In order to diagnose the pathological condition of vertiginous patients, a detailed observation of nystagmus in addition to examination of body equilibrium and other neurotological tests are essential. For this purpose, methods for precise observation and analysis of the eye movements have been studied and have been developed up to the present. How to precisely record eye movements has been one of the long-term goals of researchers and clinicians who are interested in the analysis of eye movements. Devices are currently available which can quite accurately record human eye movements, based on the principle of video-oculography (VOG). Improvement of these devices, however, can be expected in the near future along with technological advancement, coupled with further development of the software engines which analyze the recorded movements of the eye in three dimensions, thus improving the accuracy of the measurement and the speed of analysis. We clinicians will then be able to easily record and analyze the eye movements in patients with vertigo and/or disequilibrium. Furthermore, from the data provided by vector analysis of the slow phase of nystagmus, diagnosis of the localization of the disease in the peripheral labyrinth will also be possible.
Seventeen patients with central vertigo that began with vertigo, seen between 2000 and 2008 at the Department of Otorhinolaryngology of Osaka Medical College Hospital, were investigated. The patients included 14 males and three females. Their mean age was 59.2 years (range 27-82). The cases consist of six cerebellar infarctions, two anterior inferior cerebellar artery (AICA) syndromes, two Wallenberg syndromes, two medial longitudinal fasciculus (MLF) syndromes, three other brain-stem infarctions, one viral encephalitis, and one acute cerebellar ataxia. Thirteen cases (77%) had a history of a disorder that might reduce the cerebral blood flow, and six (46%) had multiple risk factors. The mean interval between the appearance of symptoms and the first visit to our hospital was 6.5 days, and it took 3.8 days to reach a diagnosis. Eleven patients (65%) were transported to hospital by ambulance. Seven (41%) had a delayed neurological abnormality other than vertigo. Nystagmus that was seen at the first visit suggested central vertigo in seven cases and peripheral vertigo in seven cases. In four cases (24%), the nystagmus changed over time, and initially three patients had nystagmus that suggested peripheral vertigo. In some cases, we made the diagnosis based on a neurological abnormality other than vertigo. In other cases, the diagnosis was based on the discordance between the neuro-otological findings and disturbed equilibrium that was inconsistent with peripheral vertigo. When diagnosing central vertigo that began with vertigo, it is important to consider not only neurological abnormalities but also neuro-otological findings and a balance disorder that cannot reasonably be explained as peripheral vertigo.
Autonomic dysfunction is prevalent in dizzy patients. However, evaluating the autonomic nervous system is not very popular, since it is not easy to do. The Pulse Analyzer Plus® is a small device that measures a patient's pulse from his/her finger tip with a small probe, making it possible to evaluate autonomic nervous system function in as little as 5 minutes. The algorithm is identical to the one used in the frequency analysis of electrocardiograms. We report herein on our findings on the autonomic function of 25 dizzy patients who visited our department. Age-matched control data were obtained from healthy volunteers and patients not suffering from dizziness. The measurements were conducted in 5 minutes with the patient in the sitting position. Fast Fourier Transform (FFT) was used to calculate low frequency (LF) components, which mainly reflect sympathetic nervous system function, and high frequency (HF) components, which reflect parasympathetic nervous system (PNS) function. Natural logarithm (Ln) values were calculated for LF and HF components and used for conventional comparison. The ratio of LF/HF was also calculated. The results of the normal controls were LnLF=5.2±1.6 (mean±SD), LnHF=4.3±1.2, LnLF/HF=1.2±0.3 whereas those of the dizzy patients were 4.4±1.9, 3.5±1.2 and 1.3±0.5 respectively. The HF value of the dizzy patients was significantly smaller than that of the control subjects (P<0.05). These data indicate that PNS hypofunction was present in the dizzy patients. Future studies need to determine whether autonomic dysfunction results from the therapeutic interventions used to treat dizziness.
When examining patients with vertigo, it is essential to differentiate between central and peripheral lesions. It has been reported that some infarctions associated with the posterior inferior cerebellar artery (PICA) can mimic peripheral vertigo, such as benign paroxysmal positional vertigo (BPPV). We report on a case that had been treated as BPPV at another institution and eventually turned out to be cerebellar infarction in the PICA legion. Two infarction lesions were observed in the cerebellum. Obstruction of the left vertebral artery was found on MRA. Six months from the first consultation, the BPPV decreased. We should be aware of cases of cerebellar infarction in which nystagmus mimics BPPV.
We experienced cases of invagination into the vestibule of a Teflon piston following stapes surgery as well as of the stapes itself caused by an earpick-related injury. In all three cases, the pathology was accurately determined by diagnostic imaging centered around high-resolution CT. All patients had severe invagination, and stapedectomy was considered necessary for improvement of their symptoms. Although the vestibular symptoms improved postoperatively, one patient developed hearing loss and relapse of nystagmus two months later. Our examination of the problems involved in the treatment of invagination of the stapes or stapes prosthesis into the vestibule for the acute, subacute, and chronic phases showed that different problems existed during each phase.
Objective: In 1996, we developed an in-hospital vestibular-rehabilitation program based on the Cawthorne and Cooksey program for patients with intractable dizziness and have since reported improvements of the quality of life (QOL) of these patients after the treatment. The present study was designed to show the benefit of this program with respect to the physical and emotional aspects of such patients. Methods: The subjects were 161 patients with intractable dizziness and all were informed that hospitalization was a prerequisite for participation in our program. Patients underwent a number of assessment instruments on the first day of the study, including the State-trait Anxiety Inventory (STAI); Self-rating Depression Scale (SDS); Dizziness Handicap Inventory (DHI); and the Profile of Mood States Brief Japanese Version (POMS) to respectively evaluate the subjects' state of anxiety, degree of depression, physical and emotional and functional handicap with dizziness, and profile of mood states. The Short Form Health Survey (SF-8) was used to evaluate the subjects' QOL. In addition, posturography was used to evaluate the length of locus, which indicate gross physical stability. All tests were performed again after 4 weeks of treatment. Results: Significant improvements were seen in all investigation items (STAI, SDS, DHI, POMS, the length of locus, and SF-8 scores) improved after the treatment (p<0.05). Conclusion: Improvement in the physical as well as emotional aspects of intractable dizziness patients was achieved by our vestibular rehabilitation program, which included the combination of physical rehabilitation and in-group therapy. The results strongly suggest that our rehabilitation program could improve not only the physical aspect of patients with intractable dizziness, but could also achieve improvements in their psychological aspect.