Roberto Teggi

Migrainous vertigo: results of caloric testing and stabilometric findings.

Background.— Association between migraine and vertigo has been widely studied during the last years. A central or peripheral vestibular damage may occur in patients with migrainous vertigo. Despite much evidence, at present the International Headache Society classification does not include a specific category for migrainous vertigo.

Gly460Trp α-adducin mutation as a possible mechanism leading to endolymphatic hydrops in Ménière's syndrome

Objective: Ménières disease (MD) is an inner ear disorder characterized by recurrent episodic vertigo, hearing loss that is fluctuating in the first stages, aural fullness, and tinnitus. Raised endolymphatic pressure (hydrops) is commonly accepted as a causal condition. Approximately 90% of cases of MD are sporadic, whereas the remaining 10% of cases are linked to genetic factors. The ionic composition of endolymph may also depend on the activity of Na+, K+-ATPase. Adducin is a heterodimeric cytoskeleton protein consisting of 3 subunits (&agr;, &bgr;, and &ggr;) coded by 3 different genes (ADD1, ADD2, and ADD3). ADD1 Gly460Trp polymorphism is associated with salt-sensitive hypertension and increased Na+-K+ pump activity in transfected cells. This study aims to verify the role of adducin in the development of MD. Methods: We genotyped 28 patients affected by definite MD according to American Academy of Otolaryngology-Head and Neck Surgery Foundation criteria. Results were compared with those from 2 different control populations (normotensive control group from San Raffaele Hospital and general population group). Results: We have not found any significant difference in the distribution of ADD2 C1797T and ADD3 IVS11+386A/G polymorphism genotypes. On the other hand, the frequency of ADD1 Trp allele is significantly increased in patients with MD compared with controls. Conclusion: We present data supporting the possibility that increased Na+, K+-ATPase activity may be one of the pathologic mechanisms inducing hyperosmolarity in endolymph which, in turn, may lead to hydrops.

Accompanying Symptoms Overlap during Attacks in Menière’s Disease and Vestibular Migraine

Menière’s disease and vestibular migraine (VM) are the most common causes of spontaneous recurrent vertigo. The current diagnostic criteria for the two disorders are mainly based on patients’ symptoms, and no biological marker is available. When applying these criteria, an overlap of the two disorders is occasionally observed in clinical practice. Therefore, the present prospective multicenter study aimed to identify accompanying symptoms that may help to differentiate between MD, VM, and probable vestibular migraine (pVM). Two hundred and sixty-eight patients were included in the study (MD: n = 119, VM: n = 84, pVM: n = 65). Patients with MD suffered mainly from accompanying auditory symptoms (tinnitus, fullness of ear, and hearing loss), while accompanying migraine symptoms (migraine-type headache, photo-/phonophobia, visual aura), anxiety, and palpitations were more common during attacks of VM. However, it has to be noted that a subset of MD patients also experienced (migraine-type) headache during the attacks. On the other hand, some VM/pVM patients reported accompanying auditory symptoms. The female/male ratio was statistically higher in VM/pVM as compared to MD, while the age of onset was significantly lower in the former two. The frequency of migraine-type headache was significantly higher in VM as compared to both pVM and MD. Accompanying headache of any type was observed in declining order in VM, pVM, and MD. In conclusion, the present study confirms a considerable overlap of symptoms in MD, VM, and pVM. In particular, we could not identify any highly specific symptom for one of the three entities. It is rather the combination of symptoms that should guide diagnostic reasoning. The identification of common symptom patterns in VM and MD may help to refine future diagnostic criteria for the two disorders.

Otorhinolaryngological manifestations in granulomatosis with polyangiitis (Wegener's).

Granulomatosis with polyangiitis (Wegeners, GPA) is an uncommon disease of unknown etiology classically involves the ELK triad of the ear, nose, throat (E), lungs (L) and kidneys (K) with necrotizing granulomatous inflammation and vasculitis. Most of the initial symptoms begin in the head and neck region with a wide spectrum of involvement of any site ranging from the nasal septum, paranasal sinuses, oral mucosa, larynx and even the external, middle and internal ear. Diagnosis may be delayed because the onset is heterogeneous and sometimes limited to one organ. The pathologic findings of a characteristic inflammatory reaction pattern, and the serum findings of elevated antineutrophil cytoplasmic antibodies can help to establish the diagnosis. The differentiation from other conditions that mimic GPA such as lymphoma and infections is of critical importance to initiate appropriate treatment. Treatment of the underlying disease is medical with the use of immunosuppressive agents and will not be reviewed here. This review focuses on the otorhinolaryngologic manifestation and complication of GPA as well as their surgical management and specifies the role of the otorhinolaryngologist as an integral member of the multidisciplinary care team for patients with GPA.

Transmeatal Low-Level Laser Therapy for Chronic Tinnitus with Cochlear Dysfunction

Objectives: To establish the efficacy of low-level laser therapy for tinnitus. Methods: We performed a prospective, randomized double-blind study on 60 outpatients with tinnitus presenting sensorineural hearing loss in the affected ear. They were randomly divided into two groups, the first performing active laser therapy 20 min a day for 3 months with a 650-nm, 5-mW soft laser (group L), the second using a dummy device which duplicated all aspects of active laser therapy except for the activation of the laser beam (group C). One subject in both groups dropped out due to an increase in tinnitus loudness. Two more patients in each group ceased to comply with the protocol due to familiar problems. Results: The Tinnitus Handicap Inventory (THI) was considered the main outcome measure; no statistical difference was detected between the 2 groups in the THI total score (p = 0.97), and its functional (p = 0.89), emotional (p = 0.89) and catastrophic (p = 0.89) subscales. Moreover, a visual analog scale for self-perceived loudness of the tinnitus showed no difference between the groups (p = 0.69). Regarding psychoacoustic parameters, the minimum masking level showed no difference (p = 0.42), while loudness expressed in sensation level exhibited lower values in group L (p = 0.0127). Group L subjects also presented a decreased rate of hyperacusis (p = 0.02). No changes were detected in the audiometric threshold in both groups. Conclusions: Soft laser therapy demonstrated no efficacy as a therapeutic measure for tinnitus.

Dizziness, migrainous vertigo and psychiatric disorders

OBJECTIVES This study sought to establish the prevalence of vestibular disorders, migraine and definite migrainous vertigo in patients with psychiatric disorders who were referred for treatment of dizziness, without a lifetime history of vertigo. STUDY DESIGN Retrospective study. SETTING Out-patients in a university hospital. MATERIALS AND METHODS Fifty-two dizzy patients with panic disorders and agoraphobia, 30 with panic disorders without agoraphobia, and 20 with depressive disorders underwent otoneurological screening with bithermal caloric stimulation. The prevalence of migraine and migrainous vertigo was assessed. The level of dizziness was evaluated using the Dizziness Handicap Inventory. RESULTS Dizzy patients with panic disorders and agoraphobia had a significantly p = 0.05 regarding the prevalence of peripheral vestibular abnormalities in the group of subjects with PD and agoraphobia and in those with depressive disorders. Migraine was equally represented in the three groups, but panic disorder patients had a higher prevalence of migrainous vertigo definite migrainous vertigo. Almost all patients with a peripheral vestibular disorder had a final diagnosis of definite migrainous vertigo according to Neuhauser criteria. These patients had higher Dizziness Handicap Inventory scores. The Dizziness Handicap Inventory total score was higher in the subgroup of patients with panic disorders with agoraphobia also presenting unilateral reduced caloric responses or definite migrainous vertigo, compared with the subgroup of remaining subjects with panic disorders with agoraphobia (p < 0.001). CONCLUSIONS Our data support the hypothesis that, in patients with panic disorders (and especially those with additional agoraphobia), dizziness may be linked to malfunction of the vestibular system. However, the data are not inconsistent with the hypothesis that migrainous vertigo is the most common pathophysiological mechanism for vestibular disorders.

Extended phenotype and clinical subgroups in unilateral Meniere disease: A cross-sectional study with cluster analysis

To define clinical subgroups by cluster analysis in patients with unilateral Meniere disease (MD) and to compare them with the clinical subgroups found in bilateral MD.

Efficacy of low-level laser therapy in Ménière's disease: A pilot study of 10 patients

OBJECTIVE To assess the efficacy of low-level laser therapy (LLLT) for Ménières disease (MD). MATERIALS AND METHODS Twenty patients with unilateral MD were included in the study; all presented with uncontrolled vertigo. The patients were randomly divided into two groups: group 1 patients received LLLT 20 min a day with a 5-mW soft laser for 6 mo, while group 2 received betahistine 16 mg twice a day for 6 mo. According to American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines, the main outcome for vertigo control was considered to be the number of spells per month in the 6 mo before treatment compared with the same parameter in the 6 mo of therapy. The duration of spells expressed in minutes was also considered. Moreover, a hearing test was performed before and after therapy and results were reported as the pure tone average of 500-, 1000-, 2000-, and 3000-Hz frequencies. All results were valued at baseline, and after 3 and 6 mo of therapy. RESULTS Compared to baseline, the number and duration of spells were significantly reduced in both groups; statistical significance was detected for the 3-mo control in both groups (p 0.05 with the multiple pair comparison test). Betahistine seems to have a faster action in spell reduction (p 0.05 comparing the 3-mo results between the two groups). Audiometric examination did not show a statistically significant difference between the two groups. CONCLUSIONS In our experience, LLLT seems to prevent vertigo spells in MD, although results indicate that it has a slower action than betahistine. Dose-dependent therapeutic effects could explain the last result. In our opinion, increased blood flow in the inner ear is the main mechanism leading to the therapeutic results.

Residual Dizziness after Successful Repositioning Maneuvers for Idiopathic Benign Paroxysmal Positional Vertigo

Objective: To establish a possible causal factor for residual dizziness (RD) after successful repositioning maneuvers in patients with benign paroxysmal positional vertigo (BPPV). Materials and Method: Ninety consecutive patients with idiopathic BPPV were treated with repositioning maneuvers, and the rate of RD was assessed as well as clinical data. Posturography and assessment of anxiety levels were performed on patients reporting RD. Results were compared with a control group of BPPV patients of the sample after repositioning maneuvers and without RD. Results: Twenty-eight subjects (31.1%) reported RD on the second day after successful repositioning maneuvers. The mean duration of RD was 11.6 ± 3.9 days. Patients with RD presented a higher duration of BPPV (14.1 vs. 10.9 days, p = 0.01). A correlation was demonstrated between the duration of BPPV and duration of RD (p < 0.01). Subjects with RD presented increased body sways, above all in eyes-closed conditions. Conclusion: RD is mainly correlated with duration of vertigo in BPPV patients. Anxiety was demonstrated to play a role in increased body sways.

Point prevalence of vertigo and dizziness in a sample of 2672 subjects and correlation with headaches.

SUMMARY Vertigo and dizziness are common symptoms in the general population, with an estimated prevalence between 20% and 56%. The aim of our work was to assess the point prevalence of these symptoms in a population of 2672 subjects. Patients were asked to answer a questionnaire; in the first part they were asked about demographic data and previous vertigo and or dizziness. Mean age of the sample was 48.3 ± 15 years, and 46.7% were males. A total of 1077 (40.3%) subjects referred vertigo/dizziness during their lifetime, and the mean age of the first vertigo attack was 39.2 ± 15.4 years; in the second part they were asked about the characteristics of vertigo (age of first episode, rotational vertigo, relapsing episodes, positional exacerbation, presence of cochlear symptoms) and lifetime presence of moderate to severe headache and its clinical features (hemicranial, pulsatile, associated with phono and photophobia, worse on effort). An age and sex effect was demonstrated, with symptoms 4.4 times more elevated in females and 1.8 times in people over 50 years. In the total sample of 2672 responders, 13.7% referred a sensation of spinning, 26.3% relapsing episodes, 12.9% positional exacerbation and 4.8% cochlear symptoms; 34.8% referred headache during their lifetime. Subjects suffering from headache presented an increased rate of relapsing episodes, positional exacerbation, cochlear symptoms and a lower age of occurrence of the first vertigo/dizziness episode. In the discussion, our data are compared with those of previous studies, and we underline the relationship between vertigo/dizziness from one side and headache with migrainous features on the other.