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Towards an International Classification of Vestibular Disorders Journal of Vestibular Research 19 (2009) 1–13 1 DOI 10.3233/VES-2009-0343 IOS Press Classification of vestibular symptoms: Towards an international classification of vestibular disorders First consensus document of the Committee for the Classification of Vestibular Disorders of the B ar´ any´ Society Alexandre Bisdorffa,∗, Michael Von Brevernb, Thomas Lempertc and David E. Newman-Tokerd aDepartment of Neurology, Centre Hospitalier Emile Mayrisch, L-4005 Esch-sur-Alzette, Luxembourg bVestibular Research Group Berlin, Department of Neurology, Park-Klinik Weissensee, Berlin, Germany cVestibular Research Group Berlin, Department of Neurology, Schlosspark-Klinik, Berlin, Germany dDepartment of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA On behalf of the Committee for the Classification of Vestibular Disorders of the Bar´ any´ Society: Pierre Bertholon, Alexandre Bisdorff, Adolfo Bronstein, Herman Kingma, Thomas Lempert, Jose Antonio Lopez Escamez, Måns Magnusson, Lloyd B. Minor, David E. Newman-Toker, Nicolas´ Perez,´ Philippe Perrin, Mamoru Suzuki, Michael von Brevern, John Waterston and Toshiaki Yagi Received 4 February 2009 Accepted 1 September 2009 1. Introduction such as psychiatry and headache, where often there is no histopathologic, radiographic, physiologic, or other The Committee for Classification of Vestibular Dis- independent diagnostic standard available. However, orders of the Bar´ any´ Society was inaugurated at the diagnostic standards and classification are also crucial meeting of the Bar´ any´ Society in Uppsala 2006. Its in areas of medicine such as epilepsy and rheumatolo- charge is to promote development of an implementable gy, where, although confirmatory tests do exist, there classification of vestibular disorders. is substantial overlap in clinical features or biomarkers Symptom and disease definitions are a fundamen- across syndromes. tal prerequisite for professional communication both in Interestingly, not only scientific and therapeutic clinical and research settings. However, the perceived progress but also public awareness of psychiatric and need for a formalized classification system, uniform headache disorders has vastly increased after the in- definitions, or explicit diagnostic criteria varies some- troduction of the Diagnostic and Statistical Manual what by discipline. Having structured criteria for di- of Mental Disorders (DSM) by the American Acade- agnosis is obviously mandatory for disciplines which my of Psychiatry and the International Classification rely heavily on symptom-driven syndromic diagnosis, of Headache Disorders (ICHD) by the International Headache Society (IHS). In contrast, vestibular nomen- ∗ clature remains in its infancy. Other than the definition Corresponding author: Alexandre Bisdorff, Department of Neu- rology, Centre Hospitalier Emile Mayrisch, L-4005 Esch-sur-Alzette, of Meniere` disease by the American Academy of Oto- Luxembourg. E-mail: [email protected]. laryngology – Head and Neck Surgery (AAOHNS) [3] ISSN 0957-4271/09/$17.00 2009 – IOS Press and the authors. All rights reserved 2 A. Bisdorff et al. / Classification of vestibular symptoms: Towards an international classification of vestibular disorders and the Classification of Peripheral Vestibular Dis- A small working group of clinicians formed a Classifi- orders by the Spanish Society of Otorhinolaryngolo- cation Committee and began to draft the concept of the gy [4], we are unaware of other systematic efforts to approach, analysing what existed in this area and what create widely accepted classification criteria. prior models to follow. The International Headache Although numerous advances in vestibular research Society’s International Classification of Headache Dis- have been made over the past several decades, there orders [7] provided the most inspiration. is now mounting evidence that the field may be ham- Since there is no consensus on the use of terms to pered moving forward by the lack of explicit and describe vestibular symptoms, the Committee decided uniform criteria for various clinical disorders. For to initiate the classification process by first defining and example, witness the ongoing controversy surround- building consensus around formalized definitions of ing the distinction between “vestibular migraine” and key vestibular symptoms. This document would then, “vestibular Meniere` disease” [2] or the varied use of the in turn, serve as a basis for a subsequent classification terms “vestibular neuritis,” “cochleovestibular neuri- of specific vestibular disorders. It was agreed upon tis,” “labyrinthitis,” “cochleolabyrinthitis,” and “acute that the definitions should cover all principal symptoms peripheral vestibulopathy” in the medical literature. thought to arise from disturbances of the vestibular Worse yet, problems of terminology have now been system, with this system defined broadly as the sensory demonstrated at the level of describing core vestibular inputs, central processing and motor outputs that relate symptoms such as dizziness and vertigo. Even when to balance. studied in a single, English-speaking country, the term The discussion gradually involved members and “vertigo” has been shown to have diverse meanings for opinion leaders worldwide, mainly through electronic patients [5], generalist physicians [6] and even otolo- communications as well as several in-person meetings gists [6]. and phone conferences. The task was to make the best We believe the time is right to pursue development of compromise between traditional use of terms, modern the first International Classification of Vestibular Disor- developments, and practicability in the research and ders (ICVD-I). Initially, we expect its predominant use clinical settings. A first draft was presented at the XXV would be to guide investigators conducting clinically- Bar´ any´ Society Meeting in Kyoto in April 2008 [8,9] oriented vestibular research. It is our belief that, over with the opportunity for the delegates to discuss and time, well-honed research criteria will gradually spread cast votes on controversial issues from the Committee’s to use in the clinical domain. We envision a staged discussions. and iterative development process that involves interna- The input from the Kyoto Meeting was very help- tional experts from both neurology and otolaryngology ful for the Classification Committee to see what defi- backgrounds. It is our hope that the Bar´ any´ Society will nitions were easily accepted and which were rejected partner with the AAOHNS and other neuro-otological or required further clarification. The draft was then associations who are willing to promote this project, discussed at the annual meeting in May 2008 in Lau- including funding agencies whose priorities are to sup- sanne, Switzerland of the French speaking Societ´ e´ In- port vestibular research. To initiate this process, the ternationale d’Otoneurologie. Members of the latter Committee sought first to define key vestibular symp- society as well as members of the Spanish Comision´ toms as a basis for a subsequent classification of spe- de Otoneurolog´ıa de la Sociedad Espanola˜ de Otorrino- cific vestibular disorders and then to build consensus laringolog´ıa and the American Academy of Otolaryn- around these formalized definitions. gology – Head and Neck Surgery (AAOHNS) joined the Bar´ any´ Society’s Classification Committee to final- ize the present classification. 2. Methods The Bar´ any´ Society is an international society com- 3. Results prised of vestibular experts with a wide range of back- grounds from basic science, bioengineering, and space In the attached document (Appendix 1), we present flight to clinical medicine and physiotherapy. At the the first iteration of a consensus classification of XXIV Bar´ any´ Society Meeting 2006 in Uppsala, Swe- vestibular symptoms (ICVD-I: Classification of Symp- den, the General Assembly decided to launch an initia- toms v 1.0) produced by the committee. The commit- tive to elaborate a classification of vestibular disorders. tee also developed an algorithm to facilitate coding of A. Bisdorff et al. / Classification of vestibular symptoms: Towards an international classification of vestibular disorders 3 symptoms observed in a particular patient (Appendix the head to a new position, rather than the attainment 2). Several broad principles were agreed upon as part and maintenance of that new head position. The com- of the consensus building process: mittee’s consensus, however, was that this differenti- ation was impractical given the relatively obtuse na- 1) Symptoms chosen for definition should be broad ture of the distinction and well-established status of the enough to cover the spectrum of clinical symp- symptom positional vertigo. toms typically resulting from vestibular disorders The introduction of a separate category on vestibulo- yet specific enough to enable effective research. visual symptoms was unanimously considered impor- 2) No “vestibular” symptom has a totally specific tant, but the specific symptom definitions generated meaning in terms of topology or nosology and its much discussion. The fact that vestibular dysfunction pathogenesis is likely to be incompletely under- can result in a range of visual disturbances is not always stood. well understood outside the vestibular community. De- 3) Symptom definitions should be as purely phe- veloping a category devoted to these symptoms was, in nomenological as possible without reference to a part, an explicit attempt to promote awareness around theory on pathophysiologyor
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