F. Lezius

Epidemiology of benign paroxysmal positional vertigo: a population based study

Objectives: To examine the prevalence and incidence, clinical presentation, societal impact and comorbid conditions of benign paroxysmal positional vertigo (BPPV) in the general population. Methods: Cross-sectional, nationally representative neurotological survey of the general adult population in Germany with a two stage sampling design: screening of 4869 participants from the German National Telephone Health Interview Survey 2003 (response rate 52%) for moderate or severe dizziness or vertigo, followed by validated neurotological interviews (n = 1003; response rate 87%). Diagnostic criteria for BPPV were at least five attacks of vestibular vertigo lasting <1 min without concomitant neurological symptoms and invariably provoked by typical changes in head position. In a concurrent validation study (n = 61) conducted in two specialised dizziness clinics, BPPV was detected by our telephone interview with a specificity of 92% and a sensitivity of 88% (positive predictive value 88%, negative predictive value 92%). Results: BPPV accounted for 8% of individuals with moderate or severe dizziness/vertigo. The lifetime prevalence of BPPV was 2.4%, the 1 year prevalence was 1.6% and the 1 year incidence was 0.6%. The median duration of an episode was 2 weeks. In 86% of affected individuals, BPPV led to medical consultation, interruption of daily activities or sick leave. In total, only 8% of affected participants received effective treatment. On multivariate analysis, age, migraine, hypertension, hyperlipidaemia and stroke were independently associated with BPPV. Conclusion: BPPV is a common vestibular disorder leading to significant morbidity, psychosocial impact and medical costs.

Epidemiology of vestibular vertigo A neurotologic survey of the general population

Objective: The purpose of this study was to determine the prevalence and incidence of vestibular vertigo in the general population and to describe its clinical characteristics and associated factors. Methods: The neurotologic survey had a two-stage general population sampling design: nationwide modified random digit dialing sampling for participation in the German National Telephone Health Interview Survey 2003 (response rate 52%) with screening of a random sample of 4,869 participants for moderate or severe dizziness or vertigo, followed by detailed neurotologic interviews developed through piloting and validation (n = 1,003, response rate 87%). Diagnostic criteria for vestibular vertigo were rotational vertigo, positional vertigo, or recurrent dizziness with nausea and oscillopsia or imbalance. Vestibular vertigo was detected by our interview with a specificity of 94% and a sensitivity of 88% in a concurrent validation study using neurotology clinic diagnoses as an accepted standard (n = 61). Results: The lifetime prevalence of vestibular vertigo was 7.8%, the 1-year prevalence was 5.2%, and the incidence was 1.5%. In 80% of affected individuals, vertigo resulted in a medical consultation, interruption of daily activities, or sick leave. Female sex, age, lower educational level, and various comorbid conditions, including tinnitus, depression, and several cardiovascular diseases and risk factors, were associated with vestibular vertigo in the past year in univariate analysis. In multivariable analysis, only female sex, self-reported depression, tinnitus, hypertension, and dyslipidemia had an independent effect on vestibular vertigo. Conclusions: Vestibular vertigo is common in the general population, affecting more than 5% of adults in 1 year. The frequency and health care impact of vestibular symptoms at the population level have been underestimated.

Burden of Dizziness and Vertigo in the Community

BACKGROUND Dizziness and vertigo are common, however, the cause often remains unexplained. The percentage of vertigo of vestibular origin in individuals with unselected dizziness has not been well examined, and its underestimation may lead to diagnostic bias in primary care. The purpose of this study was to reassess the burden of dizziness in the community and to quantify the contribution of vertigo of vestibular origin. METHODS A nationally representative sample of 4869 adults living in Germany was screened for moderate or severe dizziness, and 1003 individuals with dizziness underwent validated neurotologic interviews to differentiate vestibular vertigo from nonvestibular dizziness according to explicit diagnostic criteria. RESULTS Dizziness/vertigo had a prevalence of 22.9% in the last 12 months and an incidence (first episode of dizziness/vertigo) of 3.1%. For vestibular vertigo, the prevalence was 4.9% [corrected] and the incidence was 1.4%. We also found that 1.8% of unselected adults consulted a physician in the last 12 months for [corrected] dizziness/vertigo (0.9% for vestibular vertigo). Compared with nonvestibular dizziness, vestibular vertigo was more frequently followed by medical consultation (70% vs 54%; P < .001), sick leave (41% vs 15%; P < .001), interruption of daily activities (40% vs 12%; P < .001), and avoidance of leaving the house (19% vs 10%; P = .001). However, more than half of the participants with vestibular vertigo reported nonvestibular diagnoses. Age- and sex-adjusted health-related quality of life was lower in individuals with dizziness and vertigo compared with dizziness-free control subjects. CONCLUSIONS The occurrence of dizziness and vertigo is frequent and associated with a considerable personal and health care burden. Vestibular vertigo accounts for a considerable percentage of this burden, which suggests that diagnosis and treatment of frequent vestibular conditions are important issues in primary care.

Migrainous vertigo Prevalence and impact on quality of life

Objective: To investigate the epidemiology of migrainous vertigo (MV) in the general population by assessing prevalence, clinical features, comorbid conditions, quality of life, and health care utilization. Methods: We screened a representative sample of the adult population in Germany (n = 4,869) for moderate or severe dizziness/vertigo and followed up with validated neurotologic telephone interviews (n = 1,003). Diagnostic criteria for MV were as follows: 1) recurrent vestibular vertigo; 2) migraine according to the International Headache Society; 3) migrainous symptoms during at least two vertiginous attacks (migrainous headache, photophobia, phonophobia, or aura symptoms); and 4) vertigo not attributed to another disorder. In a concurrent validation study (n = 61) the interviews had a sensitivity of 84% and a specificity of 94% for vestibular vertigo and 81% and 100% for migraine. Results: The lifetime prevalence of MV was 0.98% (95% CI 0.70 to 1.37), the 12-month prevalence 0.89% (95% CI 0.62 to 1.27). Spontaneous rotational vertigo was reported by 67% of participants with MV while 24% had positional vertigo. Twenty-four percent always experienced headaches with their vertigo. Logistic regression analysis comparing participants with MV with dizziness-free migraineurs showed an independent association with coronary heart disease but not with sex, age, migrainous aura, education, stroke, hypertension, hyperlipidemia, body mass index, or depression. Age-adjusted health-related quality of life scores (SF-8 Health Survey) were consistently lower in participants with MV compared to dizziness-free controls. Two thirds of participants with MV had consulted a doctor but only 20% of these were diagnosed with MV. Conclusions: Migrainous vertigo is relatively common but underdiagnosed in the general population and has considerable personal and healthcare impact.

Screening for Menière's disease in the general population - the needle in the haystack.

Conclusion. Based on clinical history alone, 98.4% of the population with vestibular vertigo do not qualify for a diagnosis of Menières disease (MD). Although frequent in dizziness clinics, MD is rare in the general population. Objective. To narrow down the prevalence of MD in the general population. Subjects and methods. A representative sample adult population sample (n=4869) was screened for moderate or severe dizziness/vertigo. Subsequently, 1003 participants completed a validated neurotologic telephone interview on vestibular vertigo (VV). Prevalence of MD was determined by stepwise application of clinical criteria according to the AAO (1995): (1) at least two vertigo attacks of ≥20 min duration, (2) unilateral hearing loss, and (3) accompanying cochlear symptoms. Results. Lifetime prevalence of VV was 7.4%. Of 243 participants with VV, 51 (21%) had recurrent vertigo lasting ≥20 min. Of these, nine reported unilateral hearing loss, and four had accompanying cochlear symptoms (1.6% of VV patients, population prevalence 0.12%).

Zur ärztlichen Versorgung von Patienten mit benignem paroxysmalen Lagerungsschwindel

ZusammenfassungDer benigne paroxysmale Lagerungsschwindel (BPLS) ist die häufigste vestibuläre Erkrankung und kann ohne apparative Diagnostik rasch diagnostiziert und behandelt werden. Um die Wege der Erkrankten durch das Gesundheitssystem und den verursachten diagnostischen Aufwand zu erfassen wurden 42 BPLS-Patienten einer Spezialambulanz für Schwindelerkrankungen und 29 BPLS-Patienten einer neurologischen Praxis hinsichtlich ihres klinischen Verlaufs sowie durchgeführter diagnostischer und therapeutischer Maßnahmen evaluiert.Die mittlere Erkrankungsdauer seit der Erstmanifestation lag bei 3,2 Jahren mit durchschnittlich 2,4 BPLS-Episoden, die typischerweise Wochen bis Monate dauerten. Mehr als die Hälfte der Patienten fühlte sich durch den BPLS stark beeinträchtigt, ein Viertel war vorübergehend arbeitsunfähig. Durchschnittlich wurden 3 ärztliche Fachrichtungen konsultiert. Eine zerebrale Bildgebung (42%), kalorische Untersuchung (46%) und Audiometrie (49%) wurden häufiger durchgeführt als eine diagnostische Lagerungsprobe (28%). Die Mehrzahl der Patienten wurden mit unwirksamen Maßnahmen behandelt oder gar nicht. Nur 4% erhielten ein spezifisches Lagerungsmanöver nach Epley oder Semont.SummaryBenign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder which can be simply diagnosed. The evolution of highly effective positioning maneuvers has made BPPV the most successfully treatable cause of vertigo. We evaluated patients with BPPV with regard to past medical history and disease-related diagnostic and therapeutic procedures. Forty-two patients were recruited from a specialised dizziness clinic, and a further 29 patients were recruited from a neurological practice. The mean duration of the disease was 3.2 years, with an average of 2.4 episodes lasting typically several weeks to months. More than half of the patients felt severely disabled by BPPV. On average, three different medical specialities were consulted. Cerebral imaging (42%), caloric testing (46%), and audiometry (49%) were performed more often than diagnostic positioning (28%). Most patients received ineffective or no therapy, and only 4% were treated with a specific therapeutic positioning maneuver. Benign paroxysmal positional vertigo is a long-lasting and frequently recurrent disease which leads to significant morbidity and medical costs. The recent progress in the diagnosis and therapy of BPPV has not yet been widely established in medical practice in Germany.

Betahistine for Menière's disease

Betahistine, a histamine H1 agonist and H3 antagonist, has been used for the pharmacotherapy of Menières disease for many decades. Earlier its mode of action and efficacy, in particular in low dosages, were the subject of controversy mainly because valid experimental or clinical data were not available. Recent animal studies, however, showed that betahistine increases cochlear blood flow in a sigmoid dose-dependent way, thus supporting the hypothesis that it may act by improving cochlear microcirculation. In terms of its clinical efficacy, two studies demonstrated that a high-dose (at least 48 mg t.i.d.) and long-term treatment (at least six to 12 months) have a significant prophylactic effect on the occurrence of attacks in Menières disease.

Clinical evaluation of the bed cycling test

Additionally to the forearm rolling test to detect mild unilateral upper limb dysfunction, the bed cycling test (BCT) for detection of mild to moderate lower limb dysfunction was developed, evaluated and compared to the leg holding test.