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. 2016 Mar 4:7:26.
doi: 10.3389/fneur.2016.00026. eCollection 2016.

Bilateral Vestibular Hypofunction: Insights in Etiologies, Clinical Subtypes, and Diagnostics

F Lucieer  1 , P Vonk  2 , N Guinand  3 , R Stokroos  1 , H Kingma  4 , Raymond van de Berg  4
Affiliations

Bilateral Vestibular Hypofunction: Insights in Etiologies, Clinical Subtypes, and Diagnostics

F Lucieer et al. Front Neurol. .

Abstract

Objective: To evaluate the different etiologies and clinical subtypes of bilateral vestibular hypofunction (BVH) and the value of diagnostic tools in the diagnostic process of BVH.

Materials and methods: A retrospective case review was performed on 154 patients diagnosed with BVH in a tertiary referral center, between 2013 and 2015. Inclusion criteria comprised (1) imbalance and/or oscillopsia during locomotion and (2) summated slow phase velocity of nystagmus of less than 20°/s during bithermal caloric tests.

Results: The definite etiology of BVH was determined in 47% of the cases and the probable etiology in 22%. In 31%, the etiology of BVH remained idiopathic. BVH resulted from more than 20 different etiologies. In the idiopathic group, the percentage of migraine was significantly higher compared to the non-idiopathic group (50 versus 11%, p < 0.001). Among all patients, 23.4% were known with autoimmune disorders in their medical history. All four clinical subtypes (recurrent vertigo with BVH, rapidly progressive BVH, slowly progressive BVH, and slowly progressive BVH with ataxia) were found in this population. Slowly progressive BVH with ataxia comprised only 4.5% of the cases. The head impulse test was abnormal in 94% of the cases. The torsion swing test was abnormal in 66%. Bilateral normal hearing to moderate hearing loss was found in 49%. Blood tests did not often contribute to the determination of the etiology of the disease. Abnormal cerebral imaging was found in 21 patients.

Conclusion: BVH is a heterogeneous condition with various etiologies and clinical characteristics. Migraine seems to play a significant role in idiopathic BVH and autoimmunity could be a modulating factor in the development of BVH. The distribution of etiologies of BVH probably depends on the clinical setting. In the diagnostic process of BVH, the routine use of some blood tests can be reconsidered and a low-threshold use of audiometry and cerebral imaging is advised. The torsion swing test is not the "gold standard" for diagnosing BVH due to its lack of sensitivity. Future diagnostic criteria of BVH should consist of standardized vestibular tests combined with a history that is congruent with the vestibular findings.

Keywords: bilateral vestibular areflexia; bilateral vestibular hypofunction; bilateral vestibular loss; bilateral vestibulopathy; caloric tests; etiology; head impulse test; vestibular migraine.

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Figures

Figure 1
Figure 1
Distribution of certainty of etiology. A definite etiology was found in 47% of the BVH patients, a probable etiology in 22% of the BVH patients and in 31% the etiology of BVH remained idiopathic.
Figure 2
Figure 2
Distribution of etiologies in the BVH group, divided into main groups of etiology and certainty of the etiology.
Figure 3
Figure 3
Presence of migraine in the idiopathic BVH group versus the non-idiopathic BVH group. In the idiopathic BVH group, migraine was significantly more present than that in the non-Idiopathic BVH group (50% versus 11%, p < 0.001).
Figure 4
Figure 4
Clinical subtypes of BVH with respect to the etiologies in the BVH group.
See this image and copyright information in PMC

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