Search

Introduction: In 2008, the Otoneurology committee of the SEORL-PCF published a classification of peripheral vertigo, based on clinical criteria. The objective of this study was to validate this classification through analysing the diagnostic agreement among several medical assessors., Methods: Seven medical assessors, all with clinical experience, from 6 different hospitals, participated in the study. One of them selected the clinical histories of 50 consecutive patients who had consulted as a result of balance disorders (24 men and 26 women) with an average age of 53.5 years. These clinical histories -without any information that would identify the patient, the diagnosis established and the treatment- were sent to another 6 assessors. Each of these investigators established their own diagnosis, trying to adjust it to the epigraphs of the classification., Results: Of the 50 patients, there was substantial agreement as to the diagnosis (4 or more evaluators indicated the same one) in 31 cases (26 with a positive diagnosis and 5 with a negative one, which could not be included in any epigraph). The kappa index, which measures the level of accordance between 2 or more assessors, was 0.4198 (moderate level of agreement). Unanimity was achieved in only 7 cases (4 BPPV, 2 Ménière's disease and 1 vertigo associated with migraine)., Conclusions: The current classification, with the criteria it includes, allows labelling with an acceptable consensus to only 62% of the patients. Therefore, a modification in the classification is proposed in relation with the probable BPPV epigraph, as well a revision of the entries for vertigo-migraine and vertigo associated with migraine., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) is a mixture of empiricism of particle repositioning with the rationally-based knowledge obtained from clinical observations, histopathology, and neurophysiological experiments. The recently published clinical practice guideline on BPPV makes recommendations on the management of BPPV. One of the statements discourages the use of radiographic or vestibular testing, unless the diagnosis was uncertain or there were additional signs or symptoms unrelated to BPPV. The role of video-oculography in diagnosis and treatment of BPPV is argued, since vestibular testing has provided key relevant information to understand positional nystagmus in patients with BPPV.

Benign paroxysmal positional vertigo is the most common vestibular disorder and it has a significant impact on health-related quality of life. The disease is probably caused by the accumulation of lithiasis material from the otolithic membrane of the utricle. Patients experience multiple short vertigo crises lasting seconds when they go to bed or turn over. There are several clinical variants affecting posterior, horizontal or anterior canals and in some cases vestibular lithiasis can occur in two canals simultaneously. Diagnosis is by video-oculographic recording of positional nystagmus during positional tests to identify the canal affected. There are specific treatment manoeuvres for each clinical variant, which a high degree of short-term effectiveness.

Objective: To analyze the time course of caloric response in patients with Benign Paroxysmal Positional Vertigo (BPPV)., Patients: Seventy-four individuals with diagnosis of BPPV during Dix-Hallpike (DH) test., Study Design: A prospective, longitudinal study., Setting: A tertiary referral center., Intervention: Patients were treated by particle repositioning maneuvers according to the affected canal, and the effectiveness was evaluated at 180 and 360 days. Bithermal caloric response was obtained by using 44 and 30 degrees C water irrigations at diagnosis, 6 months, and 1 year after., Main Outcome Measure: Canal paresis (CP) and response to DH after treatment., Results: The effectiveness of the treatment for BPPV (absence of vertigo and positional nystagmus during DH) was 65.2% (45 of 69) after 1 year of follow-up. Twenty-five percent of (16 of 64) individuals with BPPV presented CP at diagnosis, 27% (12 of 44) at 6 months, and 16% (9 of 56) 1 year after. One year after, seven individuals with CP showed a normal caloric response, another seven demonstrated persistent CP, and one case developed a bilateral CP. The effectiveness of particle repositioning maneuvers was not significantly different between subjects with or without CP after 1 year of follow-up (odds ratio, 1.31 [95% confidence intervals, 0.35-4.89], p = 0.88)., Conclusion: Canal paresis is not associated with a lower outcome to repositioning.

Objective: To evaluate the eye movement response to the head auto-rotation test (HART) in the vertical plane in patients with benign paroxysmal positional vertigo., Design: A transversal, descriptive study. SETTING UP: Outpatient clinic in a general Hospital., Individuals: 34 posterior canal BPPV cases with a video-oculographic diagnosis, older than 18 years old, 7 of them were not able to perform the HART., Intervention: HART was performed by a an electrooculographic system with simultaneous recording of head movement by an acelerometer in the vertical plane (Vorteq, Micromedical Instruments). The HART with eyes fixation was performed 3 times to determine its reliability., Main Outcome Measures: Gain, asymmetry and phase for the vertical VOR respectively. A statistical analysis was carried out to determine the test reliability and the number of individuals with an abnormal result., Results: Gain is the only variable that showed a reproducible result in the HART for the active head movement at 1-2 Hz (test-retest reliability 0.83-0.89). The values of gain showed a moderate correlation at the frequencies 1-3 Hz (correlation 0.60-0.87). Asymmetry and phase were not reproducible variables (correlation < 0.55). Thirteen of 27 (48%) patients presented a decrease of the vertical gain, another 13 showed normal values and one case showed raised values., Conclusion: Gain is the only useful variable in the vertical HART. Forty-eight percent of patients with posterior canal BPPV have a reduced vertical gain, suggesting an impairment of inferior vestibular nerve function.

Benign paroxysmal positional vertigo (BPPV) is a recurrent chronic disease and its handicap is usually underestimated. The aim of this study is to determine the impact of the treatment by Epley maneuver on short-term BPPV-related quality of life. Forty-two individuals with BPPV were included: 39 with posterior canal affected, 2 with the lateral canal and one with the anterior canal. Diagnosis was established if a consistent clinical history was found and Dix-Hallpike test (DHT) in cases with canal posterior involvement. Subjects with positive DHT were treated by a single Epley maneuver and were recommended to avoid supine for the next 48 hours. The BPPV relapses were investigated at 7th and 30th day post-treatment. BPPV-associated quality of life was evaluated by the Dizzness Handicap Inventory Short-form (DHI-S) at days 1st and 30th post-treatment. Total and partial scores for emotional, physical and functional subscales were compared by Wilcoxon test for paired samples. Dix-Hallpike test was found positive in el 59% individuals (23/39), and 41% cases did not required any treatment. Among 23 patients treated with Epley maneuver, DHT was found negative in 90% at 30th day follow-up. Mean and standard deviation of the total scores obtained in the DHI-S at the first day were 19.22 +/- 9.66 in the DHT positive-patients and 19.79 +/- 10.14 in the whole group (DHT positive or negative). These scores significantly decreased to 10.84 +/- 10.99 at 30 days post-treatment (p = 0.002 and p = 0.001, respectively). In conclusion, the DHI-S is a specific health questionnaire able to assess BPPV-related health and the effectiveness of treatment.

Headache and episodic vertigo are common symptoms in adults. Migraine-related dizziness and vertigo is a clinical process that is difficult to assess because specific diagnostic criteria are lacking. Although studies have demonstrated a relationship between migraine and dizziness, the prevalence of headache among patients with episodic vertigo is underestimated. A clinical inventory was used to determine the prevalence of headache among 150 patients with episodic vertigo and the impact that dizziness had on the quality of life using an ordinal scale for disability. Patients were questioned about drug use and self-perceived effectiveness. Twenty-three percent of the patients experienced a severe problem that disabled them for work. The prevalence of headache was 68.6% (71% of women and 64% of men). Forty-five percent of patients with episodic vertigo and 44% with headache did not obtain any benefit from symptomatic treatment. A subset of patients suffered from migraine-related dizziness and vertigo and were able to control their balance disorder with migraine therapy.

The structured clinical history is the most sensitive test for diagnosing vertigo. Its diagnostic effectiveness on the first visit was analyzed and key signs and symptoms with high predictive value for common causes of vertigo were identified. One hundred outpatients who complained of dizziness or loss of balance were evaluated using a structured clinical interview. Each questionnaire was examined independently by three blinded investigators, who assigned a diagnosis and identified the elements of the history that figured most prominently in the diagnosis. The gold standard was defined as independent selection of the same diagnostic category by all three investigators. A first-visit diagnosis was obtained in 40% of patients (95% confidence interval 30-50%): 38% women and 42% men. Causes included benign positional paroxysmal vertigo (BPPV, 13 patients), headache-associated vertigo (9), Meniere disease (7), cervical vertigo (3), psychiatric dizziness (2), post-traumatic vertigo (2), vertebro-basilar transient ischemic attack (1), vestibular neuritis (1), convulsive seizure (1), and presyncope (1). The best predictors of BPPV were the precipitating mechanism (specificity [SP] 100%), positional nystagmus (sensitivity [SE] 90%, SP 63%), and the Dix-Hallpike test (SE 82%, SP 71%). Elements predictive of headache-associated vertigo were duration of the attack (minutes) and a personal history of headache (both, SP 100%). Other predictors were facial hypoesthesia (SE 92%, SP 47%) and associated neurological disease (SE 82%, SP 58%).

A case of left horizontal-canal benign paroxysmal positional vertigo (HC-BPPV) in a woman with a 7-year history of episodic vertigo when turning over in bed is reported. The diagnosis was established with the patient lying down with her head raised 30 degrees with respect to the horizontal plane. Treatment with positional maneuvers (270 degrees contralateral head rotation in 3 steps) resolved the attacks. Positional testing failed to elicit symptoms 7 days, 14 days, 1 month, and 2 months after treatment. Four months after treatment, the patient remains asymptomatic. Published cases of HC-BPPV are discussed, as well as the differential diagnosis with posterior semicircular canal BPPV.