Treatment:
Particle repositioning maneuvers (Epley’s canalith-repositioning
maneuver) (Image 2) was observed to be most used method for the
management of the dizziness. The patients with posterior canal BPPV were
treated with Epley’s canalith-repositioning maneuver. Subjects with
lateral canal BPPV were treated with Barbecue Roll maneuver. All other
subgroups were treated as per standard pre-existing management
guidelines, which also included neurology/ neurosurgery/ psychiatry
referrals. The patients with recurrence required further testing and
multidisciplinary team management.
DHI score :
The average baseline DHI score was 19.37 (± 13.46) with range of 0 to
64, which reduced to 9.22 (±10.94) 3 weeks after treatment (p value
<0.0001) as presented in Fig.3.
Discussion :
In our study population 58.61% of the subjects were male. The average
age of study population was 42.69 years. However, Neuhauser, H K
reported that dizziness is two to three times more prevalent in women
than in men[14]. A neurotologic survey study reported that the
prevalence of vestibular-borne dizziness in adults with ages 18 to 79
years was estimated at 7.4% (95% CI: 6.5 to 8.3%), and the frequency
was three times greater in the elderly than in young adults [15,
18].
Diagnosing causes of dizziness can be difficult due to the subjective,
non-specific symptom and with wide range of differential diagnosis.
Hence, patient centric history taking is most important for
understanding and the management. History taking should focus on
dizziness description as well as prior medication. Questioning regarding
symptoms, frequency of occurrence, time of onset, duration and trigger
for dizziness and associated symptoms would help to narrow the diagnosis
of dizziness. This approach is known as ‘SO STONED’. ‘SO STONED’ stand
for (i) S = Symptoms: Characterization of the symptoms helps to locate
the problem (ii) O= Often: Frequency of attack of vertigo /dizziness
(iii) S = Since: This focuses on how long the symptoms already exist
(iv) T=Trigger: A specific act or situation that provokes or aggravates
(v) O = Otology (vi) N = Neurology: To rule out lesions of the central
nervous system (vii) E = Evolution: Evolution of symptoms (viii) D =
Duration: It is particularly important for differential diagnosis
[24].In the present study mostly reported associated symptom was
nausea/vomiting and the trigger was ‘head movement’. 46.27% of the
patients reported the duration of dizziness to be few seconds-minutes.
TiTrATE is also a patient assessment tool for vertigo / dizziness
[13]. The approach uses the Timing of the symptom, the Triggers that
provoke the symptom, And a Targeted Examination. The responses place the
dizziness into one of three clinical scenarios: episodic triggered,
spontaneous episodic, or continuous vestibular [10]. Similarly, HINT
(HI: Head Impulse, N: Nystagmus direction and TS: Testing Skew) is a
diagnostic tool for dizziness proposed to differentiate between acute
peripheral vestibular lesions from central [7]. In
our study most cases of dizziness were due to the peripheral causes.
ICVD-I by the Committee for the Classification of Vestibular Disorders
of the Barany Society classified vertigo and dizziness based on the
description as (i) Vertigo (ii) Dizziness (iii) Vestibulo-visual
symptoms (iv) Postural symptoms [2]. In our study population,
vertigo [spinning dizziness] (65.30%) was the most common type
followed by vestibulo visual [disequilibrium] (17.22%) and postural
symptoms [lightheadedness] (13.11%). A study Post, Robert E et al
similarly reported vertigo (45-54%) to be a common type followed by
disequilibrium (up to 16%), presyncope (up to 14%) and lightheadedness
(approximately 10%) [16].
ICVD-I by the Committee for the Classification of Vestibular Disorders
of the Barany Society further classified vertigo and dizziness based on
the trigger as spontaneous and triggered [2]. In the present study
head motion (61.18%) was the most reported trigger. Only two subjects
reported sound-induced dizziness and one subject had trauma. For 148
(38.05%) subjects, dizziness was spontaneous.
Vertigo includes BPPV, vestibular neuritis (viral infection of the
vestibular nerve), labyrinthitis (infection of the labyrinthine organs),
and Meniere disease (increased endolymphatic fluid in the inner ear)
[5,16]., Poor vision commonly observed with
disequilibrium [16]. TIA and stoke are important causes underlying
disequilibrium [16]. Kerber, Kevin A et al reported that 0.7%
patients with isolated dizziness symptom had a stroke/TIA [8]. In
the present study two subjects were diagnosed with TIA.
BPPV is the most common cause of dizziness/vertigo worldwide with a
lifetime prevalence of 2.4%, a 1-year prevalence of 1.6%, and 1-year
incidence of 0.6% [9, 22]. This concurs with our study findings
where 56.30% subjects were diagnosed with BPPV.
The Dix-Hallpike maneuver is a diagnostic tool for BPPV. The
Dix-Hallpike maneuver is the gold standard for diagnosing benign
positional paroxysmal vertigo caused by a posterior canal
otolith[1]. It was the most used diagnostic modality in our study.
Presently accepted treatment for BPPV is the canalith repositioning
maneuver (CRM) described by Epley in 1992 [4]. It was the most and
successfully used management in our study. This concurs with the
meta-analysis findings by Prim-Espada, M P et al, who reported that, the
BPPV patients managed by Epley’s maneuver had a six and half times more
chance of improvement in the clinical symptoms [17]. Wang, Yi-Hong
et al, in the study for BPPV management in primary care recommend the
use of the Epley’s maneuver and barbecue roll for the treatment of
posterior semicircular canal-BPPV and horizontal semicircular
canal-BPPV, respectively [23].
The eyes move in the direction of the endolymph in the semicircular
canals. The endolymph movement in the canal either stimulates or
inhibits the respective canals. The horizontal canals try to push the
eyeballs to the opposite side whereas the vertical Canals try to pull
the eyeball in their respective planes. The Superior ( Anterior) Canal
tries to pull the eyeball up whereas the Inferior(Posterior) canal tries
to pull the eyeball down following the Ewald’s second and third law.
In Dix Hallpike test a down beating nystagmus in supine position (right
or left) indicates Anterior canal and up beating nystagmus indicates
Posterior canal involvement. If posterior canal is involved ( upbeat
nystagmus), side can be determined either by side on which nystagmus is
seen, or if seen on both sides ( bilateral posterior canal BPPV), by the
direction of torsional component. Torsional component direction can be
made more obvious by asking patient to look down while performing in Dix
Hallpike test, and torsional component would beat in the direction of
the involved canal. After being sure of side, Epley’s maneuver or
Semont’s maneuver for that side can be done. If despite proper side
localization and despite repeated Epley’s or Semont’s, patient is not
relieved of symptoms, recalcitrant or short arm posterior canal BPPV
should be considered. In which case, the supine head flexion test should
be done to look for up-beating nystagmus. The presence of upbeat
pseudo-spontaneous nystagmus in sitting position would also give a clue
for same.
Lateral ( Horizontal) canalolithiasis is characterized by a geotropic
nystagmus whereas cupulolithiasis is characterized by apogeotropic
nystagmus in any lateral positions. Most intense nystagmus gives the
side of canal involved irrespective of canalolithiasis and less intense
the side of cupulolithiasis . In geotropic variant turning to the
affected side gives maximum intensity nystagmus and in apogeotropic
turning to the affected side gives less intensity nystagmus. In supine
position nystagmus is on the opposite side in canalolithiasis and same
side in cupulolithiasis. In geotropic variant ( bowing / pitch forward)
the direction of nystagmus gives side of the affected ear. In
apogeotropic variant (leaning backwards / pitch backwards) the direction
of nystagmus gives side of the affected ear. Initial pseudo-spontaneous
nystagmus in canalolithiasis will be towards the opposite side.
If anterior canal involvement can also be confirmed with supine head
extension test and , irrespective of side, the Yacovino maneuver is
advised to correct it.
Dyslipidemia was the common most comorbidity in our study population
followed by hypertension, and diabetes mellitus. The role of
comorbidities (dyslipidemia, hypertension, and diabetes mellitus in
peripheral vestibular diseases is a matter of further research. As our
study was retrospective and we did not intend to find any correlation
between comorbidities and vertigo / dizziness. It would be difficult for
us to comment on the co-relation of comorbidities with peripheral
dizziness. However, a study by Shreenivas V reported that the presence
of comorbidities worsens the status of BPPV and increases the risk of
recurrence even after successful repositioning maneuver [19]. There
are also studies showing correlation between comorbidities and
vestibulopathies [12, 21].
In the present study, the average baseline DHI score was 19.37 (± 13.46)
with range of 0 to 64, which reduced to 9.22 (±10.94) three weeks after
treatment (p value <0.0001); showing improvement in the
symptoms as well as QOL. Most causes of dizziness were peripheral.
Conclusion :
Vertigo / dizziness related to peripheral causes accounts for a
significant proportion of cases in routine otolaryngology practice. From
our study we can easily conclude that vertigo / dizziness related
disorders negatively affect QOL. Proper diagnosis and management would
help to improve the symptoms and QOL. Simple office-based,
patient-oriented detail history taking, and clinical examination is
important in the diagnosis and management of the dizziness. History
taking or questions should focus on the type of dizziness, associated
features, duration, and triggers which would help in pinpointing
differential diagnosis and the management. Red flags like focal
neurological signs should be taken seriously and investigated further.
List of abbreviations :
BPPV: Benign paroxysmal positional vertigo
DHI: Dizziness Handicap Inventory
ICVD-I: International Classification of Vestibular Disorders I
QOL: Quality of life
TIA: Transient ischemic attack
References: