Vertigo/dizziness is estimated to account for 2.5% of all emergency department (ED) visits. Although vertigo and dizziness are said to be attributable to benign vestibular disorders in most patients visiting the ER, the symptoms are attributable to dangerous causes, such as cerebrovascular disease, in a few cases (1.7%-3%). It is important to identify cases of stroke among the numerous patients with vertigo and dizziness visiting the ER, not only to overemphasize HINTS, but also to identify dizziness occurring concomitantly with other neurological symptoms. Acute vertigo and dizziness occurring in association with hemiplegia, unilateral sensory disturbance, dysarthria, oculomotor dysfunction or limb ataxia strongly suggest infratentorial strokes. Even if no neurological symptoms are noticeable in the patients presenting with vertigo and dizziness, presence of impaired standing and walking, namely truncal ataxia, should lead to the suspicion of lower cerebellar stroke. Rare cases of stroke, however, present with only nystagmus, mimicking benign paroxysmal positional vertigo and vestibular neuritis. Vertebrobasilar insufficiency, subclavian steal syndrome, and Bowhunter syndrome are atypical types of vertigo associated the risk of ischemic stroke. It should be recognized that multiple supratentorial infarcts and lateral medullary infarcts could cause chronic dizziness.

　　In September 2019, we introduced a tympanic membrane massage device for transtympanic positive-pressure therapy at our institution. This treatment is selected for patients definitively diagnosed as having Ménière's disease (Stage 4) or delayed endolymphatic hydrops with recurrent vertigo attacks, who insist on omit conservative treatment. In the past, surgical treatments, such as endolymphatic sac surgery and selective vestibular neurectomy were considered for patients with the symptoms described above. At present, however, we proactively provide transtympanic positive-pressure therapy using the above-mentioned tympanic membrane massage device, because it is very minimally invasive and easy to perform. Until September 2020, we have provided transtympanic positive-pressure therapy using the tympanic membrane massage device to 24 patients (including 20 patients with definitively diagnosed Ménière's disease and 4 with definitively diagnosed delayed endolymphatic hydrops). In these patients with a definitive diagnosis, the vertigo coefficient was calculated, and the therapeutic effect of this treatment modality was examined. The following six factors were used to calculate the vertigo coefficient: subjective distress level, daily life limitations, number of vertigo attacks per month, and scores on the DHI (Dizziness Handicap Inventory) and VAS (Visual Analog Scale). Our findings revealed the following two useful effects of trans-tympanic positive pressure therapy using the aforementioned device: 1) the scores for subjective distress level and daily life limitations decreased during the course of treatment (p<0.001), and 2) the number of vertigo attacks per month decreased significantly after one month of treatment could be omitted (p＝0.001). Thus, our present study demonstrated that “transtympanic positive-pressure therapy using the tympanic membrane massage device” is an effective treatment method for alleviating the symptoms of intractable Ménière's disease and definite delayed endolymphatic hydrops. Long-term follow-up of the patients is warranted to establish the usefulness of this treatment.

　　The effectiveness of psychotherapy as a treatment for chronic dizziness, including Persistent Postural-Perceptual Dizziness (PPPD) and Psychogenic Vertigo, has been reported. In Japan, the number of institutions that can provide psychotherapy for chronic dizziness is limited, and the current status of psychotherapy for chronic dizziness patients is not entirely clear. The purpose of this study was to clarify the clinical characteristics and outcomes of psychotherapy in patients who undergo psychotherapy, and to examine the selection criteria of patients for psychotherapy. The subjects were 18 patients who visited our clinic between January and December 2021 with chronic dizziness of more than 3 months' duration, in whom psychotherapy was indicated. The mean number of days from the first visit to the indication of psychotherapy was 33.28 ± 60.91 days. The mean Dizziness Handicap Inventory (DHI) score was 51.6, which was in the severe range, and the mean Hospital Anxiety and Depression Scale (HADS) scores were 12.1 for anxiety and 9.0 for depression, indicating high levels of both anxiety and depression. The primary diagnosis was PPPD in 9 patients and psychogenic vertigo in 9 patients. There were no significant differences in the DHI and HADS scores between the two groups. The patients with dizziness lasting for more than 1 year reported more impairment in daily functioning due to dizziness than patients with dizziness lasting for less than 1 year. Psychotherapy proved effective in 7 patients (38.9%). The results of this study suggested that cases with severe handicap, psychiatric symptoms, and impaired life function were suitable for psychotherapy. The indications and effectiveness of psychotherapy in patients with chronic dizziness were clearly revealed in this study.

　　Introduction: Current treatment of Meniere's disease is limited to prevention of attacks by reducing endolymphatic hydrops. There is no treatment that provides immediate relief during the vertigo episodes. Thus, animal model experiments are needed being conducted to identify curative treatments for Meniere’s disease. Although animal models of endolymphatic hydrops for Meniere's disease exist, there are no animal models in which vertigo can be induced. In the present study, a mouse model was created to induce irritative nystagmus.

　　Methods: Ten male C 57 B 6 J mice aged 7-11 weeks old were used. Nystagmus was induced by intratympanic injection of 0.2 ml of 3.4 M potassium chloride solution at 37℃ into the left ear. The head was elevated to 40° from the natural body position. Nystagmus in both eyes was recorded with an infrared camera, and the horizontal and vertical eye movements were analyzed using a novel method developed by us.

　　Results: All mice showed a change from irritative to paralytic nystagmus, as seen in patients with Meniere's disease. Irritative nystagmus appeared 6.22 ± 0.83 min after the intratympanic injection and lasted for 4.42 ± 0.72 min. Subsequently, the irritative nystagmus changed to paralytic nystagmus.

　　Conclusion: We were able to create a mouse model of vertigo, in which we induced nystagmus that changed from the irritative to the paralytic type. This animal model could be useful in the future to develop a curative treatment for vertigo attacks in patients with Meniere's disease presenting with irritative nystagmus.

　　In the aging society, we often encounter elderly patients presenting with vertigo; however, it is not easy to determine which patients might require MRI. Therefore, we tried to screen for patients who might require to undergo MRI at a primary medical facility.

　　We retrospectively examined the records of patients who had developed the symptom of vertigo during the previous one year, who were older than 60 years of age, and in whom a clinical diagnosis had been made. Ten patients who showed acute/old infarcts or arterial stenosis/obstruction on brain MRI, or showed symptoms of TIA (transient ischemic attack), were diagnosed as having vertigo of central origin and were classified into the central group. Forty-six patients were diagnosed as having vertigo of peripheral origin and were classified into the peripheral group.

　　Comparison of the eye movements in these 2 groups revealed direction-fixed horizontal nystagmus and geotropic positional nystagmus only in the peripheral group, whereas, downbeat nystagmus was observed more frequently in the central group. In regard to the subjective description of vertigo, the central group mainly complained of vertigo without a rotating sensation, while the peripheral group mainly complained of vertigo with a rotating sensation.

　　In conclusion, MRI at a primary medical facility may be considered in patients complaining of vertigo without a rotating sensation and those showing downbeat nystagmus.