Kathleen M. Jacobson

Benign positional vertigo Clinical and oculographic features in 240 cases

We report the clinical and oculographic features in 240 patients with benign positional vertigo (BPV). In each case, after a rapid position change from the sitting to head-hanging position, a stereotyped torsional paroxysmal positional nystagmus was visually observed and recorded with electronystagmography (ENG). The mean age of onset was 54 years, with a range of 11 to 84 years. In slightly more than one-half of the cases (122/240) a likely diagnosis was determined. The most common identifiable causes were head trauma (17%) and viral neurolabyrinthitis (15%). Females outnumbered males approximately two to one in the idiopathic group. Abnormalities on bithermal caloric testing were found in 47% of patients. Only two patients, both with well-documented neurologic disorders, had central signs on ENG. Our data are consistent with a peripheral, posterior semicircular canal origin of BPV.

Horizontal semicircular canal variant of benign positional vertigo

We report the clinical features and results of quantitative eye-movement testing in 13 patients with episodic positional vertigo and nonfatiguing direction-changing horizontal positional nystagmus (beating to the right with the head turned to the right and beating to the left with the head turned to the left). The benign history and lack of associated neurologic findings support a peripheral localization of the lesion. This syndrome probably represents a horizontal semicircular canal variant of benign positional vertigo. Free-floating debris in one horizontal canal may explain many of the clinical and oculographic findings.

Comparison of static and dynamic posturography in young and older normal people

Objective: To measure sway velocity during static and dynamic posturography in “normal’ older people and to determine which tests best distinguish young from older subjects.

Migraine and Benign Positional Vertigo

Because inner ear symptoms are common in patients with migraine, we questioned whether benign positional vertigo (BPV) is more common in patients with migraine than in the general population. We reviewed the records of 247 patients seen in our neurotology clinic over the past 5 years with a confirmed diagnosis of BPV. Each patient had the typical history of BPV, and in each case the characteristic torsional vertical positioning nystagmus was identified. All were interviewed regarding migraine symptoms by means of standard International Headache Society criteria. Migraine was 3 times more common in patients with BPV of unknown cause than in those with BPV secondary to trauma or surgical procedures. Most patients were cured with the particle repositioning maneuver, regardless of the cause. Presumably, patients with migraine suffer recurrent damage to the inner ear (due to vasospasm or some other mechanism) that predisposes them to recurrent bouts of BPV.

Persistent direction‐changing positional nystagmus Another variant of benign positional nystagmus?

Positional nystagmus that does not fatigue, persists as long as the position is held, and changes direction in different head positions has typically been attributed to central vestibular lesions. We recently studied three patients who presented with positional nystagmus having these features but almost certainly of benign peripheral origin. All three had an initial history typical of benign positional vertigo and, in two, the persistent direction-changing positional nystagmus occurred after the patient underwent a maneuver to remove debris from the posterior semicircular canal. The positional nystagmus profile and clinical course are consistent with the debris leaving the posterior semicircular canal and becoming attached to the cupula of the horizontal semicircular canal.

Disequilibrium in older people A prospective study

Objective: To identify the clinical and neuroimaging features in older people with disequilibrium of unknown cause. Background: Many older people show a deterioration of balance without an identifiable cause. Whether the disequilibrium is a normal aging phenomenon, the result of yet unidentified neuropathology, or a combination of the two is unknown. Methods: Twenty-nine patients who complained of disequilibrium (ages 75 to 92) and 29 age- and sex-matched control subjects completed five yearly examinations including history and semiquantitative neurologic examination, activities of daily living, visual acuity, mini-mental status, bedside gait and balance score (Tinetti), Purdue pegboard, and vestibular function testing. Concerns about falling and number of falls were quantified. Subcortical white matter lesions (WML) and frontal atrophy (FA) were graded (blindly), and the ventricular-brain ratio (VBR) was measured from MRIs of the brain. Results: On entry, patients differed from control subjects only in measures of balance, concerns about falling, and falls. Over the 5 years, patients were four times more likely to fall than control subjects. The number of falls was highly correlated with measures of balance (p < 0.001). The VBR as well as the frequency of WML and FA were all significantly (p< 0.001) greater in patients than in control subjects. Conclusion: Disequilibrium of unknown cause in older people is associated with frequent falls, concerns about falling, brain atrophy, and WML on MRI. Some cases are probably caused by small-vessel ischemic disease.

Age-Related Changes in Vestibular Function

Abstract: The objective of this study was to identify age‐related changes in the vestibulo‐ocular reflex (VOR) in normal older subjects and patients complaining of disequilibrium followed serially over time. Cross‐sectional studies have found decreases in vestibular function in older subjects compared to younger subjects, but no prior longitudinal studies have been made following the same older subjects over time. We measured VOR responses using step and sinusoidal stimuli in 110 normal subjects and 51 patients with disequilibrium of unknown cause. This report focuses on 57 normal subjects who were able to return for five yearly examinations and 7 patients who were found to have severe bilateral vestibulopathy on the initial examination. In the normal subjects, there was a significant shortening of the VOR time constant to step changes in angular velocity and an amplitude‐dependent decrease in gain and increase in phase lead of low‐frequency sinusoidal responses over the five examinations. There was also a decrease in the gain of visual‐vestibular responses at low frequencies of sinusoidal stimulation over the five examinations. The patients with bilateral vestibulopathy showed relatively little change in vestibular function over the five years of follow‐up.

A Prospective Study of Posturography in Normal Older People

OBJECTIVE: To follow posturographic measurements over time in a group of normal older subjects to see if sway increases with aging and if sway is greater in those with deteriorating balance and falls.

Posturography and Balance Problems in Older People

OBJECTIVE: To determine which measurements and test conditions on posturography are most useful for identifying balance problems in older people.

Idiopathic bilateral vestibulopathy

We report the clinical features of 22 patients with acquired bilateral vestibulopathy of unknown cause. All had either absent or markedly decreased responses to both caloric and rotational testing. They presented with dysequilibrium and imbalance, worse at night; most reported oscillopsia but none had associated hearing loss or other neurologic symptoms. Nine reported prior prolonged episodes of vertigo consistent with the diagnosis of bilateral sequential vestibular neuritis. Of the remaining 13, none had exposure to known ototoxins or a positive family history. Idiopathic bilateral vestibulopathy is an important cause of progressive imbalance in adults and should be considered even though hearing is normal.