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Occupational Exposures Tied to Higher Risk for Vertigo

Occupational exposure to noise and/or vibrations is associated with the presence of vertigo, according to a study recently published in the Journal of Clinical Medicine.

Inés Sánchez-Sellero, Ph.D., and Andrés Soto-Varela, Ph.D., both from Universidade de Santiago de Compostela in Spain, and colleagues examined the relationship between occupational noise and/or vibration exposure and vertigo. The analysis included 393 patients (193 with Meniere disease, 63 with vestibular migraine, 21 with vestibular neuritis, and 116 with benign paroxysmal positional vertigo), as well as data from the general population.

The researchers found that differences in the distribution of occupations between patients with vertigo and the general population were significant (Chi-square, P = 4.065 × e−20). Additionally, patients with vertigo had significantly more exposure to noise (Fisher's exact test, P = 2.97 × e−10; odds ratio, 2.595) and vibrations (Fisher's exact test, P = 6.23 × e−10; odds ratio, 2.722) compared with the control group. Findings were similar for both men and women.

"A relationship between occupational exposure to noise and/or vibrations and the presence of vertigo was observed," the authors write. "Protective and preventive measures could help prevent the occurrence of some diseases involving vertigo."

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Recording of Nystagmus During Vertigo in Meniere Disease May Offer Therapeutic Aid

Nystagmus during vertigo attacks in patients with Meniere disease can be video-recorded with a mobile phone and provide a helpful therapeutic aid, according to a study published online Dec. 12 in the Journal of Clinical Medicine.

Valéria Ionescu, from the Centre Hospitalier Universitaire de Saint Etienne in France, and colleagues describe the characteristics of nystagmus during vertigo attacks, the feasibility of self-video recording of eye movements by mobile phone, and the therapeutic implication of nystagmus. Patients with definite MD according to the Barany Society were included in the study; they were recorded during their attacks by videonystagmoscopy by the physician and/or mobile phone by the patient or immediate surroundings.

Overall, eight, eight, and one patients were video-recorded by mobile phone, videonystagmoscopy, or both, respectively. The researchers found that in 14 patients (seven irritative type, five deficit type, and two changed from deficit to irritative type), the nystagmus was horizontal. In three patients, the nystagmus was vertical (two down-beating and one up-beating); in two patients, the vertical nystagmus changed to a more classical horizontal nystagmus.

"The direction of the nystagmus during vertigo attacks in MD is mostly horizontal, although it can be vertical and can change direction," the authors write. "From a diagnostic point of view, the direction of the nystagmus is of no value to deducing the affected side in MD. The nystagmus during vertigo attacks can be video-recorded by the mobile phone of the patient, which is objective proof of the impact on daily life and confirms a disabling MD. From a therapeutic point of view, this was a helpful aid when chemical labyrinthectomy was being considered."

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Triple Semicircular Canal Plugging Effective for Vertigo Control in Meniere Disease

Triple semicircular canal plugging (TSCP) is effective for vertigo control but is associated with a risk for hearing loss in patients with Meniere disease (MD), according to a systematic review and meta-analysis published online Dec. 5 in PLOS ONE.

Jia quan Zhu, from Fengdu General Hospital in Chongqing, China, and colleagues conducted a meta-analysis involving 367 patients with MD from seven studies to examine the effects of TSCP on hearing. The studies reported on duration, follow-up time, hearing loss, and vertigo control outcomes in patients with MD.

The researchers found that TSCP efficiently alleviated vertigo with a rate of 99 percent and yielded a rate of hearing loss of 22 percent. In a subgroup analysis, for hearing loss, 14 and 24 percent of patients had disease duration of more than or less than 12 months, respectively. The corresponding rates of vertigo control were 100.0 and 99.0 percent. Hearing loss rates were 23 and 20 percent in studies with follow-up time of more than or less than 24 months, respectively. The corresponding rates for vertigo control were 99.0 and 99.0 percent. Disease duration and follow-up time had no significant impact on hearing loss or vertigo control rates.

"In MD patients who have failed to control the symptoms by conventional treatment or nondestructive surgery such as an endolymphatic capsule, TSCP can not only effectively relieve vertigo, but also preserve residual hearing in most patients," the authors write.

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Acupuncture May Improve Meniere Disease Symptoms

Acupuncture may improve the symptoms of vertigo, tinnitus, ear fullness, and hearing loss in patients with Meniere disease, according to a review published online Dec. 10 in Frontiers in Medicine.

Mingjie Tang, from the Nanjing University of Chinese Medicine in China, and colleagues conducted a systematic literature review to evaluate the efficacy of acupuncture treatment for Meniere disease.

Based on six studies, the researchers found that treatment of Meniere disease with acupuncture or acupuncture combined with Western medicine was superior to Western medicine alone (control) in terms of efficacy rate (risk ratio, 1.20). Compared with control, acupuncture also reduced the dizziness handicap inventory (mean difference [MD], 6.94), tinnitus handicap inventory (MD, 6.52), stuffy ear visual analog scale (MD, 0.87), and pure tone audiometry score (MD, 6.57). Methodological shortcomings included failure to implement blinding, inappropriate outcome measures, and heterogeneity of clinical interventions, such as selected acupoints, acupuncture sessions, and therapist techniques.

"Due to the lack of literature included in this study and methodological weaknesses like randomization, blinding, and clinical heterogeneity, more well-designed long-term follow-up randomized controlled trials are needed to evaluate the efficacy and safety of acupuncture," the authors write.

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Most With Intractable Meniere Disease Experience Symptom Relief

Most patients with intractable Meniere disease (MD) experience symptom relief over time, according to a study published online Oct. 23 in Frontiers in Neurology.

F.R. Gerritsen, from Haga Hospital in The Hague, Netherlands, and colleagues described the evolution of vertigo attacks among patients with intractable MD in whom surgery was considered in a retrospective cohort study. Patients with definite unilateral MD and persisting vertigo attacks despite intratympanic steroid injection treatment were included in the study. All patients had been wait-listed for participation in a trial examining nonablative surgery; they were wait-listed between June 2016 and June 2021. To assess the evolution of the vertigo attacks, their data were collected in September 2022.

The analysis included 35 patients; 25 (71 percent) declined surgery. The researchers found that 21 of the 33 patients (64 percent) with complete information on vertigo attacks were free of vertigo attacks on data collection after a median disease duration of 5.3 years. The duration of disease was longer for patients who did versus those who did not undergo surgery.

"The current population was thought to suffer intractable disease, and yet most patients experienced relieve of symptoms in just over one year," the authors write. "Knowledge of the generally benign evolution of MD may be of value for patients and clinicians when weighing treatment options."

One author was employed by The Novo Nordisk Foundation Center for Stem Cell Medicine.

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Symptom Pattern of Meniere Disease Often Changes Over Time

Meniere disease (MD) shows a complex disease course, with initial symptoms decreasing and others persisting and worsening over time, according to a study published online Nov. 7 in Frontiers in Neurology.

Ilmari Pyykko, M.D., from Tampere University in Finland, and colleagues analyzed the symptom profile of MD with a focus on the cessation of episodic vertigo, the longitudinal disease course, and the impact of major symptoms on quality of life (QoL). The analysis included 365 patients with definite MD.

The researchers found that the onset of MD was characterized by simultaneous hearing loss, vertigo, and tinnitus in 38 percent of participants. Many experienced a significant delay in diagnosis, with 20 percent experiencing a delay of more than five years. Over time, the frequency and duration of vertigo attacks generally decreased, with attacks becoming shorter and less severe as the disease progressed. One-third of patients (34 percent) had spontaneous remission from episodic vertigo. Additionally, 65.5 percent of participants reported balance issues, 34 percent mild vestibular drop attacks (VDAs), and 10 percent severe falls. Longer disease duration was associated with VDAs. More than one-third of patients (34.5 percent) developed bilateral hearing loss, with a higher risk associated with younger age at onset, migraines, and family history of MD. Participants with constant dizziness and with factors like fatigue, depression, VDA, and hearing loss experienced lower QoL.

"Assessing MD solely on primary symptoms like vertigo and hearing loss is insufficient; a comprehensive evaluation is necessary for effective management," the authors write.

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Study Looks at Hearing, Balance in Adolescent Meniere Disease

Adolescent Meniere disease (MD) has a higher pure-tone average threshold, lower speech discrimination score, and lower otoacoustic emission pass rates than recurrent vertigo of childhood (RVC), according to a study published in the August issue of Laryngoscope: Investigative Otolaryngology.

Xiaofei Li, M.D., Ph.D., from Shandong University in Jinan, China, and colleagues examined clinical features in adolescent MD in a retrospective analysis of the medical records of adolescents with MD (aged 11 to 17 years). Features were compared to those with RVC.

The researchers found that adolescent MD showed a higher pure-tone average threshold compared with RVC, a lower speech discrimination score, and lower otoacoustic emission pass rates. A significant reduction in equilibrium score, composite sensory score, and vestibular sensory score was exhibited by adolescents with MD. Compared with adolescents with unilateral MD, those with bilateral MD exhibited worse performance in equilibrium score and strategy score. The more severe endolymphatic hydrops detected by gadolinium-enhanced magnetic resonance imaging, the higher the auditory brainstem response threshold and the lower the otoacoustic emission pass rate for the affected ear.

"Adolescents with MD have similar vestibular information inputs with that of RVC, but the ability for the nerve center to use these clues to maintain balance is worse in adolescents with MD," the authors write. "There were potential differences in vestibular weights in adolescents with unilateral and bilateral MD, also potential effects on vision and proprioception."

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Vestibular Neurectomy Effective for Severe Meniere Disease

Vestibular neurectomy is an effective vertigo treatment in patients with severe Meniere disease, according to a study published online June 7 in the Journal of Clinical Medicine.

Agnieszka Jasińska-Nowacka, M.D., Ph.D., from the Medical University of Warsaw in Poland, and colleagues evaluated functional outcomes and balance compensation in patients with severe Meniere disease after vestibular neurectomy. The analysis included data from 20 patients with unilateral Meniere disease before and two years after vestibular neurectomy.

The researchers found that all patients reported a complete resolution of vertigo attacks after the vestibular neurectomy, while 95 percent of patients reported functional-level improvement according to a scale proposed by the American Academy of Otolaryngology-Head and Neck Surgery. All patients showed clinical improvement in the Dizziness Handicap Inventory, with the average result decreasing from 81.7 to 16.4. There were no statistically significant differences between the sensory organization test results before and after vestibular neurectomy. There were significant correlations between a patient’s age and postoperative results of the Dizziness Handicap Inventory and posturography.

"Vestibular neurectomy is an effective vertigo treatment in patients with severe Meniere disease with no clinical improvement despite conservative treatment," the authors write. "It results in subjective physical, functional, and emotional improvement, enabling patients to return to daily activities and work."

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Vestibular Neurectomy Effective for Meniere Disease

For patients with Meniere disease (MD), vestibular neurectomy is effective, resolving vertigo episodes and resulting in hydrops regression, according to a study published online July 30 in Acta Neurologica Belgica.

Agnieszka Jasińska-Nowacka, M.D., Ph.D., from the Medical University of Warsaw in Poland, and colleagues assessed endolymphatic hydrops in patients with severe MD before and after vestibular neurectomy. Magnetic resonance imaging was performed before and after vestibular neurectomy in 20 patients with unilateral definite MD.

The researchers found that in all patients, endolymphatic hydrops were visualized in the preoperative scans. All patients presented a complete resolution of vertigo episodes after the vestibular neurectomy. Analyzing the cochlea and vestibule, regression of the endolymphatic hydrops was observed in 35 and 15 percent of cases, respectively. Withdrawal of the hernia was visualized in 71.43 percent of patients with utricular herniation into the lateral semicircular canal. In 17.64 percent of cases, asymmetrical contrast enhancement in the cochlea regressed. Analyzing all parameters collectively, partial regression of at least one of the radiological signs was confirmed in the follow-up examination in 60 percent of patients. After the surgery, no progression of the endolymphatic hydrops was visualized in either the cochlea or the vestibule.

"Although it is known to be an effective symptomatic treatment of vertigo attacks, vestibular neurectomy may also effectively halt the progression of the endolymphatic space dilatation and result in hydrops regression," the authors write.

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Endolymphatic Duct Blockage Beneficial for Vertigo in Meniere Disease

Endolymphatic duct blockage (EDB) is more effective than intratympanic methylprednisolone (ITMP) injection for controlling vertigo symptoms among patients with Meniere disease (MD), according to a study published online May 24 in the European Archives of Oto-Rhino-Laryngology.

Issam Saliba, M.D., from the University of Montreal Hospital Research Centre, and colleagues conducted a retrospective study to compare the effectiveness of EDB and ITMP injection to control refractory MD symptoms. Overall, 36 patients received ITMP injection and 52 underwent EDB.

The researchers found that at 24 months postoperatively, 90.4 and 43.4 percent of the EDB and ITMP groups, respectively, had complete control of vertigo. No significant difference was seen in tinnitus or aural fullness control. The reduction in tinnitus and aural fullness frequency at 24 months was significant within the EDB group; for the ITMP group, only the reduction in tinnitus was significant. Compared with preoperative levels, at 24 months, pure-tone average, bone conduction average, and speech discrimination score were significantly worse in the ITMP group. In the EDB group, pure-tone average was stable, with no difference relative to the ITMP group; bone conduction average and speech discrimination score were stable and better, respectively, than that seen in the ITMP group. No significant difference was seen in vestibular paresis before and after treatment in each group.

"Endolymphatic duct blockage surgery for the treatment of refractory Meniere's disease is an effective procedure that results in excellent vertigo control, significant improvement of aural fullness and tinnitus, and preserved hearing function at the postoperative period of 24 months," the authors write.

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Triple Semicircular Canal Occlusion + Endolymphatic Sac Decompression Alleviates Vertigo

Triple semicircular canal occlusion combined with endolymphatic sac decompression (ESD) may be an effective treatment option for managing frequent vertigo attacks in patients with Meniere disease, according to a study published online April 16 in Frontiers in Neurology.

Jiawang Tian, from the Third Affiliated Hospital of Sun Yat-Sen University in Guangzhou, China, and colleagues evaluated the efficacy of triple semicircular canal occlusion combined with endolymphatic sac decompression in the treatment of frequent vertigo in patients with Meniere disease. The analysis included 11 patients enrolled to undergo triple semicircular canal occlusion with endolymphatic sac decompression.

The researchers found that the successful control rate of vertigo was 100 percent (nine of nine) in the average 23-month postoperative follow-up period, with a complete control rate of 88.89 percent (eight of nine) and substantial control rate of 11.11 percent (one of nine).

"Triple semicircular canal occlusion combined with endolymphatic sac decompression may be an effective treatment option for managing frequent vertigo attacks in patients with Meniere disease," the authors write. "This combination therapy has the potential to become a significant addition to the treatment framework for Meniere disease."

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Cochlear Implants Aid Meniere Disease Outcomes

Cochlear implantation (CI) positively impacts hearing, vertigo, tinnitus, and quality of life in patients with Meniere disease (MD), according to a study published online May 20 in European Archives of Oto-Rhino-Laryngology.

Miray-Su Yılmaz Topçuoğlu, Dr. Med., from the University Hospital Heidelberg in Germany, and colleagues investigated the impact of CI in patients with MD. The analysis included 11 ears from individuals with MD receiving CI between 2014 and 2022.

The researchers found that following implantation, there was a significant enhancement in Word Recognition Scores at sound levels of 65 dB and 80 dB versus before treatment (preoperatively versus 12 months postoperatively). No significant enhancement was seen for 50 dB. There were significant MD-related impairment improvements postoperatively, as measured by the visual analogue scale, Dizziness Handicap Inventory, Tinnitus Handicap Inventory, and Nijmegen Cochlear Implant Questionnaire. There were also significant improvements seen in the Functional Level Scale.

"In patients suffering from MD, the prioritized treatment goals include not only improved hearing but also the rehabilitation of vertigo and tinnitus, as well as the enhancement of quality of life," the authors write. "Due to the retrospective nature and small number of patients, not only in this study but also in other comparable studies, multicenter studies with a prospective study design should be carried out in the future."

Several authors disclosed ties to MED-EL and Cochlear.

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Instrument Developed to Assess Quality of Life in Meniere Disease

FRIDAY, May 3, 2024 (HealthDay News) -- A brief, valid instrument has been developed for assessing quality of life in Meniere disease, according to a study published online April 30 in The Laryngoscope.

Alexandra E. Quimby, M.D., M.P.H., from the Hospital of the University of Pennsylvania in Philadelphia, and colleagues created a 24-item Meniere disease quality of life (MenQOL) instrument using a sequential process of expert input, patient focus groups, and analyses of responses to draft questionnaires. The MenQOL and Short-Form-36 version 2 (SF-36v2) were administered to 50 patients with Meniere disease and 60 patients with tinnitus, vertigo, or hearing loss from other causes.

The researchers found that the MenQOL has a single domain based on exploratory factor analysis. For the instrument as a whole, a Cronbach's α score of 0.914 indicated high internal consistency. Relative to comparison patients, patients with Meniere disease had significantly worse quality of life based on mean MenQOL scores (52.5 ± 15.8 versus 43.2 ± 12.6), indicating good construct validity. In bivariate linear regressions, significant inverse relationships were seen between total MenQOL scores and SF-36v2 physical and mental composite scores, indicating acceptable concurrent validity (slopes, −0.94 and −1.16, respectively).

"Subsequent to further study confirming validity and examining changes over time and in response to treatment, we hope that the instrument may become a widely adopted disease-specific QOL scale for use in Meniere disease," the authors write.

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Meniere Disease Is a Heterogeneous Condition

TUESDAY, Feb. 6, 2024 (HealthDay News) -- Meniere disease is a heterogeneous condition with subgroups characterized by specific clinical features, according to a study published online Jan. 6 in The Laryngoscope.

John Phillips, Ph.D., from the Norfolk and Norwich University Hospitals NHS Foundation Trust in the United Kingdom, and colleagues conducted an observational study involving patients with Meniere disease to identify distinct clinical subtypes. Four hundred eleven patients were recruited into the study.

The researchers identified two main clusters: Cluster 1 was more likely to include patients diagnosed with ear infections (odds ratio, 0.30), while those reporting tinnitus in both ears, low pitched tinnitus, and stress as a trigger for vertigo attacks were significantly more likely to be in cluster 2 (odds ratios, 11.89, 21.09, and 14.94, respectively). Clustering in cluster 2 was significantly more likely for those diagnosed with benign paroxysmal positional vertigo, autoimmune disease, depression, migraines, drug allergy, and hay fever (odds ratios, 13.14, 5.97, 4.72, 3.13, 3.25, and 3.12, respectively).

"Appreciating how Meniere's disease may exist as a spectrum of clinical subtypes is key to directing further research into its underlying pathophysiologic mechanisms, to the targeting of specific treatment strategies, and to permitting a better understanding of the physiology of the inner ear microenvironment," the authors write.

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Diagnostic Accuracy High in Emergency Departments

THURSDAY, Dec. 29, 2022 (HealthDay News) -- Diagnostic accuracy is high in the emergency department, with about 5.7 percent of patients misdiagnosed, according to a report published Dec. 15 by the Agency for Healthcare Research and Quality.

David E. Newman-Toker, M.D., Ph.D., from the Johns Hopkins University Evidence-based Practice Center in Baltimore, and colleagues examined diagnostic errors or misdiagnosis-related harms in emergency departments in the United States or other developed countries. A total of 279 studies that addressed three key questions were included.

According to the report, in the United States, diagnostic accuracy is high in the emergency department overall, but about 5.7 percent of patients receive an incorrect diagnosis. As a result of this incorrect diagnosis, some suffer an adverse event (about 2.0 percent) and some of these adverse events are serious (about 0.3 percent). These rates are equivalent to those in primary care and hospital inpatient care. Overall, five conditions account for 39 percent of serious misdiagnosis-related harms (stroke, myocardial infarction, aortic aneurysm/dissection, spinal cord compression/injury, and venous thromboembolism), while the top 15 conditions accounted for 68 percent. Considerable variation is seen in diagnostic error rates by disease, ranging from 1.5 percent for myocardial infarction to 56 percent for spinal abscess. For a given disease, the likelihood of error is increased with nonspecific or atypical symptoms. Dizziness or vertigo increases the odds of misdiagnosis 14-fold over motor symptoms for stroke.

"Scalable solutions to enhance bedside diagnostic processes are needed, and these should target the most commonly misdiagnosed clinical presentations of key diseases causing serious harms," the authors write.

Diagnostic Errors in the Emergency Department: A Systematic Review

Guidelines Developed for ED Management of New Dizziness, Vertigo

THURSDAY, June 8, 2023 (HealthDay News) -- In a consensus statement published in the May issue of Academic Emergency Medicine, guidelines are presented for the emergency department management of patients with new dizziness or vertigo without an obvious medical or neurological cause.

Jonathan A. Edlow, M.D., from Harvard Medical School in Boston, and colleagues developed guidelines relating to adults with acute dizziness and vertigo in the emergency department. Fifteen evidence-based recommendations were developed based on the timing and triggers of the dizziness.

The authors noted that emergency clinicians should receive training in bedside physical examination techniques for patients with acute vestibular syndrome (AVS) and diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV) as an overarching recommendation. For patients with AVS, to help distinguish central from peripheral causes, HINTS (head impulse-nystagmus-test of skew) should be used in patients with nystagmus; finger rub can further aid with excluding stroke in patients with nystagmus; and severity of gait unsteadiness should be used in patients without nystagmus. Brain computed tomography should not be used. Routine magnetic resonance imaging should not be used as a first-line test if a clinician trained in HINTS is available, but can be used as a confirmatory test for patients with central or equivocal HINTS examination.

"The good news is with a bit of training and the algorithmic approach discussed in GRACE-3 [Guidelines for Reasonable and Appropriate Care in the Emergency Department 3], we can learn to take much better care of these patients, faster, with more confidence and less imaging," Edlow said in a statement.

Several authors disclosed ties to industry.

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Vestibular Dysfunction May Be Modifiable Risk Factor for Cognitive Decline

MONDAY, May 8, 2023 (HealthDay News) -- Vestibular dysfunction is a potentially modifiable risk factor for cognitive decline, according to a study published online April 4 in Frontiers in Neuroscience.

Jiake Zhong, from the Beijing Tsinghua Changgung Hospital and School of Clinical Medicine at Tsinghua University, and colleagues evaluated the cognitive functions, vertigo symptoms and related physical, functional, and emotional effects of patients with Meniere disease (MD) before and after treatment (three, six, and 12 months). Outcomes were assessed using the Montreal Cognitive Assessment and Dizziness Handicap Inventory.

The researchers found that before therapy, cognitive function (especially in memory) was impaired in MD patients compared with healthy controls. Cognitive impairment improved after effective therapy and was related to the severity of vertigo, particularly in functional and physical impacts.

"Given that MD patients in the middle and late stages often have progressive hearing loss that is challenging to recover from, the vestibular function is more likely to be a potentially modifiable risk factor for cognitive decline," the authors write. "In the future, we will conduct more objective and comprehensive evaluations, such as the number, duration, and frequency of vertigo attacks, cognitive tasks in various subdomains, and neuro-electrophysiological indexes on the patients and further explore the relationships between them with larger samples."

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Most Patients With Acute Low-Tone Hearing Loss Have Recovery

WEDNESDAY, April 5, 2023 (HealthDay News) -- For patients with acute low-tone hearing loss (ALHL) without vertigo, partial or complete recovery is reported frequently, although recurrence seems to be relatively common, according to a review published online March 7 in The Laryngoscope.

Ryan J. Huang, M.D., from the Duke University School of Medicine in Durham, North Carolina, and colleagues conducted a scoping review of the literature to examine recovery from hearing loss, recurrence and/or fluctuation of hearing loss, and progression to Meniere disease among patients presenting with ALHL without vertigo. Data were included from 41 studies.

The researchers identified extensive heterogeneity between studies with respect to defining ALHL, treatment methods, and follow-up time. Partial or complete recovery of hearing was reported in the majority of patients (>50 percent) in most of the cohorts (39 of 40), although reports of recurrence were relatively common. Progression to Meniere disease occurred rarely. In six of eight studies, shorter time from onset of symptoms to treatment predicted better hearing outcomes.

"While the literature suggests that the majority of patients with ALHL appear to experience hearing improvement, recurrence and/or fluctuation are common," the authors write. "Additional studies and randomized controlled trials utilizing standardized criteria for diagnosis, study inclusion, and hearing outcome are needed to determine the natural history and ideal treatment for ALHL."

One author disclosed serving on the surgical advisory boards for Med-El and Advanced Bionics.

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