Judith A. White

Atrophy of the stria vascularis as a cause of sensorineural hearing loss

Correlations were made between pure‐tone thresholds and computer‐aided cross‐sectional measurements of the stria vascularis on histological sections of postmortem cochleas from 24 subjects who had reliable audiometric records. The criterion for selection was strial atrophy as the predominant pathological change in 17 experimental ears and normal hearing for seven control ears. Losses in the summed cross‐sectional areas of stria vascularis showed a direct correlation with hearing loss. The cause for the strial atrophy is presumed to be a genetically determined predisposition for early cellular decay. The mechanism by which strial atrophy causes hearing loss is speculative.

Canalith repositioning for benign paroxysmal positional vertigo.

Objective: To evaluate the efficacy of canalith repositioning maneuvers (Semont, Epley, and modified maneuvers) in the treatment of posterior canal benign paroxysmal positional vertigo (BPPV) in comparison to the rate of resolution in the untreated control cohort. Data Sources: Source articles were identified by a MEDLINE search of English language sources before 2004 plus manual crosschecks of bibliographies from identified articles, selected national meeting abstracts, review article references, and textbook chapters. Study Selection: Each controlled trial that compared canalith repositioning patients to untreated control subjects in posterior canal benign positional vertigo (blinded and unblinded) was reviewed for inclusion. Data Extraction: Data were abstracted systematically, scaled on validity and comparability, and cross-checked independently by another author. Data Synthesis: Studies were combined with fixed effects meta-analysis to estimate spontaneous resolution, 95% confidence intervals (CI) of effect size, and heterogeneity. Conclusion: Canalith repositioning is more effective than observation alone for the treatment of benign paroxysmal positional vertigo, despite spontaneous resolution rates of one in three at 3 weeks. Public health implications are discussed, based on the high frequency of unrecognized BPPV reported in elderly patients, and the improvements after canalith repositioning in postural control and health-related quality of life (SF 36 Health Survey) documented in the literature.

Diagnosis and Management of Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo

Objective: Describe the diagnosis, treatment, and outcome of a group of 20 patients with lateral semicircular canal benign paroxysmal positional vertigo (LSC-BPPV). Study Design and Setting: Retrospective review of 20 patients with LSC-BPPV (10 with geotropic and 10 with apogeotropic nystagmus) presenting to a tertiary balance center. Diagnosis was confirmed with infrared nystagmography in Dix-Hallpike positioning tests and supine positional tests. Patients were treated with one or more particle repositioning maneuvers. Results: Addition of supine positional nystagmus tests to Dix-Hallpike positioning testing improves sensitivity in the diagnosis of LSC-BPPV. Treatment outcomes in the apogeotropic LSC-BPPV group were poorer than the geotropic LSC-BPPV group. Significance: Adding supine positional testing to routine vestibular diagnostic testing will increase the identification of LSC-BPPV. Apogeotropic LSC-BPPV is more challenging to treat.

Otolaryngologic Manifestations of Sarcoidosis: Presentation and Diagnosis

Neuro‐otologic manifestations of sarcoidosis are rare. Dizziness in particular is a rare presenting complaint of the patient afflicted with this systemic granulomatous disorder. Head and neck and sinonasal presentations of this disease are more common. We reviewed our experience with six such patients who presented for management of their otolaryngologic (ORL) manifestations in order to delineate the involvement of the otolaryngologist in the treatment and diagnosis of these patients, with a focus upon the relevant tests and procedures in the otolaryngologists de novo diagnosis of sarcoidosis. Studies ordered in the course of otolaryngologic evaluation and their utility in the diagnosis of sarcoidosis by the otolaryngologist are reviewed and classified into useful, supportive, and ancillary. The otolaryngologist played an important role in diagnosis, with four of six patients diagnosed to have sarcoidosis on the basis of their otolaryngologic presentations. Biopsy was performed by the otolaryngologist for diagnosis of sarcoidosis in all four of these cases. Steroids were central to treatment. Oral steroid therapy was the principal treatment: both patients with neuro‐otologic sarcoid were sucessfully managed with oral steroids. Intralesional steroids were necessary to treat the skin lesion. One of six patients patients experienced complications related to steroid use.

Positional Vertigo: As Occurs Across All Age Groups

This article reviews the pathophysiology, diagnosis, and treatment of benign paroxysmal positional vertigo of the posterior and lateral semicircular canals and summarizes the evidence-based outcome data. The authors discuss this common cause of vertigo, its cause and prevalence across the life span, and efficacy of treatment through both physical repositioning maneuvers and surgery.

Diagnosis and Management of Lateral Semicircular Canal Conversions during Particle Repositioning Therapy

INTRODUCTION Lateral semicircular canal (LSC) canalolithiasis conversion occurs in patients undergoing particle repositioning therapy (PRT) for posterior semicircular canal (PSC) benign paroxysmal positional vertigo (BPPV). Herdman and Tusa 1 have reported a rate of 4%, and such conversions were initially reported by Baloh et al.2 and mentioned by Epley.3 In our clinic, PRT for PSC BPPV is performed by the method described by Oas.4 Dix-Hallpike positioning testing using videonystagmography (VNG) is repeated immediately after PRT for the involved PSC (Fig. 1) to ascertain whether PRT has been successful. No mastoid vibration is used for the typical case. If repeat DixHallpike positioning indicates persistent PSC BPPV, another cycle of PRT is performed. LSC conversions are recognized by the development of new horizontal nystagmus (geotropic or apogeotropic) during repeat DixHallpike positioning or PRT. LSC BPPV was first described by Cipparrone et al.5 and McClure6 in 1985, characterized by nystagmus provoked by supine bilateral head turns and beating toward the undermost ear (geotropic horizontal positional nystagmus). Since their publications, two distinct subtypes of LSC BPPV have emerged based on the direction of the horizontal nystagmus during supine positional testing: geotropic and apogeotropic. Geotropic LSC BPPV beats toward the undermost ear on supine positional testing and is characterized by short latency and prolonged duration of horizontal nystagmus with poor fatigability. Apogeotropic LSC BPPV, thought to be rarer, was not reported until later by Pagnini et al.7 and Baloh et al.8 Apogeotropic LSC BPPV is characterized by similar short latency, prolonged duration horizontal nystagmus, but the direction beats away from the undermost ear on supine positional testing. Geotropic LSC BPPV is thought to be caused by otoconial debris moving under the influence of gravity within the

Cervicogenic dizziness as a cause of vertigo while swimming: an unusual case report

We present the unusual case of a competitive swimmer with cervicogenic dizziness manifesting as vertigo while she was surface swimming. This patient complained of brief and episodic room-spinning vertigo consistently associated with swimming the freestyle stroke and was referred to an otolaryngology clinic for evaluation. She did not have significant complaints of neck pain while swimming. Her history, examination findings, laboratory study results, differential diagnoses, and treatment are discussed in detail. A succinct overview of cervicogenic dizziness--a controversial diagnosis often overlooked by otolaryngologists-is also provided.

Can active lateral canal benign paroxysmal positional vertigo mimic a false-positive head thrust test?

We present a patient with positive head thrust test (HTT) and video-oculography (VOG) findings suggestive of active lateral semicircular canal (LSCC) benign paroxysmal positional vertigo (BPPV). This patient was seen in a tertiary vestibular clinic for episodic vertigo. He exhibited robust corrective refixation saccades on HTT to the right and evidence of active contralateral LSCC BPPV on positional testing. Treatment of the LSCC BPPV led to immediate resolution of vertigo and near-normalization of the HTT on follow-up testing. The pathophysiologic basis and clinical implications of LSCC BPPV mimicking a false-positive HTT are discussed in detail.

The incidence of coexistent autonomic and vestibular dysfunction in patients with postural dizziness

PURPOSE To evaluate the incidence of coexistent peripheral vestibular dysfunction and cardiovascular autonomic dysfunction in patients undergoing evaluation for dizziness exacerbated by postural changes. MATERIALS AND METHODS Retrospective case review of 56 sequential patients seen from 2003 to 2006 at a tertiary center for a primary complaint of dizziness who underwent both passive tilt table testing for evaluation of neurocardiogenic etiology and quantitative vestibular testing. The vestibular test battery consisted of alternating bithermal caloric testing; computerized sinusoidal vertical axis rotation (at frequencies 0.01-0.64) with infrared videonystagmography; and oculomotor and positional testing including bilateral Dix-Hallpike, head center supine, and 30-degree supine head turns right and left. RESULTS Eight of the 56 subjects had caloric weakness. Forty-five subjects (80%) had abnormal tilt table test findings. The incidence of coexistent neurocardiogenic and vestibular test abnormalities was 10.7%. There was no significant association between abnormal tilt table test result and caloric weakness (Fisher exact test; P = .64). The degree of compensation seen on vestibule-ocular reflex gain testing did not affect tilt table findings (chi2; P = .872). CONCLUSIONS There is no difference in the rate of postural orthostatic intolerance in subjects with evidence of caloric weakness compared with those with normal caloric function.

Utility of an Abbreviated Dizziness Questionnaire to Differentiate Between Causes of Vertigo and Guide Appropriate Referral: A Multicenter Prospective Blinded Study.

Objective: Test performance of a focused dizziness questionnaires 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.