The Niigata PPPD Questionnaire (NPQ) is a useful tool for screening and assessing the severity of Persistent Postural-Perceptual Dizziness (PPPD), the most common form of chronic dizziness encountered in practice. The NPQ is primarily a screening tool that allows PPPD to be suspected at the initial visit. A total score of ≥27 and/or a visual stimulation score of ≥9 are threshold values to identify 70%–80% of patients with PPPD. In patients diagnosed as having PPPD, use of the NPQ before the start of treatment and 1, 3, 6, and 12 months after the start of treatment may be recommended to assess the disease severity and treatment outcomes. Reduction in the total score by more than 13 points, in the score for upright posture/walking by more than 7 points, in the movement by more than 5 points, and in the visual stimulation factor by more than 5 points may be considered as reflecting significant improvement. Based on analysis of the responses to the NPQ, PPPD has been subdivided into three subtypes: the visual-dominant subtype, the active motion-dominant subtype, and the mixed subtype.

The Dix-Hallpike test and supine head roll test are head positioning nystagmus tests that are mainly used for the diagnosis of benign paroxysmal positional vertigo (BPPV) and identification of the affected side. There are several issues to consider while performing these tests, and those performing the tests should have a common understanding. The Dix-Hallpike test must be performed on both sides, but if the head torsion angle is large, it may lead to misdiagnosis of bilateral posterior canal-BPPV. In addition, the speed of head positioning must be fast. In Japan, the supine head roll test is often performed in the supine position without the head raised by 30 degrees. By changing the head position between the left and right ear-down positions at approximately the same angle and at the same speed, and with the assumption that the otoliths move the same distance in the same area, the affected side can be estimated by Ewald's law. Elevating the head by 30 degrees while the patient lies supine is not always necessary. In lateral canal BPPV-canalolithiasis, nystagmus induced by rapid head positioning is strong, while in lateral canal BPPV-cupulolithiasis, there is no difference in the intensity of the induced nystagmus depending on the speed of head positioning. Therefore, head positioning should be performed quickly. However, to evaluate the affected side in lateral-canal BPPV, findings of lying-down nystagmus and positional nystagmus in the sagittal plane (face-up supine, sitting and prone positions) are required, in addition to performance of the supine head roll test.

Background: The relationship between cisplatin and vestibular function still remains controversial. Some clinical and animal studies have reported high-frequency vestibulo-ocular reflex (VOR) impairments induced by cisplatin. The video head impulse test (vHIT) may enable clinicians to detect the effects of cisplatin therapy in the high frequency range of the VOR.

Materials and Methods: The subjects were two males with laryngeal cancer and five females with uterine cervical cancer (mean age: 59.4 years) who received treatment with cisplatin. The vHIT and the subjective visual vertical (SVV) measured by the bucket method were examined before the start of cisplatin and after every cycle (weekly 40 mg/m² or triweekly 80 mg/m²) of cisplatin-based therapy. Air conduction hearing was also evaluated in the patients with uterine cervical cancer.

Results: The group mean VOR did not differ significantly depending on the cumulative cisplatin dose in the range of 0 to 240 mg/m². However, five and two patients exhibited an increase and decrease, respectively, of the VOR gain outside the normal range (0.8–1.2). Furthermore, two patients also exhibited covert catch-up saccades. The occurrence of covert saccades was not correlated with the VOR gain, but increased as the cumulative cisplatin dose increased. No significant change in the SVV was observed either during or after the treatment. The hearing levels fluctuated slightly. The ranges of fluctuation at 500 and 1000 Hz were smaller than that at other frequencies.

Conclusion: Cisplatin did not impair the functions of the semicircular canals at moderate doses, on average. However, some patients exhibited decrease and increase of the VOR gain and covert saccades. The increase in VOR gain and covert saccades was possibly associated with slight cisplatin-induced vestibulopathy or endolymphatic hydrops. vHIT is a simple tool to monitor the functions of the semicircular canals during and after cisplatin treatment.

Response to treatment with carbamazepine or oxcarbazepine is a criterion for the diagnosis of vestibular paroxysmia (VP). In this report, we describe two suspected cases of VP based on their clinical symptoms and response to carbamazepine. Although these patients responded to carbamazepine, they did not meet the diagnostic criteria for VP. Therefore, based on our clinical findings from these cases, carbamazepine may be effective in treating patients with vertigo just as it is in patients with VP. In VP, carbamazepine regulates pathological neurotransmission by controlling sodium metabolism in the cerebellar pontine angle and inner ear canal. Additionally, it may be effective for treating conditions similar to VP, such as neurovascular compression syndrome and vertebrobasilar artery circulatory disorders. In the first case, the patient was a 70-year-old man who frequently presented with dizziness. An MRI of the head revealed vascular compression in the inner ear canal. The second case was that of a 59-year-old man who repeatedly had episodes of vertigo. Investigations, including MRI and MRA, showed a vertebral artery insufficiency. Both patients responded to carbamazepine but did not fully meet the diagnostic criteria for VP.

Refractory cases of benign paroxysmal positional vertigo (BPPV) are characterized by bilateral onset, frequent recurrence, and various subtypes. Etiology and pathophysiology were assessed in 35 cases of refractory BPPV that required multiple rounds of treatment (>10 times) in 1 year after undergoing the canalith repositioning procedure (CRP). The conditions were investigated based on patients’ clinical courses after undergoing CRP. Additionally, the treatment approaches were evaluated. The suspected causes of refractory BPPV included systemic or local otolith organ damage (97%), CRP failure (71%): lack of effective CRP for BPPV-cupulolithiasis; canalith jam caused by the size and number of otoliths in the semicircular canals, re-entry and canal conversion (34%): habitual head position during sleep with the affected-ear-down, and complications of secondary BPPV and central disorders (31%). The pathological conditions often coexisted. Recommended treatment approaches include measurement of vitamin D and prescription of supplements, extension of the time for maintaining head position at 135° with the healthy-ear-down, tapping of the affected temporal region, and keeping the patients’ heads with the affected-ear-up during sleep on the day of CRP.

In this study, we evaluated the diagnosis and factors underlying the development of intractable dizziness/vertigo in patients managed at a university hospital by retrospective analysis of patients’ medical records. The participants included 78 patients, comprising 35 men and 43 women, who visited our outpatient department on account of intractable dizziness between April 2021 and December 2022. The associations between the duration of illness and 10 different variables were evaluated. The median age was 65.5 years, and the median duration of illness was 305.5 days. Among the patients, 60% were referred from otorhinolaryngology departments. Other peripheral vertigo conditions associated with vestibular dysfunction formed the most commonly diagnosed conditions, followed by benign paroxysmal positional vertigo, dizziness of unknown cause, Meniere’s disease, vertigo-associated primary headache, persistent postural perceptual dizziness, central vertigo, and orthostatic dizziness. Among the other peripheral vertigo conditions associated with vestibular dysfunction, compensatory vestibular insufficiency was suggested to be present in 12 patients. Ten of these patients were aged. In most cases of unknown cause, lack of characteristic findings or additional investigations underlie the lack of a known cause. Multivariate analysis revealed that age and comorbidity of multiple dizziness disorders are factors associated with the duration of illness. In diagnosing refractory vertigo, loss of characteristic findings, prolonged vestibular decompensation, necessity of examination in other departments, comorbidity of multiple dizziness disorders, and repetitive nature of the disease should be considered. In older patients with multiple episodes of dizziness, diagnosis and treatment should be made with consideration for the prolonged duration of illness.

Dizziness is a commonly reported symptom that often becomes chronic. This article describes the basic concepts of cognitive behavioral therapy (CBT) and the clinical presentation of patients with dizziness from a CBT perspective, followed by a report on the practice of CBT for patients with chronic dizziness at our department. Finally, we discuss the usefulness and limitations of CBT as a treatment strategy for chronic dizziness and compare them with those of other treatment methods.

CBT is a treatment method in which the therapist organizes the patient’s problems and attempts to improve or solve them by teaching the patient problem-solving skills and self-control training. In CBT, the pathology of chronic dizziness is understood through the cognitive-behavioral model and fear-avoidance model. Chronic dizziness patients suffer from characteristic cognitive and behavioral problems that arise from experiencing the dizziness symptom. CBT is aimed at resolving these cognitive and behavioral issues in an attempt to improve the patients’ symptoms and enhance the patients’ quality of life.

Our research group developed and implemented a CBT program for a group of chronic dizziness patients. The results showed improvements in anxiety, depression, dizziness-related functional impairment, and dizziness exacerbation factors, with no adverse events observed. CBT can contribute to improvement of the dizziness symptom by modifying the patients’ attention to and evaluation of their own dizziness.

Comparison of CBT with other treatments revealed that the results of CBT were comparable to those of pharmacotherapy and that CBT may share some commonalities with vestibular rehabilitation. CBT is a broad-spectrum intervention based on a model of symptom exacerbation and maintenance, regardless of the cause. Although this article reports the treatment efficacy of CBT in our practice and suggests that it may yield outcomes comparable to pharmacotherapy, evidence in Japan still remains limited.