Vertigo and Dizziness: Common Complaints

Description:

The third edition of this successful book has been fully revised, expanded and updated to reflect the recent advances in vertigo and dizziness, especially with regard to current classifications and clinical trials. The book starts by covering the fundamentals of anatomy and physiology of the vestibular and the ocular motor systems. It provides guidance on how to take the patient history, laboratory and imaging analysis and principles of therapy exploring different therapeutic strategies. It then goes on to cover in detail the diagnosis and current treatment of peripheral, central and functional vestibular disorders as well as miscellaneous rare vestibular syndromes.

Using a uniform chapter style to address the various diseases and adopting a reader-friendly educational format, this is an indispensable guide for clinicians who treat patients with vertigo, dizziness and balance disorders. Hundreds of patient videos are included for the diseases demonstrating typical patient histories and clinical findings. Chapters have also been expanded to discuss the current classification and therapies as well as new and ongoing clinical trials with ample new figures.

Written by three top experts in the field, this book is aimed at a broad range of medical specialists, namely neurologists, ENT specialists, neuro-otologists, ophthalmologists, physiotherapists, general practitioners as well as residents and students.

Via app: download the SN More Media app for free, scan a link with play button and access videos directly on your smartphone or tablet.

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Preface to the Third Edition

Since the last edition in 2013, our understanding of the pathophysiology, etiology, diagnosis, terminology, and therapy of peripheral, central, and functional vestibular syndromes has continued to improve. This has a major impact on our daily clinical practice.

Laboratory testing of the function of the semicircular canals can now be easily done using the video head impulse test, which provides valid and quantitative data. The simple measurement of subjective visual vertical has become an important diagnostic procedure, which is now also a part of clinical routine. Genetic testing has improved our understanding of the etiology of acute unilateral vestibulopathy/vestibular neuritis, Menière’s disease, and downbeat nystagmus. Vertigo and dizziness in the emergency department has been identified as a very relevant issue, and there are now several studies that show how to discriminate acute peripheral from acute central vestibular syndrome, which has a major impact on clinical practice. Studies have also shown that central spinning vertigo is found mainly in acute unilateral caudal brainstem or cerebellar lesions affecting relevant central vestibular cerebellar areas. Imaging, in particular structural and functional magnetic resonance tomography, has helped to further elucidate the bilateral organization of the central vestibular networks within the brainstem, cerebellum, thalamus, and cortex, which can now be correlated with typical vestibular syndromes and disorders affecting spatial orientation. Higher central vestibular disorders, which, for instance, impair spatial orientation or multisensory attention (neglect), indicate a right-hemispheric lesion, which is compatible with the right-sided thalamocortical dominance of the vestibular system.

Since 2009, the Committee for the International Classification of Vestibular Disorders of the Bárány Society has developed internationally accepted and clinically oriented diagnostic criteria for the most frequent vestibular disorders, which are updated continuously. They are most helpful for clinicians and also for clinical research, in particular for the design of clinical trials. So far, the following vestibular disorders have been reclassified: benign paroxysmal positional vertigo, Menière’s disease, bilateral vestibulopathy, presbyvestibulopathy (a new and clinically relevant entity), vestibular paroxysmia, vestibular migraine, persistent perceived postural dizziness (one of the several forms of functional dizziness), orthostatic dizziness, mal de débarquement syndrome, different types of nystagmus vertigo and dizziness in childhood, vascular vertigo as well as acute unilateral vestibulopathy/vestibular neuritis.

Finally, there are several new trials on the treatment of various vestibular disorders: benign paroxysmal positional vertigo, Menière’s disease, bilateral vestibulopathy, vestibular paroxysmia, vestibular migraine, and cerebellar dizziness. We would, however, like to point out that there are still considerable deficits, in particular, in terms of treatment of vestibular disorders due to a lack of up-to-date randomized, placebocontrolled treatment trials, for example, for Menière’s disease or functional dizziness.

We would like to thank all the doctors and technicians in the Department of Neurology and the German Center for Vertigo and Balance Disorders at Ludwig Maximilian University Munich. We would also particularly like to thank our neuroorthopticians Claudia Frenzel, Miriam Glaser, Cornelia Karch, Nicole Lehrer, Barbara Muschaweckh, Mona Klemm, and Annika Aurbacher for their careful neuroophthalmological examinations, documentation, and video recordings of

patients. We are grateful to Dietmar Lauffer and Anna Huppert for the photographs taken to show typical examination techniques and treatment options for vestibular disorders. Our thanks also go to Sabine Esser and Amelie-Christine Strupp for creating figures used in this book; to Prof. Thomas Liebig and Dr. Robert Forbig at the Institute for Neuroradiology at LMU Munich, and Dr. Valerie Kirsch for their contributions to the imaging of the central and peripheral vestibular system; as well as to Prof. Andreas Zwergal for his contribution to the chapter on acute central vertigo and Prof. Julia Dlugaiczyk for her contribution on vestibular evoked myogenic potentials.

Finally, we would also like to thank Springer Nature London for the careful editing of this book.

Table of contents :
Preface to the Third Edition
Preface to the Second Edition
Preface to the First Edition
Contents
1: Vertigo and Dizziness: Frequent Multisensory Symptoms
1.1 Introduction
1.2 The Vestibular System
1.3 Peripheral and Central Vestibular Syndromes
1.4 The Frequency of the Various Vestibular Diseases and Syndromes
1.5 Anxiety, Fears, and Vertigo/Dizziness
1.6 Psychiatric Comorbidities in Patients with Vertigo and Dizziness
References
2: Patient History
2.1 Time Course of Symptoms
2.1.1 Attacks or Episodes
2.1.2 Acute Onset of Symptoms Lasting Many Hours to Weeks: Acute Vestibular Syndrome (AVS)
2.1.3 Symptoms Persisting for More Than 3 Months: Chronic Vertigo or Dizziness
2.2 The Type of Symptoms
2.3 Triggers, Exacerbation, Improvement, and Modulating Factors of Symptoms
2.4 Accompanying Symptoms
2.5 Focused or Specific Patient History to Differentiate Between an Acute Peripheral and an Acute Central Vestibular Syndrome
2.6 Additional Sources of Information from the Patient
References
3: Combined Neuro-Otological and Neuro-Ophthalmological Bedside Examination
3.1 Specific Examination of the Vestibular System
3.1.1 Examination for Components of the Ocular Tilt Reaction (OTR)
3.1.1.1 Head Tilt
3.1.1.2 Examination for a Vertical Deviation (VD) of the Eyes (Skew Deviation) Using the Cover and Uncover Test and the Alternating Cover Test
3.1.1.3 Measurement of the Subjective Visual Vertical (SVV) with the “Bucket Test”
3.1.2 Examination for Spontaneous Nystagmus
3.1.3 Head Impulse Test, Halmagyi-Curthoys Test
3.1.4 Diagnostic Positioning Maneuvers to Look for BPPV of the Posterior, Horizontal or Anterior Canal or a Central Positional Nystagmus
3.1.4.1 Diagnosis of BPPV of the Posterior Canal
3.1.4.2 Diagnosis of a BPPV of a Horizonal Semicircular Canal
3.1.4.3 Diagnosis of a BPPV of an Anterior Semicircular Canal
3.1.4.4 Central Positional Nystagmus
3.1.5 Examination of Stance and Gait
3.1.5.1 Romberg Test
3.1.5.2 Clinical Gait Analysis
3.1.6 Additional Clinical Vestibular Examinations
3.1.6.1 Head-Shaking Test
3.1.6.2 Hyperventilation-Induced Nystagmus
3.1.6.3 Examination for Signs of a Third Mobile Window
3.2 Examination of the Ocular Motor System
3.2.1 Examination in Primary Position and the Various Cover Tests
3.2.2 Specific Examination for Nystagmus or Nystagmus-like Periodic Eye Movements
3.2.3 Examination of the Range of Eye Movements (Motility)
3.2.4 Examination for a Gaze-Holding Deficit
3.2.5 Clinical Examination of Smooth Pursuit Eye Movements
3.2.6 Vergence Test and Convergence Reaction
3.2.7 Clinical Examination of Saccades
3.2.8 Examination of Optokinetic Nystagmus
3.2.9 Testing the Visual Fixation Suppression of the Vestibulo-Ocular Reflex
References
4: Laboratory Examinations and Imaging
4.1 Laboratory Testing of Vestibular Function
4.1.1 Video Head Impulse Test (Video-HIT)
4.1.2 Caloric Testing
4.1.3 Rotatory Chair Testing
4.1.4 Vestibular-Evoked Myogenic Potentials (VEMP)
4.1.4.1 Cervical Vestibular-Evoked Myogenic Potentials (cVEMP)
4.1.4.2 Ocular-Vestibular-Evoked Potentials (oVEMP)
4.2 Pure-Tone Audiogram and Acoustic-Evoked Potentials
4.3 Laboratory Examinations of the Ocular Motor System
4.4 Neuro-Orthoptic and Psychophysical Tests
4.5 Posturography and Gait Analysis
4.6 Additional Laboratory Examinations
4.6.1 Imaging of the Petrous Bone, the Cerebellopontine Angle, the Brainstem, and Cerebellum with Computed Tomography and Magnetic Resonance Imaging
References
5: General Principles of Therapy
5.1 Physical Therapy
5.2 Pharmacotherapy: The Four Ds
5.2.1 Symptomatic Therapy of Acute Vertigo, Nausea, and Vomiting
5.2.2 Improvement of Central Compensation, Enhancement of Central Vestibular Plasticity, and Adaption
5.2.3 Specific and Causative Pharmacotherapy
5.3 Psychological/Psychiatric and Behavioral Treatment
5.4 Surgical Treatment (. Table 5.4)
References
6: Peripheral Vestibular Syndromes
6.1 Introduction and Classification
Reference
7: Bilateral Vestibulopathy
Box 7.1 Diagnostic Criteria for Bilateral and Probable Bilateral Vestibulopathy According to the Classification Committee of the Bárány Society (Strupp et al. 2017)
7.1 Epidemiology
7.2 Diagnosis
7.2.1 Patient History
7.2.2 Bedside Testing
7.2.3 Laboratory Testing
7.2.4 Complementary Laboratory Testing
7.2.4.1 Cervical and Ocular Vestibular-Evoked Myogenic Potentials (c/oVEMP)
7.2.5 Imaging
7.3 Summary of Laboratory Testing and Clinically Relevant Points
7.4 Pathophysiology
7.5 Etiology
7.6 Differential Diagnosis and Clinical Problems
7.7 Combined Central and Peripheral Vestibular Deficits
7.8 Course of the Disease
7.9 Treatment: Therapeutic Principles, Aims, and Pragmatic Therapy
7.9.1 Pragmatic Therapy
7.9.1.1 Informing and Educating the Patient
7.9.2 Primary Prevention
7.9.3 Causative Treatment
7.9.4 Lifelong, Daily Vestibular Exercises for Stance and Gait and to Prevent Falls
7.10 New Procedures, Measures, and Perspectives
References
8: Acute Unilateral Vestibulopathy/Vestibular Neuritis
Box 8.1 Diagnostic criteria for Acute Unilateral Vestibulopathy/Vestibular Neuritis
Box 8.2 Diagnostic criteria for “Probable Acute Unilateral Vestibulopathy”
8.1 Epidemiology
8.2 Diagnosis
8.2.1 Patient History
8.2.2 Bedside Examination
8.2.3 Laboratory Tests
8.3 Complementary Laboratory Examinations
8.3.1 Cervical and Ocular VEMP (c/oVEMP)
8.3.2 Imaging
8.3.3 Audiogram and Otoscopy
8.4 Differential Diagnosis and Clinical Problems
8.4.1 Acute Central Vestibular Syndrome (ACVS)
8.4.2 Other Peripheral Vestibular Disorders
8.5 Diagnosis: The Essentials for Clinical Practice
8.6 Pathophysiology and Pathological Anatomy
8.7 Etiology
8.8 Course of the Disease
8.9 Therapy: Principles, Aims, and Pragmatic Treatment
8.9.1 Causative Treatment
8.9.2 Symptomatic Therapy of Acute Vertigo, Nausea, and Vomiting
8.9.3 Vestibular Exercises to Improve Central Compensation
8.9.4 Pharmacotherapy for the Improvement of Central Compensation, Enhancement of Central Vestibular Plasticity, and Adaption
8.9.5 Pragmatic Therapy
References
9: Benign Paroxysmal Positional Vertigo
9.1 Epidemiology
9.2 Posterior Canal BPPV
Box 9.1 Diagnostic Criteria of the Bárány-Society for Canalolithiasis of pcBPPV (von Brevern et al. 2015)
9.2.1 Diagnosis
9.2.1.1 Patient History
9.2.1.2 Bedside Examination
9.2.1.3 Laboratory Examination
9.2.2 Differential Diagnoses and Clinical Problems
9.2.2.1 Central Positional
9.2.3 Diagnosis: The Essentials for Clinical Practice
9.2.4 Pathophysiology and Therapeutic Principles
9.2.5 Etiology and Associated Factors
9.2.6 Course of the Disease and Its Consequences
9.2.7 Treatment: Principles, Aims, and Pragmatic Therapy
9.2.7.1 Therapeutic Principles
9.2.7.2 Pragmatic Therapy
Semont Liberatory Maneuver
Epley Maneuver
9.2.7.3 Comparison of the Semont, SemontPLUS and Epley Maneuvers, Additional Measures, Follow-up Examinations, and Secondary Functional Dizziness
9.2.7.4 Side Effects of the Therapeutic Maneuvers
9.2.7.5 Recurrences after Successful Treatment Maneuvers
9.3 Benign Paroxysmal Positional Vertigo of the Horizontal Canal (hcBPPV)
9.3.1 Canalolithiasis of Horizontal Canal BPPV
9.3.1.1 Clinical Examination
9.3.1.2 Therapy of Horizontal Canal Canalolithiasis
9.3.1.3 Pragmatic Therapy
9.3.2 Cupulolithiasis of Horizontal Canal BPPV
9.3.2.1 Clinical Examination
9.3.2.2 Treatment of Cupulolithiasis of hcBPPV
9.3.2.3 Pragmatic Therapy
9.4 BPPV of the Anterior Canal (acBPPV)
References
10: Menière’s Disease
Box 10.1 Diagnostic Criteria of MD
10.1 Epidemiology
10.2 Diagnosis
10.2.1 Patient History
10.2.2 Clinical Examination
10.2.3 Laboratory Examinations
10.2.4 Complementary Laboratory Testing
Box 10.2 Clinical Subgroups of Patients with MD (Frejo et al. 2017)
10.3 Imaging
10.3.1 Contrast MRI of the Inner Ear and Endolymphatic Hydrops
10.4 Differential Diagnoses and Clinical Problems
10.4.1 Diagnosis: The Essentials for Clinical Practice
Box 10.3 Important Differential Diagnoses for MD (in Alphabetical Order)
10.5 Pathological Anatomy, Pathophysiology, and Etiology
10.6 Course of the Disease
10.7 Treatment
10.7.1 Prophylactic Therapy: Aims and Principles
10.7.1.1 Oral Treatment
10.7.1.2 Intratympanic Administration of Steroids and Gentamicin
10.7.1.3 Surgical Treatment
10.7.2 Pragmatic Therapy
10.7.2.1 Symptomatic Treatment of the Attacks
10.7.2.2 Prophylactic Therapy
10.7.2.3 Betahistine Dihydrochloride
10.7.2.4 Intratympanic Treatment
10.7.2.5 Surgical Treatment
10.7.2.6 Treatment of Tumarkin’s Otolithic Catastrophe
10.7.2.7 Physiotherapy
References
11: Vestibular Paroxysmia
11.1 Epidemiology
11.2 Diagnosis
11.2.1 Patient History
11.2.2 Bedside Examination
11.2.3 Laboratory Examinations
11.2.4 Imaging
11.2.5 Differential Diagnosis
11.2.6 Diagnosis: The Essentials
11.3 Course of the Disease
11.4 Pathophysiology and Etiology
11.5 Therapy: Principles and Pragmatic Therapy
11.5.1 Pragmatic Therapy
11.5.1.1 Pharmacotherapy
11.5.1.2 Surgical Treatment
References
12: Syndrome of the Third Mobile Windows
12.1 Superior Semicircular Canal Dehiscence Syndrome (SCDS)
Box 12.1 Diagnostic Criteria for Superior Canal Dehiscence Syndrome (SCDS)
12.1.1 Diagnosis
12.1.1.1 Patient History
12.1.1.2 Physical Examination
Clinical Examination of the Vestibular System
Clinical Testing of Hearing and ENT Examination
12.1.1.3 Laboratory Examinations
Vestibular Laboratory Testing
12.1.1.4 Audiological Examination
12.1.2 Imaging
12.1.3 Syndrome of Different Third Mobile Windows, Differential Diagnoses and Clinical Problems
Box 12.2 Alphabetical List of the Important Differential Diagnoses of Syndrome of the Third Mobile Windows
12.1.4 Diagnosis: The Essentials
12.1.5 Pathophysiology and Etiology
12.1.6 Therapy: Principles and Pragmatic Treatment
12.1.6.1 Pragmatic Therapy
12.2 Perilymphatic Fistula/Transient Perilymphatic Leakage
Box 12.3 Suggested Japanese Classification of the Subtypes and Possible Etiologies of Perilymphatic Fistula (2017)
12.2.1 Terminology, Pathophysiology, and Therapeutic Principles
12.2.1.1 Terminology
12.2.1.2 Pathophysiology
12.2.1.3 Etiology
12.2.2 Pragmatic Therapy
12.2.3 Conservative Therapy
12.2.4 Surgical Therapy
References
13: Central Vestibular Disorders
13.1 General Survey of Central Vestibular Syndromes
13.1.1 Clinical Synopsis
13.1.2 The Bilateral Central Vestibular Network
13.1.3 Anatomical Separation of Peripheral and Central Vestibular Structures
13.1.4 Dominance of the Central Thalamocortical Vestibular System
13.1.5 Reciprocal Inhibitory Interaction Between the Vestibular, the Visual, and the Somatosensory Systems
13.1.6 Frequent Causes of Central Vestibular Disorders
13.2 Clinical Aspects of Central Vertigo and Dizziness Disorders
13.2.1 Differential Diagnostics of the Acute Vestibular Syndrome (AVS): Peripheral Versus Central
13.2.2 Central Vestibular Syndromes in the Three Planes of Action of the VOR
13.2.2.1 Overview 3.2.1 Syndromes of the VOR and Its Clinical Symptoms
Horizontal Plane (Yaw)
Sagittal Plane (Pitch)
Frontal Plane (Roll)
13.2.2.2 Central Vestibular Syndromes in the Horizontal (Yaw) Plane
13.2.2.3 Central Vestibular Syndromes in the Sagittal (Pitch) Plane
13.2.2.4 Downbeat Nystagmus Syndrome (DBN)
13.2.2.5 Upbeat Nystagmus (UBN)
13.2.2.6 Therapy for DBN and UBN
13.2.2.7 Central Vestibular Syndromes in the Vertical (Roll) Plane
13.2.3 Central Spinning or Non-Spinning Vertigo
13.2.3.1 Cortical Versus Mesencephalic Vertigo
13.2.4 Thalamic Astasia and Lateropulsion
13.3 Higher (Cognitive) Vestibular Syndromes
13.3.1 Hemispatial Neglect
13.3.2 Room Tilt Illusion
13.3.3 Pusher Syndrome
13.3.4 Disorders of Orientation in Space and Navigation
13.4 Cerebellar Vertigo and Dizziness
References
14: Vestibular Migraine
Box 14.1 Diagnostic Criteria for Vestibular Migraine (Consensus Document of the Bárány Society and the International Headache Society) (Lempert et al. 2012a, b)
14.1 Patient History
14.2 Epidemiology
14.3 Diagnosis
14.3.1 Characteristics of Attacks
14.4 Clinical Examination
14.4.1 During the Attack-Free Interval
14.4.2 During the Attack
14.5 Technical Examinations
14.6 Differential Diagnosis and Clinical Problems
14.7 Course
14.8 Pathophysiology and Therapeutic Principles
14.8.1 Aspects From Functional and Structural Imaging
14.9 Pragmatic Therapy
14.9.1 Treatment of the Attacks
14.9.2 Prophylactic Treatment
References
15: Functional Dizziness and Vertigo
15.1 Current Classification
Box 15.1 Diagnostic Criteria of Persistent Postural-Perceptual Dizziness (PPPD or 3PD) (Staab et al. 2017)
15.1.1 Epidemiology and Psychiatric Comorbidity
15.1.2 Diagnosis
15.1.2.1 History
15.2 Clinical and Technical Examinations
15.3 Further Clinical Aspects and Course of the Illness
15.3.1 Differential Diagnosis
15.4 Pathophysiology and Therapeutic Principles
15.4.1 Efference-Copy Model
15.4.2 Analysis of Stance and Gait
15.4.3 Brain Imaging
15.5 Therapy
References
16: Vertigo and Dizziness in Childhood
16.1 Clinical Aspects
16.1.1 Epidemiology
16.1.2 Clinical Synopsis
16.1.2.1 Vestibular Migraine of Childhood and “Recurrent Vertigo of Childhood”
16.1.2.2 Benign Paroxysmal Positional Vertigo (BPPV)
16.1.2.3 Vestibular Paroxysmia
16.1.2.4 Syndrome of the Third Mobile Windows
16.1.2.5 Acute Peripheral Vestibular Syndrome
16.1.2.6 Vertigo and Dizziness Following a Traumatic Head/Brain Injury
16.1.2.7 Bilateral Vestibulopathy
16.1.2.8 Functional Dizziness
16.1.2.9 Central Vertigo/Dizziness Syndromes
16.1.3 Differential Diagnoses of Vertigo, Dizziness, and Balance Disorders
16.1.4 Attacks of Vertigo
16.1.5 Sustained Vertigo (Lasting Days or a Few Weeks)
16.1.6 Stance and Gait Imbalance With and Without Oscillopsia
16.2 Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood
16.3 Episodic Ataxias
16.4 Motion Sickness
16.5 Visual Height Intolerance and Acrophobia
16.6 Therapy of Childhood Forms of Vertigo
References
17: Medication-Related Dizziness
References
18: Traumatic Forms of Vertigo and Dizziness
18.1 Traumatic Peripheral Vestibular Forms of Vertigo
18.1.1 Post-traumatic BPPV
18.1.2 Traumatic Vestibulopathy
18.1.3 Traumatic Syndrome of the Third Mobile Windows: Superior Semicircular Dehiscence Syndrome and the rare Perilymph Fistula
18.1.4 Alternobaric Vertigo
18.1.5 Otolithic Dizziness
18.2 Traumatic Central Vestibular Syndromes
18.3 Traumatic Cervical Vertigo and Dizziness
18.4 Post-traumatic Functional Dizziness
References
19: Motion Sickness
19.1 Clinical Aspects and Pathogenesis
19.2 Course and Therapeutic Principles
19.3 Pragmatic Therapy
References
20: Mal de Débarquement Syndrome
Box 20.1 Criteria for the Diagnosis of Mal de Débarquement Syndrome (Cha et al. 2020)
20.1 Pathophysiology
20.2 Therapy
References
21: Visual Height Intolerance and Acrophobia
21.1 Definitions and Grading of Susceptibility
21.2 Epidemiology and Susceptibility Across Lifespan
21.3 Stance, Gait, and Visual Exploration Under Real Height Stimulation
21.4 Irrational Anxiety of Falling Rather Than Perception of Height is Causative
21.5 The Role of Absolute Height Above Ground on the Magnitude of Visual Height Intolerance and Acrophobia
21.6 Behavioral Recommendations for Prevention and Therapy of Visual Height Intolerance
References
22: Cervical Dizziness
22.1 Head Motion-Induced Cervical Split-Second Vertigo
22.2 Vertebral Artery Compression/Occlusion Syndrome
References
23: A Historical View of Vertigo, Dizziness, and Balance Disorders
23.1 Synopsis
23.2 Etymology
23.3 Definitions
23.4 Seasickness/Motion Sickness
23.5 Fear of Heights
23.6 Vertigo and Alcohol
23.7 Allusions to Specific Vertigo Syndromes: Vestibular Migraine and Menière’s Disease
23.8 Insights from the Eighteenth to the Twentieth Centuries on Vertigo and Motion Perception
References
Index