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Ménière’s disease is an inner-ear disorder caused by endolymphatic hydrops, characterised by recurrent episodes of vertigo, fluctuating hearing loss, and tinnitus. Ménière’s disease can be classified as ‘probable’ and ‘definite’ according to the criteria determined by the Bárány Society.
Methods
This analytical cross-sectional retrospective study included 28 Ménière’s disease patients (15 with definite Ménière’s disease and 13 with probable Ménière’s disease). Vestibular function was assessed using ocular-vestibular evoked myogenic potentials, cervical-vestibular evoked myogenic potentials and caloric test.
Results
The results of these tests were evaluated separately for probable Ménière’s disease and definite Ménière’s disease groups and comparisons were made. Significant differences in vestibular evoked myogenic potential asymmetry rates were observed between the probable Ménière’s disease and definite Ménière’s disease groups, with the definite Ménière’s disease group exhibiting a higher rate of abnormal responses.
Conclusion
This suggests that vestibular evoked myogenic potentials testing may be a valuable tool in distinguishing between these two subtypes of Ménière’s disease. Further research is necessary to validate these findings and explore their implications for clinical practice.
Cinema has a long tradition of exploiting the notion of the double. This is because of the cinematic resources that are available to convincingly portray, visually, a doppelgänger. Alfred Hitchcock was the master of this form. In several films including Shadow of a Doubt, Strangers on a Train, The Wrong Man, Vertigo, and Psycho, Hitchcock established himself as the master of horror and exploited several different manifestations of the double. Other films dealing with the double, including The Matrix, Solaris, and Avatar, are also discussed.
The study aimed to determine the patterns of the vestibular and ocular motor findings in cerebellar infarction (CI).
Methods:
We retrospectively analyzed vestibular and ocular motor test results in 23 CI patients and 32 acute unilateral vestibulopathy (AUVP) patients.
Results:
Among CI cases, the posterior inferior cerebellar artery (PICA) was the most commonly affected territory. Vertigo is predominantly observed in patients with infarctions affecting PICA or anterior inferior cerebellar artery (AICA). Lesions involving the superior cerebellar artery (SCA) mainly result in dizziness. Saccadic intrusion and oscillation, abnormal bilateral smooth pursuit (SP) and abnormal saccades were more prevalent in the CI group than in the AUVP group (all p < 0.05). Horizontal saccades were abnormal in 11 patients (47.8%) with CI. All AUVP patients had normal horizontal saccades. Horizontal SP was impaired in 13 patients (56.5%) with CI, with decreased gain toward both sides in 10 and toward 1 side in 3. Impaired horizontal SP was noted in nine patients (28.1%) with AUVP, with decreased gain toward the contralesional side in all cases. A total of 26.3% (5/19) of patients with CI exhibited subjective visual vertical (SVV) deviation toward the affected side and 31.6% (6/19) toward the unaffected side. In patients with AUVP, 70.0% (21/30) showed SVV deviation toward the affected side.
Conclusions:
Vertigo is mainly seen in PICA or AICA infarctions. SCA lesions mostly cause dizziness. Saccadic intrusion and oscillation, abnormal bilateral SP and abnormal saccades contribute to the diagnosis of CI. Moreover, SVV deviation varies depending on the cerebellar structures involved.
The aim of this study is to identify risk factors for residual dizziness in benign paroxysmal positional vertigo patients after repositioning manoeuvres and explore the mediation role of lipid indicators.
Methodology
In all, 110 benign paroxysmal positional vertigo patients treated from January 2019 to February 2022 were studied. Data on demographics, diseases, behaviours, and lipids were collected. Multivariate logistic regression assessed risk factors, and mediation analyses explored effects via lipid indicators. Odds ratios and 95 per cent confidence intervals are reported.
Results
Differences between groups with and without residual dizziness included limb weakness, hypertension, nausea, arteriosclerosis, medication, dizziness handicap inventory scores, hospital anxiety and depression scale scores, and lipid distributions (p < 0.05). Significant risk factors were sleep disorders, medication, hypertension, triglycerides, and total cholesterol (p < 0.05). Total cholesterol mediated 9.1 per cent of the effect of sleep disorders on residual dizziness.
Conclusion
Managing lipid levels and sleep disorders is crucial in treating residual dizziness in benign paroxysmal positional vertigo patients after repositioning.
Ménière’s disease is a chronic inner-ear disease attributed to endolymphatic hydrops. Magnetic resonance imaging with gadolinium allows visualisation of endolymphatic hydrops in vivo and may be an adjunct to diagnosis.
Methods
Thirty-eight patients suspected of having Ménière’s disease underwent T2 weighted three-dimensional fluid-attenuated inversion recovery and true inversion recovery sequence magnetic resonance imaging 4 hours post double-dose intra-venous gadolinium. Presence of endolymphatic hydrops was graded by two radiologists at 0 and 4 months. Correlation to clinical diagnosis was assessed using Fisher’s exact test.
Results
Hydrops was identified in 88 per cent, 17 per cent and 27 per cent of patients with Definite Ménière’s, Probable Ménière’s and Undifferentiated disease, respectively. A significant correlation existed between diagnosis and presence of hydrops. Sensitivity and specificity were 88 per cent and 67 per cent, respectively. Intra- and inter-observer agreement for presence and grading of hydrops was near-perfect and substantial to near-perfect, respectively.
Conclusion
Magnetic resonance imaging demonstrates radiographic hydrops with significant correlation to clinical diagnosis and good intra- and inter-observer agreement.
To identify changes in hearing loss, tinnitus, vertigo, and migraine in individuals with Ménière’s disease diagnosed with coronavirus disease 2019 and during the UK national lockdown.
Method
Patients were questioned regarding coronavirus disease 2019 status and how their symptoms of hearing loss, tinnitus, vertigo, and migraine changed because of the pandemic. Of the 411 participants recruited into this study, 382 had a self-reported coronavirus disease 2019 status.
Results
Of those individuals with a positive coronavirus disease 2019 diagnosis, 43 (11.3 per cent) were more likely to experience worsening symptoms of hearing loss and tinnitus. Worsening symptoms of hearing loss and tinnitus, but improved symptoms related to vertigo, were observed during the UK national lockdown.
Conclusion
A diagnosis of coronavirus disease 2019 and/or experiencing the consequences of a national lockdown potentially resulted in a worsening of hearing loss and tinnitus symptoms. Symptoms of vertigo were found to have improved during the same period.
This study aimed to evaluate clinical characteristics, treatments and outcomes of paediatric temporal bone fractures at our institute.
Methods:
A retrospective study of paediatric skull fractures confirmed by imaging from January 2010 to December 2022. Data on demographics, clinical presentations, injury mechanisms and complications were analysed, and fractures were categorised into otic capsule sparing (OCS) and violating (OCV).
Results:
Of 369 skull fracture cases, 88 (24 per cent) involved temporal bones, predominantly caused by falls and vehicle accidents. Common symptoms were loss of consciousness, hematoma, and hemotympanum, with complications like facial nerve injury and cerebrospinal fluid leaks in 3.4 per cent of cases. OCV fractures led to more severe complications, including hearing loss. Audiology showed 65 per cent without hearing impairment, while others had various degrees of loss.
Conclusion:
Paediatric temporal bone fractures, particularly OCV types, pose significant challenges. Early detection and thorough management are vital, underscoring the need for consistent data collection and regular audiometric monitoring.
Patients presenting to the emergency department with acute vertigo pose a diagnostic challenge. While ‘benign’ peripheral vestibulopathy is the most common cause, the possibility of a posterior circulation stroke is paradoxically the most feared and missed diagnosis in the emergency department.
Objectives
This review will attempt to cover the significant advances in the ability to diagnose acute vertigo that have occurred in the last two decades. The review discusses the role of neurological examinations, imaging and specific oculomotor examinations. The review then discusses the relative attributes of the Head Impulse-Nystagmus-Test of Skew plus hearing (‘HINTS+’) examination, the timing, triggers and targeted bedside eye examinations (‘TiTrATE’), the associated symptoms, timing and triggers, examination signs and testing (‘ATTEST’) algorithm, and the spontaneous nystagmus, direction, head impulse testing and standing (‘STANDING’) algorithm. The most recent technological advancements in video-oculography guided care are discussed, as well as other potential advances for clinicians to look out for.
Balance dysfunction and vestibular conditions are major problems requiring significant resources. There is significant national and international variation in management pathways for such patients.
Methods
This paper outlines a collaborative project run by the ENT department and two vestibular rehabilitation trained physiotherapists to establish a clinic to manage patients referred to ENT with vestibular and/or balance complaints. As part of a six-month pilot, two physiotherapy-led balance clinics were provided per week.
Results
A total of 159 new patients were seen, with only 15 needing ENT consultant input. This led to the successful creation of substantive posts; the clinic has seen 698 patients in its first two years.
Conclusion
Patient outcomes and experience have been positive, and accompanied by reduced waiting and in-service times. The authors discuss some of the pitfalls, challenges and opportunities of developing this type of clinic.
This pilot study aimed to evaluate a training programme for primary care physiotherapists focused on the assessment and management of benign paroxysmal positional vertigo.
Methods
A six-month training programme and toolkit utilising the revised Standards for Quality Improvement Reporting Excellence (‘SQUIRE 2.0’) guidelines was developed to facilitate the learning of new knowledge and skills in the assessment and management of benign paroxysmal positional vertigo following Gagne's model of instructional design. A pre- and post-training knowledge and confidence questionnaire evaluated the impact of the training programme.
Results
Eleven participants started the training programme and five completed it. On average, knowledge increased by 54 per cent (range, 41–95 per cent) and confidence increased by 45 per cent (range, 31–76 per cent). A 73 per cent improvement in practical skills acquisition was demonstrated after the initial training session.
Conclusion
A structured approach to learning demonstrates improvements in knowledge, skills and confidence of physiotherapists in the evidence-based management of benign paroxysmal positional vertigo.
To examine the newly established role of a primary contact physiotherapist in an ENT clinic, in an Australian cohort and context, over two phases of development.
Methods
A retrospective cohort study was conducted with data collected from a medical record audit. Over the study duration, the primary contact physiotherapist completed initial appointments with patients; follow-up appointments were subsequently conducted by medical staff.
Results
There was a 46 per cent reduction in patients with suggested vestibulopathy requiring an ENT medical review. This reduction could hypothetically increase to 71 per cent with follow-up primary contact physiotherapist appointments. Improvements in the service delivery model and a primary contact physiotherapist arranging diagnostic assessments could improve waitlist times and facilitate better utilisation of medical staff time.
Conclusion
The primary contact physiotherapist can help in the management of patients with suspected vestibulopathy on an ENT waitlist. This is achieved through: a reduction of patients requiring ENT review, improvements to waitlist time and improved utilisation of medical specialists’ time.
Persistent postural-perceptual dizziness classifies patients with chronic dizziness, often triggered by an acute episode of vestibular dysfunction or threat to balance. Unsteadiness and spatial disorientation vary in intensity but persist for over three months, exacerbated by complex visual environments.
Method
Literature suggests diagnosis relies on a clinical history of persistent subjective dizziness and normal vestibular and neurological examination findings. Behavioural diagnostic biomarkers have been proposed, to facilitate diagnosis.
Results
Research has focused on understanding the neural mechanisms that underpin this perceptual disorder, with imaging data supporting altered connectivity between neural brain networks that process vision, motion and emotion. Behavioural research identified the perceptual and motor responses to a heightened perception of imbalance.
Conclusion
Management utilises head and body motion detection, and downregulation of visual motion excitability, reducing postural hypervigilance and anxiety. Combinations of physical and cognitive therapies, with antidepressant medications, help if the condition is associated with mood disorder.
Differential diagnosis of acute vertigo syndrome is challenging given the similarities between clinical presentations of posterior circulation stroke and peripheral vestibular dysfunction. The Head Impulse, Nystagmus, Test of Skew (‘HINTS’) assessment is a clinical bedside test used to aid diagnosis.
Methods
Comprehensive training on use of the Head Impulse, Nystagmus, Test of Skew assessment was provided to one stroke consultant, and the effectiveness of the test in that setting was assessed. Further education was completed with more members of the stroke and emergency department multi-disciplinary team. Quality improvement measures including magnetic resonance imaging use and bed utilisation were explored.
Results
Following training of one stroke consultant, the Head Impulse, Nystagmus, Test of Skew assessment was found to be a feasible, accurate bedside test within this acute stroke service. Further training for the multi-disciplinary team was completed, but outcome measures were not explored because of the coronavirus disease 2019 pandemic and maternity leave.
Conclusion
There is a role for trained members of the multi-disciplinary team to successfully use the Head Impulse, Nystagmus, Test of Skew assessment in hyperacute stroke settings, to aid diagnosis in acute vertigo syndrome.
Driving capacity is affected by vestibular disorders and the medications used to treat them. Driving is not considered during medical consultations, with 92 per cent of patients attending a centre for dizziness not discussing it with the doctor.
Objective
To investigate if medical record prompts facilitate dizziness and driving conversations in ENT balance clinics.
Methods
A questionnaire was designed to reflect the current standards of practice and advice given regarding driving and dizziness during balance clinic consultations.
Results
Medical record prompts facilitated the improved frequency and recording of shared decision-making conversations about driving and dizziness in 98 per cent of consultations.
Conclusion
This study highlights the benefits of medical record prompts for documented and accurate shared decision-making conversations surrounding dizziness, vertigo, vestibular conditions and driving. This potentially improves safety for all road users, and protects the patient and clinician in the event of road traffic accidents and medico-legal investigations.
It was known from ancient times that vertigo was a malady and that the inner ears of animals contained an intricate network of structures named the labyrinth, whose function was unknown. The flourishing of human vestibular anatomy in the Renaissance period still adhered to age-old notions of traditional spiritual philosophy. In the post-Renaissance period, when science was being redefined and challenging these traditional thoughts, vestibular physiology was born. Started by Flourens, it gathered momentum with Hogyes, Goltz, Breuer, Mach, Crum Brown, Ewald, Brown Sequard and Baginsky in the 19th century. They discovered the role of the vestibular organ in sensing balance and the fine intricacies of vestibular physiology valid to this day. Ménière shattered the concept of traditional aetiology of vertigo and de Cyon challenged the Kantian concept of space. The science catapulted to the modern century. This article traces the history of these pioneers of vestibular physiology.
In decision making regarding the management of vestibular schwannomas, alongside clinical outcomes, an understanding of patient reported health-related quality of life measures is key. Therefore, the aim of this research is to compare health-related quality of life in vestibular schwannoma patients treated with active observation, stereotactic radiotherapy and microsurgical excision.
Methods
A cross-sectional study of patients diagnosed with unilateral sporadic vestibular schwannomas between 1995 and 2015 at a specialist tertiary centre was conducted. Patients completed the Penn Acoustic Neuroma Quality of Life questionnaire and handicap inventories for dizziness, hearing and tinnitus.
Results
Of 234 patients, 136 responded (58.1 per cent). Management modality was: 86 observation, 23 stereotactic radiotherapy and 25 microsurgery. Females reported significantly worse dizziness; males reported significantly worse physical disability. Patients less than 65 years old reported significantly worse tinnitus and pain scores. Overall, quality of life was higher in the observation group.
Conclusion
Conservative management, where appropriate, is favourable with higher quality-of-life outcomes in this cohort. This must be weighed against the risks of a growing tumour.
There have been many studies linking falls and benign paroxysmal positional vertigo. This article collates those studies, and demonstrates how a community falls service fast-tracked patients with benign paroxysmal positional vertigo by implementing validated screening tools and recognised guidance.
Objective
This study aimed to explore whether routine screening of referrals to a community falls service can identify those with benign paroxysmal positional vertigo, for fast-tracked management.
Methods
Patients referred to a community falls service were screened for possible benign paroxysmal positional vertigo using the Dizziness Handicap Inventory, and triaged to a physiotherapy-led falls and benign paroxysmal positional vertigo assessment service.
Results
Twenty-five per cent of patients were fast-tracked to a falls and benign paroxysmal positional vertigo assessment service for management. The community falls service waiting list reduced by 25 per cent.
Conclusion
The data support incorporating assessment and treatment of benign paroxysmal positional vertigo into routine practice within all falls services.
Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic.
Method
Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine.
Results
A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging.
Conclusion
This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.
There is a high prevalence of dizziness, vertigo and balance symptoms in the general population. Symptoms can be generated by many inner-ear vestibular disorders and there are several diagnostic tests available that can help identify the site of the vestibular lesion. There is little consensus on what diagnostic tests are appropriate, with diagnostics either not completed or minimally performed, leading to missed diagnosis, unsatisfactory results for patients and costs to healthcare systems.
Methods
This study explored the literature for different neuro-vestibular diagnostic tests not currently considered in the traditional standard vestibular test battery, and examined how they fit effectively into a patient care pathway to help quickly and succinctly identify vestibular function.
Results
A vestibular patient care pathway is presented for acute and subacute presentation of vestibular disorders.
Conclusion
An accurate diagnosis following a rigorous anamnesis and vestibular testing is paramount for successful management and favourable outcomes.
1986 marked a fresh departure in W.G. Sebald’s literary œuvre. Having written poetry for decades and, for a short time, worked on experimental scripts, Sebald reinvented himself as a prose writer and concentrated on fashioning an innovative form of highly stylized, illustrated docufiction. From approximately July 1986 to early 1988, he worked on a first collection of literary prose that had no official working title and was usually referred to simply as the Prose Project. An unsuccessful funding application provides a detailed insight into what the overall project was supposed to look like, but while Sebald worked on it, the project underwent adaptations and was never published in the originally envisaged form. This essay considers archival material relating to the Prose Project, which reveals the common origins of Vertigo and The Emigrants, and assesses the development of Sebald’s ground-breaking intermedial process and the poetological implications of his turn towards narrative prose.