The clinical application of head-shaking test combined with head-shaking tilt suppression test in distinguishing between peripheral and central vertigo at bedside vs. examination room

Abstract Objectives: To investigate the clinical value of using Head-Shaking Test (HST) + Head-Shaking Tilt Suppression Test (HSTST) to distinguish between peripheral and central vertigo as well as to analyze the consistency of findings between tests at the bedside vs. in the examination room. Methods: We retrospectively analyzed patients who presented for central or peripheral vertigo from July 2019 to July 2021. The results were compared between HST and HST+HSTST. The concordance between bedside and examination room outcomes was analyzed. Results: Forty-seven (58.8%) patients in the peripheral vertigo group and 33 (41.2%) patients in the central vertigo group were included. In the peripheral group, 44 (both examination room and bedside: 93.6%) patients had horizontal Head-Shaking Nystagmus (hHSN), most of which were suppressed in HSTST. However, in the central group, most cases had perverted HSN (pHSN; examination room: 72.7%; bedside: 66.7%), which was seldomly suppressed in HSTST. The HST+HSTST showed a >20% higher specificity in identifying peripheral vertigo than HST alone. The bedside results were consistent with the examination room results using the kappa test (p< 0.001). Conclusions: Suppressed hHSN was a strong indicator of peripheral vertigo. Conversely, pHSN was more often seen in central vertigo, which was not readily suppressed in HSTST. The bedside results of HST+ HSTST yielded qualitative agreement with the tests in the examination room. HST+ HSTST could be used as reliable methods in the clinic to distinguish between peripheral and central vestibular disorders. Level of evidence: Level 3.

Síndrome de Lermoyez, presentación de caso clínico / Lermoyez´s syndrome, a case report presentation

Lermoyez´ syndrome is an unusual clinical variant of Ménière's disease, because in both pathologies there is a peripheral vascular disorder, what It consists in the dilation of the labyrinthine membranes associated with an increase in the volume of the endolymph. Clinically, they have severe frequency fluctuations of hearing loss, tinnitus and vertigo attacks. FinaIly, it evolves to the deterioration of hearing in all frequencies. Lermoyez´ síndrome, or labyrinthine angiospasm, has an unknown etiopathogeny, although several theories have been proposed, but none explains its nature, nor its clinical course, being one of them the allergy. Their diagnosis is clinical, they present the typical triad (peripheral vertigo crisis with neurosensory hearing loss and tinnitus and/or otic fullness), but they characterised by the improvement in hearing just after a sudden vertigo attack. With the development of the disease, dizziness attacks and hearing recovery become more and more rare, and disappear. Treatment aims to relieve symptoms during crises and improve disease progression. It is present the clinical case of Lermoyez syndrome, in a male patient with allergic pathology, who was diagnosed with Ménière's disease at the beginning. It is a rare syndrome described described in classical ENT (ear-nose-throat)

El síndrome de Lermoyez es una variante clínica inusual de la enfermedad de Ménière. En ambas afecciones existe un trastorno vascular periférico, que consiste en la dilatación de las membranas laberínticas, asociadas con aumento del volumen de la endolinfa. Clínicamente, el individuo presenta fluctuaciones en la audición (hipoacusia neurosensorial en las frecuencias graves), acúfenos y ataques de vértigo. En su evolución final se deteriora la audición en todas las frecuencias. El síndrome de Lermoyez, o angioespasmo laberíntico, tiene una etiopatogenia desconocida, aunque se han propuesto varias teorías, pero ninguna explica su naturaleza ni su curso clínico, y una de ellas es la alergia. Su diagnóstico es clínico, presentan la triada típica (crisis de vértigo periférico con hipoacusia neurosensorial y acúfenos o plenitud ótica), pero el síndrome de Lermoyez se caracteriza por la mejora de la audición tras un ataque brusco de vértigo. Con el avance de la enfermedad, los ataques de vértigo y la recuperación de la audición llegan a ser cada vez más raros, hasta desaparecer. El tratamiento tiene como finalidad aliviar los síntomas durante las crisis y mejorar la evolución de la enfermedad. Se presenta un caso clínico de síndrome de Lermoyez, en un paciente varón con afección alérgica, cuyo diagnóstico de inicio fue de enfermedad de Ménière. Es un síndrome infrecuente, descrito en la otorrinolaringología clásica

Vértigo posicional paroxístico benigno: factores de riesgo asociados y eficacia de las maniobras de reposición / Benign paroxysmal positional vertigo: associated risk factors and efficacy of particle repositioning maneuvers

INTRODUCCIÓN: El vértigo posicional paroxístico benigno (VPPB) es el vértigo periférico más frecuente. El tratamiento depende del compromiso de los canales semicirculares (CSC) y/o cúpulas, y consiste en maniobras de reposición de partículas. OBJETIVO: Evaluar los factores de riesgo asociados al VPPB en pacientes atendidos en el Servicio de Otorrinolaringología de la Red de Salud UC Christus. Evaluar la tasa de éxito de las maniobras de reposición. MATERIAL Y MÉTODO: Estudio retrospectivo. Se revisaron casos de VPPB con indicación de maniobras de reposición durante los años 2016-2017. Se obtuvo información demográfica, antecedentes médicos, la maniobra realizada y su éxito. Se evaluaron comorbilidades y temporada del año. RESULTADOS: Se incluyeron 195 consultas, realizándose 293 maniobras. La mayoría de los pacientes fueron mujeres (74%) con edad promedio de 63 años. Comorbilidades más frecuentes fueron hipertensión, dislipidemia y diabetes mellitus. El 20% presentó una hipofunción vestibular concomitante, 23% presentó antecedentes de VPPB y 8% compromiso bilateral. Canalolitiasis del CSC posterior fue predominante (90%). En el 77,3% se resuelve el caso con una maniobra. Los casos fueron más frecuentes en primavera y otoño. CONCLUSIONES: El VPPB fue más frecuente en mujeres, con una edad promedio de 63 años. La mayoría presentó canalolitiasis unilateral lográndose resolución con una maniobra de reposición.

INTRODUCTION: Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo. The treatment depends on the semicircular canal (SCC) and/or cupula involved and consists of particle repositioning maneuvers. AIM: Analyze risk factors associated with BPPV for patients seen at the otorhinolaryngology department of the UC Christus health center. Evaluate the success rate of the repositioning maneuvers. MATERIAL AND METHODS: Retrospective study. All cases of BPPV for which a repositioning maneuver was prescribed during the years 2016-2017 were reviewed. Data obtained includes demographics, medical history, maneuver performed, and its success rate. Comorbidities and seasonality were evaluated. RESULTS: 195 cases were included; with 293 maneuvers. The majority were women (74%), and the average age was 63 years. Common comorbidities were hypertension, dyslipidemia and diabetes mellitus. Concurrently, 20% had unilateral vestibular hypofunction, 23% had a history of BPPV, and 8% had bilateral involvement. Posterior SCC canalithiasis was most common (90%). In 77.3%, the case was resolved with one maneuver. Cases were most frequent in the spring and autumn season. CONCLUSION: BPPV was more common in women with an average age of 63 years. The majority of patients presented with unilateral canalithiasis obtaining a complete recovery with a single maneuver.

One Case of Peripheral Vertigo Disorder with Sustained Constipation Effectively Treated with the Theory of “Opening the North Window to Get the South Wind” / 日本東洋医学雑誌

One case of peripheral vertigo disorder with sustained constipation was effectively treated with the applica­tion of a Kampo medicine proverb : “opening the north window to get the south wind (balmy summer breeze)”. The therapeutic strategy behind this proverb is to cure the superior (south) disease by unblocking the inferior (north) pathogenic stagnation, and thus activate internal qi movement, blood and body fluid circulation in the body. A 69-­year-­old female with postural vertigo episodes associated with the benign paroxysmal positional vertigo (BPPV) was effectively treated with tokakujokito, and her constipation discomfort was resolved at the same time. Based on these results, otolaryngologists should consider the inferior disease (the lower gastroin­testinal tract disorder) when treating the superior disease (the inner ear-­based disorder), and pay attention to the harmony and balance among qi, blood and body fluid throughout the body.

Clinical Significance of Perverted Head-Shaking Nystagmus / 대한평형의학회지

OBJECTIVES: We investigated clinical significance of head shaking nystagmus (HSN) and perverted HSN (pHSN) in patients with peripheral and central vestibular disorders. METHODS: We reviewed medical records of 822 consecutive subjects who were referred to a dizziness clinic. We performed neurologic examination including video-oculography in darkness for 60 seconds before, during and for 100 seconds after head-shaking. HSN was considered to develop when post-head-shaking nystagmus last at least 5 beats with latency from end of head-shaking of no more than 5 seconds, and a velocity at least 3°/sec. RESULTS: In control group (n=45), there were observed spontaneous nystagmus (SN) in 2.2%, HSN in 17.8%, pHSN in 6.7%. In patients with peripheral vestibular disorder group (n=397), there were observed SN in 14.1%, HSN in 40.6%, pHSN in 9.8%. In patients with central vestibular disorder group (n=217), there were observed SN in 17.5%, HSN in 24.0%, pHSN in 13.4%. In unspecified dizziness group (n=208), there were observed SN in 1.9%, HSN in 13.0%, pHSN in 1.9%. pHSN was frequently observed in central vestibular disorders such as stroke, vestibular migraine, cerebellar ataxia, and vertebro-basilar insufficiency. However, pHSN was also observed at higher rate than expected in peripheral vestibular disorders including benign paroxysmal positional vertigo especially involving vertical canals, Meniere disease and even in unilateral vestibulopathy. CONCLUSIONS: Our results show that perverted HSN in dizzy populations was frequently observed not only in cases of central vestibular disorders but also in peripheral disorders. Perverted HSN can develop by any conditions that cause difference in vestibular velocity storage in vertical component of vestibular-ocular reflex.

Comparison of electrophysiological features in peripheral vertigo and central vertigo / 临床神经病学杂志

Objective To compared the electrophysiological features in peripheral vertigo and central vertigo. Methods The electronystagmograph ( ENG ) and brainstem auditory evoked potentials ( BAEP ) were applied in peripheral vertigo group(85 cases) and central vertigo group(61 cases).Result ENG abnomal was in 67 cases (78.8%) in peripheral vertigo group.Overshoot or undershoot of dysmetria test was in 6 cases ( 7.1%);spontaneous nystagmus was in 5 cases(5.9%);abnormal of gaze test was in 16 cases(18.8%); eye tracking test typeⅠwas in 42 case(49.4%), typeⅡwas in 17 cases(20.0%), and typeⅢwas in 8 cases(9.4%); bilateral asymmetry of optokinetic nystagmus test was in 19 cases(22.4%);positioning nystagmus was in 51 cases(60.0%);abnormal of cold and hot test was in 31 cases(36.5%).ENG abnomal was 42 cases(49.4%) in central vertigo group.Overshoot or undershoot of dysmetria test was in 19 case(31.1%);spontaneous nystagmus was in 13 cases (21.3%);abnormal of gaze test was in 23 cases(37.7%);eye tracking test typeⅠwas in 35 cases(57.4%), typeⅡwas in 13 cases(21.3%), and typeⅢwas in 8 cases(13.1%);bilateral asymmetry of optokinetic nystagmus test was in 33 cases(54.1%); positioning nystagmus was in 2 cases(3.3%); abnormal of cold and hot test was in 6 cases(9.8%).Compared with peripheral vertigo group, the abnormal rates of optokinetic nystagmus test, gaze test, eye tracking test, optokinetic nystagmus test in central vertigo group were significantly increased, and the abnormal rates of positioning nystagmus, cold and hot test in central vertigo group were significantly decreased (all P<0.05). There were 32 cases(37.6%) in peripheral vertigo group with BAEP abnormal, and 31 cases(50.8%) were in central vertigo group with BAED abnormal.Compared with central vertigo group, the latency ofⅠwave andⅠ-Ⅲwave latency delayed in peripheral vertigo group were significantly increased, the latency ofⅤwave andⅠ-Ⅴwave latency delayed were significantly decreased ( all P<0.05 ) .Conclusions There are high sensitivity of optokinetic nystagmus test, gaze test, eye tracking test, optokinetic nystagmus test of ENG to the diagnosis of central vertigo. There are high sensitivity of positioning nystagmus, cold and hot test to the diagnosis of peripheral vertigo.The positive rate of BAEP is relatively lower, but it can provide objective foundation for location of vertigo patients.

The clinical value of dynamic posturography in the peripheral vertigo / 临床耳鼻咽喉头颈外科杂志

Objective:To explore the clinical value of dynamic posturography in the diagnosis of peripheral vertigo. Method:One hundred and sixty peripheral vertigo patients with full clinical documents in vertigo clinic of our hospital from May 2007 to May 2008 were retrospectively analyzed in this study. All the patients firstly underwent the inspection of static and dynamic posturography and then were subjected to caloric test using videonystagmogra-phy. The results were conducted a comparative analysis. Surface of the statokinesigram (SSKG) was selected as assessment parameter of static posturography. The result of sensory organization test (SOT) were selected as assessment parameters of dynamic posturography. The unilateral weakness was selected as assessment parameter of caloric test. Twenty normal subjects were selected as control. Result: Among the 160 cases with peripheral vertigo, results of SOT in dynamic posturography were abnormal in 144 cases, with a sensitivity of 90. 0%; caloric test was abnormal in 110 cases, with a sensitivity of 68. 8%; static posturography was abnormal in 76 cases, with a sensitivity of 47. 5%. There existed a statistically significant difference between dynamic posturography and caloric test or static posturography. There were 40 patients(25. 0%) who had normal caloric test results in which dynamic posturograph findings were abnormal. Among the 20 cases of normal people, results of SOT in dynamic posturography were abnormal in only one case(5. 0%). Conclusion:With its superior sensitivity and specificity, dynamic posturography has been an objective and reliable approach in the diagnosis of peripheral vertigo. It can help to confirm the presence of abnormalities in some peripheral vertigo patients whose caloric results are normal.

A Case of Cerebellar Hemangioma Mimicking Peripheral Vestibulopathy

Central vertigo of cerebellar origin may present the syndromes similar to those of peripheral vertigo such as vestibular neuronitis. The character of those vertigo syndrome depend on the location, extent, and the etiology of the lesion such as stroke, inflammation, mass. Cavernous hemangioma may be clinically silent, but can cause variable neurologic manifestations including central vertigo if it affects the vestibular system. We report a rare case of cerebellar cavernous hemangioma with the vertigo syndrome closely mimicked vestibular neuronitis.