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Vestibular Disorders Thin a Few Weeks Or Months; in Some Cases, However, It Can Last for Years

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Vestibular Disorders Thin a Few Weeks Or Months; in Some Cases, However, It Can Last for Years Polski Przegląd Neurologiczny, 2008, tom 4, supl. A „benign” because it usually resolves spontaneously wi- Vestibular disorders thin a few weeks or months; in some cases, however, it can last for years. If left untreated, it persists in about Update on diagnosis and treatment 30% of patients. The canalolithiasis hypothesis explains Klaus Jahn, Michael Strupp all of the manifestations of positioning vertigo and ny- Department of Neurology, University of Munich stagmus. According to this hypothesis, the condition is due to the presence of agglomerates of many otoconia Key words: vestibular disorders, vertigo, dizziness that nearly fill the lumen of the semicircular canal and Abstract are freely mobile within it. BPPV is treated with positio- ning maneuvers: rapid repositioning of the head can move Vertigo is not a separate disease process, but a multi- the otoconial agglomerate out of the semicircular canal sensory and sensorimotor syndrome with various etiolo- so that it can no longer cause positioning vertigo. The gies and pathogeneses. It is among the most common symp- treatments of choice are the Semont and Epley maneu- toms presented to doctors, with a lifetime prevalence of vers. Most patients can perform these maneuvers them- around 20–30%. Patients have often consulted multiple selves after brief training. The cure rate is more than 95% physicians before a diagnosis is made and therapy can be within a few days, as shown by multiple controlled stu- initiated. A careful history remains the cornerstone of dia- dies and meta-analyses. The rate of recurrence of BPPV gnosis. Once the correct diagnosis is made, specific and is about 15–30% per year. effective treatments are available for most peripheral, cen- tral, and psychogenic forms of dizziness. Treatment may Vestibular neuritis include medication, physiotherapy, and psychotherapy; The clinical syndrome of vestibular neuritis is charac- a few limited cases may require surgical treatment. The terized by: treatment of choice for acute vestibular neuritis is the ad- • persistent rotational vertigo with a pathological incli- ministration of corticosteroids. Ménière’s disease is tre- nation of the visual vertical axis toward the side of ated with high-dose, long-term betahistine. the affected labyrinth; • spontaneous, horizontally rotating nystagmus toward The common types of dizziness and vertigo the unaffected side, producing apparent movement of and their treatment the environment („oscillopsia”); Peripheral vestibular vertigo • gait deviation and falling tendency toward the affec- A functional classification of peripheral vestibular di- ted side; sorders divides them into three main types, which can be • nausea and vomiting; distinguished on the basis of their typical symptoms and • unilateral dysfunction of the horizontal semicircular signs: canal, as revealed by the Halmagyi-Curthoys head im- • chronic, bilateral dysfunction of the vestibular nerve pulse test for the function of the vestibulo-ocular re- or the peripheral vestibular organs; flex, as well as by caloric testing. • acute, unilateral vestibular dysfunction; A viral and/or autoimmune etiology for vestibular neu- • paroxysmal pathological excitation or inhibition of the ritis is probable but has not yet been proven. The treat- vestibular nerve or vestibular organs. ment is symptomatic, causal, and physiotherapeutic: Benign paroxysmal positioning vertigo (BPPV) • symptomatic treatment: antivertiginous medications, This is the most common type of vertigo; it mainly af- such as 100–300 mg of dimenhydrinate in the first fects older patients and has a lifetime prevalence of 2.4%. three days if necessary to treat severe nausea and vo- It is characterized by brief attacks of rotational vertigo, miting; accompanied by vertical positioning nystagmus that ro- • „causal” treatment: methylprednisolone at an initial tates toward the lower of the two ears and beats toward dose of 100 mg daily, reduced in 20-mg steps every the forehead. The attacks are precipitated by reclination of four days, significantly improves the recovery of peri- the head, or by lateral positioning of the head or body, with pheral vestibular function; the affected ear downward. After a change in position of • physical therapy: a further principle of treatment is one of these types, rotational vertigo and nystagmus arise the promotion of central compensation by physical after a latency of a few seconds and then take a characteristic therapy. Equilibrium training significantly lessens the crescendo-decrescendo course, lasting in total 30–60 se- time required for vestibulospinal compensation and conds. The nystagmus corresponds to a so-called ampullo- postural regulation to develop. fugal excitation of the affected posterior vertical semi- Ménière’s disease circular canal of the affected ear. More than 90% of cases This condition is probably due to labyrinthine endo- are idiopathic; the remaining, symptomatic cases are most lymphatic hydrops with periodic rupturing of the mem- commonly due to head trauma, vestibular neuritis, or brane that separates the endolymphatic and perilympha- Ménière’s disease. BPPV also arises with greater than tic spaces. These ruptures precipitate the paroxysmal at- usual frequency after prolonged bed rest necessitated by tacks that last a few minutes to hours. A classic Ménière’s other diseases, or after surgery. BPPV of the horizontal attack consists of rotatory vertigo, tinnitus, hearing impa- semicircular canal is rare and is precipitated by rotation irment, and pressure sensation in one ear. The lifetime of the head in the recumbent position. BPPV is called prevalence of this condition is approximately 0.5%. It usu- www.ppn.viamedica.pl 30 Polski Przegląd Neurologiczny, 2008, tom 4, supl. A Tabela 2. Badanie przedmiotowe w zawrotach głowy Test Patologia Oczopląs spontaniczny P: Ostre jednostronne uszkodzenie przedsionka P: Obwodowy Z: centralny Z: Pień mózgu/móżdżek Z: Odruch oczno-przechyleniowy Z: Zaburzenia otolitowe obwodowe i centralne P: Head thrust (HT) dla kanału poziomego Ostre i przewlekłe jednostronne uszkodzenie przedsionka (zawsze obwodowe) Z: HT dla kanałów pionowych i otolitowy Head shaking Ostre i przewlekłe jednostronne uszkodzenie przedsionków (zawsze obwodowe) P: Poziomy Z: Pionowy Ruchy gałek ocznych i vertigo wywołane przez manewry P: BPPV Z: Vertigo położeniowe centralne, przetoka, dehiscencja kanału górnego P: Wolne śledzenie i sakkady Zaburzenia centralne Z: Skośne sakkady i hamowanie odruchu oczno-przedsionkowego Chód Przedsionkowe i centralne z zaburzeniami wyższych funkcji mózgowych lub bez takich zaburzeń P: Ocena jakościowa Z: Ocena ilościowa i z zadaniami P — podstawowy; Z — zaawansowany; BPPV (bening paroxysmal positional vertigo) — łagodne położeniowe zawroty głowy iting in the check-out line at a store; often, avoidance med by repeated exposure to the precipitating situation(s) behavior results. The symptoms typically improve when and by regular participation in sports; these activities the patient participates in sports or has had a small amo- strengthen the patient’s confidence in his or her own unt of alcohol to drink. The affected patients often have balancing ability; finally, if the symptoms persist, phar- an obsessive-compulsive personality, in the sense of macotherapy with a selective serotonin reuptake inhibi- „accentuated” personality traits, with a marked tendency tor and/or cognitive behavioral therapy can be initiated. toward introspection and a need to „have everything Combined therapy according to this approach leads to under control”. The central problem in phobic postural marked improvement in more than 70% of patients, even vertigo is the patient’s attempt to establish conscious con- if the disorder has been present for many years. trol over body equilibrium, which leads to a „spiral of self- -observation”. When this happens, the body’s own move- References ments may be perceived as movements of the outside 1. Brandt T. Phobic postural vertigo. Neurology 1996; 46: 1515–1519. 2. Brandt T. Vertigo –– its multisensory syndromes. 2nd edition. Springer, London world. The clinical neurological examination and ancil- 1999. lary tests reveal no relevant pathological findings. These 3. Huppert D., Strupp M., Theil D., Glaser M., Brandt T. Low recurrence rate of vestibular neuritis: a long-term follow-up. Neurology 2006; 67: 1870–1871. patients can be treated with three or four of the follo- 4. Neuhauser H.K. Epidemiology of vertigo. Curr. Opin. Neurol. 2007; 20: 40–46. wing measures: a thorough diagnostic assessment serves 5. Strupp M., Zingler V.C., Arbusow V. i wsp. Methylprednisolone, valacyclovir, or to reassure the patient that the symptoms are not caused the combination for vestibular neuritis. N. Engl. J. Med. 2004; 351: 28–35. by an organic disorder; psycho-educative explanation in- Adres do korespondencji: Klaus Jahn, MD forms the patient about the underlying mechanism of Department of Neurology, University of Munich excessive self-observation; desensitization can be perfor- Marchioninistr. 15, 81377 Munich, Germany e-mail: [email protected] www.ppn.viamedica.pl 32 Kurs 3. Zawroty głowy i zaburzenia gałkoruchowe ally begins on one side, and the frequency of attacks is Vestibular migraine or migraine with vestibular aura highly variable. Ménière’s disease becomes bilateral in 50% Vestibular migraine is characterized by recurrent at- of cases and is the second most common cause of bilateral tacks that last minutes to hours and usually consist of ro- vestibulopathy.
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