I want to suggest the use of systolic blood pressure in the approach to patients who complain of dizziness. I propose that we should place such patients into three group when we first see them. The first group is patients with vertigo, in most of whom the symptoms of dizziness are due to CNS diseases or internal ear diseases. Although the problem in 90% of this group is caused by an internal ear disease, CNS diseases must be ruled out as quickly as possible, especially in patients with a high systolic blood pressure. The second group consists of patients with pre-syncope. Although the problem in most of this group is neurally mediated, cardiovascular and hypovolemic problems must be ruled out as quickly as possible, especially in patients with a low systolic blood pressure. The third group comprises patients with ill-defined dizziness, in whose case we had better investigate all causes, including the diseases associated with vertigo and pre-syncope.
We devised an original non-specific positional therapeutic strategy for benign paroxysmal positional vertigo (BPPV), and we achieved better results than before, however, there were intractable cases. The background factor of such cases was examined in this study. The study subjects comprised is 54 patients in whom it took three months or more before giddiness disappeared from among 666 cases who were diagnosed in our department as having BPPV. The background factors examined were the existence of the period to consultation, age, sex, past history, car sickness and lack of an exercise habit. It was revealed that history of any blow to the head, blow, whiplash injury, car sickness, lack of an exercise habit and the time to consultation were significantly different between intractable cases and treatable cases. Our results suggested that cases of BPPV associated with blows to the head were prone to be intractable to non-specific therapy. The characteristics of patients who easily become intractable cases were as follows. BPPV easily occurred with a history of any blow to the head, the reason for which we believed was that such cases would quite probably not undergo a medical examination at a hospital because their BPPV-related symptoms were relatively short. Therefore, it was possible that they might not consult any hospital doctor for a long time from the disease onset and the recovery of their symptoms was prone to be delayed. In addition, they may have recognized that positional therapy was important to cure their symptoms, however they felt severely nauseous because of vertigo during therapy. As a result, they became prone not to remaining still because of positional vertigo and their symptoms would probably become intractable. It is necessary to give early and appropriate treatment to avoid intractability of their symptoms. We additionally noted that repeated explanations regarding the treatment of the disease were also important to ensure good compliance with their BPPV treatment.
We report herein on a case of acoustic neuroma, which showed persistent geotropic positional nystagmus at the fourth time under clinical observation. This positional nystagmus was static direction-changing positional nystagmus (DCPN) canceled at 20 degrees yaw head rotation from the supine position. This nystagmus was also cancelled when the head was rotated 180 degrees from this position. We termed these head positions the “neutral point”. In addition, when the head was rotated to either side away from the neutral point, this case showed nystagmus beating away from the neutral point (as the geotropic direction). This positional nystagmus observed at all positions except for the neutral points was thought to occur due to “light cupula”, which may be determined by the specific gravity of its endolymph in the lateral semi-circular canal. The affected side was thought to be that to which the neutral point deviated from the supine position, so the affected side of this positional nystagmus corresponded to that of the acoustic neuroma. Acoustic neuromas localized in the internal auditory meatus at the early stage, may influence peripheral endo-organs such as the lateral semi-circular canal in any way and show symptoms associated with peripheral vestibular disorder before paralytic nystagmus will appear, derived from a retrolabyrinthine neural disorder caused by the progression of the tumor.
We previously reported on preparatory study for a new dynamic equilibrium examination, the “Foulage test” using normal subjects. This is a unique stepping test on a stabilometer, keeping both toes constantly in contact with the plate and lifting up only the heels alternately, BPM 120, 60 seconds, 120 steps, with eyes open and closed. The total locus length (L) and the environed area (A) are measured. We found a new equilibrium parameter FT (=120A/L). In order to evaluate how FT can measure body sway, we applied this examination to patients with dizziness. Two hundred forty six patients, 60 men, 186 women, 14 to 87 years old, mean of age was 59.2, were tested. According to the sway level, patients were classified into 4 groups from stable “level 0” to almost falling “level 3”. We analyzed FT and sway level of each group. FT increased gradually (p<0.05 Steel-Dwass test) concomitantly with the sway level. This study may establish the Foulage test as a possible new dynamic equilibrium examination.
Many patients with acoustic neuromas complain of hearing loss, tinnitus or equilibrium disturbance. In our previous gait studies using tactile sensors placed under both feet, we demonstrated that the presence of an acoustic neuroma could cause unstable gait. Three dimensional motion analysis is a useful tool to assess abnormal gait performance. The purpose of this study was to examine the gait performance with spatiotemporal and kinematic parameters using three dimensional motion analysis in patients with acoustic neuromas. Seventeen patients (7 males, 10 females; mean age: 64.1±11.1 years old) with a unilateral acoustic neuroma were enrolled in this study. Twenty-one healthy subjects (12 males, 9 females; mean age: 37.6±19.1 years old) served as controls. Subjects were asked to walk freely with eyes open or closed for a distance of nearly 4 m. Spatiotemporal and kinematic components, including gait speed, stride length, stride duration, % stance phase, step width, head movements (vertical, yaw, pitch, and roll), gait deviation, forefoot motion, and angle between foot and floor (foot flexion angle) during walking, were calculated using three dimensional coordinates. At the subject's heel strike during walking, the mean foot flexion angle in the patient group was significantly smaller than the mean value in the healthy subjects. The decrease of the angle in the acoustic neuroma patients may be associated with a gait abnormality caused by vestibular disorders. Based on three dimensional motion analysis, we propose a useful parameter to evaluate the vestibular disorders in patients with an acoustic neuroma.
In the course of Meniere's disease (MD), approximately one third of patients progress from unilateral to bilateral MD. For optimal treatment, the potential risk for contralateral ear involvement should be properly assessed. This study aimed to explore factors predicting progression from unilateral to bilateral Meniere's disease. Clinical records of 180 consecutive patients with definite MD were reviewed. Patients were classified into the following 3 groups: patients with unilateral MD (CEI-, contralateral ear involvement-), patients exhibiting progression from unilateral to bilateral MD (CEI+), and patients with bilateral MD at the time of first consultation (BL, bilateral). Age, gender, duration of symptoms, stage of disease, left-right difference on caloric test, results of vestibular-evoked myogenic potential (VEMP) recording, subjective visual horizontal, and time to remission of vertigo attacks were compared. When stages 1 with 2 and 3 with 4 were combined, there were more cases of stage 3 or 4 disease in both the CEI+ and BL groups than in the CEI- group. On VEMP responses, the proportions of patients exhibiting normal responses on both sides or absent responses on both sides in the CEI+ and BL groups were larger than those in the CEI- group. In a regression analysis, stage 3 or 4 and lack of left-right difference in the VEMP response were factors significantly associated with contralateral ear involvement. In patients with unilateral MD, stage 3 or 4 disease and lack of any left-right difference in the VEMP responses at initial examination were risk factors for contralateral ear involvement.