Neil T. Shepard

Auditory and vestibular symptoms and chronic subjective dizziness in patients with Ménière's disease, vestibular migraine, and Ménière's disease with concomitant vestibular migraine

Objective To compare presentations of Ménière’s disease (MD), vestibular migraine (VM), and Ménière’s disease plus vestibular migraine (MDVM), with and without comorbid chronic subjective dizziness (CSD). Study Design Retrospective review with diagnosis confirmed by consensus conference of investigators using published criteria for MD, VM, and CSD. Setting Ambulatory, tertiary dizziness clinic. Patients Approximately 147 consecutive patients with diagnoses of MD, VM, or MDVM, with/without comorbid CSD. Interventions Diagnostic consultation. Main Outcome Measures Similarities and differences between diagnostic groups in demographics; symptoms; and results of neurotologic, audiometric, and vestibular laboratory assessments. Results Seventy-six patients had MD, 55 MD alone. Ninety-two patients had VM, 71 VM alone. Twenty-one patients had MDVM, representing about one-quarter of those diagnosed with MD or VM. Clinical features thought to differentiate VM from MD were found in all groups. Twenty-seven patients with VM (38%) had ear complaints (subjective hearing loss, aural pressure, and tinnitus) during episodes of vestibular symptoms and headache, including 10 (37%) with unilateral symptoms. Conversely, 27 patients with MD alone (49%) had headaches with migraine features that did not meet full IHS diagnostic criteria, migrainous symptoms (photophobia, headache with vomiting), or first-degree relative with migraine. Including MDVM patients, 59% (45/76) of all patients with MD had migrainous features. Thirty-two patients had CSD; most (29; 91%) were in the VM group. Conclusion Comorbidity was common between MD and VM, and their symptoms overlapped. More specific diagnostic criteria are needed to differentiate these diseases and address their coexistence. CSD co-occurred with VM but was rarely seen with MD.

Investigation of the Coherence of Definite and Probable Vestibular Migraine as Distinct Clinical Entities

Objectives: To investigate the following: 1) associations between vestibular symptoms and migraine in a well-characterized cohort of tertiary neurotology patients, 2) effects of comorbidity on clinical presentations, and 3) validity of proposed definitions of definite (dVM) and probable vestibular migraine (pVM). Study Design: Retrospective chart review. Setting: Tertiary neurotology center. Patients: All 228 subjects with headache were selected from a larger investigation of 410 patients with vestibular symptoms who underwent comprehensive medical, surgical, and behavioral neurotologic consultations. Subjects had at least one of 4 diagnoses: dVM/pVM, Ménières disease, benign paroxysmal positional vertigo, or chronic subjective dizziness. Interventions: Subjects were divided into migraine (n = 164) and nonmigraine headache (n = 64) groups by International Headache Society criteria, then subdivided by those with vestibular symptoms related or unrelated to headache. Subjects meeting proposed criteria for dVM (n = 46) and pVM (n = 42) were identified. Statistical analyses investigated discriminating features and cohesiveness in each group, with or without comorbidity. Main Outcome Measures: Characteristics of dVM and pVM. Results: Migraine, particularly migraine with aura, was more often related to vestibular symptoms than nonmigrainous headache. dVM and pVM groups did not differ in demographics, clinical histories, examinations, or vestibular testing. Numerous differences existed between dVM/pVM subjects with and without comorbid Ménières disease, benign paroxysmal positional vertigo, or chronic subjective dizziness. The pVM group contained 4 subtypes. Conclusion: These results support an association between vestibular symptoms and migraine but not proposed distinctions between dVM and pVM. pVM does not appear to be a coherent diagnostic entity. Comorbid conditions are important causes of vestibular symptoms in patients with migraine.

Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: A pilot study.

BACKGROUND Persistent postural-perceptual dizziness (PPPD) (formerly chronic subjective dizziness) may be treated using the habituation form of vestibular and balance rehabilitation therapy (VBRT), but therapeutic outcomes have not been formally investigated. OBJECTIVE This pilot study gathered the first data on the efficacy of VBRT for individuals with well-characterized PPPD alone or PPPD plus neurotologic comorbidities (vestibular migraine or compensated vestibular deficits). METHODS Twenty-six participants were surveyed by telephone an average of 27.5 months after receiving education about PPPD and instructions for home-based VBRT programs. Participants were queried about exercise compliance, perceived benefits of therapy, degree of visual or motion sensitivity remaining, disability level, and other interventions. RESULTS Twenty-two of 26 participants found physical therapy consultation helpful. Fourteen found VBRT exercises beneficial, including 8 of 12 who had PPPD alone and 6 of 14 who had PPPD with co-morbidities. Of the 14 participants who found VBRT helpful, 7 obtained relief of sensitivity to head/body motion, 5 relief of sensitivity to visual stimuli, and 4 complete remission. Comparable numbers for the 12 participants who found VBRT not helpful were 1 (head/body motion), 3 (visual stimuli), and 0 (remission). CONCLUSIONS This pilot study offers the first data supporting the habituation form of VBRT for treatment of PPPD.

Use of the Dynamic Visual Acuity Test as a screener for community-dwelling older adults who fall

Adequate function of the peripheral vestibular system, specifically the vestibulo-ocular reflex (VOR; a network of neural connections between the peripheral vestibular system and the extraocular muscles) is essential for maintaining stable vision during head movements. Decreased visual acuity resulting from an impaired peripheral vestibular system may impede balance and postural control and place an individual at risk of falling. Therefore, sensitive measures of the vestibular system are warranted to screen for the tendency to fall, alerting clinicians to recommend further risk of falling assessment and referral to a falling risk reduction program. Dynamic Visual Acuity (DVA) testing is a computerized VOR assessment method to evaluate the peripheral vestibular system during head movements; reduced visual acuity as documented with DVA testing may be sensitive to screen for falling risk. This study examined the sensitivity and specificity of the computerized DVA test with yaw plane head movements for identifying community-dwelling adults (58-78 years) who are prone to falling. A total of 16 older adults with a history of two or more unexplained falls in the previous twelve months and 16 age and gender matched controls without a history of falls in the previous twelve months participated. Computerized DVA with horizontal head movements at a fixed velocity of 120 deg/sec was measured and compared with the Dynamic Gait Index (DGI) a gold standard gait assessment measurement for identifying falling risk. Receiver operating characteristics (ROC) curve analysis and area under the ROC curve (AUC) were used to assess the sensitivity and specificity of the computerized DVA as a screening measure for falling risk as determined by the DGI. Results suggested a link between computerized DVA and the propensity to fall; DVA in the yaw plane was found to be a sensitive (92%) and accurate screening measure when using a cutoff logMAR value of >0.25.

Comorbidities in vestibular migraine

A growing body of clinical and epidemiological evidence supports a specific relationship between vestibular symptoms and migraine. Without a biomarker or complete understanding of pathophysiology, diagnosis of vestibular migraine (VM) currently depends upon symptoms in two dimensions: episodic vestibular symptoms temporally related to migraine symptoms. The Bárány Society and the International Headache Society have recently developed consensus diagnostic criteria. However, many issues remain unsettled, including the type, duration, and timing of vestibular symptoms related to headache that should be required for diagnosing VM. This paper focuses on the challenging third dimension of comorbidity, a frequent cause of diagnostic uncertainty that may confound clinical application and research validation of VM criteria. Several other neurotologic conditions occur more frequently in migraineurs than controls, including benign paroxysmal positional vertigo, Ménières disease, and motion sickness. Patients with VM also have high rates of chronic subjective dizziness, which may be associated with anxious, introverted temperaments that can affect clinical presentation and treatment response. Broadly inclusive studies of well-characterized patients with other neurotologic and psychiatric comorbidities are needed to fully understand how vestibular symptoms and migraine interact in order to truly validate vestibular migraine, distill its essential features, define its boundaries, and characterize overlapping comorbidities.

Age effect on the Gaze Stabilization test

Impairments of the vestibular-ocular reflex (VOR) lead to a decline in visual acuity during head movements. Dynamic visual acuity (DVA) testing is a sensitive assessment tool for detecting VOR impairments. DVA evaluates accuracy of visual acuity during fixed velocity head movements. In contrast, the Gaze Stabilization test (GST) is a new functional evaluation of the VOR that identifies a persons maximum head velocity (in degrees per second) a person can maintain with stable vision of a target (i.e. optotype). The objective of this study was to evaluate the effect of age on the GST in participants without vestibular disease. The study was conducted in a vestibular and balance laboratory at a tertiary medical center. A total of 87 healthy adult volunteers were included in this study. The main outcome measure was the association between age and both GST maximum head velocity in the yaw (right/left) plane and velocity symmetry. A significant negative correlation was found between age and maximum head velocity (r =-0.469, p< 0.001). Our results suggest that age should be considered when interpreting GST results in the yaw plane, however standardization of testing methods should be established as variation in results has been reported in the literature.

Long-term dizziness handicap in patients with vestibular schwannoma: a multicenter cross-sectional study.

Objective (1) To characterize long-term dizziness following observation, microsurgery, and stereotactic radiosurgery (SRS) for small to medium-sized vestibular schwannoma (VS) using a validated self-assessment inventory; and (2) to identify clinical variables associated with long-term dizziness handicap. Study Design Cross-sectional observational study. Setting Two independent tertiary academic referral centers: one located in the United States and one in Norway. Subjects and Methods All patients with sporadic VS of less than 3 cm who underwent primary microsurgery, SRS, or observation between 1998 and 2008 were identified. Subjects were surveyed via a postal questionnaire using the Dizziness Handicap Inventory (DHI) and a VS symptom questionnaire. Results The overall survey response rate was 79%. A total of 538 respondents (mean age, 64 years; 56% female) were analyzed, and the mean time interval between treatment and survey was 7.7 years. Pretreatment variables associated with greater dizziness handicap included female sex, older age, larger tumor size, preexisting diagnosis of headache or migraine, and symptoms of dizziness predating treatment. Significant posttreatment features strongly associated with poor long-term DHI scores included frequency and severity of ongoing headache. On multivariable analysis, treatment modality did not influence long-term dizziness handicap. Conclusion At a mean of approximately 8 years following treatment, over half of patients with VS reported ongoing dizziness. The authors have identified several baseline features that may help predict the risk of lasting dizziness. Treatment modality does not appear to influence long-term DHI score. We found a strong association between posttreatment headache and poor dizziness handicap. Future study is needed to further define this relationship.

Adverse effects of health anxiety on management of a patient with benign paroxysmal positional vertigo, vestibular migraine and chronic subjective dizziness ☆

INTRODUCTION Care of patients with vestibular symptoms focuses primarily on physical otoneurologic disorders; however, psychological factors can sustain symptoms, confound assessment, and adversely affect treatment. Health anxiety is a particularly pernicious process that simultaneously magnifies physical symptoms and inhibits medical care. OBJECTIVE To demonstrate the excess morbidity caused by vestibular health anxiety and its successful management in a patient with otoneurologic disease. METHOD Report of a 41-year-old woman with recurrent benign paroxysmal positional vertigo, vestibular migraine, and chronic subjective dizziness, who expressed grave concerns about her health, repeatedly questioned her otoneurologic diagnoses, and failed physical therapy and medication treatment until her health anxiety and otoneurologic illnesses were addressed simultaneously. CONCLUSION Health anxiety is an empirically validated concept that explains troublesome health-related beliefs and behaviors. It is frustrating for patients and health care teams, but can be treated successfully in otoneurology practice, thereby reducing physical symptoms, emotional distress, functional impairment, and health care overutilization.

Performance of Fukuda Stepping Test as a Function of the Severity of Caloric Weakness in Chronic Dizzy Patients

BACKGROUND The purpose of the Fukuda Stepping Test (FST) is to measure asymmetrical vestibulospinal reflex tone resulting from labyrinthine dysfunction. The FST is a low cost evaluation for dizzy patients; however, when compared with gold standard caloric irrigation unilateral weakness (UW) value ≥25%, the FST has not been shown to be a sensitive tool for identifying unilateral vestibular hypofunction. PURPOSE The purpose of this technical report is to further evaluate the clinical utility of FST with and without headshake as a function of increased caloric asymmetry for individuals with unilateral peripheral vestibular pathology. RESEARCH DESIGN Retrospective review of FST results with and without head shaking component as compared to gold standard, caloric irrigation UW outcome values at four severity levels: 0-24% UW (normal caloric value); 25-50% UW (mild caloric UW); 51-75% UW (moderate caloric UW); 76-100% UW (severe caloric UW). STUDY SAMPLE 736 chronic (≥8 wk symptom complaints) dizzy patients. RESULTS Standard FST and FST following a head shake task are insensitive to detecting mild to moderate peripheral vestibular paresis. Increased test performance was observed for patients with severe canal paresis (>76% UW); however, continued inconsistencies were found in turn direction toward the severe unilateral vestibular dysfunction. CONCLUSIONS Overall, the FST provides little benefit to clinicians when used in the vestibular bedside examination.

Clinical use of the gaze stabilization test for screening falling risk in community-dwelling older adults.

Objective This study examined the clinical use of the computerized gaze stabilization test (GST) as a screener for falls. Design Cross-sectional, descriptive. Setting Tertiary medical center. Subjects Fifteen older community-dwelling adults with a history of falls and 15 controls without a history of falls were recruited for participation in the study. Main Outcome Measures Participants performed GST with yaw plane head movements. The GST velocity was measured and compared with the dynamic gait index (DGI). Receiver operating characteristic (ROC) curves and area under the ROC curve (AUC) identified GST velocity cut points for identification of fallers based on history of falls and as compared with DGI score. Results Our results suggested that GST can discriminate between individuals at risk for falls versus those not at risk. ROC analysis identified an AUC of 0.92 (⩽100.5 degrees per second criterion value) for GST based on history of falls and an AUC of 0.85 (⩽100.5 degrees per second criterion value) based on DGI for classifying falling risk. When GST and DGI scores were combined, the protocol identified an AUC of 1.0 (100% sensitivity, 100% specificity) for identifying falling risk. Conclusion There were significant head movement velocity differences from participants classified by history of falls and the DGI. Therefore, GST may serve as a potential falling risk assessment measure for older individuals with a history of falls. It is recommended that GST be used in a combined protocol with DGI to accurately identify individuals with falling risk rather than used in isolation.