Updated March 19, 2013: Preview of The Medifocus Guidebook On: Vertigo

Preview of the Medifocus Guidebook on:
Vertigo
Updated March 19, 2013
This document is only a SHORT PREVIEW of the Medifocus Guidebook on Vertigo. It is
intended primarily to give you a general overview of the format and structure of the
Guidebook as well as select pages from each major Guidebook section listed in the Table of
Contents.
To purchase the COMPLETE Medifocus Guidebook on Vertigo (132 pages; Updated March
19, 2013), please:
Call us at:
800-965-3002 (United States)
301-649-9300 (Outside the United States)
Order online through our website:
Printed Version
Mailed to you and bound for easy reading.
Includes free online access to the electronic guidebook for one full year.
Electronic Version
Adobe PDF document that can be viewed or printed on any computer
Online updates are included for one full year.
Table of Contents
Background Information .................................................................... 8
Introduction ................................................................................................. 8
About Your Medifocus Guidebook ........................................................... 10
Ordering Full-Text Articles ....................................................................... 13
The Intelligent Patient Overview .................................................. 15
Guide to the Medical Literature .................................................... 50
Introduction ............................................................................................... 50
Recent Literature: What Your Doctor Reads ........................................... 51
Review Articles ..................................................................................... 51
General Interest Articles ....................................................................... 60
Surgical Therapy Articles ..................................................................... 86
Clinical Trials Articles .......................................................................... 88
Repositioning Therapy Articles ............................................................ 95
Centers of Research............................................................................. 99
United States ........................................................................................... 101
Other Countries ....................................................................................... 107
Tips on Finding and Choosing a Doctor .................................. 123
Directory of Organizations ............................................................. 129
Copyright 2013 MediFocus Guide from Medifocus.com, Inc.www.medifocus.com (800) 965-3002 2
1 - Background Information
Introduction
Chronic or life-threatening illnesses can have a devastating impact on both the patient and
the family. In today's new world of medicine, many consumers have come to realize that
they are the ones who are primarily responsible for their own health care as well as for the
health care of their loved ones.
When facing a chronic or life-threatening illness, you need to become an educated
consumer in order to make an informed health care decision. Essentially that means finding
out everything about the illness - the treatment options, the doctors, and the hospitals - so
that you can become an educated health care consumer and make the tough decisions. In
the past, consumers would go to a library and read everything available about a particular
illness or medical condition. In today's world, many turn to the Internet for their medical
information needs.
The first sites visited are usually the well known health "portals" or disease organizations
and support groups which contain a general overview of the condition for the layperson.
That's a good start but soon all of the basic information is exhausted and the need for more
advanced information still exists. What are the latest "cutting-edge" treatment options?
What are the results of the most up-to-date clinical trials? Who are the most notable
experts? Where are the top-ranked medical institutions and hospitals?
The best source for authoritative medical information in the United States is the National
Library of Medicine's medical database called PubMed, that indexes citations and
abstracts (brief summaries) of over 7 million articles from more than 3,800 medical
journals published worldwide. PubMed was developed for medical professionals and is
the primary source utilized by health care providers for keeping up with the latest advances
in clinical medicine.
A typical PubMed search for a specific disease or condition, however, usually retrieves
hundreds or even thousands of "hits" of journal article citations. That's an avalanche of
information that needs to be evaluated and transformed into truly useful knowledge. What
are the most relevant journal articles? Which ones apply to your specific situation? Which
articles are considered to be the most authoritative - the ones your physician would rely on
in making clinical decisions? This is where Medifocus.com provides an effective solution.
Medifocus.com has developed an extensive library of MediFocus Guidebooks covering a
wide spectrum of chronic and life threatening diseases. Each MediFocus Guidebook is a
high quality, up- to-date digest of "professional-level" medical information consisting of
the most relevant citations and abstracts of journal articles published in authoritative,
trustworthy medical journals. This information represents the latest advances known to
modern medicine for the treatment and management of the condition, including published
results from clinical trials. Each Guidebook also includes a valuable index of leading
authors and medical institutions as well as a directory of disease organizations and support
groups. MediFocus Guidebooks are reviewed, revised and updated every 4-months to
ensure that you receive the latest and most up-to-date information about the specific
condition.
About Your MediFocus Guidebook
Introduction
Your MediFocus Guidebook is a valuable resource that represents a comprehensive
synthesis of the most up-to-date, advanced medical information published about the
condition in well-respected, trustworthy medical journals. It is the same type of
professional-level information used by physicians and other health-care professionals to
keep abreast of the latest developments in biomedical research and clinical medicine. The
Guidebook is intended for patients who have a need for more advanced, in-depth medical
information than is generally available to consumers from a variety of other resources. The
primary goal of a MediFocus Guidebook is to educate patients and their families about
their treatment options so that they can make informed health-care decisions and become
active participants in the medical decision making process.
The Guidebook production process involves a team of experienced medical research
professionals with vast experience in researching the published medical literature. This
team approach to the development and production of the MediFocus Guidebooks is
designed to ensure the accuracy, completeness, and clinical relevance of the information.
The Guidebook is intended to serve as a basis for a more meaningful discussion between
patients and their health-care providers in a joint effort to seek the most appropriate course
of treatment for the disease.
Guidebook Organization and Content
Section 1 - Background Information
This section provides detailed information about the organization and content of the
Guidebook including tips and suggestions for conducting additional research about the
condition.
Section 2 - The Intelligent Patient Overview
This section of your MediFocus Guidebook represents a detailed overview of the disease or
condition specifically written from the patient's perspective. It is designed to satisfy the
basic informational needs of consumers and their families who are confronted with the
illness and are facing difficult choices. Important aspects which are addressed in "The
Intelligent Patient" section include:
The etiology or cause of the disease
Signs and symptoms
How the condition is diagnosed
The current standard of care for the disease
Treatment options
New developments
Important questions to ask your health care provider
Section 3 - Guide to the Medical Literature
This is a roadmap to important and up-to-date medical literature published about the
condition from authoritative, trustworthy medical journals. This is the same information
that is used by physicians and researchers to keep up with the latest developments and
breakthroughs in clinical medicine and biomedical research. A broad spectrum of articles
is included in each MediFocus Guidebook to provide information about standard
treatments, treatment options, new clinical developments, and advances in research. To
facilitate your review and analysis of this information, the articles are grouped by specific
categories. A typical MediFocus Guidebook usually contains one or more of the following
article groupings:
Review Articles: Articles included in this category are broad in scope and are
intended to provide the reader with a detailed overview of the condition including
such important aspects as its cause, diagnosis, treatment, and new advances.
General Interest Articles: These articles are broad in scope and contain
supplementary information about the condition that may be of interest to select
groups of patients.
Drug Therapy: Articles that provide information about the effectiveness of specific
drugs or other biological agents for the treatment of the condition.
Surgical Therapy: Articles that provide information about specific surgical treatments
for the condition.
Clinical Trials: Articles in this category summarize studies which compare the safety
and efficacy of a new, experimental treatment modality to currently available
standard treatments for the condition. In many cases, clinical trials represent the latest
advances in the field and may be considered as being on the "cutting edge" of
medicine. Some of these experimental treatments may have already been
incorporated into clinical practice.
The following information is provided for each of the articles referenced in this section of
your MediFocus Guidebook:
Article title
Author Name(s)
Institution where the study was done
Journal reference (Volume, page numbers, year of publication)
Link to Abstract (brief summary of the actual article)
Linking to Abstracts: Most of the medical journal articles referenced in this section of your
MediFocus Guidebook include an abstract (brief summary of the actual article) that can be
accessed online via the National Library of Medicine's PubMed database. You can easily
access the individual abstracts online via PubMed from the "electronic" format of your
MediFocus Guidebook by clicking on the corresponding URL address that is provided for
each cited article. If you purchased a printed copy of a MediFocus Guidebook, you can still
access the article abstracts online by entering the individual URL address for a particular
article into your web browser.
Section 4 - Centers of Research
We've compiled a unique directory of doctors, researchers, medical centers, and research
institutions with specialized research interest, and in many cases, clinical expertise in the
management of the specific medical condition. The "Centers of Research" directory is a
valuable resource for quickly identifying and locating leading medical authorities and
medical institutions within the United States and other countries that are considered to be
at the forefront in clinical research and treatment of the condition.
Inclusion of the names of specific doctors, researchers, hospitals, medical centers, or
research institutions in this Guidebook does not imply endorsement by Medifocus.com,
Inc. or any of its affiliates. Consumers are encouraged to conduct additional research to
identify health-care professionals, hospitals, and medical institutions with expertise in
providing specific medical advice, guidance, and treatment for this condition.
Section 5 - Tips on Finding and Choosing a Doctor
One of the most important decisions confronting patients who have been diagnosed with a
serious medical condition is finding and choosing a qualified physician who will deliver
high-level, quality medical care in accordance with curently accepted guidelines and
standards of care. Finding the "best" doctor to manage your condition, however, can be a
frustrating and time-consuming experience unless you know what you are looking for and
how to go about finding it. This section of your Guidebook offers important tips for how to
find physicians as well as suggestions for how to make informed choices about choosing a
doctor who is right for you.
Section 6 - Directory of Organizations
This section of your Guidebook is a directory of select disease organizations and support
groups that are in the business of helping patients and their families by providing access to
information, resources, and services. Many of these organizations can answer your
questions, enable you to network with other patients, and help you find a doctor in your
geographical area who specializes in managing your condition.
2 - The Intelligent Patient Overview
VERTIGO
Introduction to Vertigo
What is Vertigo?
Vertigo is more than dizziness. The word "dizziness" is often used to describe a variety of
sensations, from lightheadedness to feeling weak or unsteady. An individual may experience a
feeling of "passing out" that often disappears when the person lies down. This kind of
lightheadedness or dizziness may be caused by a temporary drop of blood pressure or reduced
blood flow to the head, which can occur when a person gets up too quickly from a sitting or lying
down position.
The dizziness of vertigo is different. Individuals with vertigo always have the sense that they or
their surroundings are spinning. Vertigo is defined as a false illusion of motion with a distinct
sensation of rotation ("the room was spinning around me") and is caused by vestibular dysfunction
(an inner ear balance disorder). Lying down does not necessarily bring relief. The most common
form of vertigo is called benign paroxysmal positional vertigo (BPPV), and is caused by
conflicting signals received by the brain from various sensory systems that monitor balance and
the position of the body in space. The term "paroxysmal" connotes a sudden attack.
Acute vertigo refers to an attack that consists of a well-defined, isolated spell of vertigo with a
distinct onset and conclusion. Recurrent attacks of vertigo are referred to as chronic vertigo.
Vertigo is usually accompanied by nystagmus (involuntary oscillation of the eyes), which is
triggered by an inner ear disturbance. Vertigo attacks can occur spontaneously (e.g., due to sudden
head movement) or can be secondary to other conditions (e.g., head trauma, labyrinthitis, or
prolonged bed rest).
The Vestibular System
The human ear is a complex sensory organ which is involved with two important functions,
namely auditory (hearing) and vestibular (balance). The auditory system regulates hearing, while
the vestibular system is responsible for maintaining the body's orientation in space, the body's
balance, and posture. The vestibular system also regulates motion and keeps objects in visual
focus as the body moves. The auditory and vestibular systems are intimately related.
Any major disturbance to the smooth operation of the vestibular system may result in symptoms
such as dizziness, unsteadiness in walking, feeling disoriented in space, or poor balance. These
sensations may also be accompanied by nausea and/or vomiting. Disturbances to the auditory
system can result in problems such as hearing loss or tinnitus (ringing in the ears).
In order to understand the various factors involved in vertigo, it is important to be familiar with the
structures that comprise the vestibular system and their role in balance and spatial orientation.
The ear consists of three parts: the _outer (external) ear, middle ear, and inner ear (labyrinth).
While each part of the ear is involved with receiving and interpreting sound waves necessary for
hearing, the inner ear has an additional role of being responsible for the body's balance and
orientation in space.
There are three parts to the inner ear itself. These organs of the inner ear comprise a system of
fluid passages that are located in the hollowed-out area of the temporal bone at the base of the
skull. The three parts of the inner are the cochlea, semicircular canals, and the vestibule:
Cochlea - Organ of hearing coiled in the shape of a snail and located towards the front of the
inner ear.
Semicircular canals - Three loop-shaped structures located towards the rear of the inner ear
that are oriented at right angles to each other. They are organs of balance that contain fluid
and fine hair-like structures that function to maintain the body's balance while turning and
moving. They are referred to as posterior, horizontal, and anterior semicircular canals, and
each responds to different directions of movement or acceleration. Each semicircular canal
contains:
crista - A bulging area at the entrance to each canal that is covered by sensory hair
cells, which connect to the nerve endings of the vestibulocochlear nerve
cupula - A gelatinous mass which sits atop the crista
endolymph - A viscous fluid which is found throughout the vestibular system and
which moves with the sway of motion
Vestibule - The region between the semicircular canals and the cochlea. The semicircular
canals converge at one end, and the other end connects to the cochlea. The vestibule contains
two membranous sacs called otolith organs that are both involved with balance. These are
called the utricle and saccule:
utricle - The larger of the two sacs that communicates with the semicircular canals.
The utricle contains tiny particles or stones made of calcium carbonate called otoconia
which are held together by a gel-like substance. The otoconia sit atop small hairs with
sensors that help detect back-and-forth motion. The hairs are connected to nerve
endings of the vestibulocochlear nerve. The utricle senses movement in the horizontal
plane (i.e., forward-backward, left-right, or any combination thereof).
saccule - The smaller of the two sacs that is connected to the cochlear duct (a duct that
curves through the cochlea) and to the utricle. It also contains otoconia arranged like
those in the utricle, and it responds to movement in the vertical plane (i.e., up-down
movement).
How Does the Vestibular System Work?
When any movement occurs, the endolymph moves relative to the motion. The movement of the
endolymph causes the cupula of the semicircular canals and the structures in the utricle and
saccule to bend. Pressure of the otoliths on the hair cells provides sensory input about acceleration
and gravity. The displacement caused by the bending is picked up by the hair cells underneath,
which are attached to the nerve endings of the auditory nerve. The brain "translates" this message
as movement and, depending on the exact configuration of the nerve impulses, determines the
exact direction of the body's movement in space.
The sensation of movement is also coordinated with the visual and skeletal systems, so that a
person is oriented in space both when standing still and when in motion. The postural and visual
responses to head motion are determined by reflexes mediated by the vestibular nuclei in the
brain, which coordinate the information received by the vestibular system. These reflexes are
protective, in that they cause people to automatically try to "catch themselves" when they are off
balance or falling.
The sense of balance is regulated by a number of factors:
Visual signals (ocular system)
Sensory responses in the skin, muscles, and joints (somatosensory system)
Spine and movement (skeletal system)
Inner ear function (vestibular system)
The vestibular system works together with the visual and skeletal systems in order to help a person
maintain balance. If everything is synchronized, balance is achieved. When the central nervous
system detects mismatching or conflicting information, it reacts by trying to compensate or
habituate to the new information, in order to reconcile the competing sensations. "Compensation"
of the central nervous system takes place unconsciously, and reflects its capacity to adapt rapidly
to change. The center for this compensation or "conflict resolution" is in the vestibular nuclei.
Vertigo is the sensation that occurs when there is no compensation or habituation of conflicting
information from the central nervous system to the brain.
Nystagmus is an involuntary oscillation of the eyes that automatically occurs when the conflicting
information (and resultant vertigo) is related to position in space. It is characterized by involuntary
eye movements that are triggered by inner ear stimulation. The eye oscillation begins as a slow
tracking movement and is followed by rapid resetting, during which the eyes rapidly beat, or
oscillate, towards the right or left. Nystagmus is called rotational or rotatory if the beating is not
purely horizontal or vertical. When nystagmus originates in the peripheral aspect of the vestibular
system (e.g., inner ear dysfunction), it will stop when the eyes fixate on an object. If the
nystagmus originates from the central aspect of the vestibular system (e.g., as in multiple sclerosis
or because of a cranial nerve lesion) it does not stop with gaze fixation.
Lesions along any of the multiple pathways that coordinate functions of the vestibular system
related to posture, motion perception, and spatial orientation, can cause vertigo.
Examples of vertigo-inducing, vestibular system lesions include:
Lesions in the vestibulo-spinal pathway that result in postural imbalance
Lesions in the vestibulo-ocular pathway that result in nystagmus
Lesions in the vestibular system that result in vertigo
Lesions in the reticular formation (a network of neurons that runs through the brainstem)
that result in nausea and/or vomiting
Thus, vertigo is not a single process but rather a multi-sensory syndrome.
Classification of Vertigo
In general, there are three types of vertigo - peripheral, central, psychogenic.
Peripheral vertigo - Occurs when there is a problem either with the portion of the inner ear
that controls balance, or with the vestibular nerve. Benign paroxysmal positional vertigo
(BPPV) is the most common form of peripheral vertigo.
Central vertigo - Caused by a dysfunction within the brain (cerebellum or brain stem).
Central vertigo may be associated with migraine headache, transient ischemic attacks (TIA),
stroke, multiple sclerosis, or acoustic neuroma. Although central vertigo is a rare
phenomenon, the symptoms, such as nausea and dizziness, may persist for years. Central
vertigo has a much more gradual onset than peripheral vertigo, and is associated with other
neurological symptoms.
Psychogenic vertigo - May occur in patients with an underlying psychological disorder, such
as anxiety or panic attacks.
Another type of vertigo, vascular vertigo, is caused by problems with the blood supply to the inner
ear or the balance centers of the brain, and can be of central or peripheral origin. Vascular vertigo
can occur in people who suffer from conditions such as migraine headache, atherosclerosis,
diabetes, hypertension, or obesity.
What Causes Vertigo?
Causes of vertigo vary depending on whether the vertigo is of peripheral, central, or of
psychogenic origin.
Peripheral Vertigo
Peripheral vertigo may be caused by several factors, including:
Idiopathic (unknown) origin - This describes the most common form of peripheral vertigo,
benign paroxysmal positional vertigo (BPPV), in which, for unknown reasons, head
movement triggers vertigo that may range in intensity from mild to severe. The mechanism
causing BPPV is known (calcium crystals move into vestibular system and displace fluids,
which disrupts balance), but the reason for this to occur is unknown.
Head trauma - Head injury accounts for approximately 17% of cases of peripheral vertigo.
Peripheral vestibulopathy - Abnormality of the inner ear. Some conditions of peripheral
vestibulopathy include vestibular neuritis (inflammation of the vestibular nerve usually
caused by a viral infection), which accounts for approximately 15% of cases of peripheral
vertigo; or bacterial labyrinthitis (inflammation of the labyrinth caused by a bacterial
infection).
Meniere's disease - Abnormality of the inner ear that is associated not only with vertigo, but
also with tinnitus (ringing in the ears), hearing loss, and pain or pressure in the affected ear.
It is related to a change in fluid volume within the labyrinth.
Perilymphatic fistula - Abnormal contact (a small opening) between the space containing the
perilymph (a fluid that fills the cochlea) and the middle ear, caused either by pressure
changes in the cerebrospinal fluid or in the middle ear. Symptoms include positional vertigo,
imbalance, and nystagmus. The attacks are usually episodic, not chronic.
Medication - Certain medications may cause vertigo as a side effect, including aspirin, some
chemotherapeutic agents such as cisplatin, diuretics such as furosemide (Lasix), sedatives
such as phenobarbital, or antipsychotics such as chlorpromazine (Thorazine).
Motion Sickness - A sensation of dizziness and nausea when traveling in a vehicle (e.g., car,
plane, or boat)
Central Vertigo
Central vertigo may also be caused by several factors, including:
Acoustic neuroma - A benign tumor arising from cells in the auditory nerve (eighth cranial
nerve). The most common presenting symptom of acoustic neuroma is sudden or gradual
sensorineural hearing loss; however, up to 40% of individuals diagnosed with acoustic
neuroma may also experience vertigo.
Cerebellopontine angle tumors - These tumors develop on the vestibular portion of the
eighth cranial nerve. They are associated with progressive hearing loss, tinnitus (ringing in
the ears), and vertigo.
Cerebellar infarction - A stroke in the cerebellum, located at the base of the brain.
Epileptic vertigo - Focal epileptic discharges in certain portions of the temporal lobe of the
brain.
Basilar artery migraine headaches - Headaches may be associated with nausea, vomiting,
visual disturbances, aversion to light (photophobia), aversion to sound (phonophobia), and
attacks of vertigo, as well as other signs of brainstem dysfunction.
Multiple sclerosis (MS) - Vertigo is reported to occur in 20-50% of MS patients. It typically
lasts for days or weeks and symptoms are similar to those of vestibular neuritis or
labyrinthitis.
Parkinson's disease - A degenerative movement disorder associated with tremor, hypokinesia
(decreased body movement), rigidity, and postural instability, including vertigo.
Psychogenic Vertigo
Psychological causes of vertigo may be associated with disorders related to the body's orientation
in space:
Acrophobia - An extreme or irrational fear of heights, also known as space and motion
disorder, accompanied by the sensation of vertigo.
Phobic postural vertigo - This is the most frequent form of psychogenic vertigo and is the
third most common cause of vertigo in general. It is characterized by vertigo while standing
as well as during motion. It may be precipitated by perceptual stimuli (e.g., staircases, cliff
edges), or during social situations (e.g., attending a concert). Individuals with phobic
postural vertigo tend to avoid situations that precipitate the vertigo and thus minimize its
occurrence.
Benign Paroxysmal Positional Vertigo
Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo. It was
originally identified in 1921 by Dr. Robert Barany, who described the syndrome as paroxysmal
(sudden) vertigo together with nystagmus as a result of changing head positions. Benign
paroxysmal positional vertigo is characterized by short-lived, sudden episodes of vertigo brought
on by rapid changes in head position or other movements such as rolling over in bed, tilting the
head, or looking up or down. BPPV may occur at unpredictable moments and can last for weeks or
even years, but individual episodes of vertigo are short-lived.
Although the exact cause of BPPV is not known, it appears to correlate very strongly with aging,
since the greatest incidence occurs in people over 50 years of age. The possibility arises that this
type of vertigo may involve a slow degeneration of the vestibular system in the inner ear. The
most common identifiable cause of BPPV in people under the age of 50 is thought to be head
trauma. However, most cases of BPPV are idiopathic and cannot be associated with a causative
event.
Many people experience their first attack of BPPV when waking up in the morning and are quite
frightened by the intensity of the symptoms. The actual vertigo is usually of short duration (less
than a minute), but the intensity of the sensation is so strong that individuals often report
experiencing a much longer attack. Most cases of BPPV resolve within a few weeks or months
without any treatment. Often people can identify the exact movement that causes their vertigo
attacks and then tend to avoid these movements in order to prevent the onset of symptoms.
Typically, BPPV is characterized by the following symptoms:
Dizziness
Sense of rotational vertigo
Rotational nystagmus which resolves with time
Nausea and/or vomiting
There are three forms of BPPV, each related to the specific semicircular canal involved, namely:
posterior, horizontal, and anterior BPPV. Although some symptoms are specific to the location of
origin, the majority of symptoms are common to all types.
Posterior Benign Paroxysmal Positional Vertigo
Posterior vertigo involves the posterior semicircular canal and is the most common form of BPPV.
It accounts for up to 70% of cases where the specific semicircular canal involved can be identified.
Posterior vertigo is characterized by:
Episodic vertigo
Episodes that last up to one minute in duration
Nystagmus in a horizontal or rotatory (non-linear) direction
Latency (time until nystagmus develops) of 5-30 seconds
Movements that may provoke posterior vertigo include:
Lying down on a bed
Rolling over in bed
Extending the neck
Bending over
Reaching for something high
Sudden movement of the head
Rapid change of head position
Extending the head backward in order to look up
Horizontal Benign Paroxysmal Positional Vertigo
Horizontal vertigo originates in the horizontal semicircular canal and is usually precipitated by
turning over in bed from side to side, or by lying flat in bed and turning the head from side to side.
It is thought to account for approximately 20% of cases of BPPV. BPPV is most likely to be seen
in patients over 50 years of age. While the symptoms of horizontal BPPV are similar to posterior
BPPV, the pattern of the symptoms differ, in that individuals are not affected by changes in body
position (e.g., getting up, lying down); rather, intense vertigo is precipitated by turning the head
from side to side while lying down, and the direction of nystagmus is horizontal, and changes
direction depending on which way the head is turned.
Horizontal vertigo is characterized by:
Very sudden onset of vertigo
Duration of vertigo is longer than 30 seconds
Short latency of nystagmus (time from onset of vertigo until nystagmus appears)
Vertigo is very intense and residual symptoms may remain intense for a longer duration than
for posterior BPPV
May be associated with severe autonomic responses, such as sweating
Anterior Benign Paroxysmal Positional Vertigo
Information about vertigo arising from the anterior semicircular canal is limited. Anterior vertigo
is thought to account for up to 10% of cases and is usually transient when it occurs.
What Causes Benign Paroxysmal Positional Vertigo?
The exact physiological mechanism responsible for BPPV is a subject of debate. Two theories that
prevail at the present time are:
Cupulolithiasis theory
Canalolithiasis theory
Cupulolithiasis Theory
This theory is the older of the two theories and suggests that tiny particles of calcium carbonate
crystals (also known as otoconia, otoliths, or canaliths) that are attached to the tiny hairs in the
inner ear, break off and float into the endolymph in the semicircular canal. These particles
(sometimes called debris) are heavier than the endolymph itself and are, therefore, pulled down by
gravity towards the cupula, to which they adhere. As gravity pulls the particles down, their extra
weight forces the hairs under the cupula to bend. The cupula over-responds to any movement of
the head because it is not in its proper position and continues to respond even after the head has
stopped moving. The conflicting information received by the brain from the ear's disrupted
vestibular system regarding the body's spatial orientation causes vertigo.
Canalolithiasis Theory
This is a newer theory that was proposed by J.M. Epley in 1980. It is widely accepted and
proposes that otoliths become displaced from the utricle and float into one of the semicircular
canals (usually the posterior) due to gravitational pull. With head movement, the otoliths rotate
along the arc of the canal. This causes abnormal movement of the endolymph resulting in the
bending of the hairs floating below the cupula of the affected canal, despite cessation of actual
movement. The prolonged bending of the hairs triggers impulses to the brain of the sensation of
movement, which conflicts with messages coming from the visual system and from the
musculoskeletal system (no sign of movement). The result is vertigo. Since the particles move
slowly, there is a delay in the onset of nystagmus.
The major difference between the two theories is whether the vertigo is caused by debris that floats
freely or by debris that adheres to the cupula. Both theories are still the subject of debate, since
they do not adequately explain why the various therapeutic maneuvers to dislodge the debris
particles are not effective for all cases of BPPV.
Incidence of Vertigo
Vertigo accounts for over 7.5 million medical visits in the United States each year. The incidence
of vertigo is estimated to be 64 per 100,000 people, and the distribution between male and female
is approximately equal. Vertigo is a common complaint among older persons, especially those
between the ages of 50-70, and is the most common reason for contacting a health care
professional in individuals over 65 years of age. Vertigo is thought to affect up to 30% of the
population at any given time.
Other statistics about the incidence of vertigo include:
With every five years of age, there is a 10% increase in the probability of experiencing
vertigo.
The incidence of the various etiologies of vertigo is estimated as:
40% are due to vestibular dysfunction
25% are due to disequilibrium or presyncope (moments leading up to fainting)
15% are due to psychiatric conditions
10% are due to central nervous system lesions
10% are of nonspecific origin
The most common type of vertigo is benign paroxysmal positional vertigo (BPPV), which will be
explained in detail below and which is the main focus of this Medifocus Guidebook on Vertigo.
Risk Factors for Vertigo
Some underlying medical conditions that may be risk factors for vertigo include:
Cardiovascular conditions (e.g., angina, myocardial infarction, stroke, postural hypotension)
Sensory (hearing) dysfunction
Neurologic conditions (e.g., Parkinson's disease)
Psychological factors (e.g., anxiety, depressive symptoms)
Diabetes
Medications (e.g., anticonvulsants, aspirin)
Alcohol
Smoking
Head injury
Ear surgery
Aging
Vasculitis (inflammation of blood vessels)
The Intelligent Patient Overview in the complete Medifocus Guidebook on Vertigo also
includes the following additional sections:
Diagnosis of Vertigo
Treatment Options for Vertigo
Quality of Life Issues in Vertigo
New Developments in the Treatment of Vertigo
Questions to Ask Your Doctor about Vertigo
To Order the Complete Guidebook on Vertigo Click Here
Or Call 800-965-3002 (USA) or 301-649-9300 (Outside USA)
3 - Guide to the Medical Literature
Introduction
This section of your MediFocus Guidebook is a comprehensive bibliography of important recent
medical literature published about the condition from authoritative, trustworthy medical journals.
This is the same information that is used by physicians and researchers to keep up with the latest
advances in clinical medicine and biomedical research. A broad spectrum of articles is included in
each MediFocus Guidebook to provide information about standard treatments, treatment options,
new developments, and advances in research.
To facilitate your review and analysis of this information, the articles in this MediFocus
Guidebook are grouped in the following categories:
Review Articles - 31 Articles
General Interest Articles - 94 Articles
Surgical Therapy Articles - 6 Articles
Clinical Trials Articles - 19 Articles
Repositioning Therapy Articles - 12 Articles
The following information is provided for each of the articles referenced in this section of your
MediFocus Guidebook:
Title of the article
Name of the authors
Institution where the study was done
Journal reference (Volume, page numbers, year of publication)
Link to Abstract (brief summary of the actual article)
Linking to Abstracts: Most of the medical journal articles referenced in this section of your
MediFocus Guidebook include an abstract (brief summary of the actual article) that can be
accessed online via the National Library of Medicine's PubMed database. You can easily access
the individual abstracts online via PubMed from the "electronic" format of your MediFocus
Guidebook by clicking on the URI that is provided for each cited article. If you purchased a
printed copy of the MediFocus Guidebook, you can still access the abstracts online by entering the
individual URI for a particular abstract into your computer's web browser.
Recent Literature: What Your Doctor Reads
Database: PubMed <May 2009 to March 2013>
Review Articles
1.
Positional dizziness.
Author: Fife TD
Institution: Barrow Neurological Institute, 240 West Thomas Road, Suite 301, Phoenix,
Arizona 85013, USA. tfife@email.arizona.edu
Journal: Continuum (Minneap Minn). 2012 Oct;18(5 Neuro-otology):1060-85. doi:
10.1212/01.CON.0000418376.80099.24.
Abstract Link: http://www.medifocus.com/abstracts.php?gid=TL016&ID=23042060
2.
Modifications of the Epley (canalith repositioning) manoeuvre for posterior
canal benign paroxysmal positional vertigo (BPPV).
Authors: Hunt WT; Zimmermann EF; Hilton MP
Institution: Peninsula College of Medicine and Dentistry, Royal Devon & Exeter Hospital,
Exeter, UK.
Journal: Cochrane Database Syst Rev. 2012 Apr 18;4:CD008675.
3.
Recurrent spontaneous attacks of dizziness.
Author: Lempert T
Institution: Schlosspark-Klinik, Heubnerweg 2, 14059 Berlin, Germany.
thomas.lempert@schlosspark-klinik.de
Journal: Continuum (Minneap Minn). 2012 Oct;18(5 Neuro-otology):1086-101. doi:
10.1212/01.CON.0000421620.10783.ac.
The Guide to the Medical Literature in the complete Medifocus Guidebook on Vertigo
includes the following sections:
Review Articles - 31 Articles
General Interest Articles - 94 Articles
Surgical Therapy Articles - 6 Articles
Clinical Trials Articles - 19 Articles
Repositioning Therapy Articles - 12 Articles
4 - Centers of Research
This section of your MediFocus Guidebook is a unique directory of doctors, researchers, medical
centers, and research institutions with specialized research interest, and in many cases, clinical
expertise in the management of this specific medical condition. The Centers of Research directory
is a valuable resource for quickly identifying and locating leading medical authorities and medical
institutions within the United States and other countries that are considered to be at the forefront in
clinical research and treatment of this disorder.
Use the Centers of Research directory to contact, consult, or network with leading experts in the
field and to locate a hospital or medical center that can help you.
The following information is provided in the Centers of Research directory:
Geographic Location
United States: the information is divided by individual states listed in alphabetical
order. Not all states may be included.
Other Countries: information is presented for select countries worldwide listed in
alphabetical order. Not all countries may be included.
Names of Authors
Select names of individual authors (doctors, researchers, or other health-care
professionals) with specialized research interest, and in many cases, clinical expertise
in the management of this specific medical condition, who have recently published
articles in leading medical journals about the condition.
E-mail addresses for individual authors, if listed on their specific publications, is also
provided.
Institutional Affiliations
Next to each individual author's name is their institutional affiliation (hospital,
medical center, or research institution) where the study was conducted as listed in their
publication(s).
In many cases, information about the specific department within the medical
institution where the individual author was located at the time the study was conducted
is also provided.
Centers of Research
United States
AL - Alabama
Name of Author Institutional Affiliation
Chisolm TH Alabama Hearing and Balance Associates, Foley, Alabama 36535,
USA. rroberts@hearingandbalance.net
Roberts RA Alabama Hearing and Balance Associates, Foley, Alabama 36535,
USA. rroberts@hearingandbalance.net
AZ - Arizona
Fife TD University of Arizona College of Medicine, Barrow Neurological
Institute, Phoenix, Arizona 85013, USA. tfife@email.arizona.edu
CA - California
Baloh RW Department of Neurology, University of California, Los Angeles,
CA, USA. yhcha@mednet.ucla.edu
Cha YH Department of Neurology, University of California, Los Angeles,
CA, USA. yhcha@mednet.ucla.edu
Ishiyama G Department of Neurology, David Geffen School of Medicine at
UCLA, Los Angeles, CA 90095, USA.
gishiyama@mednet.ucla.edu
Johnston SC Department of Neurology, University of California, San Francisco,
San Francisco, CA, USA. akim@ucsf.edu
Kim AS Department of Neurology, University of California, San Francisco,
San Francisco, CA, USA. akim@ucsf.edu
Nelson JA University of California at San Diego, Department of Emergency
Medicine.
Park JH Department of Neurosciences, University of California, San Diego,
Medical Center, 9350 Campus Point Drive, La Jolla, CA, USA.
The Centers of Research in the complete Medifocus Guidebook on Vertigo includes the
following sections:
Centers of Research for relevant states in the United States
Centers of Research listed for relevant countries outside the United States
5 - Tips on Finding and Choosing a
Doctor
Introduction
One of the most important decisions confronting patients who have been diagnosed with a serious
medical condition is finding and choosing a qualified physician who will deliver a high level and
quality of medical care in accordance with currently accepted guidelines and standards of care.
Finding the "best" doctor to manage your condition, however, can be a frustrating and
time-consuming experience unless you know what you are looking for and how to go about
finding it.
The process of finding and choosing a physician to manage your specific illness or condition is, in
some respects, analogous to the process of making a decision about whether or not to invest in a
particular stock or mutual fund. After all, you wouldn't invest your hard eared money in a stock or
mutual fund without first doing exhaustive research about the stock or fund's past performance,
current financial status, and projected future earnings. More than likely you would spend a
considerable amount of time and energy doing your own research and consulting with your stock
broker before making an informed decision about investing. The same general principle applies to
the process of finding and choosing a physician. Although the process requires a considerable
investment in terms of both time and energy, the potential payoff can be well worth it--after all,
what can be more important than your health and well-being?
This section of your Guidebook offers important tips for how to find physicians as well as
suggestions for how to make informed choices about choosing a doctor who is right for you.
Tips for Finding Physicians
Finding a highly qualified, competent, and compassionate physician to manage your specific
illness or condition takes a lot of hard work and energy but is an investment that is well-worth the
effort. It is important to keep in mind that you are not looking for just any general physician but
rather for a physician who has expertise in the treatment and management of your specific illness
or condition. Here are some suggestions for where you can turn to identify and locate physicians
who specialize in managing your disorder:
Your Doctor - Your family physician (family medicine or internal medicine specialist) is a
good starting point for finding a physician who specializes in your illness. Chances are that
your doctor already knows several specialists in your geographic area who specialize in your
illness and can recommend several names to you. Your doctor can also provide you with
information about their qualifications, training, and hospital affiliations.
The Tips on Finding and Choosing a Doctor in the complete Medifocus Guidebook on
Vertigo includes additional information that will assist you in locating a highly qualified and
competent physician to manage your specific illness.
6 - Directory of Organizations
American Academy of Otolaryngology--Head and Neck Surgery
1650 Diagonal Road, Alexandria, VA 22314-2857
703.836.4444
www.entnet.org
American Hearing Research Foundation
8 South Michigan Avenue, Suite #814 Chicago, IL 60603-4539
312.726.9670
sparmet@american-hearing.org
www.american-hearing.org
Balance and Dizziness Disorders Society (BADD)
5525 West Boulevard; Vancouver, BC V6M 3W6; CANADA
604.878.8383
info@balanceanddizziness.org
www.balanceanddizziness.org
House Ear Clinic
2100 West 3rd Street, 5th Floor; Los Angeles, CA 90057
213.483.9930 213.484.2642 (TDD)
info@hei.org
www.houseearclinic.com
Massachusetts Eye and Ear Infirmary
243 Charles Street, Boston, MA 02114
617.523.7900
www.masseyeandear.org
National Institute on Deafness and Other Communication; Disorders
31 Center Drive MSC 2320; Bethesda, MD 20892-2320
800.241.1044
nidcdinfo@nidcd.nih.gov
www.nidcd.nih.gov
The Directory of Organizations in the complete Medifocus Guidebook on Vertigo includes
a list of selected disease organizations and support groups that are helping people diagnosed
with Vertigo.
This document is only a SHORT PREVIEW of the Medifocus Guidebook on Vertigo. It is
intended primarily to give you a general overview of the format and structure of the
Guidebook as well as select pages from each major Guidebook section listed in the Table of
Contents.
To purchase the COMPLETE Medifocus Guidebook on Vertigo (132 pages; Updated March
19, 2013), please:
Call us at:
800-965-3002 (United States)
301-649-9300 (Outside the United States)
Order online through our website:
Printed Version
Mailed to you and bound for easy reading.
Includes free online access to the electronic guidebook for one full year.
Electronic Version
Adobe PDF document that can be viewed or printed on any computer
Online updates are included for one full year.
Disclaimer
Medifocus.com, Inc. serves only as a clearinghouse for medical health information and
does not directly or indirectly practice medicine. Any information provided by
Medifocus.com, Inc. is intended solely for educating our clients and should not be
construed as medical advice or guidance, which should always be obtained from a licensed
physician or other health-care professional. As such, the client assumes full responsibility
for the appropriate use of the medical and health information contained in the Guidebook
and agrees to hold Medifocus.com, Inc. and any of its third-party providers harmless from
any and all claims or actions arising from the clients' use or reliance on the information
contained in this Guidebook. Although Medifocus.com, Inc. makes every reasonable
attempt to conduct a thorough search of the published medical literature, the possibility
always exists that some significant articles may be missed.
Copyright
Copyright 2011, Medifocus.com, Inc. All rights reserved as to the selection,
arrangement, formatting, and presentation of the information contained in this report,
including our background and introductory information.

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