Table 1 - uploaded by Steven D Rauch
Content may be subject to copyright.
Source publication
We sought to test a 3-parameter model for diagnosis of dizziness based on the type and temporal characteristics of the dizziness and on hearing status.
We conducted a prospective blinded study at a tertiary referral neurotology practice. Before examination, patients completed a questionnaire reporting type and timing of dizziness symptoms and heari...
Contexts in source publication
Context 1
... reporting true vertigo on their question- naires were assigned presumptive diagnoses ac- cording to the diagnostic algorithm in Table 1, based on their self-report of dizziness type, dura- tion, and hearing loss status. The 4 diagnoses in this diagnostic matrix (benign paroxysmal posi- tional vertigo [BPPV], Meniere's disease, vestib- ular neuritis, labyrinthitis) represent the 4 most common causes of otogenic vertigo. ...
Context 2
... the 35 patients with clinical diagnoses of BPPV (n 8), Meniere's disease (n 15), ves- tibular neuritis (n 9), and labyrinthitis (n 3), 21 (60%) were correctly classified/diagnosed by the simple 2 2 matrix shown in Table 1. The remaining 14 were either misclassified (i.e., they had 1 of the 4 putative diagnoses but were as- signed to the wrong cell of the matrix) or unclas- 56 KENTALA and RAUCH January 2003 sified (i.e., they did not fit in the matrix because of reporting intermediate-duration vertigo without hearing loss or dysequilibrium without true verti- go). ...
Citations
... Given the volume of patients, along with associated healthcare costs, it is not surprising that investigators have created questionnaire tools to assist clinicians in the identification of vestibular disorders (Kentala & Rauch 2003;Zhao et al. 2011;Roland et al. 2015). For example, Jacobson et al. (2019) described the development of the dizziness symptom profile (DSP). ...
... The structure of this questionnaire allows for the identification of "symptom clusters" consistent with isolated or co-occurring vestibular disorders (Jacobson et al. 2019). This is unique in the area of dizziness questionnaires and is a noted weakness of other questionnaires (Kentala & Rauch 2003;Roland et al. 2015). ...
Objectives:
Dizziness is among the most common reasons people seek medical care. There are data indicating patients with dizziness, unsteadiness, or vertigo may have multiple underlying vestibular disorders simultaneously contributing to the overall symptoms. Greater awareness of the probability that a patient will present with symptoms of co-occurring vestibular disorders has the potential to improve assessment and management, which could reduce healthcare costs and improve patient quality of life. The purpose of the current investigation was to determine the probabilities that a patient presenting to a clinic for vestibular function testing has symptoms of an isolated vestibular disorder or co-occurring vestibular disorders.
Design:
All patients who are seen for vestibular function testing in our center complete the dizziness symptom profile, a validated self-report measure, before evaluation with the clinician. For this retrospective study, patient scores on the dizziness symptom profile, patient age, and patient gender were extracted from the medical record. The dizziness symptom profile includes symptom clusters specific to six disorders that cause vestibular symptoms, specifically: benign paroxysmal positional vertigo, vestibular migraine, vestibular neuritis, superior canal dehiscence, Meniere disease, and persistent postural perceptual dizziness. For the present study, data were collected from 617 participants (mean age = 56 years, 376 women, and 241 men) presenting with complaints of vertigo, dizziness, or imbalance. Patients were evaluated in a tertiary care dizziness specialty clinic from October 2020 to October 2021. Self-report data were analyzed using a Bayesian framework to determine the probabilities of reporting symptom clusters specific to an isolated disorder and co-occurring vestibular disorders.
Results:
There was a 42% probability of a participant reporting symptoms that were not consistent with any of the six vestibular disorders represented in the dizziness symptom profile. Participants were nearly as likely to report symptom clusters of co-occurring disorders (28%) as they were to report symptom clusters of an isolated disorder (30%). When in isolation, participants were most likely to report symptom clusters consistent with benign paroxysmal positional vertigo and vestibular migraine, with estimated probabilities of 12% and 10%, respectively. The combination of co-occurring disorders with the highest probability was benign paroxysmal positional vertigo + vestibular migraine (~5%). Probabilities decreased as number of symptom clusters on the dizziness symptom profile increased. The probability of endorsing vestibular migraine increased with the number of symptom clusters reported.
Conclusions:
Many patients reported symptoms of more than one vestibular disorder, suggesting their symptoms were not sufficiently captured by the symptom clusters used to summarize any single vestibular disorder covered by the dizziness symptom profile. Our results indicate that probability of symptom clusters indicated by the dizziness symptom profile is comparable to prior published work on the prevalence of vestibular disorders. These findings support use of this tool by clinicians to assist with identification of symptom clusters consistent with isolated and co-occurring vestibular disorders.
... First, there is difficulty in assessing vertigo from different forms of dizziness, particularly in the pediatric population. Even with the aid of advanced computer algorithms but without genetic data, diagnostic accuracy in the assessment of the dizzy patient is estimated at around 65% [57]. Second, this study used a list of candidate genes based on known inner-ear-expressed genes, genes previously associated with balance disorders in mice, and migraine genes. ...
Vertigo due to vestibular dysfunction is rare in children. The elucidation of its etiology will improve clinical management and the quality of life of patients. Genes for vestibular dysfunction were previously identified in patients with both hearing loss and vertigo. This study aimed to identify rare, coding variants in children with peripheral vertigo but no hearing loss, and in patients with potentially overlapping phenotypes, namely, Meniere’s disease or idiopathic scoliosis. Rare variants were selected from the exome sequence data of 5 American children with vertigo, 226 Spanish patients with Meniere’s disease, and 38 European–American probands with scoliosis. In children with vertigo, 17 variants were found in 15 genes involved in migraine, musculoskeletal phenotypes, and vestibular development. Three genes, OTOP1, HMX3, and LAMA2, have knockout mouse models for vestibular dysfunction. Moreover, HMX3 and LAMA2 were expressed in human vestibular tissues. Rare variants within ECM1, OTOP1, and OTOP2 were each identified in three adult patients with Meniere’s disease. Additionally, an OTOP1 variant was identified in 11 adolescents with lateral semicircular canal asymmetry, 10 of whom have scoliosis. We hypothesize that peripheral vestibular dysfunction in children may be due to multiple rare variants within genes that are involved in the inner ear structure, migraine, and musculoskeletal disease.
... For instance, Kentala and Rauch deliberately excluded questions on positional dizziness stating that "many patients believe that any head position enhances their symptoms, and asking about symptoms induced by head position could be misleading" (123). This corresponds with our findings and illustrates important challenges in diagnosing BPPV by questionnaires. ...
Link to instituion website at UiB with accepted versions of all included papers: https://hdl.handle.net/11250/3029731
Background: Dizziness and unsteadiness are common symptoms that can be caused by pathologies in various organ-systems. In the general population such symptoms are associated with increased mortality, but it is not known if this increased mortality is caused by vestibular pathology. Today, many of the common vestibular diagnoses depend on patient-reported symptoms alone, and the evidence base for evaluating and treating patients with dizziness has been described as low.
Aim: To critically evaluate which symptoms reported by dizzy patients provide useful information, and further to evaluate the interrelations between posturography, inner ear function, and long-term survival.
Material and methods: A cohort of patients examined from 1992 to 2004 at an otolaryngology department for suspected vestibular disorder.
Results: While most patients (72.1%) chose only one timing category, fewer than half the patients (47.1%) describe their complaints with only one type of dizziness. Vomiting was associated with increased risk for caloric asymmetry (Odds ratio 1.60, 95 % CI 1.24–2.06). A 10-dB increase in hearing loss in the best-hearing ear was associated with a 6.0% increase in path length measured on a balance platform. The standardized mortality ratio was 1.03 (0.94–1.12). Periodic or short attacks of dizziness were associated with reduced mortality with a hazard ratio of 0.62 (0.50–0.77) and 0.76 (0.63–0.93), respectively. Both self-reported and unsteadiness on posturography were associated with increased mortality with a hazard ratio of 1.30 (1.08–1.47) and 1.44 (1.14–1.82).
Conclusions: The timing of vestibular symptoms and a differentiation between nausea and vomiting should be targeted when interviewing patients. The type of dizziness provides additional information but does not appear useful for categorization. The association between hearing and postural balance was not explained by unilateral vestibular disorders. Vestibular pathology is probably not the main cause of the increased mortality seen among patients with vestibular symptoms and balance problems in the general population. Further studies exploring cause of death related to vestibular symptoms, hearing, and postural balance are advocated.
... (25,26) Preexisting algorithms can be implemented through telemedicine platforms that stratify patients and reduce the number of in-person examinations for dizziness. (29) If patients rely on lip reading in the otology clinic, telemedicine visits can mitigate masks being a barrier to communication. ...
... When a patient complains of dizziness, preexisting algorithms can be implemented through telemedicine platforms to stratify patients with life threating complications, those requiring medical intervention, and those who can be treated virtually (29). As the patient history is the primary component of diagnosis for dizziness, virtual consultation could reduce the amount of patients in the clinic (30). ...
Objectives: As institutions modified medical practices to mitigate the spread of the SARS-CoV-2 virus, providers were forced to modify care through the implementation of telemedicine. The objective of this article is to review the current practices of otolaryngology during the COVID-19 pandemic and the limitations of telemedicine in current practice. Methods: A thorough review of the PubMed and MEDLINE databases was performed for publications between 2020 and 2021. Studies discussing telemedicine in otolaryngology during COVID-19 pandemic were selected. Results: As worldwide cases of COVID-19 continue to oscillate, we must continue to be vigilant in our clinical practice, implementing safe techniques to mitigate the spread of the SARS-CoV-2 virus through the continual use of telemedicine in all specialties of otolaryngology. Trends of increased patient acceptance of the use of telemedicine have been seen across subspecialities, including otolaryngology. Conclusion: Currently there are challenges associated with the implementation of telemedicine in the field of otolaryngology that rely heavily on adjunct physical examination, imaging studies, and specialty procedures. However, telemedicine has tremendous potential and can be adapted to include in the otolaryngologist’s toolbelt during public health emergencies such as the COVID-19 pandemic.
... Our search identified 6 self-administered questionnaires [19][20][21][22][23][24] designed to aid in the management of the vertiginous patient ( Table 5 and Table 6). All the questionnaires were able to assess patients for BPPV and MD. ...
... All the questionnaires were able to assess patients for BPPV and MD. Four of the 6 vestibular questionnaires also had the ability to identify VN. [21][22][23][24] Vestibular migraine was the most identified central cause of vertigo, with 5 of the 6 questionnaires being able to select for patients with this disorder. [19][20][21]23,24 From an initial 16-page questionnaire, Bayer et al 19 selected a limited set of items for further investigation. ...
Objective:
The evaluation of peripheral vestibular disorders in clinical practice is an especially difficult endeavor, particularly for the inexperienced clinician. The goal of this systematic review is thus to evaluate the design, approaches, and outcomes for clinical vestibular symptom triage and decision support tools reported in contemporary published literature.
Data sources:
A comprehensive search of existing literature in August 2020 was conducted using MEDLINE, CINAHL, and EMBASE using terms of desired diagnostic tools such as algorithm, protocol, and questionnaire as well as an exhaustive set of terms to encompass vestibular disorders.
Review methods:
Study characteristics, tool metrics, and performance were extracted using a standardized form. Quality assessment was conducted using a modified version of the Quality of Diagnostic Accuracy Studies 2 (QUADAS-2) assessment tool.
Results:
A total of 18 articles each reporting a novel tool for the evaluation of vestibular disorders were identified. Tools were organized into 3 discrete categories, including self-administered questionnaires, health care professional administered tools, and decision support systems. Most tools could differentiate between specific vestibular pathologies, with outcome measures including sensitivity, specificity, and accuracy.
Conclusion:
A multitude of tools have been published to aid with the evaluation of vertiginous patients. Our systematic review identified several low-evidence reports of triage and decision support tools for the evaluation of vestibular disorders.
... The predictive power ranged from 60% to 84% in those studies. 6,8,12,15,16 However, prior studies were formulate with the numbers of self-administration questions (between 4---163 items) and available only in English language. 6,8,12,16,17 Differences in language may affect the understanding and responses of patients. ...
... 6,8,12,15,16 However, prior studies were formulate with the numbers of self-administration questions (between 4---163 items) and available only in English language. 6,8,12,16,17 Differences in language may affect the understanding and responses of patients. Furthermore, there has never been a general available report or publication about using an algorithm of a structured questionnaire. ...
Introduction
“Dizziness” is a common complaint in clinical practice that can occur with anyone. However, since the symptom is caused by a wide range of disorders, a general clinician usually faces some difficulty to detect the cause.
Objective
This study aimed to formulate and validate a simple instrument that can be used to screen and predict the most likely cause of dizziness in Thai outpatients.
Methods
This study was divided into two phases. Phase I included 41 patients diagnosed with common causes of dizziness to determine the algorithm and construct the “structural algorithm questionnaire version 1”. In addition, to test and retest its content validity and reliability until the instrument had an acceptable level of both. Phase II of the study pertained to evaluating its accuracy in clinical trials, 150 patients with dizziness had a face-to-face interview while they were waiting for their medical appointment.
Results
The degree of agreement between the algorithm results and clinical diagnoses was within an acceptable level (κ = 0.69). Therefore, this algorithm was used to construct the structural algorithm questionnaire version 1. The content validity of the structural algorithm questionnaire version 1evaluated by seven experts. The content validity index values of the questionnaire ranged from 0.71 to 1.0. The Cohen’s kappa coefficient (κ) of intra-rater reliability of the structural algorithm questionnaire version 10.71. In clinical trials, 150 patients with dizziness had a face-to-face interview while they were waiting for their appointment. The overall agreement between their questionnaire responses and final diagnoses by specialists showed a moderate degree of clinical accuracy (κ = 0.55).
Conclusions
The structural algorithm questionnaire version 1had a well-developed design and acceptable quality pertaining to both validity and reliability. It might be used to differentiate the cause of dizziness between vestibular and non-vestibular disorders, especially of outpatients with dizziness symptoms.
... Other studies have corroborated the diagnostic utility of vestibular symptoms. [19][20][21][22][23] Before subjecting the patient to a battery of clinical testing, it would be useful to identify certain screening questions that are more indicative of vestibular impairment. Previous studies have demonstrated the utility of screening questions in diagnosis. ...
Introduction: A number of vestibular function tests have been used to evaluate vestibular symptoms among people living with HIV (PLWH). However, these tests are inconsistent due to poor sensitivity and specificity. This study attempts to identify sensitive and specific vestibular symptoms that may be useful in selecting appropriate HIV-positive adults for clinical vestibular function tests.
Methods: Participants were enrolled from the Baltimore-Washington, DC, site of the Multicenter AIDS Cohort Study and the Washington, DC, site of the Women’s Interagency HIV Study. A total of 246 participants were evaluated using the Dix-Hallpike (DH) maneuver and the eyes closed, standing on foam (ECF) position in the Romberg test, and completed the Adult Balance and Dizziness Supplemental questionnaire of the 2008 National Health Interview Survey. The sensitivity and specificity were calculated using self-reported vestibular dysfunction from the questionnaire data compared with vestibular dysfunction determined by clinical testing.
Results: Sixty participants (24.4%) reported vestibular dysfunction. The prevalence of abnormal tests was 40.8% for DH–any nystagmus, 1.5% for DH–classical nystagmus, 40.3% for DH–nonclassical nystagmus, 38.3% for gaze-evoked nystagmus, and 15.7% for Romberg ECF. Sensitivity of self-reported vestibular symptoms for all vestibular function tests reported ranged from 23.1% to 50.0%. These symptoms were moderately specific and ranged from 73.3% to 77.9%.
Conclusions: Despite adequate specificity, the low sensitivity of self-reported symptoms of vestibular dysfunction were not useful to rule out a vestibular disorder in this sample of middle-aged PLWH. Therefore, clinical testing is needed to confirm the diagnosis of a vestibular disorder in the management of HIV disease.
... The gold standard for the diagnosis of posterior canal BPPV is the Dix-Hallpike maneuver, whereas horizontal canal BPPV is mostly diagnosed with the supine roll test (5). Besides diagnostic positional maneuvers, patient history is critical for the recognition of BPPV and for classifying the etiology (7,8). The evaluation of a patient with dizziness can be difficult because of the broad etiology and wide array of questions and tests necessary to come to a diagnosis. ...
Introduction: This prospective cohort study determined which questions in patient history are most likely to identify symptoms that are independently associated with a diagnosis of benign paroxysmal positional dizziness (BPPV) in patients presenting with dizziness, and to evaluate whether the patient's age and type of BPPV are of influence.
Methods: We included adult patients with dizziness referred to our dizziness center, Apeldoorn, the Netherlands, from December 2018 to November 2019. All patients completed a questionnaire, underwent vestibular testing and received a diagnosis. Symptoms strongly suggesting BPPV were tested with multivariable analysis to determine their independent associations with BPPV. Subgroup analysis was performed for patient age, and the type of BPPV.
Results: We included a total of 885 patients, 113 of whom (13%) were diagnosed with BPPV. The duration of dizziness spells <1 min (Q2) and dizziness provoked by rolling over in bed (Q4) were independently associated with the diagnosis BPPV. Q2 showed a sensitivity of 43%, and a specificity of 75%; Q4 scored 81% and 68%, respectively. Overall, the way patients perceived their dizziness (vertigo, light-headedness or instability) was not independently associated with the diagnosis BPPV. In younger patients, light-headedness and instability decreased the likelihood of BPPV compared to vertigo.
Conclusion: The most reliable predictors for BPPV in patient history are a short duration of the dizziness spell and provocation of dizziness by rolling over in bed. Unlike younger patients, elderly patients with BPPV do not only perceive the dizziness as vertigo, but also as a feeling of instability.
... Dizziness and vertigo are common complaints among patients seen in otolaryngology clinics and account for approximately 10% of consultations (1). Usually the diagnostic process starts with an interview that guides further clinical and laboratory testing (2,3). Thus, it is important to establish how clinicians can use the anamnestic information to determine a diagnosis with the appropriate use of laboratory investigations. ...
Objective:
To determine if symptoms regarding timing and triggers of dizziness are useful for categorizing patients with dizziness, and to evaluate how patient-reported symptoms predict vestibular asymmetry, postural sway, and vestibular diagnoses.
Study design:
Retrospective chart review.
Setting:
Tertiary referral center.
Patients:
Patients referred for suspected vestibular disease.
Interventions:
Patients completed a symptom questionnaire before laboratory testing with static posturography and bithermal caloric tests.
Main outcome measure:
Evaluate whether responses from a symptom questionnaire predict caloric asymmetry, postural balance, and diagnoses.
Results:
One thousand four hundred fifty seven patients, 60.1% women, mean age 49.9 (±16.6) years were included. Vomiting was the strongest predictor for caloric asymmetry in adjusted analysis, odds ratio (OR): 1.60 (95% confidence interval [CI]: 1.24-2.06), followed by chronic hearing loss OR: 1.59 (1.19-2.13). Patients who reported constant dizziness had impaired postural balance, quantified as 15% increase in postural sway in adjusted analyses (7.25-24.6%). We found no association between caloric asymmetry and postural instability with eyes closed.
Conclusion:
Most patients were able to describe the timing of their symptoms and a categorization based on timing seems feasible. There seemed to be an over-reporting of triggers and confirmatory testing of triggers is therefore advocated. Vomiting, but not nausea, was a strong indicator of vestibular disease in this primarily outpatient population. Caloric asymmetry and postural balance were not associated, and assessment of fall risk may be warranted in patients who reports constant dizziness, visual disturbances or dizziness triggered by light, darkness or sounds.
... Other otological disorders causing vertigo may be differentiated from BPPV by their clinical characteristics including their temporal pattern and the presence or absence of hearing loss. Whereas BPPV is characterized by acute, discrete episodes of brief positional vertigo without associated hearing loss, other otological causes of vertigo manifest different temporal patterns and may additionally demonstrate associated hearing loss (Kentala, et al., 2003). In distinction to BPPV, Ménière's disease is characterized by discrete episodic attacks, with each attack exhibiting a characteristic triad of sustained vertigo, fluctuating hearing loss, and tinnitus (Baloh, et al., 1987), (Wladislavosky-Waserman, et al., 1984). ...
... The time course of the vertigo is often the best differentiator between BPPV and vestibular neuritis or labyrinthitis. In vestibular neuritis or labyrinthitis, the vertigo is of gradual onset, developing over several hours, followed by a sustained level of vertigo lasting days to weeks (Kentala, et al., 2003) (Kentala, et al., 1996) (Kentala, et al., 1999). The vertigo is present at rest (not requiring positional change for its onset), but it may be subjectively exacerbated by positional changes. ...
... Among the central causes of vertigo that should be distinguished from BPPV are migraine-associated vertigo, vertebrobasilar TIA, and intracranial tumors. Vestibular migraine has been described as a common cause of vertigo in the adult population (Reploeg, et al., 2002) and may account for as many as 14 percent of cases of vertigo (Kentala, et al., 2003). Diagnostic criteria include 1) episodic vestibular symptoms; 2) migraine according to International Headache Society criteria; 3) at least two of the following migraine symptoms during at least two vertiginous episodes: migrainous headache, photophobia, phonophobia, or visual or other aura; and 4) other causes ruled out by appropriate investigations (Headache Classification Subcommittee of the International Headache Society, 2004). ...
Renewing the Dutch guideline for medical specialists: BPPV.
