Dominique Vibert

Benign paroxysmal positional vertigo in older women may be related to osteoporosis and osteopenia.

Benign paroxysmal positional vertigo (BPPV), so-called canalolithiasis and cupulolithiasis, usually occurs after head trauma or viral vestibular neuritis. In many cases, the cause remains obscure, and it often affects women more than 50 years old. The goal of this work was to study a possible relationship between BPPV and osteopenia or osteoporosis. Thirty-two women, whose ages ranged from 50 to 85 years (median age, 69 years), who had BPPV and were free of any other otoneurologic history, were selected. The diagnosis of osteopenia or osteoporosis was confirmed by a bone mineral density measurement made with dual x-ray absorptiometry of spine and hip (T-score). The BPPV was unilateral in 26 patients and bilateral in 6 patients. Our results showed osteopenia or osteoporosis in 24 of the 32 patients (75%) with BPPV. The T-scores were compared in 3 age groups to those of 83 healthy women. The patients with BPPV had a significantly lower (p < .026) T-score in all groups. Possible pathophysiological mechanisms are discussed to explain the apparent correlation between BPPV and osteopenia or osteoporosis.

Ultrastructural Changes in Otoconia of Osteoporotic Rats

The etiology of benign paroxysmal positional vertigo (BPPV) remains obscure in many cases and women are affected more often than men. A recent prospective study, performed in women >50 years of age suffering from recurrent BPPV, showed associated osteopenia or osteoporosis in a large percentage of these patients. These results suggested the possible relationship between recurrent BPPV and a decreased fixation of calcium in bone in women >50 years. To test this hypothesis, an experimental study was performed in adult female rats. Utricular otoconia of female rats in which osteopenia/osteoporosis was induced by bilateral ovariectomy (OVX) were compared to those of sham-operated adult females rats (SHAM), as control group. First Study: The morphology of theutricles of OVX and SHAM rats was analyzed with scanning electron microscopy. In osteopenic/osteoporotic rats, the density of otoconia (i.e. the number of otoconia per unit area) was decreased (p = 0.036)and their size was increased (p = 0.036) compared to the control group. Second Study: To test the role of calcium turnover in such morphological changes, utricular otoconia of 2 other groups of OVX and SHAM rats, previously injected with calcein subcutaneously, were examined by conventional and epifluorescence microscopy. In epifluorescence microscopy, labeling with calcein showed no significant fluorescence in either group. This finding was interpreted as a lack of external calcium turnover into otoconia of adult female rats. The ultrastructural modifications of otoconia in osteopenic/osteoporotic female adult rats as well as the role of estrogenic receptors in the inner ear are discussed. The possible pathophysiological mechanisms which support the relationship between recurrent BPPV in women and the disturbance of the calcium metabolism of osteopenia/osteoporosis are debated.

Trunk sway in mildly disabled multiple sclerosis patients with and without balance impairment

Multiple sclerosis (MS) causes a broad range of neurological symptoms. Most common is poor balance control. However, knowledge of deficient balance control in mildly affected MS patients who are complaining of balance impairment but have normal clinical balance tests (CBT) is limited. This knowledge might provide insights into the normal and pathophysiological mechanisms underlying stance and gait. We analysed differences in trunk sway between mildly disabled MS patients with and without subjective balance impairment (SBI), all with normal CBT. The sway was measured for a battery of stance and gait balance tests (static and dynamic posturography) and compared to that of age- and sex-matched healthy subjects. Eight of 21 patients (38%) with an Expanded Disability Status Scale of 1.0–3.0 complained of SBI during daily activities. For standing on both legs with eyes closed on a normal and on a foam surface, patients in the no SBI group showed significant differences in the range of trunk roll (lateral) sway angle and velocity, compared to normal persons. Patients in the SBI group had significantly greater lateral sway than the no SBI group, and sway was also greater than normal in the pitch (anterior–posterior) direction. Sway for one-legged stance on foam was also greater in the SBI group compared to the no SBI and normal groups. We found a specific laterally directed impairment of balance in all patients, consistent with a deficit in proprioceptive processing, which was greater in the SBI group than in the no SBI group. This finding most likely explains the subjective symptoms of imbalance in patients with MS with normal CBT.

Menière's disease in the elderly.

OBJECTIVES To assess the prevalence, presentation, treatment, and evolution of Menières disease in elderly patients (> or = 65 yr old). STUDY DESIGN Retrospective clinical study and case report. SETTING A neuro-otology referral center at the university hospital in Bern, Switzerland, and a neurotologic practice in Geneva, Switzerland. PATIENTS Patients were selected from the hospital clinic and otolaryngologic practice registers. Among 8423 neurotologic checkups performed between 1988 and 1998, 432 (5.1%) patients had definite Menières disease and 66 (15.3%) of these patients were > or = 65 years old. INTERVENTION The files of these 66 patients were analyzed. RESULTS Menières disease in the elderly had 2 modes of presentation: reactivation of longstanding Menières disease (40.9%) and de novo Menières disease (59.1%), where the first dizzy spells, tinnitus, and hearing loss appeared after 65 years of age. Drop attacks occurred in 11.1 and 25.6% of the cases, respectively, and could be responsible for misdiagnosis of strokes of the brainstem. The patients were treated by mild antivertiginous drugs (betahistine, cinnarizine). Twenty-seven patients (41%) underwent surgery: transtympanic ventilation tubes (19 patients), sacculotomy (4 patients), vestibular neurectomy (3 patients), surgical labyrinthectomy (1 patient). The vertigo spells disappeared in 73.3 to 100% of the cases according to the type of surgery performed. CONCLUSION Our study shows that Menières disease in the elderly is not at all uncommon. It can appear as a de novo disease or as a reactivated longstanding disease. Drop attacks are more frequent than reported in general patient populations with Menières disease and can mimic a stroke of the brainstem. Medical and surgical treatments have to be cautious because many of these elderly patients are fragile.

Skew Deviation After Vestibular Neuritis

We treated five patients with vestibular neuritis who had strabismus. Three of them spontaneously noted vertical diplopia. During the following weeks and months, strabismus progressively resolved, indicating the recently acquired nature of the oculomotor condition. In three of these individuals, a change in visual vertical and cyclotorsion of the globes suggested that strabismus was a form of skew deviation that occurred as a part of an ocular tilt reaction resulting from the peripheral vestibular lesion. Strabismus appears to occur frequently in this common vestibular condition.

Acute peripheral vestibular deficits after whiplash injuries.

We report 3 patients who had acute peripheral vestibular dysfunction minutes to hours after a car collision with whiplash injury without head trauma. The accident was a frontal collision in 1 case, a rear impact in the second, and lateral in the third. All patients complained immediately of cervicalgia, headache, acute vertigo with a sensation of erroneous body movements, and slipping of image with head movements. A sudden sensation of tilting of the environment when driving, tinnitus, and hyperacusis were also described. The otoneurologic findings showed bilateral canalolithiasis in 1 patient and an acute peripheral vestibular deficit in 2 patients. Tilt of the subjective visual vertical was measured in all patients. Cerebral magnetic resonance imaging yielded normal findings. As angular and linear accelerometers, the vestibular organs are directly exposed to high forces generated by whiplash mechanisms. Vertigo generated by peripheral vestibular lesions is probably underestimated in whiplash injuries and may often be incorrectly attributed to cervical or cerebral lesions.

Benign paroxysmal positional vertigo in mountain bikers.

We evaluated 4 men who had benign paroxysmal positional vertigo (BPPV) that occured several hours after intensive mountain biking but without head trauma. The positional maneuvers in the planes of the posterior and horizontal canals elicited BPPV, as well as transitory nystagmus. This was attributed to both the posterior and horizontal semicircular canals (SCCs) on the left side in 1 patient, in these 2 SCCs on the right side in another patient, and to the right posterior SCC in the other 2 patients. The symptoms disappeared after physiotherapeutic maneuvers in 2 patients and spontaneously in the other 2 patients. Cross-country or downhill mountain biking generates frequent vibratory impacts, which are only partially filtered through the suspension fork and the upper parts of the body. Biomechanically, during a moderate jump, before landing, the head is subjected to an acceleration close to negative 1g, and during impact it is subjected to an upward acceleration of more than 2g. Repeated acceleration-deceleration events during intensive off-road biking might generate displacement and/or dislocation of otoconia from the otolithic organs, inducing the typical symptoms of BPPV. This new cause of posttraumatic BPPV should be considered as an injury of minor severity attributed to the practice of mountain biking.

Ocular tilt reaction associated with a sudden idiopathic unilateral peripheral cochleovestibular loss.

We recently observed a female patient who was suffering from acute right peripheral cochleovestibular loss associated with a marked vertical diplopia. Otoneurological examination showed profound deafness, and absence of nystagmic response to caloric and pendular rotatory test in the right ear. Neuroophthalmological examination showed skew deviation with right hypotropia, excyclotorsion, and tilt of the static visual vertical directed to the right side. Immunological and serological examinations were normal. Neurological examination and extensive neuroradiological investigations failed to demonstrate any central nervous system involvement. In this patient, skew deviation and tilt of the static visual vertical were interpreted as signs of an acute unilateral otolithic dysfunction, due to a sudden idiopathic peripheral vestibular loss.

Fabry's disease: otoneurologic findings in twelve members of one family

Fabrys disease corresponds to an inherited disorder transmitted by an X-linked recessive gene. It generates a dysfunction of glycosphingolipid metabolism due to an enzymatic deficiency of α-galactosidase activity, resulting in glycosphingolipid deposits in all areas of the body. The clinical (heart, kidney, and central nervous system) manifestations are more severe in hemizygous boys than in heterozygous girls. They appear during childhood or adolescence: acroparesthesia, joint pain, angiokeratoma, corneal dystrophy, hypohydrosis or anhydrosis, and renal failure. The otoneurologic symptoms consist of hearing fluctuation, progressive unilateral or bilateral hearing loss, and episodes of vertigo or dizziness. Otoneurologic findings in 12 of 26 members of the same family are presented: the mother and 9 of her 12 children, as well as 2 of her 14 grandchildren: 4 healthy persons, 4 heterozygous female carriers, and 4 hemizygous male patients. Three of the male patients had fluctuation of hearing, sudden hearing loss, and episodes of vertigo and dizziness. The otoneurologic examinations showed a bilateral cochleovestibular deficit (n = 1), a right cochleovestibular deficit (n = 1), and a bilateral hearing loss combined with a right vestibular deficit (n = 1). Histopathologic evidence of glycosphingolipid accumulation in vascular endothelial and ganglion cells, as well as atrophy of the stria and spiral ligament, might explain the otoneurologic symptoms and findings.

Scuba diving with cochlear implants.

We report on a patient with bilateral cochlear implants (a Med-El Combi40 and a Med-El Combi40+), as well as considerable experience in scuba diving with both of his implants. After having been exposed to 68 and 89 dives, respectively, in depths of up to 43 m, both cochlear implants are in working order and the patient continues to receive excellent speech recognition scores with both cochlear implant systems. The presented data show that scuba diving after cochlear implantation is possible over a considerable number of dives without any major negative impact on the implants.