What do we treat?

Definition and Characteristics

Persistent Postural-Perceptual Dizziness (PPPD) is the second most common cause of vestibular symptoms in adults after Benign Paroxysmal Positional Vertigo (BPPV). The Barany Society defined it in 2017 as a chronic vestibular syndrome in which the patient experiences dizziness, instability, or non-rotational vertigo symptoms on most days for at least 3 months.

Another characteristic of this syndrome is that it can occur without a specific trigger, but symptoms are exacerbated by three factors:
– Upright posture.
– Active or passive movements.
– Visual stimuli in motion or complex visual patterns (e.g., supermarkets, sidewalk tiles, or a busy street).

PPPD may develop after an event that causes vertigo, dizziness, balance problems, or psychological stress. This does not imply that PPPD is a structural or psychiatric condition.

Patients with PPPD may experience significant functional impairment, especially in severe cases.

Diagnosis

To diagnose PPPD, an extensive evaluation of the patient is necessary to rule out other potential causes for the symptoms. In addition to imaging tests, the following assessments may be performed for diagnosis:
– Audiometry.
– Videonystagmography.
– Caloric testing.
– vHIT (Video Head Impulse Test).
– VEMPs (Vestibular Evoked Myogenic Potentials).
– Functional tests (SOT, LOS, AVD, VVS, etc.).

Treatment

The treatment of this functional disorder should include at least the following elements:
– Education about the condition.
– Vestibular Rehabilitation.
– Balance-focused functional exercises.

In some cases, the following may also be necessary:
– Selective serotonin reuptake inhibitors (SSRIs).
– Cognitive-Behavioral Therapy.

Definition and Characteristics

Migraine associated with vertigo is one of the most common disorders in the population. The Barany Society, in collaboration with the International Headache Society, has developed a consensus document that defines Vestibular Migraine as an episodic vestibular syndrome with the following characteristics:
– At least 5 episodes of vestibular symptoms (vertigo or dizziness) of moderate to severe intensity, lasting between 5 minutes and 72 hours.
– Current or prior history of migraine with or without aura.
– One or more migraine features in at least 50% of the vestibular episodes.
– Headache with at least 2 of the following characteristics: unilateral, pulsating, moderate to severe pain, worsened by routine physical activity or Valsalva maneuver.
– Photophobia and phonophobia.
– Visual aura.

Diagnosis

The diagnosis of vestibular migraine is based on the clinical data mentioned. However, as indicated by the Spanish Society of Otolaryngology, a differential diagnosis is important. In addition to imaging tests, the following assessments may be performed for diagnosis:
– Audiometry.
– Videonystagmography.
– Caloric testing.
– VHIT (Video Head Impulse Test).
– Functional tests (SOT, LOS, AVD, VVS, etc.).

Treatment

Existing scientific evidence suggests that the treatment of vestibular migraine should address the following aspects:
– Pharmacological treatment during crises or prophylactic (preventive) treatment.
– Pain education.
– Vestibular rehabilitation.

Definition and Characteristics

Ménière’s disease is a vestibular syndrome characterized by episodes of spontaneous vertigo lasting from 20 minutes to 12-24 hours, typically associated with hearing loss, tinnitus, or ear noises, as well as ear fullness, along with symptoms like dizziness, nausea, etc.

Diagnosis

The diagnosis is primarily clinical but should be supported by other tests such as caloric testing, audiometry, cVEMPS, MRI of the internal auditory canal, etc.

Treatment

– Dietary prescriptions (low-salt diet and healthy eating).

– Medications.

– Intratympanic gentamicin.

– Vestibular rehabilitation.

Definition and Characteristics

Vestibular hypofunction, often referred to as VH, is a peripheral vestibular dysfunction that involves the impairment of the vestibular organ or nerves. It can affect one ear (unilateral) or both ears (bilateral). Additionally, it can manifest as acute, recurrent, or chronic (sequelae) conditions. The clinical presentation of this dysfunction in an acute situation consists of vertigo associated with nystagmus (involuntary eye movements) and vestibular ataxia (postural imbalance and unsteadiness in walking). Autonomic symptoms (nausea, vomiting, sweating, etc.), perceptual and auditory alterations may also appear. In cases of chronic clinical presentations, the most characteristic symptoms are postural imbalance and gait instability. Patients often describe situations of blurred vision, constant dizziness, oscillopsia (visual disturbance where objects appear to jump or bounce), etc., when walking, during rapid head or body movements, and worsening in darkness or on uneven terrain.

This uncompensated vestibular hypofunction can lead to symptoms such as dizziness, imbalance, and/or oscillopsia, alterations in gaze stability, gait instability, cognitive deficits, visually induced vertigo, impairment in navigation and spatial orientation, and, therefore, it can negatively impact patients’ quality of life, impairing their ability to perform activities of daily living, drive, work, and increasing the risk of falls.

Diagnosis

For diagnosis, we have cutting-edge tests associated with comprehensive clinical assessment (otoscopy, auditory evaluation, videonystagmography, vHIT, VIN, rotary chair testing, caloric tests, VEMP, battery of clinical tests, etc.).

Treatment

There is strong evidence supporting vestibular rehabilitation aimed at vestibular compensation to reduce symptoms and improve the patient’s condition. This is based on the functional assessment of each patient and is individualized according to the deficits found. In general, adaptation, substitution, and habituation exercises are performed, using the latest technologies and therapeutic advances, including a rotary chair and specific tests, a functional exercise area, and strength training, balance and gait re-education, computerized dynamic posturography, and virtual reality.

Definition and Characteristics

Presbyvestibulopathy (PVP) is a condition associated with aging, as it occurs due to the aging of the balance system. The Classification Committee of the Bárány Society defines it as a chronic vestibular syndrome that exhibits the following characteristics:

– Instability.
– Gait disturbances.
– Recurrent falls.

Diagnosis
Assessment of possible mild vestibular deficits with findings on vestibular function tests falling between normality and the established limits for bilateral vestibulopathy:

– vHIT (Video Head Impulse Test) for high-frequency range. Gains between 0.8 and 0.6.
– Rotational chair testing for the middle-frequency range. (Horizontal angular RVO gain should be between > 0.1 and < 0.3)
– Caloric test for low frequencies. (Sum of peak slow-phase nystagmus velocities should be between < 25°/s and > 6°/s)

PVP often appears in conjunction with other age-related deficits such as loss of visual acuity, proprioceptive deficits, and cortical, cerebellar, and extrapyramidal function impairments. Additionally, the diagnosis may require the performance of functional tests (SOT, LOS, AVD, VVS, etc.).

Treatment
– Vestibular rehabilitation.
– Functional balance-focused exercises.

Cases in which the patient relates dizziness, vertigo, or instability with episodes of neck pain will be addressed by a multidisciplinary team to make a precise diagnosis and design a comprehensive treatment and rehabilitation program based on current scientific evidence.

Definition and Characteristics

The ear, in its vestibular function, does not operate alone when it comes to detecting and processing movements and generating balance responses. It requires a Central Nervous System that interprets this information, integrates it with information from other bodily receptors like vision, and formulates and coordinates the responses needed to meet the demands of our daily lives. Therefore, it is logical that an injury to the central nervous system can lead to problems of dizziness, vertigo, and instability.

Diagnosis

Dizziness is one of the suspicious symptoms of an acute injury to the central nervous system (such as a stroke), especially when combined with other signs like difficulty speaking (dysarthria) or swallowing (dysphagia), or loss of strength or sensation in the limbs. Hence, in an evaluation of an acute episode of vertigo or dizziness, it is crucial to rule out neurological signs and promptly refer in case of suspicion.

However, it’s not only acute conditions that can manifest with vestibular symptoms. Cerebellar disorders, demyelinating diseases like Multiple Sclerosis, and neurodegenerative conditions like Parkinson’s Disease can also cause vestibular symptoms. Even some strokes, such as those affecting the basilar artery, can lead to vertigo and balance issues as sequelae.

Treatment

A treatment program for neurological patients should be interdisciplinary, multifactorial, individualized, and developed in consultation with the patients and their support system. Neurological and vestibular rehabilitation play a crucial role within this framework, both in reducing symptoms through habituation techniques and in the recovery or compensation of impaired or lost functions.

In terms of evidence, some of the most commonly used and effective strategies or tools in this field include functional exercises, graded exposure, and immersive virtual reality, especially when combined with dynamic posturography. This combination provides maximum multisensory stimulation along with control over the environment and the task being performed.

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Definition and Characteristics

Cinetosis, also known as motion sickness or traveler’s sickness, is a common problem in individuals who experience motion-induced nausea when traveling by car, train, plane, and/or boat. Patients often report symptoms such as pallor, nausea, cold sweats, and vomiting, along with drowsiness, headache, and more.

Diagnosis

The diagnosis is typically made through clinical questioning and the differential diagnosis with other medical conditions.

Treatment

– Pharmacological treatment.
– Vestibular rehabilitation, primarily using habituation and controlled gradual exposure. Additionally, an educational approach can help the patient reframe their perspective when facing such situations.

In our center, we have immersive virtual reality and computerized dynamic posturography, which assists us in providing the most advanced treatments in this field.

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Vascular vertigo, Vestibular Schwannoma, Perilymphatic Fistula, Anterior Canal Dehiscence” are examples of other diagnoses that can be reached through a thorough otoneurological examination.

Our otoneurologist makes her knowledge and the necessary technical resources available to patients in order to provide the most accurate diagnostic approach in each case.

If you experience vertigo, dizziness, or instability, you can contact us, and we will be happy to assist you.