[Show abstract][Hide abstract] ABSTRACT: Abstract Conclusions: Persistent geotropic nystagmus indicates a condition of a light cupula, which is accompanied by vestibular disability and a high incidence of pathological findings in the vestibular tests. The prevalence of migraine is high. Objectives: To examine subjective symptoms and characteristics of nystagmus in patients with persistent geotropic nystagmus using vestibular tests, as well as possible correlations to migraine in this group. Methods: We enrolled 20 patients with a mean age of 53 years. The slow phase velocity (SPV) of the geotropic nystagmus and the nystagmus with the patient's head in the supine (S) and prone (P) positions was recorded. All patients completed caloric tests, subjective visual horizontal (SVH), and vestibular evoked myogenic potential (VEMP). All tests were repeated at follow-up (FU). Results: SPV of the geotropic nystagmus directed to the left was 5.5°/s and that to the right was 3.5°/s. In 72% of patients, nystagmus in the P position was opposite to that in the S position. The vestibular tests were pathologic in about 60% of patients. At FU geotropic nystagmus was found in 40% of patients, but was significantly less intense. The vestibular test results remained at the same level at FU. Recurrent vertigo was reported in 78% of the patients. In all, 40% of the patients suffered from migraine.
[Show abstract][Hide abstract] ABSTRACT: Abstract Conclusion: A positional nystagmus pattern compatible with a condition of a heavy cupula (cupulolithiasis) in the lateral semicircular canal could be reproduced in hemi-labyrinthectomized subjects during positional alcohol nystagmus 2 (PAN 2). The nystagmus pattern was opposite to that found in the same subjects during PAN 1. The affected side could not be judged by applying Ewald's second law. Objectives: To mimic the condition of a heavy cupula in the lateral semicircular canal by using unilaterally deafferented subjects during PAN 2 and compare (a) results reported in the literature with those of patients with cupulolithiasis, and (b) the nystagmus findings in the same subjects during PAN 1. Methods: Five hemi-labyrinthectomized subjects were studied during PAN 2 when they kept their heads pointed straight forward or turned sideways in the prone and supine positions, respectively. Results: When the subjects were examined with their heads turned in the supine or prone positions, the alcohol-induced nystagmus pattern was compatible with that of cupulolithiasis. When the head was pointed straight forward in the prone and supine positions, the nystagmus directions were opposite to those found during PAN 1. Directional preponderance was not seen for the apogeotropic nystagmus for either ampullofugal or ampullopetal deviation of the cupula.
[Show abstract][Hide abstract] ABSTRACT: A positional nystagmus pattern compatible with a condition of a light cupula in the lateral semicircular canal seen in clinical patients could be reproduced only partially in hemi-labyrinthectomized subjects during the stage of positional alcohol nystagmus 1 (PAN 1).
To mimic the condition of a light cupula in the lateral semicircular canal by using unilaterally deafferented subjects during the stage of PAN 1 and compare the results with those of patients with a light cupula.
Five hemi-labyrinthectomized subjects were studied during PAN 1 with videonystagmography when they kept their heads straight forward or turned sideways in the prone and supine positions, respectively. A zero zone, indicating a cupula dysfunction, in which the geotropic nystagmus changed direction during slow head turn in the supine position, was also looked for.
When the subjects were examined with their heads turned left or right in the supine or prone positions, the alcohol-induced nystagmus pattern was compatible with that of a light cupula. However, the nystagmus directions at the head straight forward in the prone and supine positions, as well as localization of the zero zones, deviated from the pattern seen in patients with a light cupula.
[Show abstract][Hide abstract] ABSTRACT: Besides spontaneous attacks of vertigo or unsteadiness, other symptoms, i.e. drop attacks, lateropulsion, illusions that the room or body is tilted, 'walking on pillows' or 'stepping into a hole', occur without precipitating head movement in almost 50% of patients with peripheral vestibular dysfunctions. The sensation of static tilt was closely connected to migraine and Meniere's disease (MD).
To record the prevalence of the different symptoms with respect to vestibular diagnosis and its relation to migraine.
Data from 100 patients with MD, benign paroxysmal positional vertigo (BPPV), or unilateral peripheral vestibular impairment (UPVI) were analyzed with respect to vestibular diagnosis and migraine as a secondary diagnosis.
Spontaneous attacks of vertigo or unsteadiness occurred in 74% and 48% of patients, respectively. Vertigo was significantly more often reported in patients with MD and BPPV. In patients with BPPV, the duration of spontaneous vertigo was shorter than in patients with MD. The relative incidence of other symptoms were: unsteadiness, 48%; 'stepping into a hole', 46%; lateropulsion, 35%; 'walking on pillows', 21%; and drop attacks, 19%. Only the sensation of static tilt, which occurred in 8% of patients, was significantly correlated to MD or to migraine.
[Show abstract][Hide abstract] ABSTRACT: The patient, a 45-year-old female with Ménière's disease, was submitted to endolymphatic sac surgery because of frequent spells of vertigo. The day after surgery she became dizzy and lost the hearing in the operated ear. She presented with a brisk nystagmus towards the healthy ear; however, a remaining vestibular function on the operated side was still present. The head impulse test was normal and in the positioning test, when turning to the operated ear, the spontaneous nystagmus was replaced by a transient horizontal nystagmus in the opposite direction. It is likely that this geotropic nystagmus was elicited from the operated ear because of debris that had accumulated in the lateral semicircular canal. Due to a suspicion of post surgical edema, the patient was treated with prednisolone, but the progression of the lesion could not be arrested. The signs of canalithiasis disappeared, but the head impulse test became pathologic as did the caloric reaction. The patient remained deaf in the operated ear.
[Show abstract][Hide abstract] ABSTRACT: A persistent geotropic positional nystagmus indicates a dysfunction in the lateral semicircular canal with a cupula of less specific weight than the surrounding endolymph. It is possible to determine the side of the affected cupula by recording the nystagmus pattern in yaw and pitch plane.
To identify the clinical features in patients with a persistent geotropic positional nystagmus, establish lateralizing signs and relate the findings to a pathophysiologic mechanism.
Six patients with acute onset vertigo of a peripheral origin and persistent geotropic nystagmus were examined with videonystagmoscopy and the nystagmus characteristics in different positions of the head in yaw and pitch plane were studied.
Besides the persistent geotropic nystagmus, a zero zone was found with no nystagmus, beyond which the nystagmus changed direction when the head of the patient in supine position was gradually rotated from side to side. The zero zone was present when the head was turned slightly towards one side and is thought to represent a position where the affected cupula is aligned with the gravitational vertical. With the head bent forwards the nystagmus direction was to the non-affected side and when the head was bent backwards to the affected side.
[Show abstract][Hide abstract] ABSTRACT: Menière's disease is defined as the presence of recurrent, spontaneous episodic vertigo, hearing loss (HL), aural fullness, and tinnitus. The occurrence of attacks is unpredictable. The etiology is still unknown, but the disease has a pathologic correlate in hydropic distension of the endolymphatic system. Earlier studies have shown increased incidence of stress on the same day as vertigo attacks, but it has not been determined whether stress occurring on the day of the vertiginous episode came before or after the onset of the vertigo.
A case-crossover study including 46 patients with active Menière's disease.
Relative risks with 95% confidence intervals (CI).
During the study period, 153 Menière's attacks were reported. Twenty-four (52%) of the 46 patients reported attacks. Twelve of the 153 (8%) attacks occurred within 3 hours after exposure to emotional stress. The relative risk of having an attack was 5.10 (95% CI 2.37-10.98) during 3 hours after being exposed to emotional stress. Twenty-nine percent of the patients with attacks had at least one attack after exposure to emotional stress. For mental stress, the relative risk was 4.16 (95% CI 1.46-11.83) and the hazard period 1 hour, but only five attacks were exposed. No excess risk was found after physical stress.
Being exposed to emotional stress increases the risk of getting an attack of Menière's disease during the next hour, and the hazard period is possibly extended up to 3 hours.
The Laryngoscope 11/2004; 114(10):1843-8. · 2.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To study vestibular function in deaf children.
In 36 deaf children the function of the semicircular canals, saccules and utricles was measured by means of caloric testing, recordings of vestibular-evoked myogenic potentials (VEMPs) and measurements of the subjective visual horizontal (SVH) at different body tilts, respectively.
In total, 30% of subjects had caloric hypo- or areflexia and 24% had a caloric asymmetry. VEMPs were weak or absent bilaterally in 22% of cases, and asymmetric in 19%. Regarding the utricle, 17% of subjects had a pathologically reduced perception of roll tilt to both sides and 25% had an asymmetry. In total, 30% of subjects were pathologic in all 3 tests and 30% were completely normal. Semicircular canal function correlated best with the function of the saccule. If hearing was better than 90 dB (pure-tone average of 0.5, 1.0 and 2.0 kHz) vestibular function was often normal. For hearing levels of 100-120 dB, otolith function declined significantly.
Vestibular function tends to be preserved up to a point where hearing is nearly extinct. Hearing level correlates more closely with otolith function, especially that of the utricle, than with semicircular canal function.
[Show abstract][Hide abstract] ABSTRACT: To evaluate self-reported quality of life in Ménière's disease patients by a multidimensional approach and to identify predictors of the results.
Tertiary referral hospital centers.
One hundred-twelve patients with Ménière's Disease.
Questionnaires concerning quality of life: Short Form 12 (SF-12) including the Mental Component Summary (MCS-12) and the Physical Component Summary (PCS-12), Hospital Anxiety and Depression Scale (HAD), Sickness Impact Profile (SIP), the Function Level Scale (FLS) from the American Association of Otology's criteria for reporting results of treatment of Ménière's Disease, Vertigo Symptom Scale (VSS), Hearing Disability Handicap scale (HDHS), Tinnitus Severity Questionnaire (TSQ), and Sense of Coherence (SOC) Scale.
The Ménière's patients rated their quality of life significantly worse than did healthy reference groups in both the physical and the psychosocial dimensions. The SOC affected the results of the HAD, the MCS-12, and the psychosocial dimension of the SIP. The VSS affected the results of PCS-12, both dimensions of the SIP, and the FLS. The speech perception subscale of the HDHS affected the MCS-12, and tinnitus severity affected the HAD anxiety subscale. The results of the FLS correlated with the physical dimension of quality of life.
The Ménière's patients experienced a worse quality of life than did healthy subjects. Vertigo mainly influenced the physical dimension, whereas tinnitus and hearing loss influenced the psychosocial dimension. Sense of coherence had an impact on the psychosocial dimension. The FLS was not sensitive enough to serve as an outcome of treatment results but needed to be complemented by quality of life instruments.
[Show abstract][Hide abstract] ABSTRACT: A 75-year-old man with incapacitating anterior canal benign paroxysmal positional vertigo (BPPV) was relieved of symptoms following anterior semicircular canal occlusion using a transmastoid approach. The preoperative symptoms were similar to those of posterior canal BPPV. The preoperative findings on Dix-Hallpike's maneuver were a paroxysmal torsional nystagmus with a down-beating component that increased when the patient's gaze was directed towards the affected ear. The most provoking head movement for the vertigo/nystagmus was Dix-Hallpike's maneuver with the affected ear lowermost.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the self-rated quality of life associated with vertigo, hearing loss, and tinnitus in Ménière's patients, and to identify potential relationships between these findings, treatment regimens, and sense of coherence in comparison to the classification of the American Academy of Otolaryngology-Head and Neck Surgery (AAO/HNS).
Tertiary referral hospital centers.
112 patients with Méniére's disease, who had undergone endolymphatic sac surgery or intratympanic gentamicin injections, or were surgically untreated.
Questionnaires concerning quality of life aspects and symptom-specific instruments: the Vertigo Symptom Scale (VSS), the Hearing Disability Handicap scale (HDHS), the Tinnitus Severity Questionnaire (TSQ), the AAO/HNS criteria for reporting results of treatment of Ménière's disease, and the Sense of Coherence Scale.
A majority of the patients reported their quality of life in general as very good or good. There was no difference in general quality of life, present hearing loss, or tinnitus between the three treatment groups, but the gentamicin-treated patients had less vertigo than did the other groups. Sense of coherence showed a strong correlation to reported quality of life in all measurements.
Even though the gentamicin-treated patients had less vertigo, no difference in overall quality of life was found between the surgically treated and untreated patients. The sense of coherence seems to be an important factor in the patient's experience of quality of life. Quality of life instruments can measure both specific symptoms and related aspects on quality of life and may give complementary information to the AAO/HNS classification in evaluating the treatment of patients with Ménière's disease.
[Show abstract][Hide abstract] ABSTRACT: Peripheral vestibular disorders may result in physical as well as psychosocial dysfunction. Such a situation demands a capacity to cope which lately has been discussed as an important factor in the health outcome. Antonovsky has described the concept of sense of coherence (SOC) as such a trait and has developed a questionnaire (the SOC Scale) to measure it. The aim of this study was to describe the patients' self-rated degree of SOC and to set this in relation to their perception of the self-rated quality of life. The results showed that patients with a strong SOC scored statistically less self-rated handicap, less emotional distress, less impact on working capacity and sleep and rest and less psychosocial dysfunction than those with weak SOC scores. It is suggested that the SOC Scale may serve as a tool to identify patients who are at risk of poorer quality of life and in need of supportive care.
[Show abstract][Hide abstract] ABSTRACT: Recently Minor and co-workers described patients with sound- and pressure-induced vertigo due to dehiscence of the superior semicircular canal. Identifying patients with this 'new' vestibular entity is important, not only because the symptoms are sometimes very incapacitating, but also because they can be treated. We present symptoms and findings in eight such patients, all of whom reported pressure-induced vertigo that increased during periods of upper respiratory infections. Pulse-synchronous tinnitus and gaze instability during head movements were also common complaints. All patients lateralized Weber's test to the symptomatic ear. In some of the patients the audiogram also revealed a small conductive hearing loss. However, the stapedius reflexes were always normal. A vertical/torsional eye movement related to the superior semicircular canal was seen in most of the patients in response to pressure changes and/or sound stimulation. One patient also had superior canal-related positioning nystagmus. Testing vestibular evoked myogenic potentials revealed in all patients a vestibular hypersensitivity to sounds. In the coronal high-resolution 1-mm section CT scans the dehiscence was visible on 1 to 4 sections. Moreover, the skull base was rather thin in this area and cortical bone separating the middle ear and the antrum from the middle cranial fossa was absent in many of the patients. Two of the patients have undergone plugging of the superior semicircular canal using a transmastoid approach and both patients were relieved of the pressure-induced symptoms.
[Show abstract][Hide abstract] ABSTRACT: The increased use of video systems for the detection of nystagmus is a new diagnostic tool in the diagnosis of patients with vestibular disorders. Small video cameras mounted in a light sealed mask visualize the eyes which are illuminated with infrared light. Compared to the well-established use of Frenzel glasses the patient has no visual references at all. This new technique requires standards for normal limits. Thirty subjects between 20 and 78 years of age with no history of vestibular disorders were examined with infrared video-oculoscopy with the gaze in primary position, after head-shake and in supine position with head torsion and Dix-Hallpike positions backward and forward according to a standardized procedure at our department. Two subjects had spontaneous nystagmus, but nystagmus after head-shake was not found in any. No subject had torsional nystagmus in the Dix-Hallpike positions. In the elderly subjects horizontal nystagmus in head hanging position was a frequent finding.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to describe quality-of-life aspects in a group of patients (n = 99) suffering from peripheral vestibular disorder, using three different self-rated instruments, the Vertigo Symptom Scale (VSS), the Vertigo Handicap Questionnaire (VHQ) and the Sickness Impact Profile (SIP). The results showed that the type of dizziness that most influenced the quality-of-life aspects were: frequent short- or long-term dizziness, nausea, and the feeling that the ground was distant or as though the patient were walking on clouds. However, several of the impairments in daily life were neither related to the disease itself nor the demographic data. This verifies the necessity of investigating other factors such as personality and coping capacity. The results of this study also demonstrate the patients' need of psychosocial support. A comprehensive assessment and evaluation is important in order to identify each patient's needs.
[Show abstract][Hide abstract] ABSTRACT: Seven to eight years after a disease period of vestibular neuritis 19 patients previously examined at our department were given a questionnaire about whether they had experienced any audiovestibular symptoms since they first fell ill. All 19 patients responded and 18 consented to participate in the long-term follow-up study. The patients were subjected to a clinical evaluation, a bithermal caloric test and audiological examinations with stapedius reflex measurements with use of the same technique as at the first examinations. Ten of the 18 patients had experienced recurrent vestibular symptoms with sensation of dysequilibrium and vertigo. Six of these 10 patients also had periods of positional vertigo. The remaining nine patients were free of symptoms. None of the patients had noticed any change in their hearing ability. The mean caloric side difference at the 7- or 8-year follow-up was not significantly higher in the group of patients with symptoms than in the group without symptoms. Neither did the group of patients with pathologically elevated stapedius reflex thresholds at onset display a larger mean caloric side difference than the group of patients with normal thresholds. However, a small caloric side difference at onset of the disease served as a predictor for residual vestibular symptoms. It is speculated whether the group of patients with residual symptoms had a different pathophysiological localization of their disease within the vestibular system than the group of patients with no symptoms at follow-up.
[Show abstract][Hide abstract] ABSTRACT: Recently Minor and co-workers described patients with sound- and pressure-induced vertigo due to dehiscence of bone overlying the superior semicircular canal. Identifying patients with this "new" vestibular entity is important, not only because the symptoms can be very incapacitating, but also because they are surgically treatable. We present symptoms and findings for three such patients. On exposure to sounds, especially in the frequency range 0.5-1 kHz, they showed vertical/torsional eye movements analogous to a stimulation of the superior semicircular canal. They also showed abnormally large sound-induced vestibular-evoked myogenic potentials (VEMP), i.e. the short latency sternomastoid muscle response considered to be of saccular origin. The VEMP also had a low threshold, especially in the frequency range 0.5-1 kHz. However, in response to saccular stimulation by skull taps, i.e. when the middle ear route was bypassed, the VEMP were not enlarged. This suggests that the relation between the sound-induced and the skull tap-induced responses can differentiate a large but normal VEMP from an abnormally large response due to dehiscence of bone overlying the labyrinth, because only the latter would produce large sound-induced VEMP compared to those induced by skull taps.
[Show abstract][Hide abstract] ABSTRACT: The subjective visual horizontal (SVH) was measured by means of a small, rotatable, luminous line in darkness in the upright head and body position and at 10, 20 and 30 degrees of tilt to the right and left before, and repeatedly during a follow-up period of 1 year after intratympanic gentamicin instillations in 12 patients with recurrent vertigo attacks. This treatment caused a loss of the bithermal caloric responses on the diseased side. Shortly after treatment there was a significant tilt of SVH towards the treated side (group mean = 10.6 degrees). Repeated testing made it possible to characterize mathematically the changes with time for SVH. For the group of patients as a whole this otolithic component of vestibular compensation was best described by a power function, SVH = 8.65t(-0.16) degrees, where t is time in days after maximum tilt of SVH. After 1 year, SVH was still significantly tilted towards the treated side (group mean = 3.16 degrees). Gentamicin treatment also caused a significant reduction in the perception of head and body tilt towards the deafferented side, while the perception of tilt towards the healthy side did not show any significant changes. During follow-up there was a gradual improvement in the perception of tilt towards the treated side. However, a significant asymmetry in roll-tilt perception was still present 1 year after deafferentation. There was no correlation between SVH in the upright position and roll-tilt perception, suggesting that these parameters are to some extent dependent on different afferent input from the vestibular organ. They were also found to be complementary for the detection of vestibular disturbance.
[Show abstract][Hide abstract] ABSTRACT: The subjective visual horizontal (SVH) was measured by means of a small rotatable luminous line in darkness in the upright body position and at 10, 20 and 30 degrees of body tilt to the right and left prior to, and during a follow-up period after, stapedotomy in 12 patients with otosclerosis. In the acute stage after surgery, SVH in the upright body position was significantly tilted away from the operated side. In addition, the perception of roll tilt towards the operated side (Kop) was significantly increased after stapedotomy, while the perception of roll tilt towards the healthy side (Khe) showed a slight but not significant reduction. After exclusion of two outliers, a statistically significant correlation was found between changes in Kop and in Khe. The slope of the regression line was 1.8:1, probably corresponding to a preference of the utricle for ipsilateral as opposed to contralateral head tilt. In four patients there was a weak ( < 1 degrees/s) spontaneous nystagmus, not systematically related to the side of surgery, while in most cases there were no nystagmus or subjective vertigo symptoms. These specific changes in the subjective horizontal show that the otolithic effects on perception can be dissociated from canal effects. Further, the results are opposite to those for patients with unilateral loss of vestibular function. The tilt of SVH after stapedotomy indicates an increase in resting activity of utricular afferents. In addition, based on recent theories on otolith function, we suggest that an increased activity in saccular afferents is of major importance for the changes in roll-tilt perception because of its interaction with the utricle on the central nervous level.