Joel A. Goebel

Migraine-associated dizziness: patient characteristics and management options.

Objective To determine patient characteristics and effectiveness of therapy for migraine-associated dizziness. Study Design Retrospective chart review. Setting Tertiary referral center. Patients Patients were identified through a code query of billing records for the diagnosis of migraine-associated vertigo or disequilibrium, based on the International Headache Society criteria. There were 81 patients (61 women, 20 men) with an average age of 36.6 years (range, 8–71 yr); all except four patients were evaluated between 1995 and 1999. Follow-up was obtained from chart review. Mean follow-up time was 54.5 weeks, with a range of 4 to 456 weeks. Intervention One or more treatment methods, including dietary manipulation, medication (tricyclic antidepressants, beta-blockers or calcium-channel blockers), and neurology consultation, were applied sequentially as necessary. Main Outcome Measure Response to therapy was defined as greater than 75% reduction in symptom recurrence rate. Results Overall, 72% of patients experienced resolution or dramatic reduction of their attacks of vertigo or disequilibrium. Of the 13 patients treated with the introduction of dietary manipulation alone, 100% received significant relief. Of the 31 patients treated with dietary manipulation and the addition of a medication, 77% of these patients had significant relief. Of the final group of 37 patients treated with another medication or a neurology consultation, 57% received substantial relief. Of the responders, the majority (>95%) experienced an equal reduction in both vertigo or disequilibrium and headache symptoms. Interestingly, 100% of the patients in the migraine without active headache group received substantial relief of their vertigo or disequilibrium symptoms with migraine therapy. Conclusion We conclude that there is effective therapy for the common problem of migraine-associated dizziness.

Vestibular dysfunction after cochlear implantation.

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.

Diagnostic criteria for Menière's disease

This paper presents diagnostic criteria for Menières 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 Menières disease and probable Menières disease. The diagnosis of definite Menières 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 Menières 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.

Posturographic Evidence of Nonorganic Sway Patterns in Normal Subjects, Patients, and Suspected Malingerers

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.

Anatomic Considerations in Vestibular Neuritis

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.

Anatomic Differences in the Lateral Vestibular Nerve Channels and their Implications in Vestibular Neuritis

Hypothesis: Anatomic differences may render the superior division of the vestibular nerve more susceptible to injury during vestibular neuritis. Background: Neural degeneration has been identified in temporal bone studies of vestibular neuritis. Previous anatomic and physiologic studies of vestibular neuritis have demonstrated that the superior division of the vestibular nerve is preferentially affected, with sparing of the inferior division. A preliminary temporal bone study has implicated neural entrapment as a possible cause for this preferential injury. Methods: Two independent unbiased observers performed histologic analysis of 184 temporal bones from our temporal bone library. Measurements of the medial, midpoint, and lateral portions of the superior vestibular, inferior vestibular, and the singular nerves and their bony channels lateral to the internal auditory canal were made. These measurements included the length and width of each bony channel and an estimated percent of each channel occupied by bony spicules at each location. Results: The lengths of the bony channels of the singular nerve (0.598 mm) and the inferior vestibular nerve (0.277 mm) were significantly shorter than the average length of the superior vestibular channel (1.944 mm; p < 0.0001). The total percent of the channel occupied by bone at the midpoint was significantly greater for the superior vestibular (28%) compared with either the singular (0%) or the inferior vestibular channel (18%) (p < 0.0001). Conclusion: The lateral bony channel of the superior vestibular nerve is seven times longer than the inferior vestibular and more than three times longer than the singular channel. There are a larger percentage of bony spicules occupying the superior vestibular compared with the inferior vestibular or singular channels. In addition, the superior nerve passes through a longer area of severe narrowing compared with the inferior or singular nerves. This anatomic arrangement of a longer bony channel with more interspersed bony spicules could make the superior vestibular nerve more susceptible to entrapment and ischemia.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION.

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).

Dynamic posturography and caloric test results in patients with and without vertigo.

Patients with Dizziness Were Evaluated with Caloric Stimulation and with Dynamic Platform Posturography (Neurocom Equltest). The Ability of These Tests To Detect Abnormalities in Patients with and Without Vertigo Was Assessed. In 159 Patients, roughly a third had abnormal calorics while half experienced one or more “falls” during posturography. Calorics revealed proportionately more abnormalities in patients with vertigo, whereas posturography alone did not distinguish between patients with or without vertigo. Posturography did, however, Identify abnormalities in a third of patients with normal calorics, regardless of their history of vertigo. Overall, more patients with vertigo had at least one abnormal test result (70%) compared with patients without vertigo (47%). We conclude that caloric abnormalities correlate with a history of vertigo, whereas posturographic deficits can be Identified regardless of the presence of vertigo.

Dose-related effects of alcohol on dynamic posturography and oculomotor measures.

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 subjects 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.

Soft-Wall Reconstruction of the Posterior External Ear Canal Wall

A simple method of reconstructing a previously removed posterior ear canal with an autogenous, bilaminar membrane is described. The resulting air-filled mastoid cavity is an anatomic extension of the middle ear cleft and is separated from the ear canal by a functional barrier that is continuous with the tympanic membrane. The acoustic characteristics of an associated tympanoplasty are not significantly altered, and many of the problems that are associated with an exteriorized cavity are avoided. In contradistinction to other methods of mastoid obliteration or reconstruction, the semitransparent nature of the soft canal wall allows inspection of the underlying cavity for residual or recurrent disease. The technique can be used to repair either a newly created cavity or a previous radical (or modified radical) mastoidectomy defect. The functional results of thirty ears reconstructed in this fashion are detailed. A variable amount of soft-wall retraction was noted postoperatively in 47% of the ears; however, the long-term functional results in these cases remain satisfactory.