Jeremy Hornibrook

Benign Paroxysmal Positional Vertigo (BPPV): History,Pathophysiology, Office Treatment and Future Directions

BPPV is the most common cause of vertigo. It most often occurs spontaneously in the 50 to 70 year age group. In younger individuals it is the commonest cause of vertigo following head injury. There is a wide spectrum of severity from inconsistent positional vertigo to continuous vertigo provoked by any head movement. It is likely to be a cause of falls and other morbidity in the elderly. Misdiagnosis can result in unnecessary tests. The cardinal features and a diagnostic test were clarified in 1952 by Dix and Hallpike. Subsequently, it has been established that the symptoms are attributable to detached otoconia in any of the semicircular canals. BPPV symptoms can resolve spontaneously but can last for days, weeks, months, and years. Unusual patterns of nystagmus and nonrepsonse to treatment may suggest central pathology. Diagnostic strategies and the simplest “office” treatment techniques are described. Future directions for research are discussed.

Horizontal Canal Benign Positional Vertigo

The existence of horizontal canal benign positional vertigo (BPV) was predicted from temporal bone studies in 1973, but was not clinically confirmed until later. In this series of 300 patients with BPV, 35 (12%) were identified as having the horizontal canal variant. The essential features are the onset of vertigo when the patient assumes a supine position and bidirectional horizontal nystagmus as the head is turned from side to side. In one third it appeared as a canal “conversion” in patients undergoing repositioning treatment for posterior canal BPV. The mechanism can be canalithiasis or cupulolithiasis. Repositioning treatment is a 360° horizontal head and body rotation that has a high success rate if the symptomatic ear is correctly identified.

MRI Inner Ear Imaging and Tone Burst Electrocochleography in the Diagnosis of Ménière's Disease.

Objective To compare the sensitivity of gadolinium MRI inner imaging with tone burst electrocochleography (EcochG) for diagnosing endolymphatic hydrops. Study Design A prospective study on patients who were to have an MRI scan to exclude retrocochlear pathology. Setting Tertiary care center. Patients One hundred and two patients: 57 patients with Possible, Probable, or Definite Ménière’s Disease, 25 with asymmetrical hearing loss, 18 with sudden sensorineural hearing loss, and 2 with unilateral tinnitus had additional MRI inner ear imaging and click and tone burst stimulus EcochG testing. Intervention Diagnostic. Main Outcome Measure To compare the sensitivity of the two techniques. Results In 30 patients with symptom-based Definite Ménière’s Disease, tone burst EcochG was positive in 25 (83%) and the click EcochG was positive in 9/30 (30%), and gadolinium MRI imaging diagnosed hydrops in 14 (47%). A positive result for either MRI imaging or tone burst EcochG was seen in 26 patients (87%). In 14 subjects with symptom-based Probable Ménière’s Disease, 10 (71%) had either a positive EcochG or MRI. In 13 with Possible Ménière’s Disease, four (31%) had a positive EcochG or MRI. Conclusion This study confirms the greatly enhanced diagnostic sensitivity of tone burst EcochG over click response in diagnosing endolymphatic hydrops in Ménière’s disease. Even though adequate MRI imaging was achieved in 90%, tone burst EcochG was a more sensitive test.

Transtympanic Electrocochleography for the Diagnosis of Ménière's Disease

This paper evaluated the diagnostic power of electrocochleography (ECochG) in detecting Ménières disease (MD) as compared with two subjective assessment methods, including the clinical guidelines provided by the American Academy of Otolaryngology—Head and Neck Surgery Committee on Hearing Equilibrium and the Gibson score. A retrospective study of 250 suspected MD cases was conducted. The agreement between the three assessment methods was found to be relatively high, with a total reliability being higher than 70%. Participants who tested “positive” with ECochG exhibited a higher occurrence rate of asymmetric hearing threshold as well as the four MD symptoms, namely, vertigo, hearing loss, tinnitus, and aural fullness. The “positive” ECochG group also showed a high correlation between the ECochG measures in response to stimuli at adjacent frequency ranges, suggesting that the interfrequency ECochG correspondence may be sensitive to the presence of endolymphatic hydrops and thus may serve as a useful diagnostic marker for MD.

Evaluating iPhone Recordings for Acoustic Voice Assessment

Aims: This study examined the viability of using iPhone recordings for acoustic measurements of voice quality. Methods: Acoustic measures were compared between voice signals simultaneously recorded from 11 normal speakers (6 females and 5 males) through an iPhone (model A1303, Apple, USA) and a comparison recording system. Comparisons were also conducted between the pre- and post-operative voices recorded from 10 voice patients (4 females and 6 males) through the iPhone. Participants aged between 27 and 79 years. Results: Measures from iPhone and comparison signals were found to be highly correlated. Findings of the effects of vowel type on the selected measures were consistent between the two recording systems and congruent with previous findings. Analysis of the patient data revealed that a selection of acoustic measures, such as vowel space area and voice perturbation measures, consistently demonstrated a positive change following phonosurgery. Conclusion: The present findings indicated that the iPhone device tested was useful for tracking voice changes for clinical management. Preliminary findings regarding factors such as gender and type of pathology suggest that intra-subject, instead of norm-referenced, comparisons of acoustic measures would be more useful in monitoring the progression of a voice disorder or tracking the treatment effect.

HSP70 antibodies in 80 patients with "clinically certain" Meniere's disease.

Objectives: We tested the claim that a significant proportion of patients with Menieres disease have antibodies to heat shock protein 70 (HSP70) antigen, which may lead to defective endolymphatic sac function and vertigo attacks. Methods: Serum samples were taken from 80 subjects with a “certain” diagnosis of Menieres disease (American Academy criteria plus electrocochleographic confirmation of endolymphatic hydrops with tone burst stimuli) and were tested for HSP70 antibodies with the OTOblot (hsp70) Western blot assay. The response was recorded as negative, positive, or equivocal. Samples from 80 sex- and age-matched blood donors were used as controls. Results: Of 80 patients with “clinically certain” Menieres disease, 14 were positive for HSP70 antibodies or equivocal; of 80 controls, 10 were positive or equivocal. There was no significant difference (p = 0.239). There was no correlation with bilateral disease, “activity” of Menieres disease, or stage of Menieres disease. Conclusions: Patients with an unequivocal diagnosis of Menieres disease do not have a significantly raised incidence of HSP70 antibodies.

Vasopressin in definite Meniere's disease with positive electrocochleographic findings.

Abstract Conclusion: There was no evidence of a mean raised vasopressin level in 80 subjects suffering from definite Menieres disease with positive electrocochleographic findings. There was no correlation with stress. The only group with a mildly raised level comprised those who had had a vertigo attack within a day. The most likely cause is nausea, which is the most potent trigger for vasopressin release. Objective: It has been claimed that patients with Menieres disease have raised vasopressin levels. This has been linked with a long-standing notion that that there is a link between stress and Menieres disease, so that an increase in vasopressin could trigger a vertigo attack. Methods: Serum vasopressin concentrations were measured in 80 patients with Menieres disease whose diagnosis was based on conventional symptom criteria plus electrocochleographic evidence of endolymphatic hydrops. Results: The community mean for vasopressin is 2.2 pmol/L (SD = 2.4). For all 80 Menieres patients the mean vasopressin concentration was 2.1 pmol/L (SD = 1.6), and 2.8 pmol/L (SD = 0.9) when the last attack was within a day.

Acute longus colli calcific tendonitis causing neck pain and dysphagia

Calcific tendonitis of the longus colli muscle is a condition not well recognized in the otolaryngology literature despite its presentation with common ENT symptoms of dysphagia and neck pain. We present a case, its relevant radiology, and provide a discussion on the presentation, diagnosis, and management of the condition. A 56-year-old man with a 2-month history of a painful stiff neck after minor trauma presented to the emergency department with progressive symptoms and dysphagia lasting 2 days. He was systemically well with no fever or malaise and had no significant medical history. ENT and neck examination were normal apart from painful restricted neck lateral flexion and extension, plus edematous nasopharyngeal mucosa on flexible nasoendoscopy (FNE). Laboratory studies were normal including his white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-neotrophil cytoplasmic antibodies (ANCA) rheumatoid factor, and antinuclear antibodies. A lateral cervical spine radiograph showed thickening of the upper cervical prevertebral tissue, with an oval opacification anterior of the vertebral body of C2 (Fig 1). Computer tomography (CT) demonstrated a 13-mm area of calcification anterior to C2 with a 6-mm low attenuation collection in the prevertebral tissue adjacent to C2-4 (Fig 2). A magnetic resonance imaging (MRI) scan performed 5 days after presentation showed thin fluid in the prevertebral space with no significant surrounding reactive changes and confirmed the diagnosis of reactive effusion. He was admitted and managed with simple analgesia. His symptoms significantly improved such that he had no dysphagia and minimal residual neck discomfort and was discharged home 2 days later. At review 1 month later, his symptoms had completely resolved and FNE confirmed resolution of prevertebral edema.

oVEMPs and cVEMPs in patients with 'clinically certain' Menière's disease.

Abstract Objective: To measure ocular vestibular-evoked myogenic potentials (oVEMPs) and cervical vestibular-evoked myogenic potentials (cVEMPS) in Menière’s disease patients with confirmed cochlear hydrops and in the normal ears of volunteers. Methods: oVEMPs and cVEMPs were measured in 18 patients with a symptomatic diagnosis of Menière’s disease and tone burst electrocochleographic confirmation of hydrops, and in the ears of 22 volunteers. Results: Threshold measures: For cVEMP: no significant differences between Menière’s ears and controls; for oVEMP: significantly elevated thresholds in affected ears of Menière’s ears compared with their unaffected ears, but not with controls. Latency measures: cVEMP N1 peaks were significantly prolonged compared with the left and right ears of controls, but not with the non-affected ear. Amplitude measures: cVEMP P1N1 and N1P2 measures were significantly reduced compared with the right ear of controls, but not with the non-affected ear; For oVEMP, N2P2 amplitudes were significantly reduced compared with both ears of controls but not with the non-affected ear. Conclusion: Abnormalities of oVEMPs and cVEMPs were found in 18 Menière’s disease patients who had an independent confirmation of cochlear hydrops. The overlap of the results from Menière’s patients compared with normal controls limits the use of VEMP abnormalities as a sole reliable diagnostic test for Menière’s disease.

A New Theory for Ménière’s Disease: Detached Saccular Otoconia:

Ménière’s disease is an inner ear disorder characterized by vertigo attacks, fluctuating and progressive hearing loss, tinnitus, and aural fullness in the affected ear. The pathophysiology of Ménière’s disease remains elusive. Theories so far are anatomical variation in the size or position of the endolymphatic sac and duct, viral inflammation or autoimmune involvement of the sac, or a genetically determined abnormality of endolymph control. Animal studies on blocking the ductus reuniens and endolymphatic duct have produced hydrops in the cochlea, saccule, and utricle. Cone beam computed tomography images show a similar pattern with apparent obstruction of the ductus reuniens, saccular duct, and endolymphatic sinus. New studies documenting the age of onset of Ménière’s disease show a pattern similar to benign paroxysmal positional vertigo, raising the possibility that the fundamental cause of Ménière’s disease might be detached saccular otoconia.