, which contributed to the patient’s long-term disability. Establishing the correct diagnosis, educational work with the patient, conducting vestibular gymnastics led to an improvement in the condition, regression of instability. The issues of the effectiveness of vestibular gymnastics, the use of betahistine to accelerate the recovery of patients with VN are discussed.

Drug and non-drug treatments of vertigo

Patients with complaints of “dizziness” often make an odyssey of visits to physicians belonging to various specialties. The prevalence of vertigo in the population is 17–30%. In most cases, disorders of various areas of the vestibular analyzer form the pathogenetic basis of vertigo and unsteadiness, while the most common cause of these complaints is the pathology of the peripheral area of the vestibular system: benign paroxysmal positional vertigo, vestibular neuronitis, Meniere’s disease. The cerebral vessel disease caused by hypertensive cerebral microangiopathy and cerebral atherosclerosis can also manifest by vertigo and unsteadiness. They can be represented by acute cerebrovascular disorders in the vertebrobasilar arterial system, transient ischemic attacks, as well as manifestations of chronic cerebrovascular disease (chronic cerebral ischemia, discirculatory encephalopathy). Episodes of recurrent spontaneous vestibular vertigo can be caused by vestibular migraine, which is rarely diagnosed in our country. The variety of reasons for complaints of vertigo and unsteadiness defines many therapeutic approaches to the treatment of these diseases. In recent times, modern drug and non-drug approaches to the treatment have been developed for patients with various diseases manifested by vertigo and unsteadiness. The most effective treatment is a comprehensive therapeutic approach that combines non-drug therapy, including vestibular gymnastics, training on the stabilographic platform with biofeedback according to the support reaction, and drugs that help reduce the severity, duration, and frequency of vertigo attacks, as well as accelerate vestibular compensation. Many studies have shown the efficacy of drugs enhancing microcirculation used for the prophylactic treatment of various causes of vertigo and unsteadiness.