Vestibular Disorders

Abstract

Background: Recent research findings have improved the understanding of the diagnosis, pathophysiology, genetics, etiology, and treatment of peripheral, central, and functional vestibular vertigo syndromes.

Method: A literature search, with special attention to the current classification, treatment trials, Cochrane analyses, and other meta-analyses.

Results: There are internationally accepted diagnostic criteria for benign positional paroxysmal vertigo, Menière's disease, bilateral vestibulopathy, vestibular paroxysmia, and functional dizziness. Whether an acute vestibular syndrome is central or peripheral can usually be determined rapidly on the basis of the history and the clinical examination. "Cere - bellar vertigo" is a clinically important entity. For bilateral vestibulopathy, balance training is an effective treatment. For Menière's disease, preventive treatment with betahistine (48 mg and 144 mg per day) is not superior to placebo. For vestibular paroxysmia, oxcarbazepine has been shown to be effective. Treatments that are probably effective for functional dizziness include vestibular rehabilitation, cognitive behavioral therapy, and serotonin reuptake inhibitors.

Conclusion: The diagnostic assessment of vestibular syndromes is much easier for clinicians now that it has been internationally standardized. There is still a lack of randomized, controlled trials on the treatment of, for example, Menière's disease, vestibular migraine, and "cerebellar vertigo."

Figure 1

The frequency of various vestibular syndromes among 34 860 patients in a specialized outpatient clinic Absolute frequencies of various vertigo/dizziness syndromes in the supraregional specialized outpatient clinic of the German Center for Vertigo and Balance Disorders and the Department of Neurology, LMU, Munich, Germany (1998–2019). BPPV, Benign paroxysmal positional vertigo.

Figure 2

The clinical examination of a patient complaining of vertigo, dizziness, or postural imbalance.

Figure 3

Imaging of the inner ear a) and b) Contrast-enhanced MRI of a patient with Menière’s disease: a) evidence of vestibular (arrow) and cochlear endolymphatic hydrops in a high-resolution FLAIR sequence 4 h after the administration of intravenous contrast medium; b) 3D reconstruction of a segmented, contrast-enhanced MRI-based visualization of the endo- and perilymphatic spaces (endolymphatic hydrops shown in red and purple). c) and d) High-resolution computer-tomographic imaging of the petrous bone, revealing dehiscence of the left superior semicircular canal; c) the petrous bone CT depicts the bony defect (arrow); d) the 3D reconstruction shows that the defect occupies a considerable length of the superior semicircular canal.

eFigure

Video head-impulse test (vHIT):