A rare case report of bilateral vestibulopathy due to otosyphilis.

RATIONALE: Bilateral vestibulopathy is an important cause of imbalance. There are multiple etiologies of bilateral vestibulopathy (BVP), but reports of BVP due to otosyphilis are rare. PATIENT CONCERNS: A 39-year-old male was referred to our medical center due to vertigo, persistent dizziness and gait disturbance for 2 months. DIAGNOSES: Bilateral vestibulopathy due to otosyphilis was considered in this case, as confirmed through analyses of vestibular function, laboratory tests, and penicillin treatment. INTERVENTIONS: The patient was was treated with a high dose of penicillin G (24 × 106 IU/d) for 14 days. OUTCOMES: The patient's symptoms had improved greatly following treatment, with dizziness and gait disturbance having completely resolved at 3 months following hospital discharge. LESSONS: Bilateral vestibulopathy should be considered when evaluating patients with acute or subacute persistent dizziness. Clinicians should also be aware of the potential for otosyphilis among patients who report BVP.

Otolithic functions in patients with residual dizziness after successful repositioning manoeuvres for unilateral posterior canal BPPV.

OBJECTIVE: To evaluate otolithic functions in patients with residual dizziness after successful canalith repositioning procedures (CRPs) for unilateral posterior canal benign paroxysmal positional vertigo (BPPV), and to investigate possible risk factors. METHODS: This case-control observational study included healthy controls and patients with residual dizziness after improvement following CRP for BPPV. All participants were subjected to full history taking, otoscopy, audiological basic evaluation, Dix-Hallpike test to search for posterior canal BPPV, residual dizziness screening, and vestibular evoked myogenic potential (VEMP) testing. Between-group differences were assessed and possible factors associated with residual dizziness were identified by univariate analysis. RESULTS: A total of 50 patients with residual dizziness (mean age, 56.53 ± 7.46 years [29 female: 21 male]) and 50 healthy controls (mean age, 58.13 ± 7.57 years [20 female: 30 male]) were included. A significant difference in VEMP latencies was found between the patient and control group (delayed in the patient group), with no significant between-group difference in amplitude in both ears. Aging, female sex, long duration of BPPV, number of CRPs, cervical VEMP and ocular VEMP abnormalities, and winter onset, were significantly associated with the risk of residual dizziness. CONCLUSIONS: Residual dizziness is a frequent sequel of BPPV that may relate to otolithic dysfunction. VEMP changes were revealed in the form of delayed latencies.

Vestibular migraine: an update.

PURPOSE OF REVIEW: We performed a narrative review of the recent findings in epidemiology, clinical presentation, mechanisms and treatment of vestibular migraine. RECENT FINDINGS: Vestibular migraine is an underdiagnosed condition that has a high prevalence among general, headache and neuro-otology clinics. Vestibular migraine has a bimodal presentation probably associated with a hormonal component in women. These patients could have a complex clinical phenotype including concomitant autonomic, inflammatory or connective tissue conditions that have a higher prevalence of psychological symptoms, which may mistakenly lead to a diagnosis of a functional neurological disorder. A high proportion of patients with postural perceptual persistent dizziness have a migraine phenotype. Independently of the clinical presentation and past medical history, patients with the vestibular migraine phenotype can respond to regular migraine preventive treatments, including those targeting the calcitonin gene-related peptide pathways. SUMMARY: Vestibular migraine is an underdiagnosed migraine phenotype that shares the pathophysiological mechanisms of migraine, with growing interest in recent years. A thorough anamnesis is essential to increase sensitivity in patients with unknown cause of dizziness and migraine treatment should be considered (see supplemental video-abstract).

Deep Brain Stimulation for Orthostatic Tremor: An Observational Study.

BACKGROUND: Primary orthostatic tremor (OT) can affect patients' life. Treatment of OT with deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (Vim) is described in a limited number of patients. The Vim and posterior subthalamic area (PSA) can be targeted in a single trajectory, allowing both stimulation of the Vim and/or dentatorubrothalamic tract (DRT). In essential tremor this is currently often used with positive effects. OBJECTIVE: To evaluate the efficacy of Vim/DRT-DBS in OT-patients, based on standing time and Quality of Life (QoL), also on the long-term. Furthermore, to relate stimulation of the Vim and DRT, medial lemniscus (ML) and pyramidal tract (PT) to beneficial clinical and side-effects. METHODS: Nine severely affected OT-patients received bilateral Vim/DRT-DBS. Primary outcome measure was standing time; secondary measures included self-reported measures, neurophysiological measures, structural analyses, surgical complications, stimulation-induced side-effects, and QoL up to 56 months. Stimulation of volume of tissue activated (VTA) were related to outcome measures. RESULTS: Average maximum standing time increased from 41.0 s ± 51.0 s to 109.3 s ± 65.0 s after 18 months, with improvements measured in seven of nine patients. VTA (n = 7) overlapped with the DRT in six patients and with the ML and/or PT in six patients. All patients experienced side-effects and QoL worsened during the first year after surgery, which improved again during long-term follow-up, although remaining below age-related normal values. Most patients reported a positive effect of DBS. CONCLUSION: Vim/DRT-DBS improved standing time in patients with severe OT. Observed side-effects are possibly related to stimulation of the ML and PT.

Post-stroke dizziness, depression and anxiety.

OBJECTIVE: Vestibular and psychiatric disorders are very closely related. Previous research shows that the discomfort and dysfunction caused by dizziness in patients can affect psychological processes, leading to anxiety and depression, and the irritation of anxiety and depression can aggravate the discomfort of dizziness. But the causal relationship between dizziness in the recovery period of stroke and Post-stroke depression (PSD) / Post-stroke anxiety (PSA) is not clear. Identifying the causal relationship between them can enable us to conduct more targeted treatments. METHODS: We review the epidemiology and relationship of dizziness, anxiety, and depression, along with the related neuroanatomical basis. We also review the pathophysiology of dizziness after stroke, vestibular function of patients experiencing dizziness, and the causes and mechanisms of PSD and PSA. We attempt to explore the possible relationship between post-stroke dizziness and PSD and PSA. CONCLUSION: The treatment approach for post-stroke dizziness depends on its underlying cause. If the dizziness is a result of PSD and PSA, addressing these psychological factors may alleviate the dizziness. This can be achieved through targeted treatments for PSD and PSA, such as psychotherapy, antidepressants, or anxiolytics, which could indirectly improve dizziness symptoms. Conversely, if PSA and PSD are secondary to vestibular dysfunction caused by stroke, a thorough vestibular function assessment is crucial. Identifying the extent of vestibular impairment allows for tailored interventions. These could include vestibular rehabilitation therapy and medication aimed at vestibular restoration. By improving vestibular function, secondary symptoms like anxiety and depression may also be mitigated.

High fluence in laser stapedotomy aggravates transient subjective dizziness.

BACKGROUND: Laser fenestration in stapedotomy has thermal effect to the vestibule. AIMS/OBJECTIVES: To evaluate the role of energy density (fluence) in the severity of postoperative vestibular symptoms. MATERIALS AND METHODS: The retrospective chart-review study included 84 patients with otosclerosis that underwent primary laser stapedotomy. Surgical outcomes, including nystagmus, and subjective vestibular symptoms during one-month follow-up, were compared between potassium titanyl phosphate (KTP) and CO2 laser. According to this study and literature, we assessed the relationship between laser parameters and the incidence of persistent vestibular symptoms lasting more than one week after surgery. RESULTS: The KTP and CO2 laser group included 48 and 36 patients, respectively. Fluence was different between the KTP (637 J/cm2) and CO2 (141 J/cm2) laser (p < .001). The KTP group showed gradual decrease in dizziness during one-month observation period, while the CO2 group exhibited a steep recovery curve in the first postoperative week (9 and 4 d of duration, respectively). The incidence of persistent vestibular symptoms was correlated with both fluence (r = 0.80, p = .01) and spot size (r = -0.74, p = .01). CONCLUSIONS AND SIGNIFICANCE: Appropriate setting of parameters with lower fluence is desirable for the efficiency and safety of laser stapedotomy.Abbreviations: ABG: air-bone gap; SD: standard deviation.

Audiological and Vestibular Measurements in Chronic Renal Failure Patients Receiving Hemodialysis Treatment.

BACKGROUND: The aim was to evaluate the changes in the audiovestibular system in adult patients with the diagnosis of chronic renal failure who were treated with hemodialysis. METHODS: Thirty-five patients diagnosed with chronic renal failure and receiving hemodialysis treatment 3 days a week and 35 healthy individuals were tested with pure tone audiometry, video head impulse test, and post-head shake nystagmus test. Dizziness Handicap Inventory was applied to all participants. RESULTS: The Dizziness Handicap Inventory scores of the patient groups are higher than the control groups (P=.001). In the video head impulse test, there is no statistically significant difference between the patient and control groups in terms of gain asymmetry. 17.1% of the patients had both left and right lateral saccades (P=.03). A statistically significant difference was also found after the post-head shake test (P=.025). In the patient group, an inverse relationship between the presence of left anterior right posterior saccades and blood urea nitrogen-creatinine ratio and a direct relationship between the presence of right anterior left posterior saccades and creatinine elevation were determined. The presence of saccades in the video head impulse test increased significantly as the disease duration of hemodialysis patients increased. CONCLUSION: It was determined that the overt and covert saccades in the video head impulse test increased significantly as the creatinine increased and the duration of the disease increased in the patients with chronic renal failure. The common clinical usage of video head impulse test in monitoring the vestibular side effects of creatinine elevation and disease duration in chronic renal failure patients may be possible with future studies.

Frailty of the.

Vestibular frailty and presbyvestibulopathy, including benign paroxysmal positional vertigo (BPPV), can cause dizziness among elderly patients. Vestibular frailty and presbyvestibulopathy may contribute to the onset of the vicious circle of falling-bone fracture-prolonged bedridden status-senile dementia. Treatment interventions for vestibular frailty and presbyvestibulopathy should be based on vestibular rehabilitation rather than vestibular implantation or regeneration. In acute BPPV, the otolith repositioning maneuver can be used to return otolithic debris to the utricle. At the chronic remission stage, there are nutritional guidelines for improving bone density in otolith organs and rehabilitation guidelines for activating otolith organs to prevent exfoliation. Moreover, sleeping in the head-up position can prevent free-floating debris from entering the semicircular canal. Throughout their old age, the psychiatric care/support is also indispensable to keep their initiative against vestibular frailty.

Ten-year association between change in speech-in-noise recognition and falls due to balance problems: a longitudinal cohort study.

BACKGROUND: This study examined the relationship between speech-in-noise recognition and incident/recurrent falls due to balance problems ten years later (RQ-1); 10-year change in speech-in-noise recognition and falls (RQ-2a), as well as the role of dizziness in this relationship (RQ-2b). The association between hearing aid use and falls was also examined (RQ-3). METHODS: Data was collected from the Netherlands Longitudinal Study on Hearing between 2006 and December 2022. Participants completed an online survey and digits-in-noise test every five years. For this study, data was divided into two 10-year follow-up time intervals: T0 (baseline) to T2 (10-year follow-up), and T1 (5-years) to T3 (15-years). For all RQs, participants aged ≥ 40 years at baseline, without congenital hearing loss, and non-CI users were eligible (n = 592). Additionally, for RQ-3 participants with a speech reception threshold in noise (SRTn) ≥ -5.5 dB signal-to-noise ratio were included (n = 422). Analyses used survey variables on hearing, dizziness, falls due to balance problems, chronic health conditions, and psychosocial health. Logistic regressions using General Estimating Equations were conducted to assess all RQs. RESULTS: Among individuals with obesity, those with poor baseline SRTn had a higher odds of incident falls ten years later (odds ratio (OR):14.7, 95% confidence interval (CI) [2.12, 103]). A 10-year worsening of SRTn was significantly associated with a higher odds of recurrent (OR: 2.20, 95% CI [1.03, 4.71]) but not incident falls. No interaction was found between dizziness and change in SRTn. Hearing aid use (no use/ < 2 years use vs. ≥ 2 years) was not significantly associated with incident nor recurrent falls. Although there was a significant interaction with sex for this association, the effect of hearing aid use on incident/recurrent falls was not statistically significant among males nor females. CONCLUSIONS: A longitudinal association between the deterioration in SRTn and recurrent falls due to balance problems after 10 years was confirmed in this study. This result stresses the importance of identifying declines in hearing earlier and justifies including hearing ability assessments within fall risk prevention programs. Mixed results of hearing aid use on fall risk warrant further investigation into the temporality of this association and possible differences between men and women.

Vestibular Decompensation Following COVID-19 Infection in a Person With Compensated Unilateral Vestibular Loss: A Rehabilitation Case Study.

BACKGROUND AND PURPOSE: Surgical removal of a vestibular schwannoma (vestibular schwannoma resection; VSR) results in a unilateral vestibular hypofunction with complaints of dizziness and imbalance. Although the anatomic lesion is permanent, recovery of balance and diminution of dizziness occurs through central neurophysiologic compensation. Compensation of the system is maintained through daily activity. Unfortunately, interruption of stimulus, such as decreased activities due to illness, can cause decompensation. Decompensation is described as the return of symptoms consistent with that experienced during the initial insult/injury (eg, dizziness, oscillopsia, balance difficulty). This case study describes a reoccurrence of vestibular dysfunction in a person with a history of VSR following hospitalization and protracted recovery from a COVID-19 infection. It further documents her recovery that may be a result of vestibular rehabilitation. CASE DESCRIPTION: A 49-year-old woman (M.W.) with a surgical history of VSR (10 years prior) and a medical history of significant COVID-19 infection, resulting in an intensive care unit stay and prolonged use of supplemental oxygen, presented to physical therapy with persistent dizziness and imbalance. The video head impulse test confirmed unilateral vestibular hypofunction. INTERVENTION: M.W. attended biweekly vestibular rehabilitation for 6 weeks and completed daily home exercises. OUTCOMES: At discharge, M.W. demonstrated improvements in patient-reported outcomes (Dizziness Handicap Inventory), functional testing (MiniBEST, 2-Minute Walk Test), and gaze stability measures (video head impulse testing, dynamic visual acuity). DISCUSSION: Vestibular decompensation preluded by a COVID-19 infection caused a significant decrease in functional mobility. Vestibular rehabilitation targeted at gaze and postural stability effectively reduced symptoms and facilitated recovery to M.W.'s pre-COVID-19 level of function. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A458 ).

How Do Patients and Otolaryngologists Define Dizziness?

OBJECTIVE: To assess for differences in how patients and otolaryngologists define the term dizziness. METHODS: Between June 2020 and December 2022, otolaryngology clinicians and consecutive patients at 5 academic otolaryngology institutions across the United States were asked to define the term "dizziness" by completing a semantics-based questionnaire containing 20 common descriptors of the term within 5 symptom domains (imbalance-related, lightheadedness-related, motion-related, vision-related, and pain-related). The primary outcome was differences between patient and clinician perceptions of dizzy-related symptoms. Secondary outcomes included differences among patient populations by geographic location. RESULTS: Responses were obtained from 271 patients and 31 otolaryngologists. Patients and otolaryngologists selected 7.7 ± 3.5 and 7.1 ± 4.3 symptoms, respectively. Most patients (266, 98.2%) selected from more than 1 domain and 17 (6.3%) patients identified symptoms from all 5 domains. Patients and clinicians were equally likely to define dizziness using terms from the imbalance (difference, -2.3%; 95% CI, -13.2%, 8.6%), lightheadedness (-14.1%; -29.2%, 1.0%), and motion-related (9.4; -0.3, 19.1) domains. Patients were more likely to include terms from the vision-related (23.6%; 10.5, 36.8) and pain-related (18.2%; 10.3%, 26.1%) domains. There were minor variations in how patients defined dizziness based on geographic location. CONCLUSIONS: Patients and otolaryngologists commonly described dizziness using symptoms related to imbalance, lightheadedness, and motion. Patients were more likely to use vision or pain-related terms. Understanding of these semantic differences may enable more effective patient-clinician communication.

The Role of Motion Sensitivity and Headaches on Vestibular Rehabilitation Outcomes in Pediatric Vestibular Migraines.

OBJECTIVE: To determine the utility of the motion sensitivity quotient (MSQ) in diagnosing pediatric vestibular migraine (VM) and to characterize the role of motion sensitivity and headache control on vestibular rehabilitation (VR) outcomes in pediatric VM. STUDY DESIGN: Retrospective cohort analysis. SETTING: Pediatric tertiary referral center. PATIENTS: Children (≤18 years old) with dizziness who completed vestibular testing from January 2016 to August 2022, diagnosed with either VM or another vestibular disorder. INTERVENTIONS: VR, which included MSQ testing. MAIN OUTCOME MEASURES: Initial MSQ, number and duration of vestibular physical therapy (PT) sessions, PT goals met, and posttreatment MSQ. RESULTS: Two hundred fifty-seven patients met study criteria. MSQ was not a reliable diagnostic marker in pediatric VM as there was no difference in initial MSQ between VM and non-VM patients (9.4 vs. 7.8 in non-VM, p = 0.014). Both VM (n = 116) and non-VM (n = 141) patients demonstrated significant improvement in MSQ after VR (p = 0.004). However, VM patients tended to be less likely to meet at least one PT goal (60 vs. 77% in non-VM, p = 0.016, d = 0.37), although not significant. VM patients with more frequent headaches had significantly higher initial MSQ (p = 0.008). VM patients with more frequent headaches or higher initial MSQ tended to require increased number and longer duration of VR (small/medium effect size although not statistically significant after Bonferroni correction). CONCLUSION: VR is an effective treatment for both VM and non-VM pediatric patients. VM patients, especially those with severe motion sensitivity or poorly controlled headaches, may be less responsive to VR and may require increased frequency and duration of VR. Our findings propose the importance of counseling pediatric patients with severe motion sensitivity or uncontrolled migraines regarding realistic expectations of their VR course.

Patient-Reported Outcomes After Vestibular Implantation for Bilateral Vestibular Hypofunction.

Importance: Standard-of-care treatment proves inadequate for many patients with bilateral vestibular hypofunction (BVH). Vestibular implantation is an emerging alternative. Objective: To examine patient-reported outcomes from prosthetic vestibular stimulation. Design, Setting, and Participants: The Multichannel Vestibular Implant (MVI) Early Feasibility Study is an ongoing prospective, nonrandomized, single-group, single-center cohort study conducted at Johns Hopkins Hospital that has been active since 2016 in which participants serve as their own controls. The study includes adults with severe or profound adult-onset BVH for at least 1 year and inadequate compensation despite standard-of-care treatment. As of March 2023, 12 candidates completed the eligibility screening process. Intervention: The MVI system electrically stimulates semicircular canal branches of the vestibular nerve to convey head rotation. Main Outcomes and Measures: Patient-reported outcome instruments assessing dizziness (Dizziness Handicap Inventory [DHI]) and vestibular-related disability (Vestibular Disorders-Activities of Daily Living [VADL]). Health-related quality of life (HRQOL) assessed using the Short Form-36 Utility (SF36U) and Health Utilities Index Mark 3 (HUI3), from which quality-adjusted life-years were computed. Results: Ten individuals (5 female [50%]; mean [SD] age, 58.5 [5.0] years; range, 51-66 years) underwent unilateral implantation. A control group of 10 trial applicants (5 female [50%]; mean [SD] age, 55.1 [8.5] years; range, 42-73 years) completed 6-month follow-up surveys after the initial application. After 0.5 years of continuous MVI use, a pooled mean (95% CI) of within-participant changes showed improvements in dizziness (DHI, -36; 95% CI, -55 to -18), vestibular disability (VADL, -1.7; 95% CI, -2.6 to -0.7), and HRQOL by SF36U (0.12; 95% CI, 0.07-0.17) but not HUI3 (0.02; 95% CI, -0.22 to 0.27). Improvements exceeded minimally important differences in the direction of benefit (exceeding 18, 0.65, and 0.03, respectively, for DHI, VADL, and SF36U). The control group reported no mean change in dizziness (DHI, -4; 95% CI, -10 to 2), vestibular disability (VADL, 0.1; 95% CI, -0.9 to 1.1) or HRQOL per SF36U (0; 95% CI, -0.06 to 0.05) but an increase in HRQOL per HUI3 (0.10; 95% CI, 0.04-0.16). Lifetime HRQOL gain for MVI users was estimated to be 1.7 quality-adjusted life-years (95% CI, 0.6-2.8) using SF36U and 1.4 (95% CI, -1.2 to 4.0) using HUI3. Conclusions and Relevance: This cohort study found that vestibular implant recipients report vestibular symptom improvements not reported by a control group. These patient-reported benefits support the use of vestibular implantation as a treatment for bilateral vestibular hypofunction.