Search

This review aims to assist emergency physicians in finding the underlying aetiology when a patient presents with dizziness to the emergency department. After reading this review, the emergency physician will be able to consider the most relevant differential diagnoses and have an idea about dangerous aetiologies that require immediate action. The emergency physician will also know what diagnostic steps need to be taken at what time, such as the three-component HINTS Test (Head Impulse, Nystagmus, and Test-of-Skew), which helps with distinguishing central from peripheral causes of the acute vestibular syndrome. Furthermore, episodic vestibular syndromes and chronic vestibular syndromes are discussed in detail. The five most frequent categories of dizziness are vasovagal syncope / orthostatic hypotension (22.3%), vestibular causes (19.9%), fluid and electrolyte disorders (17.5%), circulatory/ pulmonary causes (14.8%) and central vascular causes (6.4%). Given that it would neither be economical nor practical to send all patients to specialists from the start, we present general guidelines for the diagnostic workup of patients presenting with dizziness to the emergency department. This review will focus on epidemiology, aetiologies, differential diagnoses and diagnostics. Treatment is described in a separate article.

This review provides an update on interdisciplinary treatment for dizziness. Dizziness can have various causes and the treatment offered should depend on the cause. After reading this article, the clinician will have an overview of current treatment recommendations. Recommendations are made for the most prevalent causes of dizziness including acute and chronic vestibular syndromes, vestibular neuritis, benign paroxysmal positional vertigo, endolymphatic hydrops and Menière’s disease, vestibular paroxysmia and vestibular migraine, cardiac causes, transient ischaemic attacks and strokes, episodic ataxia type 2, persistent postural-perceptual dizziness, bilateral vestibulopathy, degenerative, autoimmune and neoplastic diseases, upbeat- and downbeat nystagmus. Recommendations include clinical approaches (repositioning manoeuvres), medication (adding, removing or changing current medication depending on aetiology), vestibular physiotherapy, ergotherapy and rehabilitation, treatment of chest pain or stroke units and surgical interventions. If symptoms are acute and severe, medication with antivertigo agents is recommended as a first step, for a maximum period of 3 days. Following initial symptom control, treatment is tailored depending on aetiology. To assist the clinician in obtaining a useful overview, the level of evidence and number needed to treat are reported whenever possible based on study characteristics. In addition, warnings about possible arrhythmias due to medication are issued, and precautions to enable these to be avoided are discussed.

Introduction: External auditory canal cholesteatoma (EACC) is a rare disease, with an estimated incidence of approximately 1:1,000 adult and 1.6:1,000 pediatric otologic patients. Systematic studies of chronic ear disease and taste alteration prior to surgery are rare; in fact, there are no such studies for EACCs. Therefore, we describe chorda tympani nerve (CTN) dysfunction and the related clinical consequences in EACC patients. Methods/Study Design: Between 1992 and 2021, we retrospectively analyzed the symptoms, signs, and radiological and intraoperative descriptions of CTN involvement in 73 patients. Liquid taste tests and, since 2009, Taste StripsTM as well as an olfactory screening test (Smell DiskettesTM) have been performed for all symptomatic patients and, when feasible, all other EACC patients. Level of Evidence: 4. Results: Ten of 73 patients complained subjectively of dysfunction, and 8 showed abnormal taste test results. Four patients complained of olfactory dysfunction (3 cases with pathological taste tests). Gustatory dysfunction was most frequent in radiogenic EACC cases (n = 4), followed by postoperative EACC (n = 3). Two postoperative patients were asymptomatic despite abnormal test results. Rarely, patients with idiopathic (n = 2) and posttraumatic (n = 1) EACC showed acute taste dysfunction that was confirmed in each with abnormal test results. Discussion/Conclusion: CTN dysfunction often developed asymptomatically in chronic ears, except for idiopathic and posttraumatic EACCs under previous healthy middle ear conditions. Taste disturbance is not a cardinal symptom of EACC, but objective testing suggests that up to one out of 10 EACC patients with advanced disease may experience regional gustatory dysfunction prior to surgery. Especially in context of a new and acute presentation, regional taste dysfunction may alert the clinician of potential progressive EACC invasion and danger to the facial nerve. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To investigate olfactory and gustatory function in patients with maxillofacial trauma and associated fractures.Study Design: Retrospective cohort study.Methods: Olfactory and gustatory function was assessed psychophysically in 124 patients who had sustained maxillofacial trauma with an associated fracture. Five groups were defined based on the fracture type: Le Fort, mandibular, nasal, orbital, and zygomatic. Olfaction was measured with Sniffin' Sticks (threshold, discrimination, identification [TDI] score) and gustation with the taste spray method. Patients self-rated olfactory and gustatory function on a visual analog scale prior to formal testing.Results: Ten out of 124 patients were found to be anosmic (8%), with half of them found in the Le Fort (skull base) group. The Le Fort fracture group had significantly lower olfactory function than other fracture types (TDI score = 22.4 ± 10.7; P = .01; possible range = 1-48). The mean gustatory spray test score was 3.82 ± 0.4 (possible range = 0-4) without any intergroup differences. Self-rated olfactory function showed a correlation with the measured scores (r = 0.61, P < .001) across all groups.Conclusions: The present data show a significant effect of maxillofacial fracture type on the development of anosmia. Maxillofacial fractures involving the skull base, such as Le Fort fractures, are more likely to cause permanent smell loss, whereas the other fracture types are rarely associated with anosmia.Level Of Evidence: 4 Laryngoscope, 131:E331-E337, 2021. [ABSTRACT FROM AUTHOR]

Objective: Chronic rhinosinusitis (CRS) is a common health issue associated with a significant life quality impairment. Intranasal glucocorticoid is the treatment of choice both as initial therapy as well as after surgery. In contrast to nasal spray, liquid glucocorticoids in form of nasal drops have the advantage of reaching the middle and upper meatus. The efficiency of the glucocorticoid nasal drops is nevertheless strictly dependent on the head position they are being applied in. Several head positions have been described in the literature but no clear recommendation towards the best suited position exist to date.Methods: A systematic review was completed using the PubMed database. Journal articles assessing the effect of head position on intranasal drop fluid distribution, clinical effectiveness, or factors affecting patient compliance were included.Results: In total 15 publications meeting the inclusion criteria have been found, out of which 9 cover the effect of head position as a primary outcome using quantitative measures.Conclusions: The positions Lying Head Back, Lateral Head Low, and variations of those can be recommended equally at the moment. Evidence speaks against the use of the classic Head Back position because of poor clinical outcome, and against the position Head Down and Forward as initial therapeutic approach because of high discomfort. For the olfactory cleft, a new head position has been described (Kaiteki), although no comparisons to other positions exist to date. [ABSTRACT FROM AUTHOR]

Reports about fluctuating olfactory deficits are rare, as are reports of unilateral olfactory loss. We present a case of unilateral anosmia with contralateral normosmia, presenting as rapidly fluctuating anosmia. The olfactory fluctuation occurred in sync with the average nasal cycle duration. Examination after nasal decongestion, formal smell testing, and imaging revealed unilateral, left-sided anosmia of sinonasal cause, with right-sided normosmia. We hypothesize that the nasal cycle induced transient anosmia when blocking the normosmic side. Fluctuating olfactory deficits might hide a unilateral olfactory loss and require additional unilateral testing and thorough workup. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Anosmia and hypogeusia as a complication of general anesthesia," by N. M. Dhanani and colleagues, in a previous issue.

This review aims to assist emergency physicians in finding the underlying aetiology when a patient presents with dizziness to the emergency department. After reading this review, the emergency physician will be able to consider the most relevant differential diagnoses and have an idea about dangerous aetiologies that require immediate action. The emergency physician will also know what diagnostic steps need to be taken at what time, such as the three-component HINTS Test (Head Impulse, Nystagmus, and Test-of-Skew), which helps with distinguishing central from peripheral causes of the acute vestibular syndrome. Furthermore, episodic vestibular syndromes and chronic vestibular syndromes are discussed in detail. The five most frequent categories of dizziness are vasovagal syncope / orthostatic hypotension (22.3%), vestibular causes (19.9%), fluid and electrolyte disorders (17.5%), circulatory/pulmonary causes (14.8%) and central vascular causes (6.4%). Given that it would neither be economical nor practical to send all patients to specialists from the start, we present general guidelines for the diagnostic workup of patients presenting with dizziness to the emergency department. This review will focus on epidemiology, aetiologies, differential diagnoses and diagnostics. Treatment is described in a separate article.

This review provides an update on interdisciplinary treatment for dizziness. Dizziness can have various causes and the treatment offered should depend on the cause. After reading this article, the clinician will have an overview of current treatment recommendations. Recommendations are made for the most prevalent causes of dizziness including acute and chronic vestibular syndromes, vestibular neuritis, benign paroxysmal positional vertigo, endolymphatic hydrops and Menière’s disease, vestibular paroxysmia and vestibular migraine, cardiac causes, transient ischaemic attacks and strokes, episodic ataxia type 2, persistent postural-perceptual dizziness, bilateral vestibulopathy, degenerative, autoimmune and neoplastic diseases, upbeat- and downbeat nystagmus. Recommendations include clinical approaches (repositioning manoeuvres), medication (adding, removing or changing current medication depending on aetiology), vestibular physiotherapy, ergotherapy and rehabilitation, treatment of chest pain or stroke units and surgical interventions. If symptoms are acute and severe, medication with antivertigo agents is recommended as a first step, for a maximum period of 3 days. Following initial symptom control, treatment is tailored depending on aetiology. To assist the clinician in obtaining a useful overview, the level of evidence and number needed to treat are reported whenever possible based on study characteristics. In addition, warnings about possible arrhythmias due to medication are issued, and precautions to enable these to be avoided are discussed.