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Persistent positional perceptual dizziness in clinical practice: a scoping review

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Abstract

Introduction

Dizziness is an important symptom presenting in routine practice and the life time prevalence ranges from 17 to 30%. Persistent positional perceptual dizziness (PPPD) is a common cause of chronic dizziness and has often been labeled as psychogenic dizziness in the past.

Discussion

PPPD is diagnosed based on clinical criteria laid down by the Barany society. The vestibular function tests and imaging of the brain and the inner ear are often normal. Most of the patients have an underlying anxiety trait and most cases of PPPD arise following an attack of acute vertigo like Meniere’s disease and vestibular neuritis. It is important to differentiate the condition from bilateral vestibulopathy. There is no role of vestibular sedative in the treatment of such condition. Vestibular rehabilitation therapy (VRT), cognitive behavioral therapy (CBT), and selective serotonin reuptake inhibitors (SSRI) like sertraline have shown benefits. However, long-term outcome is not known.

Conclusion

PPPD is a relatively new entity in the ever-expanding field of neurotology that requires a multimodality approach for effective management. The otologists and general physicians must identify the condition so that favorable outcome can be achieved. The long-term effects of treatment with CBT and VRT are not known. It is important to formulate standard guidelines for treatment. Further research is necessary to identify the role of endogenous biomarkers in the outcome of treatment.

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References

  1. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE (2011) Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 183(9):E571-592

    Article  Google Scholar 

  2. Murdin L, Schilder AGM (2015) Epidemiology of balance symptoms and disorders in the community: a systematic review. Otolo Neurotology 36(3):387–392

    Article  Google Scholar 

  3. Guerra-Jiménez G, Rodríguez AA, González JCF, Plasencia DP, Macías AR (2017) Epidemiology of vestibular disorders in the otoneurology unit. Acta Otorinolaringol Esp 68(6):317–322

    Article  Google Scholar 

  4. Staab JP (2020) Persistent postural-perceptual dizziness. Semin Neurol 40(1):130–137. https://doi.org/10.1055/s-0039-3402736

    Article  Google Scholar 

  5. Chang J, Hwang SY, Park SK, Kim JH, Kim HJ, Chae SW, Song JJ (2018) Prevalence of dizziness and associated factors in South Korea: a cross-sectional survey From 2010 to 2012. J Epidemiol 28(4):176–184. https://doi.org/10.2188/jea.JE20160113

    Article  Google Scholar 

  6. Honaker JA, Gilbert JM, Staab JP (2010) Chronic subjective dizziness versus conversion disorder: discussion of clinical findings and rehabilitation. Am J Audiol 19:3–8

    Article  Google Scholar 

  7. Agarwal Y, Ward BK, Minor LB (2013) Vestibular dysfunction: prevalence, impact and need for targeted treatment. J Vestib Res 23(3):113–117

    Article  Google Scholar 

  8. Yardley L, Burgneay J, Nazareth I, Luxon L (1998) Neuro-otological and psychiatric abnormalities in a community sample of people with dizziness: a blind, controlled investigation. J Neurol Neurosurg Psychiatry 65:679–684. https://doi.org/10.1136/jnnp.65.5.679

    Article  Google Scholar 

  9. Staab JP, Eckhardt-Henn A, Horiic A, Jacob R, Strupp M (2017) Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the committee for the Classification of Vestibular Disorders of the Barany Society. J Vestib Res. 27:191–208

    Article  Google Scholar 

  10. Staab JP (2012) Chronic subjective dizziness. Continuum Lifelong Learning Neurol 18(5):1118–1141

    Article  Google Scholar 

  11. Indovina I, Riccelli R, Chiarella G, Petrolo C, Augimeri A, Giofrè L, Lacquaniti F, Staab JP, Passamonti L (2015) Role of the insula and vestibular system in patients with chronic subjective dizziness: an fMRI study using sound-evoked vestibular stimulation. Front Behav Neurosci 9:334. https://doi.org/10.3389/fnbeh.2015.00334

    Article  Google Scholar 

  12. Wurthmann S, Naegel S, Steinberg BS, Theysohn N, Diener HC, Kleinschnitz C, Obermann M (2017) Cerebral gray matter changes in persistent postural perceptual dizziness. J Psychosom Res 103:95–101. https://doi.org/10.1016/j.jpsychores.2017.10.007

    Article  Google Scholar 

  13. Breinbauer HA, Contreras MD, Lira JP, Guevara C, Castillo L, Ruëdlinger K, Muñoz D, Delano PH (2020) Spatial navigation is distinctively impaired in persistent postural perceptual dizziness. Front Neurol 10:1361. https://doi.org/10.3389/fneur.2019.01361

    Article  Google Scholar 

  14. Nigro S, Indovina I, Riccelli R, Chiarella G, Petrolo C, Lacquaniti F, Staab JP, Passamonti L (2019) Reduced cortical folding in multi-modal vestibular regions in persistent postural perceptual dizziness. Brain Imaging Behav 13:798–809. https://doi.org/10.1007/s11682-018-9900-6

    Article  Google Scholar 

  15. Fang Z, Huang K, Gil CH, Jeong JW, Yoo HR, Kim HG (2020) Biomarkers of oxidative stress and endogenous antioxidants for patients with chronic subjective dizziness. Sci Rep 10:1478. https://doi.org/10.1038/s41598-020-58218-w

    Article  Google Scholar 

  16. Brandt T, Deiterich M (2019) Excess anxiety’ and ‘less anxiety’: both depend on vestibular function. Curr Opin Neurol 32:000–000. https://doi.org/10.1097/WCO.0000000000000771

    Article  Google Scholar 

  17. Bourke J, Jackson G, Libby G (2018) Neuropsychiatric aspects of vestibular disorders. In: Clarke RW, Watkinson JC (eds) Scott Brown’s otorhinolaryngology head and neck surgery, 8th edition, vol 2. CRC Press Taylor and Francis group, p 909–918

  18. Chiarella G, Petrolo C, Riccelli R, Giofrè L, Olivadese G, Gioacchini FM, Scarpa A, Cassandro E, Passamonti L (2016) Chronic subjective dizziness: analysis of underlying personality factors. J Vestib Res 26:403–408. https://doi.org/10.3233/VES-160590

    Article  Google Scholar 

  19. Bittar RSM, Lins EM (2015) Clinical characteristics of patients with persistent postural-perceptual dizziness. Braz J Otorhinolaryngol 81(3):276–282. https://doi.org/10.1016/j.bjorl.2014.08.012

    Article  Google Scholar 

  20. Adamec I, Juren Meaški S, Krbot Skorić M, Jažić K, Crnošija L, Milivojević I, Habek M (2020) Persistent postural-perceptual dizziness: Clinical and neurophysiological study. J Clin Neurosci 72:26–30. https://doi.org/10.1016/j.jocn.2020.01.043

    Article  Google Scholar 

  21. Neff BA, Staab JP, Eggers SD, Carlson ML, Schmitt WR, Van Abel KM, Worthington DK, Beatty CW, Driscoll CL, Shepard NT (2012) Auditory and vestibular symptoms and chronic subjective dizziness in patients with Meniere’s disease, vestibular migraine, and Meniere’s disease with concomitant vestibular migraine. Otol Neurotol 33:1235–1244

    Article  Google Scholar 

  22. Pope JV, Edlow JA (2012) Avoiding misdiagnosis in patients with neurological emergencies. Emerg Med Int 949275:10. https://doi.org/10.1155/2012/949275

  23. Fife TD (2017) Dizziness in the outpatient care setting. Continuum (Minneap Minn) 23(2):359–395. https://doi.org/10.1212/CON.0000000000000450

    Article  Google Scholar 

  24. Brandt T, Huppert D, Strupp M, Dieterich M (2015) Functional dizziness: diagnostic keys and differential diagnosis. J Neurol 262:1977–1980. https://doi.org/10.1007/s00415-015-7826-0

    Article  Google Scholar 

  25. Yagi C, Morita Y, Kitazawa M, Yamagishi T, Ohshima S, Izumi S, Takahashi K, Horii A (2021) Subtypes of persistent postural-perceptual dizziness. Front Neurol 12:652366. https://doi.org/10.3389/fneur.2021.652366

    Article  Google Scholar 

  26. Feuereckera R, Habs M, Dieterich M, Strupp M (2015) Chronic subjective dizziness: fewer symptoms in the early morning – a comparison with bilateral vestibulopathy and downbeat nystagmus syndrome. J Vestib Res 25:67–72. https://doi.org/10.3233/VES-150547

    Article  Google Scholar 

  27. Kim SK, Kim JH, Jeon SS, Hong SM (2018) Relationship between sleep quality and dizziness. Plos One 13(3):e0192705. https://doi.org/10.1371/journal.pone.0192705

    Article  Google Scholar 

  28. Sugaya N, Arai M, Goto F (2017) The effect of sleep disturbance in patients with chronic dizziness. Acta Oto-laryngol 137(3):275–278. https://doi.org/10.1080/00016489.2016

    Article  Google Scholar 

  29. Bery AK, Azzi JL, Le A, Spitale NS, Leech J, Lelli DA, Tse D (2021) Association between obstructive sleep apnea and persistent postural-perceptual dizziness. J Vestib Res 31(5):401–406. https://doi.org/10.3233/VES-201508

    Article  Google Scholar 

  30. Sarna B, Risbud A, Lee A, Muhonen E, Abouzari M, Djalilian HR (2021) Migraine features in patients with persistent postural-perceptual dizziness. Ann Otol Rhinol Laryngol 130(12):1326–1331. https://doi.org/10.1177/00034894211007233

    Article  Google Scholar 

  31. Staab JP, Rohe DE, Eggers SDZ, Shepard NT (2014) Anxious, introverted personality traits in patients with chronic subjective dizziness. J Psychosom Res 76:80–83. https://doi.org/10.1016/j.jpsychores.2013.11.008

    Article  Google Scholar 

  32. Sohsten E, Bittar RSM, Staab JP (2016) Posturographic profile of patients with persistent postural-perceptual dizziness on the sensory organization test. J Vestib Res 26:319–326

    Article  Google Scholar 

  33. Morisod B, Mermod M, Maire R (2017) Posturographic pattern of patients with chronic subjective dizziness before and after vestibular rehabilitation. J Vestib Res 27:305–311. https://doi.org/10.3233/VES-170628

    Article  Google Scholar 

  34. Staab JP (2019) Psychiatric considerations in the management of dizzy patients. In: Lea J, Pothier D (eds) Vestibular disorders. Adv Otorhinolaryngol. vol 82. Basel, Karger, pp 170–179. https://doi.org/10.1159/000490286

  35. Wurthmann S, Holle D, Obermann M, Roesner M, Nsaka M, Scheffler A, Kleinschnitz C, Naegel S (2021) Reduced vestibular perception thresholds in persistent postural-perceptual dizziness- a cross-sectional study. BMC Neurol 21(1):394. https://doi.org/10.1186/s12883-021-02417-z

    Article  Google Scholar 

  36. Trinidade A, Harman P, Stone J, Staab JP, Goebel JA (2021) Assessment of potential risk factors for the development of persistent postural-perceptual dizziness: a case-control pilot study. Front Neurol 11:601883. https://doi.org/10.3389/fneur.2020.601883

    Article  Google Scholar 

  37. Kammerlind ACS, Ledin TEA, Odkvist LM, Skargren EIB (2011) Recovery after acute unilateral vestibular loss and predictors for remaining symptoms. Am J Otolaryngol 32:366–375. https://doi.org/10.1016/j.amjoto.2010.07.008

    Article  Google Scholar 

  38. van Vugt VA, van der Horst HE, Payne RA, Maarsingh OR (2017) Chronic vertigo: treat with exercise, not drugs. BMJ 358:j3727. https://doi.org/10.1136/bmj.j3727

    Article  Google Scholar 

  39. Axer H, Finn S, Wassermann A, Guntinas-Lichius O, Klingner CM, Witte OW (2020) Multimodal treatment of persistent postural–perceptual dizziness. Brain Behav 10:e01864. https://doi.org/10.1002/brb3.1864

    Article  Google Scholar 

  40. Popkirov S, Stone J, Holle-Lee D (2018) Treatment of persistent postural-perceptual dizziness (PPPD) and related disorders. Curr Treat Options Neurol 20(12): 50. https://doi.org/10.1007/s11940-018-0535-0

  41. Staab JP, Ruckenstein MJ, Amsterdam JD (2004) A prospective trial of sertraline for chronic subjective dizziness. Laryngoscope 114:1637–1641

    Article  Google Scholar 

  42. Staab JP, Ruckenstein MJ, Solomon D, Shepard NT (2002) Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol Head Neck Surg 128(5):554–560

    Article  Google Scholar 

  43. Horii A, Mitani K, Kitahara T, Uno A, Takeda N, Kubo T (2004) Paroxetine, a selective serotonin reuptake inhibitor, reduces depressive symptoms and subjective handicaps in patients with dizziness. Otol Neurotol 25(4):536–543

    Article  Google Scholar 

  44. Horii A, Uno A, Kitahara T, Mitani K, Masumura C, Kizawa K et al (2007) Effects of fluvoxamine on anxiety, depression, and subjective handicaps of chronic dizziness patients with or without neuro-otologic diseases. J Vestib Res 17(1):1–8

    Article  Google Scholar 

  45. Horii A, Imai T, Kitahara T, Uno A, Morita Y, Takahashi K et al (2016) Psychiatric comorbidities and use of milnacipran in patients with chronic dizziness. J Vestib Res 26(3):335–340

    Article  Google Scholar 

  46. Mahoney AEJ, Edelman S, Cremer PD (2013) Cognitive behavior therapy for chronic subjective dizziness: longer-term gains and predictors of disability. Am J Otolaryngol 34(2):115–120. https://doi.org/10.1016/j.amjoto.2012.09.013

    Article  Google Scholar 

  47. Bayden M, Yigit Y, Aksoy S (2020) Does vestibular rehabilitation improve postural control of subjects with chronic subjective dizziness. Plos One 15(9):e0238436. https://doi.org/10.1371/journal.pone.0238436

  48. Tramontano M, Princi AA, Angelis SD, Indovina I, Manzari L (2021) Vestibular rehabilitation in patients with persistent postural-perceptual dizziness: a scoping review. Hear Balance Commun 19(4):282–290. https://doi.org/10.1080/21695717.2021.1975986

    Article  Google Scholar 

  49. Mempouo E, Lau K, Green F, Bowes C, Ray J (2021) Customised vestibular rehabilitation with the addition of virtual reality based therapy in the management of persistent postural-perceptual dizziness. J Laryngol Otol 35:887–891. https://doi.org/10.1017/S0022215121002127

    Article  Google Scholar 

  50. Choi SY, Choi JH, Oh EH, Oh SJ, Choi KD (2021) Effect of vestibular exercise and optokinetic stimulation using virtual reality in persistent postural-perceptual dizziness. Sci Rep 11:14437. https://doi.org/10.1038/s41598-021-93940-z.51

    Article  Google Scholar 

  51. Eren OE, Filippopulos F, Sönmez K, Möhwald K, Straube A, Schöber F (2018) Non-invasive vagus nerve stimulation significantly improves quality of life in patients with persistent postural-perceptual dizziness. J Neurol 265(Suppl 1):63–69. https://doi.org/10.1007/s00415-018-8894-8

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of ENT, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, 522503, India

    Soumyajit Das & Ramesh Seepana

  2. Department of ENT, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, 522023, India

    Chandra Sekhar Annam & Satvinder Singh Bakshi

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  1. Soumyajit Das
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  2. Chandra Sekhar Annam
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Correspondence to Soumyajit Das.

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Das, S., Annam, C.S., Bakshi, S.S. et al. Persistent positional perceptual dizziness in clinical practice: a scoping review. Neurol Sci 44, 129–135 (2023). https://doi.org/10.1007/s10072-022-06353-9

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