There are many methods for performing a body balance function test. Body balance function tests can be divided into static body balance function tests and dynamic body balance evaluations. In recent years, the development of highly precise electrical devices has advanced body balance function tests. Regarding stabilometers for evaluating static body balance, many analysis methods have been improved as a result of progress in device accuracy and computer software. Moreover, a body tracking test (BTT) using visual stimulation has been developed as a new method for stimulus evaluation using a stabilometer for dynamic body balance evaluations. The Galvanic body sway test (GBST) can also be performed as a vestibular stimulus evaluation. These methods and evaluations as well as their associated problems are discussed.
We report a case of benign paroxysmal vertigo during childhood (BPV) transitioning into atypical basilar migraine (BM) that was effectively treated using lomerizine. A 6-year-old boy visited our hospital complaining of repeated attacks of vertigo for 3 months. His vertigo attacks lasted a few hours and were accompanied by nausea, vomiting, intense fear, and a loss of consciousness. Nystagmus was not observed during the vertigo attacks. Blood tests and imaging examinations showed no abnormal findings. The results of electronystagmography and a caloric test were unremarkable. Pure-tone audiometry showed a profound right-side sensorineural hearing loss. Among the differential diagnoses, delayed endolymphatic hydrops, epilepsy, and BM were considered. Delayed endolymphatic hydrops was considered unlikely because nystagmus had not occurred during the vertigo attacks and there was no change in hearing: electroencephalography showed no epileptic seizure waves. His vertigo attacks are currently well controlled with lomerizine. Although no obvious headaches accompanied the vertigo attacks, this case was diagnosed as atypical BM because the use of lomerizine, an agent for the treatment of migraine, was effective. Since BPV is reportedly closely related to migraine and because the start of the vertigo attacks was accompanied by the loss of consciousness, we suspect that this patient had atypical BM transitioning from BPV. Our experience in treating this patient showed that lomerizine was effective for the treatment of migrainous vertigo during childhood.
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo, and the posterior canal is the most frequently involved structure because of its anatomical position. In the majority of posterior canal BPPV cases, a particle-repositioning maneuver, such as the Epley maneuver, is effective, since the otoconia is thought to be located in the long arm of the posterior canal. However, Oas et al. has proposed a subtype of posterior canal BPPV, known as short-arm type BPPV, in which the otoconia is assumed to be located not in the long arm of the posterior canal, but in the short arm (between the utricle and the cupula). Here, we present four cases of BPPV that presumably involve the short-arm type posterior canal. The duration of nystagmus was extended in all four cases when the head was moved as in the Dix Halllpike test. Furthermore, when the head was moved back to a sitting position, the reversal of nystagmus was not or very faintly observed. As a treatment, the Epley maneuver was initially attempted, but this treatment was not effective. However, vibration methods (involving the application of vibration to the mastoid process of the affected ear with the intact ear positioned downwards) were effective in all four cases.
A questionnaire survey was administered to 183 patients with vertigo or dizziness to understand the characteristics of patients with persistent dizziness. We used the Nishiike's questionnaire, which is associated with the Dizziness Handicap Inventory (DHI). This questionnaire consists of five principal factors of handicap arising from dizziness: 1) disturbances of social activities, 2) body motion precipitating dizziness, 3) limitations of physical activity, 4) emotional disturbances, and 5) disturbances of interpersonal communications. We used the Mann-Whitney U-test for the statistical analysis, and P<0.05 was considered significant. We divided the patients into two groups: those who had a history of dizziness for over 1 year and those experiencing dizziness for less than 1 year. The score for factor 3 was significantly higher in the former group. These finding suggest that patients with persistent dizziness avoid moving their bodies. Vestibular rehabilitation is important for such patients. In addition, when the patients were divided into two groups according to the presence of nystagmus, the scores for factors 1 and 5 were significantly higher among the patients without nystagmus. Of note, the disappearance of nystagmus was not always accompanied by the recovery from dizziness. In addition, mental support may be important for these patients.
I introduced migraine associated vertigo (MAV) as one of the new clinical entities which might cause vertigo and reviewed my own patients with MAV. While MAV is quite widely accepted in Europe and the USA, it is not familiar in Japan, especially for Japanese otolaryngologists. Although the universal diagnostic criteria of MAV are still under discussion, they should include 1) episodic vertigo attacks, 2) migraine attacks, and 3) an episode of simultaneous existence of vertigo and migraine. In the clinical review, patients (N=41) were female-dominant (8 men and 33 women), and the mean of their age was 38.2 years. The majority of the patients had rotatory vertigo lasting several hours. Some patients had tinnitus and aural fullness. Their tinnitus and aural fullness could be bilateral. Caloric tests and/or vestibular evoked myogenic potentials (VEMP) could be abnormal. Concerning VEMP, some patients showed prolongation of latencies, while some showed absence of responses or shifts of characteristic frequency. These findings suggested that the pathophysiology and lesion sites of MAV could be diverse. At the current stage, establishment of universal diagnostic criteria and treatment guidelines is required.
The most prominent symptom of spinal cerebrospinal fluid (CSF) leakage is an orthostatic, tension-type headache. Other well-known symptoms include nausea, vomiting, photophobia, diplopia, depression, and amnesia. The authors address other commonly encountered symptoms such as dizziness, hearing disturbances, cerebrospinal fluid rhinorrhea, and gustatory and olfactory disturbances. The dizziness experienced in this disorder is essentially characterized as a kind of “floating sensation” or “walking on the clouds” and is associated with a high degree of unsteadiness. A considerable percentage of patients cannot remain standing even when their eyes are open; to-and-fro perturbations are particularly prominent in these patients. Rotatory vertigo attacks can occur in a small portion of patients, but usually only during the early stages of the disease. As with the headache, dizziness is aggravated by an upright or standing position. The weather also influences the intensity of both the headaches and dizziness: both are exacerbated when the atmospheric pressure is low or is falling rapidly. Water intake and/or the drip infusion of a physiological salt solution may temporarily improve dizziness and other symptoms. The usefulness of MRI for diagnosing spinal cerebrospinal fluid leakage is limited. MRI findings are equivocal in most cases; therefore, the authors perform 111In-DTPA scintigraphy for each patient in whom this disorder is suspected. The first choice of treatment for this disorder is bed rest and water intake and/or drip infusion. When these treatments are ineffective, an epidural autologous blood patch is attempted. However, not all patients are cured by this procedure, and dizziness, hearing, and/or tinnitus may worsen after treatment. In some patients, an exploratory tympanotomy is required to rule out associated or treatment-induced perilymphatic fistula. In conclusion, spinal CSF leakage is not a rare disorder, and because this disorder presents with an extremely wide spectrum of symptoms, all physicians in any field of specialization may encounter a patient with this disorder. All physicians should keep this disorder in mind.
Purpose: Perilymphatic fistula (PLF), defined as an abnormal communication between the inner and middle ear, presents with a symptomatology of hearing loss and vestibular disorder that is indistinguishable from a number of other inner ear diseases. Methods of diagnosis remain controversial. We previously showed that CTP (Cochlin-tomoprotein) was selectively detected in the perilymph. We also established a definite diagnostic test for PLF using CTP as a biochemical marker. Here, we examined the diagnostic performance of the CTP detection test to determine the usefulness of this test in a clinical setting. Methods: The CTP detection test was performed using a western blot analysis with recombinant human (rh)CTP as a spiked standard. We evaluated the specificity of the CTP detection test by also testing non-PLF cases. To describe the limitations of the test, we tested samples from patients with middle ear infection. Serially diluted perilymph was tested to determine the detection limit of the CTP test. We then applied the CTP detection test in cases of spontaneous, traumatic and iatrogenic (surgical) PLF. Findings: We established a standardized CTP detection test using high (0.27 ng) and low (0.13 ng) spiked standards of rhCTP and a western blot analysis. MEL (middle ear lavage) samples from 54 of the 55 non-PLF cases tested negative for CTP, i.e., the specificity of the test was 98.2%. MEL samples from 43 out of 46 cases with chronic suppurative otitis media or middle ear cholesteatoma tested negative for CTP. The detection limit in perilymph was 0.161 uL/lane for an average of 5 samples. We elucidated the clinical characteristics of the PLF cases in each category. Interpretation: CTP is a stable perilymph specific protein, and this CTP detection may be the first clinically established diagnostic tool for the detection of PLF with a high specificity. PLF is surgically correctable by sealing the fistula. The appropriate recognition and treatment of PLF can improve hearing and balance in afflicted patients.
The first visualization of endolymphatic hydrops in patients with Ménière's disease was performed using three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) imaging with a 3 Tesla MRI unit after gadolinium contrast agent (Gd) was injected intratympanically. The 3D-FLAIR MRI could differentiate the endolymphatic space from the perilymphatic space, but not from the surrounding bone. By optimizing the inversion time, the endolymphatic space, perilymphatic space and surrounding bone could be separately visualized on a single image using three-dimensional real inversion recovery (3D-real IR) MRI. Using 3D-FLAIR and 3D-real IR MRI, various degrees of endolymphatic hydrops were observed in the basal and upper turns of the cochlea and in the vestibular apparatus after intratympanic Gd injection. Recently, visualization of endolymphatic hydrops became possible 4 h after intravenous Gd injection in patients with Ménière's disease. We applied a heavily T(2)—weighted 3D-FLAIR technique to detect Gd more sensitively for evaluation of endolymphatic hydrops after an ordinary amount of Gd was administered intravenously. Thus, newly developed MRI techniques have contributed significantly to the evaluation of endolymphatic hydrops. The intravenous administration of an ordinary amount of Gd is routinely done clinically. The relationship between endolymphatic hydrops and clinical symptoms will be investigated widely using new techniques.
I have investigated lifestyles, behavior patterns, causative factors, and progression of hearing loss in many patients with Meniere's disease, and found that lack of recompense for pressure of business, patience or service is responsible for the onset or progression of the disease. Further, aerobic exercise proved very effective to stop vertigo and improve fixed hearing loss. Three years ago, I advocated a new therapy for Meniere's disease consisting of aerobic exercise and countermeasures to remove the harmful factors in daily life (aiming at good sleep, omission, and relaxation). Because the new therapy has been far more effective than any conventional therapies, we must renew the treatment concept of and therapeutic strategy for Meniere's disease. I suspect the possibility that the CNS emotional center, stimulated by lack of recompense against stress in activities of daily living, influences the hypothalamus, which in turn reduces blood flow to the inner ear, and produces endolymphatic hydrops. Aerobic exercise, together with correction of irregular or inactive lifestyles, removes unhealthy factors, improves the subject's general physical condition, and finally cures endolymphatic hydrops.