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BackgroundThe literature on predictors of persistent postural-perceptual dizziness (PPPD) following peripheral vestibular insults has not been systematically reviewed.MethodsWe systematically reviewed studies on predictors of PPPD and its four predecessors (phobic postural vertigo, space-motion discomfort, chronic subjective dizziness and visual vertigo). Investigations focused on new onset chronic dizziness following peripheral vestibular insults, with a minimum follow-up of 3 months. Precipitating events, promoting factors, initial symptoms, physical and psychological comorbidities and results of vestibular testing and neuroimaging were extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsWe identified 13 studies examining predictors of PPPD or PPPD-like chronic dizziness. Anxiety following vestibular injury, dependent personality traits, autonomic arousal and increased body vigilance following precipitating events and visual dependence, but not the severity of initial or subsequent structural vestibular deficits or compensation status, were the most important predictors of chronic dizziness. Disease-related abnormalities of the otolithic organs and semi-circular canals and age-related brain changes seem to be important only in a minority of patients. Data on pre-existing anxiety were mixed.ConclusionsAfter acute vestibular events, psychological and behavioural responses and brain maladaptation are the most likely predictors of PPPD, rather than the severity of changes on vestibular testing. Age-related brain changes appear to have a smaller role and require further study. Premorbid psychiatric comorbidities, other than dependent personality traits, are not relevant for the development of PPPD.

Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises.These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence.Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes.Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction.The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction.These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).

BACKGROUND: The Gaze Stabilization Test (GST) identifies vestibulo-ocular reflex (VOR) dysfunction using a decline in target recognition with increasing head velocity, but there is no consensus on target (optotype) size above static visual acuity. OBJECTIVE: To determine the optimal optotype size above static visual acuity to be used during the GST in subjects with unilateral vestibular dysfunction and healthy individuals. METHODS: Eight subjects with unilateral vestibular dysfunction (UVD) and 19 age-matched, healthy control subjects were studied with the standard GST protocol using two optotype sizes, 0.2 and 0.3 logMAR above static visual acuity (ΔlogMAR). Maximal head velocity achieved while maintaining fixation on both optotypes was measured. Sensitivity, specificity and receiver-operator characteristic area under the curve (ROC AUC) analyses were performed to determine the optimal head velocity cut off point for each optotype, based on ability to identify the lesioned side of the UVD group from the control group. RESULTS: There was a significant difference in maximal head velocity between the UVD group and control group using 0.2 ΔlogMAR (p = 0.032) but not 0.3 ΔlogMAR (p = 0.061). While both targets produced similar specificities (90%) for distinguishing normal from subjects with UVD, 0.2 ΔlogMAR targets yielded higher sensitivity (75%) than 0.3 logMAR (63%) and accuracy (86% vs 80%, respectively) in detecting the lesioned side in subjects with UVD versus controls with maximal head velocities≤105 deg/s (p = 0.017). Furthermore, positive likelihood ratios were nearly twice as high when using 0.2 ΔlogMAR targets (+ LR 10) compared to 0.3 ΔlogMAR (+ LR 6.3). CONCLUSION: The 0.2 ΔlogMAR optotype demonstrated significantly superior identification of subjects with UVD, better sensitivity and positive likelihood ratios than 0.3 ΔlogMAR for detection of VOR dysfunction. Using a target size 0.2logMAR above static visual acuity (ΔlogMAR) during GST may yield better detection of VOR dysfunction to serve as a baseline for gaze stabilization rehabilitation therapy.

Objectives: (1) To assess whether neuroticism, state anxiety, and body vigilance are higher in patients with persistent postural-perceptual dizziness (PPPD) compared to a recovered vestibular patient group and a non-dizzy patient group; (2) To gather pilot data on illness perceptions of patients with PPPD.Materials and Methods: 15 cases with PPPD and two control groups: (1) recovered vestibular patients (n = 12) and (2) non-dizzy patients (no previous vestibular insult, n = 12). Main outcome measures: Scores from the Big Five Inventory (BFI) of personality traits, Generalized Anxiety Disorder - 7 (GAD-7) scale, Body Vigilance Scale (BVS), Dizziness Handicap Inventory (DHI), modified Vertigo Symptom Scale (VSS) and Brief Illness Perception Questionnaire (BIPQ).Results: Compared to non-dizzy patients, PPPD cases had higher neuroticism (p = 0.02), higher introversion (p = 0.008), lower conscientiousness (p = 0.03) and higher anxiety (p = 0.02). There were no differences between PPPD cases and recovered vestibular patients in BFI and GAD-7. PPPD cases had higher body vigilance to dizziness than both control groups and their illness perceptions indicated higher levels of threat than recovered vestibular patients.Conclusion: PPPD patients showed statistically significant differences to non-dizzy patients, but not recovered vestibular controls in areas such as neuroticism and anxiety. Body vigilance was increased in PPPD patients when compared with both recovered vestibular and non-dizzy patient groups. PPPD patients also exhibited elements of negative illness perception suggesting that this may be the key element driving the development of PPPD. Large scale studies focusing on this area in the early stages following vestibular insult are needed.

Es werden die diagnostischen Kriterien fur M. Meniere beschrieben, die vom Klassifikationskomitee der Barany-Gesellschaft, der Japanischen Gesellschaft fur Gleichgewichtsforschung, der Europaischen Akademie fur Otologie und Neurootologie (EAONO), dem Komitee fur Gleichgewichtsstorungen der Amerikanischen Akademie fur Otolaryngologie, Kopf- und Hals-Chirurgie (AAO-HNS) sowie der Koreanischen Gesellschaft fur Gleichgewichtsstorungen erarbeitet worden sind. Diese Klassifikation enthalt 2 diagnostische Kategorien: M. Meniere und wahrscheinlicher M. Meniere. Die Diagnose eines definitiven M. Meniere basiert auf klinischen Kriterien und erfordert rezidivierende episodische Schwindelsymptome, die mit einer sensorineuralen Horminderung im niedrigen bis mittleren Frequenzbereich assoziiert sein mussen sowie mit fluktuierenden Symptomen (Horminderung, Tinnitus und/oder Vollegefuhl) im betroffenen Ohr. Die Dauer der Attacken liegt zwischen 20 min und 12 h. Ein wahrscheinlicher M. Meniere ist definiert als episodische Schwindelsymptome (Dreh- oder Schwankschwindel), assoziiert mit fluktuierenden Ohrsymptomen und einer Dauer von 20 min bis 24 h.

Supplemental Digital Content is Available in the Text., Background: Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, “Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?” Methods: A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline. Results/Discussion: Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program. Disclaimer: These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation. Video Abstract available for more insights from the author (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A124).

This paper presents diagnostic criteria for Meniere's disease jointly formulated by the Classification Committee of the Barany Society, The Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology (EAONO), the Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Korean Balance Society. The classification includes 2 categories: definite Meniere's disease and probable Meniere's disease. The diagnosis of definite Meniere's disease is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low-to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing, tinnitus and/or fullness) in the affected ear. Duration of vertigo episodes is limited to a period between 20 min and 12h. Probable Meniere's disease is a broader concept defined by episodic vestibular symptoms (vertigo or dizziness) associated with fluctuating aural symptoms occurring in a period from 20 min to 24h.

Vertebrobasilar dolichoectasia (VBD) is characterized by significant dilation, elongation, and tortuosity of the vertebrobasilar system. We present a unique case of VBD, confirmed by neuroimaging studies, showing vascular compression of the right optic tract and lower cranial nerves leading to an incongruous left homonymous inferior quadrantanopia and glossopharyngeal neuralgia.

OBJECTIVE: Test performance of a focused dizziness questionnaire's ability to discriminate between peripheral and nonperipheral causes of vertigo. STUDY DESIGN: Prospective multicenter. SETTING: Four academic centers with experienced balance specialists. PATIENTS: New dizzy patients. INTERVENTIONS: A 32-question survey was given to participants. Balance specialists were blinded and a diagnosis was established for all participating patients within 6 months. MAIN OUTCOMES: Multinomial logistic regression was used to evaluate questionnaire performance in predicting final diagnosis and differentiating between peripheral and nonperipheral vertigo. Univariate and multivariable stepwise logistic regression were used to identify questions as significant predictors of the ultimate diagnosis. C-index was used to evaluate performance and discriminative power of the multivariable models. RESULTS: In total, 437 patients participated in the study. Eight participants without confirmed diagnoses were excluded and 429 were included in the analysis. Multinomial regression revealed that the model had good overall predictive accuracy of 78.5% for the final diagnosis and 75.5% for differentiating between peripheral and nonperipheral vertigo. Univariate logistic regression identified significant predictors of three main categories of vertigo: peripheral, central, and other. Predictors were entered into forward stepwise multivariable logistic regression. The discriminative power of the final models for peripheral, central, and other causes was considered good as measured by c-indices of 0.75, 0.7, and 0.78, respectively. CONCLUSION: This multicenter study demonstrates a focused dizziness questionnaire can accurately predict diagnosis for patients with chronic/relapsing dizziness referred to outpatient clinics. Additionally, this survey has significant capability to differentiate peripheral from nonperipheral causes of vertigo and may, in the future, serve as a screening tool for specialty referral. Clinical utility of this questionnaire to guide specialty referral is discussed. Language: en

Skew deviation is a rare side effect of intratympanic gentamicin injection for intractable Meniere’s disease. When the skew deviation is accompanied by pathologic head tilt and ocular torsion, the result is an ocular tilt reaction (OTR). The authors report the case of a 56-year-old man with refractory Meniere’s disease who developed binocular vertical diplopia following intratympanic gentamicin injection and was found to have skew deviation and a partial ocular tilt reaction. The authors also review the reported cases of skew deviation following intratympanic gentamicin and confirm this phenomenon, which has only rarely been reported in the literature.

A 37-year-old man with a history of progressive bilateral sensorineural hearing loss presented to a neuro-ophthalmology clinic with an acute left homonymous hemianopsia. In this article, we discuss the clinical approach and differential diagnosis of progressive combined vision and hearing loss and guide the reader to discover the patient's ultimate diagnosis.

To report the pretreatment and posttreatment population characteristics and the overall stability of the audiologic outcomes found during the Sudden Hearing Loss Clinical Trial (ClinicalTrials.gov: Identifier NCT00097448).Multicenter, prospective randomized noninferiority trial of oral versus intratympanic (IT) steroid treatment of sudden sensorineural hearing loss (SSNHL).Fifteen academically based otology practices.Two hundred fifty patients with unilateral SSNHL presenting within 14 days of onset with 50 dBHL or greater pure tone average hearing threshold in the affected ear.Either 60 mg/d oral prednisone for 14 days with a 5-day taper (121 patients) or 4 IT doses for 14 days of 40 mg/ml methylprednisolone (129 patients).Primary end point was change in hearing [dB PTA] at 2 months after treatment. Noninferiority was defined as less than 10 dB difference in hearing outcome between treatments. In this article, pretreatment and posttreatment hearing findings will be reported in detail.A general (and stable) effect of treatment and a specific effect of greater improvement at low frequencies were found in both treatment groups.Hearing improvements are stable, and a significantly greater improvement occurs with lower frequency after either oral or IT steroid treatment of SSNHL.

These two cases illustrate several important areas of vestibular evaluation with children. The two case reports represent two children who display very different vestibular findings despite having significant sensorineural hearing loss.These case reports highlight that pediatric findings can differ significantly from adult findings, stressing the importance of comparing pediatric results with pediatric normative data. These two cases also highlight that vestibular techniques may successfully be adapted for use with hearing-impaired children. That is, rotary chair, computerized dynamic posturography, and vestibular evoked myogenic potentials can be adapted to use with children, including those who demonstrate significant sensorineural hearing loss. Although there is a paucity of research and clinical work in this area, some investigators (Eviatar and Eviatar, 1977; Buchman et al, 2004; Jacot et al, 2009) have reported very rapid recovery from pediatric vestibular deficits. However, it is important for audiologists to be aware that techniques may successfully be adapted for children and that many children should undergo thorough vestibular evaluation.

Vestibular function testing plays a critical role in understanding balance disorders. These tests augment a well-performed history and physical exam in providing quantitative information regarding vestibular reflexes, central oculomotor function and postural control strategies. Video-oculography (VOG) and caloric stimulation play a major role in evaluation of both peripheral vestibular and central oculomotor disorders. Rotational chair testing and, more recently the Dynamic Visual Acuity Test (DVAT) and Gaze Stabilization Test (GST) provide information regarding higher frequency vestibulo-ocular reflex (VOR) function. Computerized Dynamic Posturography (CDP) explores the interaction of the vestibular, visual and proprioceptive systems for posture control. Finally, the cervical Vestibular Evoked Myogenic Potential (cVEMP) test and the Dynamic Subjective Visual Vertical (DSVV) test provide information regarding saccular and utricular function, respectively. New techniques and applications continue to provide knowledge both of disease processes and potential medical, surgical and rehabilitative interventions.

Meniere's disease is a disorder of the inner ear that causes attacks of vertigo and hearing loss, tinnitus, aural fullness in the involved ear. Over the past 4 decades, the Equilibrium Committee of the AAO-HNS has issued guidelines for diagnostic criteria, with the latest version being published in 1995. These criteria were reviewed in 2015 by the Equilibrium Committee, and revisions were approved at the recent meeting of the committee at the 2015 AAO-HNSF Annual Meeting. The following commentary outlines the amended and approved criteria.

This paper presents diagnostic criteria for Menière's disease jointly formulated by the Classification Committee of the Bárány Society, The Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology (EAONO), the Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Korean Balance Society. The classification includes 2 categories: definite Menière's disease and probable Menière's disease. The diagnosis of definite Menière's disease is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low-to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing, tinnitus and/or fullness) in the affected ear. Duration of vertigo episodes is limited to a period between 20 min and 12h. Probable Menière's disease is a broader concept defined by episodic vestibular symptoms (vertigo or dizziness) associated with fluctuating aural symptoms occurring in a period from 20 min to 24h.

This paper presents diagnostic criteria for Menière's disease jointly formulated by the Classification Committee of the Bárány Society, The Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology (EAONO), the Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Korean Balance Society. The classification includes two categories: definite Menière's disease and probable Menière's disease. The diagnosis of definite Menière's disease is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low- to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing, tinnitus and/or fullness) in the affected ear. Duration of vertigo episodes is limited to a period between 20 minutes and 12 hours. Probable Menière's disease is a broader concept defined by episodic vestibular symptoms (vertigo or dizziness) associated with fluctuating aural symptoms occurring in a period from 20 minutes to 24 hours.

Objective To determine the prevalence, symptom characteristics, and potential risk factors for vestibular symptoms after cochlear implantation. Study design Case-control study design embedded within an ongoing cohort of patients undergoing implantation. Setting Academic medical center cochlear implant research program funded by the National Institutes of Health. Patients Seventy five eligible consecutive patients undergoing cochlear implantation. Intervention Medical record review. Main outcome measure Recorded symptoms of vestibular symptoms after cochlear implantation. Subjects with vestibular symptoms were considered case subjects; those without vestibular symptoms were considered control subjects. Results Twenty-nine of 75 (39%) patients experienced dizziness postoperatively. Four patients experienced a single, transient acute vertigo attack occurring less than 24 hours after surgery. The majority, 25 patients, experienced delayed, episodic onset of vertigo. The median (interquartile range) time of delayed onset was 74 (26-377) days after implantation. Delayed dizziness manifested as spontaneous episodic or positional vertigo. Preoperative dizziness, age at implantation, and age at onset of hearing loss were significantly greater in the dizzy group. Preoperative electronystagmography did not differentiate between groups. Conclusions Thirty-nine percent (29/75) of subjects with implants were dizzy after implantation. The majority of subjects experienced dizziness in a delayed episodic fashion. Dizziness was not related to implant activation. It seemed that delayed dizziness was not related to immediate surgical intervention but could result from chronic changes occurring in the inner ear; there was some suggestion this could take the form of endolymphatic hydrops.

To highlight the effectiveness, safety, and adverse effects of treating intractable posterior canal benign paroxysmal positional vertigo (BPPV) with bilateral posterior canal occlusions.Included in this study are 6 patients diagnosed with bilateral BPPV refractory to medical treatment and particle repositioning maneuvers (PRMs) who underwent bilateral posterior semicircular canal occlusions. Patients were selected from tertiary hospital referral centers in London, Ontario, Canada, and St. Louis, Missouri, USA.This study used the following interventions: preoperative and postoperative audiogram testing to monitor long-term changes in hearing, computed tomography of the head to rule out central lesions and confirm normal inner ear anatomy before surgery, magnetic resonance imaging of the head as needed to rule out posterior fossa lesions causing persistent vertigo, Dix-Hallpike maneuver to diagnose BPPV, PRM and physiotherapy vestibular rehabilitation to attempt treating BPPV before surgical intervention, and sequential transmastoid posterior semicircular canal occlusion for treatment of intractable BPPV.Postoperative resolution of vertigo induced by head movement and hearing preservation by audiometric testing and postural stability.All patients with severe debilitating bilateral BPPV refractory to medical treatment and PRM had complete resolution of their positional vertigo after bilateral sequential posterior semicircular canal occlusion. Hearing was preserved at the preoperative level in all but 1 patient who developed bilateral postoperative, mild, high-tone sensorineural loss. Residual postoperative adverse effects included transient imbalance in all patients and episodic, nonpositional vertigo in 1 patient. When stressed by extreme head motion, some patients had mild residual instability. There were no other significant long-term complications.Bilateral sequential posterior semicircular canal occlusion is a definitive, effective, and safe treatment modality for intractable bilateral BPPV, providing patients with resolution of their vertiginous symptoms. All 6 patients stated that the alleviation of their BPPV symptoms far out-weighed the residual motion sensitivity resulting from the occluded canals.

The relationship between lifetime alcohol consumption and postural control was investigated in 35 subjects with no clinically-detectable neurologic abnormalities, using computerized dynamic posturography (CDP) procedures. The estimated total number of lifetime alcoholic drinks was positively correlated with anteroposterior sway spectral power within the 2–4 Hz and 4–6 Hz frequency bands, in three Sensory Organization Test (SOT) conditions: eyes closed with stable support surface (SOT 2), eyes open with sway-referenced support (SOT 4), and eyes closed with sway-referenced support (SOT 5). All correlations remained significant after controlling for subject age, and were increased after excluding nine drug-abusing subjects. In contrast to the strong findings for frequency-based measures, no correlation was observed using conventional amplitude-based sway measures. These results suggest that 1) alcohol consumption compromises postural control in an exposure-dependent manner, and 2) sway frequency analysis reveals pathological processes not manifested in conventional CDP measures of sway amplitude.

Objective To describe the phenomenon of hyperventilation-induced nystagmus (HVN) after stereotactic radiotherapy for vestibular schwannoma. Patients We present 2 patients with vestibular schwannoma and no pretreatment vestibular symptoms who both received stereotactic radiotherapy. Within 2 months of completing treatment, both patients developed intense vertigo while exerting themselves. Video-oculography demonstrated an intense nystagmus with the fast phase directed toward the side of the schwannoma in both patients. Intervention Diagnostic. Results Patients who have undergone surgical resection of their vestibular schwannoma, or have a large tumor, will often demonstrate HVN with the fast phase directed away from the side of the tumor. This is distinct from patients with smaller lesions who have a fast-phase nystagmus toward the tumor's side. This second type of nystagmus is thought to originate from changes in the extracellular calcium concentration secondary to hyperventilation-induced alkalosis. Conclusion We hypothesize that stereotactic radiotherapy induced greater demyelination of the vestibular nerve leading to the observable sign of HVN. These patients represent the first reported cases of HVN after stereotactic radiation and illustrate the pathophysiology of HVN, which may lead to a greater understanding of the effects of stereotactic radiotherapy.

Objective: To determine whether otologists see a need to further define the word “vertigo” and assess the variety of meanings that are meant in using the word. Methods: A questionnaire was mailed to 720 members of the American Otological Society (AOS) and American Neurotological Society (ANS) to assess the need for further definition and the current understanding of the meaning of “vertigo.” Results: The response rate was 42%. Significant variability in the intended meaning of the word “vertigo” was found suggesting that the definition is inconsistent among experts. Three quarters of the respondents indicated that the word needs further definition. The word was most commonly used to indicate sensations that include spinning or turning only. Conclusion: The definition of the term “vertigo” is inconsistent among otolaryngologists. Refinement of the definition is desirable for accurate history taking and should be limited to false illusions of circular motion. (Otolaryngol Head Neck Surg 2001;125:147-50.)

Hypothesis: The authors believe that anatomic differences render the superior division of the vestibular nerve more susceptible to injury during vestibular neuritis. The purpose of the study was to investigate anatomic differences between the superior vestibular nerve and singular nerve canals. Background: Previous studies of temporal bones have revealed vestibular nerve degeneration in patients with vestibular neuritis. Although the cause of this degeneration has not been established, it has been noted that the superior division of the vestibular nerve is preferentially affected, with sparing of the inferior division. The superior vestibular nerve and the singular nerve, a branch of the inferior vestibular nerve, both pass through canals interlaced with bony networks before reaching the peripheral receptors. Methods: The authors performed histologic analysis of 40 normal temporal bones randomly selected from their temporal bone library. With a micrometer, measurements were taken of the individual canals. The ratio of the total bony spicule component to the total canal width was obtained for both the superior vestibular nerve and the singular nerve. The length of the canals was also measured. Arteriole:arteriolar canal ratios of the superior vestibular nerve and singular nerve were obtained. Results: The bony channel of the singular nerve had an average length of 0.59 mm, and the average length of the superior vestibular nerve was 2.30 mm (p < 0.001). The ratio of total bony spicule width to total canal width was significantly smaller (p < 0.05) for the singular nerve (0.30 mm) compared with the superior vestibular nerve (0.34 mm). The arteriole: arteriolar canal ratio was significantly smaller (p < 0.05) for the singular nerve (0.45 mm) than for the superior vestibular nerve (0.54 mm). Conclusion: The bony canal of the superior vestibular nerve is longer than the singular nerve canal. Additionally, the superior vestibular nerve and arteriole travel through a relatively narrower passage than the singular nerve and its vascular supply. From an anatomic standpoint, this renders the superior division of the vestibular nerve more susceptible to entrapment and possible ischemic labyrinthine changes. Key Words: Vestibular nerve—Singular nerve—Vestibular neuritis—Temporal bone.

The evaluation of vestibular complaints is not always straightforward. Fortunately, a number of developments in the clinical and laboratory assessment of patients with dizziness have led to more accurate and timely diagnosis of these complex disorders. New understanding and insight into the underlying pathophysiology of vestibular disorders in conjunction with technologic advancements have led to significant improvements in the clinical and laboratory evaluation of vestibular disease. This review summarizes recent advances in both clinical and laboratory vestibular assessment.

New methods of rotational testing of the vestibulo-ocular reflex (VOR) using manually generated or patient-generated sinusoidal head movements have recently been advocated for clinical use in circumstances where conventional rotary chair testing methods are not feasible. However, studies seeking to provide evidence for the validity of these methods by comparing their results with an accepted “gold-standard” have been conspicuously absent in the literature. In this study, we compared results for VOR gain, phase, and asymmetry obtained using whole-body and head-on-body rotational stimuli with those obtained by conventional rotary chair testing in 35 subjects with either unilateral or bilateral vestibular deficits over the range of frequencies from 0.025 Hz to 1 Hz. Our results provide evidence for the validity of manual whole-body and active and passive head-on-body rotational testing methods by demonstrating excellent agreement between each of these and conventional rotational chair testing for VOR gain, phase, and asymmetry within the frequency range studied. Small differences at specific-paradigm datapoints are likely secondary to subtle limitations of our experimental design. With further refinement, we expect the new methods will be useful adjuncts for evaluating patients with vestibular complaints in selected clinical situations.

During the last 10 years, computerized dynamic posturography has yielded various patterns of sway on the sensory organization test and the motor control test that have been associated with a variety of organic balance disorders. Some aspects of performance during computerized dynamic posturography, however, are under conscious control. Voluntary movements not indicative of physiologic response to balance system stimulation can also affect computerized dynamic posturography results. Quantification of nonorganic or "aphysiologic" response patterns in normal subjects, patients, and suspected malingerers is crucial to justify use of computerized dynamic posturography for identification of physiologically inconsistent results. For this purpose the computerized dynamic posturography records of 122 normal subjects, 347 patients with known or suspected balance disorders, and 72 subjects instructed to feign a balance disturbance were critically evaluated by use of seven measurement criteria, which were postulated as indicating aphysiologic sway. Each criterion was scored with a standard calculation of the raw data in a random, blinded fashion. The results of this multicenter study show that three of the seven criteria are significantly different in the suspected "malingerer" group when compared with either the normal or patient group. The relative strength of each criterion in discerning organic from nonorganic sway provides the examiner with a measure of reliability during platform posture testing. This study demonstrates that computerized dynamic posturography can accurately identify and document nonorganic sway patterns during routine assessment of posture control. (Otolaryngol Head Neck Surg 1997; 117:293-302.)

We describe the clinical and laboratory features of 13 patients with bilateral loss of peripheral vestibular sensitivity of no known cause. In the office, screening for this condition was possible using illegible e-testing and examination of the patient for refixation saccades after brisk head movements while attempting visual fixation. Diagnosis was confirmed by bilaterally reduced caloric responses (< 20 degrees/second on all 4 caloric irrigations) and abnormally low gain of the vestibulo-ocular reflex on rotational chair testing. The mean age of the patients was 68 years. We noted two patterns of symptom onset: onset associated with vertigo (10 patients) and insidious progressive disequilibrium not associated with vertigo (3 patients). Only 38% of the patients complained of subjective oscillopsia. The subjects performed poorly on platform posturography, particularly when deprived of visual and somatosensory feedback. When associated with vertigo, bilateral vestibular loss may be the result of bilateral sequential vestibular neuritis; when not associated with vertigo, disequilibrium may be caused by slow, symmetrical loss of peripheral function as a result of aging. Although the subjects in this report were elderly, idiopathic bilateral vestibular loss has been reported in patients of all ages.

Broad-frequency rotational chair testing is employed in clinical and research settings to evaluate the response of the vestibulo-ocular reflex (VOR) over a range of frequencies. Accurate computation of the gain and phase of the VOR is dependent upon the assumption that the subject’s head is rigidly coupled to the rotating chair over the range of frequencies employed. We tested this assumption by examining head slippage in 20 normal subjects using a standard rotational chair over the frequency range 0.025 to 2 Hz. Measurements were made with the subjects’ head optimally restrained according to our standard clinical protocol and with the head minimally restrained. Head slippage was expressed as gain and phase of the head with respect to the chair. Computation of these parameters was made by comparing the signal received from a biteblock-mounted rate sensor rigidly coupled to the skull with that of the chair’s tachometer. We found highly significant slippage of the head with respect to the chair occurred at 0.5, 1 and 2 Hz, even with the head optimally restrained, leading to increased gain and a phase lag. Gain and phase were highly variable for both conditions at 2 Hz indicating inadequate head fixation using our methods. Below 0.5 Hz, minimal head slippage occurred whether the head was restrained or simply rested against a contoured headrest. Consideration of these results may lead to changing some practices currently employed in broad-frequency rotational chair testing at frequencies of 0.5 Hz and above.

Eight subjects with unilateral hearing loss were fitted with wireless CROS and transcranial BTE CROS hearing aids. Results revealed that two subjects preferred the BTE transcranial CROS; four subjects preferred the wireless CROS; one subject found both hearing aid systems to be equally satisfactory; and one subject rejected both CROS fittings. In addition, a fitting strategy is introduced using probe microphone analysis to: (a) measure trans-cranial thresholds (TCT) in the unaidable ear in dB SPL measured near the eardrum, and (b) determine the sensation level of the real ear aided response (REAR-TCT) for uncorrected and corrected speech-weighted noise. The results highlight some of the difficulties associated with successfully fitting a transcranial CROS hearing aid.

The currently accepted "gold standard" for rotational testing of the vestibulo-ocular reflex uses a servo-controlled chair for sinusoidal whole-body rotation. Previous work in our laboratory has shown good concordance between conventional rotational chair testing and head-on-body (or "head-shake") testing for gain and phase values of the vestibulo-ocular reflex as recorded and analyzed on our rotational chair system's software. In this article we describe results obtained from 10 normal subjects and 20 patients with reduced caloric responses using a portable system being developed in our laboratory that allows an examiner to generate both whole-body and head-on-body rotational stimuli. Test frequencies within the range 0.25 to 1.0 Hz were chosen for comparison with results obtained by conventional rotational chair testing. Visual conditions for all tests included both visually enhanced vestibulo-ocular reflex (real earth-fixed target) and mentally enhanced vestibulo-ocular reflex (imagined earth-fixed target, in darkness or with vision obscured) paradigms. Our results show general agreement between head-shake and rotational chair testing and both manual whole-body rotation and head-shake testing on our portable system for vestibulo-ocular reflex gain and phase testing, with the largest differences noted at 1.0 Hz. Portable rotational testing was well tolerated by young and elderly subjects alike. We expect manual whole-body rotation and head-shake testing will be useful adjuncts for examining vestibulo-ocular reflex function when more formal rotational chair testing is not possible.

Four healthy male volunteers < 30 years of age participated in a blinded study of placebo versus low (0.45 g/kg lean body weight = LBW), medium (0.80 g/kg LBW) and high (1.05 g/kg LBW) dose ethanol ingestion to investigate its effect upon gaze and posture control. Serial electronystagmography and computerized platform posturography were performed at different points along each subject's blood alcohol concentration (BAC) curve as measured by breath analysis. Smooth pursuit and positional testing revealed subtle abnormalities at sub-intoxicating BACs. In addition, instability on posturography was evident on the Sensory Organization Test with no statistically significant influence observed on muscle latency testing as determined by sway analysis. We conclude that even low ethanol BAC levels produce widespread gaze and posture control effects which can be easily documented.

This case study summarizes findings in an adult male, aged 57, who presented to the Adult Audiology Clinic with aural atresia in the right ear resulting in a conductive hearing loss and a sudden sensorineural hearing loss in the left ear. Treatment options included reconstruction surgery in the right ear, bone anchored hearing aid in the right ear to overcome the conductive hearing loss, bone anchored hearing aid in the left ear for single sided deafness, and intratympanic steroid injections in the left ear to salvage hearing.This case study highlights that when a patient is educated on all available options the patient is then able to make a decision comfortable to him and to help improve his hearing.

Test-retest reliability of rotational chair testing for a single facility has previously been examined by others. The actual data analysis methods, however, have received far less attention. The variety of both hardware and software currently used theoretically may affect the results for a given subject tested at different facilities. The purposes of this study were, first, to quantify the amount of variability in the analysis of identical raw data files at multiple rotational chair testing facilities by using automated analysis; second, to evaluate the effect of operator intervention on the analysis; and third, to identify possible sources of variability. Raw data were collected from 10 normal subjects at 0.05 Hz and 0.5 Hz (50 degrees per second peak velocity). Diskettes containing raw electro-oculogram data files were then distributed to eight participating laboratories for analysis by two methods: (1) using automated analysis algorithms and (2) using the same algorithms but allowing operator intervention into the analysis. Response parameters calculated were gain and phase (re: velocity). The SD of gain values per subject for automated analysis ranged from 0.01 to 0.32 gain units and of phase values from 0.4 to 13.7 degrees. For analysis with operator intervention, the SD of gain values ranged from 0.02 to 0.10 gain units and of phase values from 0.4 to 4.4 degrees. The difference between automated analysis and analysis with operator intervention was significant for gain calculations (p 0.05). This study demonstrates significant variability in automated analysis of rotational chair raw data for gain and phase.(ABSTRACT TRUNCATED AT 250 WORDS)

Program Description: Otolaryngology programs continue to attract some of the best medical student applicants, but there have been increasing challenges placed on residency training. ACGME, medico-legal, public expectations, and financial pressures have changed the methods in which we train residents. This miniseminar will involve an expert panel discussion of the evolving aspects of otolaryngology residency training, which will expand into a town hall–type format using the audience response system and a roaming microphone for active audience contribution. The panel will include initiating perspectives from the ACGME RRC Executive Director, President of the Otolaryngology Program Directors Organization, members of the ABOto Education Council, an Associate Dean for GME and seasoned Program Directors. The discussion will focus on the important decision steps of both the residency applicant and program in the course of training: 1) How to select the right residency program applicant, including what is known a...

Context Idiopathic sudden sensorineural hearing loss has been treated with oral corticosteroids for more than 30 years. Recently, many patients' symptoms have been managed with intratympanic steroid therapy. No satisfactory comparative effectiveness study to support this practice exists. Objective To compare the effectiveness of oral vs intratympanic steroid to treat sudden sensorineural hearing loss. Design, Setting, and Patients Prospective, randomized, noninferiority trial involving 250 patients with unilateral sensorineural hearing loss presenting within 14 days of onset of 50 dB or higher of pure tone average (PTA) hearing threshold. The study was conducted from December 2004 through October 2009 at 16 academic community-based otology practices. Participants were followed up for 6 months. Intervention One hundred twenty-one patients received either 60 mg/d of oral prednisone for 14 days with a 5-day taper and 129 patients received 4 doses over 14 days of 40 mg/mL of methylprednisolone injected into the middle ear. Main Outcome Measures Primary end point was change in hearing at 2 months after treatment. Noninferiority was defined as less than a 10-dB difference in hearing outcome between treatments. Results In the oral prednisone group, PTA improved by 30.7 dB compared with a 28.7-dB improvement in the intratympanic treatment group. Mean pure tone average at 2 months was 56.0 for the oral steroid treatment group and 57.6 dB for the intratympanic treatment group. Recovery of hearing on oral treatment at 2 months by intention-to-treat analysis was 2.0 dB greater than intratympanic treatment (95.21% upper confidence interval, 6.6 dB). Per-protocol analysis confirmed the intention-to-treat result. Thus, the hypothesis of inferiority of intratympanic methylprednisolone to oral prednisone for primary treatment of sudden sensorineural hearing loss was rejected. Conclusion Among patients with idiopathic sudden sensorineural hearing loss, hearing level 2 months after treatment showed that intratympanic treatment was not inferior to oral prednisone treatment. Trial Registration clinicaltrials.gov Identifier: NCT00097448

Balance disorders are common in elderly people, not only resulting in distressing sensations but also leading to reduced activity levels and quality of life. It has been estimated that 30% of elderly patients experience a balance disorder. Managing these disorders is a substantial challenge for patients and their caregivers and physicians. Moreover, abnormalities in balance are associated with falls, a major cause of morbidity and mortality for elderly people. Management is complicated by the inherent difficulties in assessing the generic complaint of dizziness, as well as the likelihood of multiple, often nonvestibular causes. The authors of this mini-seminar review both vestibular and nonvestibular causes of balance disorders in elderly people, emphasizing practical therapeutic maneuvers that can be used.

Dizziness is the third most common patient complaint in general medical clinics in the US,1 and accounts for 8 million presenting complaints a year.2 It also accounts for 4% of emergency department visits.3 Dizziness and postural instability increase in prevalence with increasing age, and affect over 50% of the elderly.2 It is the most common presenting complaint for patients over seventy-five.4 For the patient, dizziness is incapacitating and leads to decreased productivity, clinical depression,5 and falls and injuries.6 Although dizziness is common and debilitating, clinical diagnosis is often difficult due to the broad differential diagnosis encompassing vestibular, neurological and cardiological factors.7 The physician must rely on a thorough history and physical examination to determine the next steps for evaluation.8 Once the correct diagnosis is made, effective treatments are often available depending on etiology.9,10,11 However, the burden of diagnosis frequently falls on primary care and emergency medicine doctors, who face significant time and resource pressures, and often find dizziness one of the more challenging aspects of practice. Patient verbal descriptions of the quality of dizziness tend to be unclear, inconsistent, and unreliable,12 and physician dependence on symptom quality over other clinical features like timing and associated symptoms might predispose them to misdiagnosis.13 In the face of such diagnostic challenges, and in the era of efficiency and cost reduction, a simple, inexpensive, and accurate questionnaire-based diagnostic algorithm would be highly welcome. Previous attempts for creating an algorithm for diagnosis of dizziness have been described. Kentala et al in 1996 were able to obtain 90% prediction accuracy in the six diagnostic categories of BPPV, Meniere’s disease, vestibular schwannoma, vestibular neuritis, sudden deafness, and traumatic vertigo using a 13-item algorithm.14 However, they had included test results such as pure-tone thresholds, caloric excitability and spontaneous nystagmus using electronystagmography, and quiet stance in posturography, in addition to history. Other similar studies using sophisticated algorithm networks or otoneurological expert systems as analysis tools also produced promising results, but similarly relied on specialized tests.15,16,17,18,19 These results could only come after a full examination and diagnosis by a balance specialist, and offer little to the primary care doctor presented with an initial complaint of dizziness. In 2003, Kentala & Rauch used a 3-parameter questionnaire to predict among the four categories of BPPV, Meniere’s disease, vestibular neuritis, and labyrinthitis, and predicted 21 out of 35 diagnoses correctly (60% accuracy).20 In order to create a screening tool that is widely adopted into standard practice, higher prediction accuracy would be desirable. For the past two decades, our balance center has utilized a standardized approach to evaluate dizzy patients, believing that a systematic analysis of patient responses will isolate important factors better than clinical judgment alone. One component of this standardized approach utilizes a clinical questionnaire filled out before the physician visit. In this study, we used the current questionnaire to systematically isolate groupings of questions which are predictive of each clinical diagnosis, and determined the power of particular sets of symptoms to distinguish between different diagnoses of dizziness.

Hearing preservation during the posterior fossa surgery depends on many factors, including tumor size and site of origin. In many cases, regardless of the presumed tumor origin, the severity of the pure-tone loss or decline in speech discrimination on preoperative testing prompts the surgeon to choose a surgical approach (translabyrinthine or transcochlear) that negates the chance for postoperative functional hearing in the involved ear. We describe a 41-year-old woman with unilateral severe sensorineural hearing loss who experienced a remarkable recovery of hearing after combined retrolabyrinthine and retrosigmoid removal of a 4 cm petrous ridge meningioma using intraoperative cochlear monitoring. Despite the tumor size, early intraoperative loss of wave I and proximity of the tumor to the porus, complete tumor removal was accomplished with preservation of the cochleovestibular bundle. Three weeks postoperatively, the patient noted marked subjective improvement and speech audiometry demonstrated an improvement in word recognition, from 0% to 86%. This improvement has remained 1 year postoperatively, with no evidence of persistent tumor on repeat MRI scan. The case report illustrates the possibility of not just hearing preservation but improvement after removal of even large posterior fossa meningiomas that do not directly invade the cochlear nerve itself.

To identify the predictive capabilities of caloric and rotational testing to distinguish peripheral from nonperipheral vestibular causes of vertigo.Retrospective case review.Academic tertiary care vestibular function test center.Two hundred dizzy patients (132 with and 68 without suspected peripheral vestibular dizziness) evaluated with bithermal binaural caloric and sinusoidal and step-velocity rotary chair (RC) tests.Caloric and RC tests.1) Receiver operating characteristic (ROC) analysis of individual caloric and rotary parameters for area under the curve (AUC) as indication of predictive value, and 2) logistic regression analysis of parameter combinations for identification of optimal test battery for predicting peripheral vestibular dysfunctionAnalysis of the individual receiver operating characteristic (ROC) curves for each caloric and RC test parameter for prediction of peripheral vestibulopathy revealed that the best overall predictive parameter was percentage of caloric weakness (CW; AUC-ROC, 0.73; 95% confidence interval, 0.66-0.80). Using 29.5% as the optimal cutoff point for CW, a specificity of 84% and sensitivity of 55% were obtained. Because of the reduced AUC for the RC parameters, no optimal cutoff points were chosen. Using a logistic regression model in predicting patients with peripheral vestibulopathy demonstrated that either comprehensive caloric and RC testing or the combination of caloric and 0.025 Hz, 0.5 Hz, and time-constant rotational testing yielded the highest predictive value (AUC-ROC, 0.79)Calculation of CW was the most promising single marker for identifying peripheral from nonperipheral vestibulopathic patients. Individual RC parameters showed limited predictive value to differentiate peripheral from nonperipheral vestibular dysfunction. However, the combination of subtests yielded an AUC-ROC only slightly less than caloric testing. The combination of caloric and RC testing revealed the strongest predictive capabilities for identifying peripheral vestibular injury. Furthermore, the combination of an abbreviated form of RC testing with caloric testing yielded nearly identical results as full caloric and rotational testing.

Evaluate the effectiveness of a head-mounted vibrotactile prosthesis for balance improvement in subjects with severe bilateral vestibular loss (BVL).Crossover study.Academic tertiary care vestibular function test center.Five subjects with severe BVL as defined by video-oculography, rotational chair, and computerized dynamic posturography criteria.Vibrotactile head tilt feedbackChange in Sensory Organization Test (SOT) Conditions 5 and 6 performance (fall-no fall, time to fall, strategy analysis) and dynamic subjective visual vertical (DSVV) response.1) Significant improvement in binary fall-no fall ratio on SOT 5 and SOT 6 combined (chi2 = 9.603, df = 1, p = 0.001); 2) Significant increase in time to fall measurements on SOT 5 (p0.001) and SOT 6 (p0.01; 1-tailed t test); 3) Nonsignificant improvement in strategy scores on SOT 5 (p = 0.156) and SOT 6 (p = 0.259; 1-tailed t test); and 4) No significant effect during eccentric DSVV testing (analysis of variance).Head-mounted vibrotactile stimulation produced significant improvement in postural stability in subjects with BVL undergoing SOT 5 and 6 testing with no effect on subjective visual vertical during DSVV testing.