Neuro-Otology

Terry D. Fife, MD

Wherever the art of medicine is loved, there is also a love of humanity. – Hippocrates

The art of medicine consists of amusing the patient while nature cures the disease. – Voltaire

Although there is truth to both quotations, the emergence of medical science in the field of neuro-otology has allowed us to offer patients more than only compassion and amusement. Our ability to diagnose and treat patients with vertigo, dizziness, imbalance, and some auditory symptoms has improved with the expansion of medical knowledge. This issue on Neuro-Otology in Seminars in Neurology assembles an impressive group of internationally recognized experts covering the current state of knowledge in disorders of equilibrium and audiovestibular disease.

Kevin Kerber, MD, a neuro-otologist from the University of Michigan draws upon his expertise in acute vertigo presentations to discuss acute continuing vertigo, a common and vexing problem for emergency room physicians and neurologists. He provides up-to-date methods for clinically distinguishing vestibular neuritis from strokes presenting with a similar isolated vertigo profile. Astute use of these methods has the promise of eliminating the excessive use of computed tomography angiography and other invasive or expensive testing.

Dr. Ji Soo Kim and Dr. Hyung Lee, both prominent neuro-otologists from the Republic of Korea (South Korea) expound further on the features and mechanisms of vertigo from posterior circulation strokes. They detail the stroke syndromes and the vascular distributions that can affect central vestibular structures causing vertigo.

Our understanding of the forms of vestibular neuritis, a common disorder affecting the vestibular nerve and labyrinth has undergone refinement in recent years. Dr. Ji-Soo Kim and colleagues Dr. Seong-Hae Jeong, MD and Mr. Hyo-Jung Kim from the Republic of Korea provide an update on the current understanding of its possible cause, of superior vestibular neuritis, and of the less common inferior vestibular neuritis. They also review the key features that should raise suspicion for a central nervous system (CNS) disorder masquerading as vestibular neuritis.

Drs. Timothy Hain and Marcello Cherchi of Chicago Hearing and Balance and Northwestern University and Dr. Dario Yacovino of the Raul Carrea Institute for Neurological Research (FLENI) in Buenos Aires, Argentina, team up to describe the syndrome of bilateral peripheral vestibular hypofunction. This is an important condition to understand and is commonly misdiagnosed because it may evolve with minimal actual vertigo. This insightful article reviews common causes, clinical features, management, and prognosis. It is valuable for patients to feel they understand the nature of their condition and what to expect as they work toward adapting to life without a fully functional vestibular system.

Benign paroxysmal positional vertigo is the most common cause of recurrent vertigo. Dr. Professor Michael von Brevern, one of the world's foremost neuro-otologists from the Vestibular Research Group at Park-Klinik Weissensee hospital in Berlin, Germany, updates the current concepts related to this disorder.

Vestibular migraine is an important and reasonably common cause of vertigo. Dr. Thomas Lempert, an internationally recognized expert and member of the Vestibular Research Group affiliated with Charité in Berlin, Germany, discusses the new classification and diagnostic criteria, possible causal mechanisms, management, and prognosis of this condition.

Many people have experienced the unpleasantness of motion sickness (sea sickness, air sickness, car sickness). World-renowned experts on this topic, Drs. Adolfo Bronstein and Michael Gresty of the Imperial College of London and Dr. John Golding of the University of Westminster in London, United Kingdom, introduce the readers to the syndrome of visual vertigo, an often unappreciated cause of dizziness in some people. Current concepts of motion sickness and its management are also discussed in this excellent review.

Recently evolving discoveries mostly from vestibular evoked myogenic potential (VEMP) testing have led to a far greater understanding of selected dysfunction of vestibular structures. Ian Curthoys, PhD and Leonardo Manzari, MD, among the world's foremost experts in disorders affecting the otolith structures, discuss our current understanding of the clinical features of such disorders and put into context the role of VEMPs in clarifying the nature and clinical features of these conditions.

Dizziness and vertigo following head trauma is quite common, but can be a confusing area due to the multitude of possible mechanisms. Together with Dr. Christopher Giza of the Brain Injury Research Center at UCLA, I discuss the labyrinthine and CNS causes of dizziness after head trauma and review the dizziness component of so-called postconcussive syndrome.

Drs. Dario Yacovino and Timothy Hain join in a thorough review of the science underlying possible mechanisms of cervicogenic vertigo. The concept of dizziness caused by cervical processes has its strong proponents and equally ardent detractors. This thoughtful and scientifically minded article addresses this entity that has long been a focal point of controversy in medicine and medical jurisprudence.

Tinnitus is a very common symptom that troubles otolaryngologists, family physicians, and neurologists because many do not feel confident that they have a logical approach to classification and treatment. Robert Levine, MD, a noted expert in tinnitus formerly at the Massachusetts Eye and Ear Infirmary and now at the Tel Aviv Sourasky Medical Center in Israel, offers a logical approach to characterizing tinnitus, ascribing mechanisms, and directing treatment when feasible.

Dr. Holly Shill of Banner Sun Health Research Institute is a nationally recognized expert in movement disorders and gait abnormalities who joins with me in describing a selection of gait and balance disorders that in our experience may go undiagnosed and unrecognized. Although some of the disorders are rare or uncommon, for the occasional patient whose medical condition has eluded diagnosis, its recognition and treatment can make a world of difference.

Vestibular rehabilitation is a broadly defined term that encompasses mechanical remedies (as with treatment of benign paroxysmal positional vertigo) as well as exercises that induce the brain's own adaptive plastic properties to circumvent deficient vestibular sensory input. Dr. Christian Kang joins with prominent neuro-otologist Dr. Ronald Tusa of Emory University in reviewing the concepts underlying exercise and maneuver-related strategies to affect recovery from vertigo.

Internationally renowned neuro-otologists Drs. Michael Strupp and Thomas Brandt along with their accomplished colleague, Olympia Kremmyda, MD, eloquently describe the pharmacological treatment options for vertigo syndromes and also for central nystagmus.

Chronic persisting dizziness and impaired balance are very common problems. Dr. Jeffrey Staab, a psychiatrist at the Mayo Clinic who has written extensively on the effects of stress and behavioral influences on dizziness, joins with esteemed colleagues Carey Balaban, PhD, and Joseph Furman, MD, PhD, from the University of Pittsburgh in explaining how our amygdala system is integral in our perception of spatial orientation. They describe the neuroscience of this process, giving practical examples of how this physiologic network that encodes and maintains emotional memory may lead to chronic subjective dizziness in some people.

Finally, I would like especially to acknowledge a previous Guest Editor of Neuro-otology for Seminars in Neurology, my mentor and colleague, Robert W. Baloh of UCLA, who has been and continues to be one of the foremost thought leaders in neuro-otology. This issue has compiled articles on topics highly relevant to patient care written by seasoned clinician-researchers at the forefront of the field, hailing from around the globe.