A Systematic Review of the Reported Proportions of Diagnoses for Dizziness and Vertigo
Introduction
Benign paroxysmal positional vertigo (BPPV) is the most common vestibular blazon of vertigo, with an estimated incidence of 64 cases per 100,000 people per yr and a lifetime prevalence of 2.4% (1, 2). The typical presentation of BPPV consists of recurrent, brief attacks of vertigo generally provoked by changes in caput position, such as looking up, bending over, lying downwardly, or rolling over in bed (three–five). Nevertheless, several alternative presentations are possible. For case, some patients present with complaints of prolonged unsteadiness instead of the typical brief vertigo awareness. This is almost mutual in elderly patients (6).
BPPV is diagnosed by provoking vertigo by positional testing and via ascertainment of typical nystagmus (5). The gold standard for the diagnosis of posterior culvert BPPV is the Dix-Hallpike maneuver, whereas horizontal canal BPPV is mostly diagnosed with the supine whorl test (v). Too 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 tin can be difficult considering of the broad etiology and wide array of questions and tests necessary to come to a diagnosis. Information technology is even more difficult in the geriatric population equally increased comorbidity may cause multiple, non-specific symptoms. This may lead to diagnostic delay or get out BPPV unrecognized, which in turn may cause patients to reduce their daily activities and increases the risk of falls (9, ten). By and large, BPPV is well-treatable with canalith repositioning procedures, and as such diagnostic delay could even lead to patients missing out on bachelor handling. In gild to prevent this diagnostic delay and promote early recognition and treatment, it may be helpful to assess which symptoms regarding patient history are the almost valuable ones for identifying BPPV in patients presenting with dizziness.
Previous research has identified several items that are useful during history taking of the patient with BPPV, such equally the nature of dizziness (i.eastward., vertigo as opposed to low-cal-headedness), the duration of attacks, and the presence and the frequency of associated symptoms (11–13). Also, the provocative head movement may differ depending on the affected canal. For example, dizziness evoked by looking up could possibly occur more often in patients with posterior culvert BPPV than in patients with horizontal culvert BPPV.
Another approach that is useful for the early detection of BPPV is the utilise of predictive models. The purpose of such a model is to predict whether a patient presenting with dizziness has BPPV based on the patient'southward answers to a set of questions. I of these models is the linear prediction (LP) model adult past Friedland et al., which has shown promising results in the prediction of BPPV (14, fifteen).
In club to facilitate the diagnosis of BPPV, our primary aim was to identify the questions that are the most valuable for history taking and to validate the predictive LP model of Friedland et al. (14). Secondly, we aimed to appraise whether the diagnostic value of these symptoms differed between young and elderly patients and betwixt patients with posterior canal BPPV and horizontal culvert BPPV.
Methods
Patients and Procedure
This prospective cohort study included all adult patients referred betwixt Dec 2018 and November 2019 to the Apeldoorn Dizziness Center (ADC), the Netherlands. The ADC is a third referral clinic for patients with dizziness.
All patients were requested to complete a study-specific questionnaire containing six questions about the nature and duration of their dizziness and the positions provoking dizziness (Tabular array one). This questionnaire, including informed consent form and study information sheet, was sent to patients' dwelling house addresses before their visit to the clinic. Patients were asked to select the all-time suitable option to describe the nature of their dizziness. For the "type of dizziness" detail, they could simply choose one of the bachelor options. For the questions regarding the duration of dizziness and the positions provoking dizziness, they could only give a Yeah or No answer.
Tabular array 1. Study-specific questionnaire.
The questionnaire was formed based on literature review of diagnostic criteria and questions constitute indicative of BPPV along with skillful opinion (v, 11–13). Because of the goal to quickly and easily recognize BPPV, special interest was placed in concise questions with express answer possibilities. Questions showing no relevant correlation to BPPV in previous literature were excluded. Questions 3–vi asking about the provocation of the dizziness also had the added goal of elucidating a potential correlation to the type of BPPV (posterior or horizontal).
All patients are subjected to our center's standard examinations for the workup for dizziness, which consist of a routine neuro-otologic test including positional testing, otoscopy, the video head-impulse test and/or caloric testing, pure-tone audiometry, the hyperventilation provocation test, the postural hypotension test, and completion of the Hospital Feet and Depression Scale.
After taking patient history and performing the standard examinations, the ENT surgeon and the neurologist assessed whether the questionnaire and the diagnostic work-up was complete. Patients were excluded if either one was incomplete and the patient was not able or willing to complete the missing questions or tests. So, they jointly formulated a diagnosis for each patient. The diagnosis of definite BPPV is based on the criteria of the "Consensus Certificate of the Committee for the Classification of Vestibular Disorders of the Bárány Society" (5). Equally for the blazon of BPPV, a torsional-vertical nystagmus with vertigo following the Dix-Hallpike maneuver is classified every bit posterior canal BPPV, while a horizontal nystagmus with vertigo during the supine roll test is classified as horizontal culvert BPPV.
If a patient experienced dizziness without a visible nystagmus, the diagnosis possible BPPV was established (n = vi). Patients who experienced BPPV-like symptoms in the by, simply had negative provocation maneuvers were diagnosed as historical BPPV (due north = 82). Both these patient groups were classified as "no BPPV."
Statistical Analysis
Continuous variables were described every bit hateful and median, and categorical variables were described equally numbers, and percentages.
We assessed the diagnostic value for each of the questions past calculating the odds ratio and its corresponding p-value using univariable logistic regression models. Side by side, the questions eliciting answers that were significantly associated with BPPV (i.eastward., p < 0.05) were entered into a multivariable logistic regression model. For the questions that strongly suggested the diagnosis of BPPV in this model, we calculated the sensitivity and specificity.
Furthermore, we repeated this part of the assay in subgroups based on the patient's age and on the blazon of BPPV (horizontal, posterior). Based on the patient's age, nosotros compared if the nature of the dizziness (Q1) differed betwixt patients younger or older than 65 years. The age cut-off was set at 65 considering this is a widely accepted cut-off value for seniority. We analyzed differences in provocation of the dizziness (Q3–Q6) by comparing two subgroups based on type of BPPV (horizontal, posterior).
For validation of the diagnostic LP model for BPPV of Friedland et al., we used our study-specific questionnaire data to create an LP value for each patient. The model of Friedland et al. was completed by substituting the variable with a "1" if it was present or a "0" if it was not present. "Lying Down or Rolling Over" was classified every bit "one" if a patient reported provocation of dizziness by lying down in bed or rolling over (Q3 or Q4). "Vertigo" was set up as "1" if the nature of the dizziness was classified as vertigo (Q1).
The LP value was then converted to an estimated probability:
In our study-specific questionnaire, we distinguished betwixt duration of more or <1 min (Q2), and as such we did not accept access to duration data to the same extent as Friedland et al. whose formula splits the length of duration (LOS) into separate entities (minutes to hours, days, days to weeks). Hence, we classified all LOS variables as "0" if our patients reported dizziness lasting shorter than 1 min. Dizziness lasting more than 1 min was categorized by chance equally "LOS: Minutes to Hours," or "LOS: Days" in a fifty:fifty distribution, except for dizziness perceived as vertigo and lasting longer than 1 min, which was categorized as "LOS: Days to Weeks."
The cut-off value ≥0.ii was used as confirmation of BPPV, based on a previous study past Friedland et al. (fourteen). Based on these LP values, a defoliation matrix was produced, and the sensitivity and specificity of the model were calculated past means of a receiver operating characteristic (ROC) curve.
Ethical Considerations
The written report was conducted in accord with the ethical standards laid down in the 1964 Declaration of Helsinki and its afterward amendments upwards to 2013 (16) and was approved by the Local Review Board of Gelre Infirmary. Written informed consent for participation in the study was obtained from all participants.
Results
A total of 885 patients were included in the study, 113 of whom (13%) were diagnosed with BPPV. The mean historic period of the population was 57 years (SD xvi.eight, min/max 18–92), and 568 (64%) were female (Tabular array 2). The mean age of patients diagnosed with BPPV was significantly higher than the mean historic period of patients without BPPV [62 years (SD 16) vs. 57 years (SD 17), p < 0.01], and the proportion of female patients was significantly higher in the BPPV group [73% (n = 82) vs. 63% (north = 486), p < 0.05]. Out of 113 patients diagnosed with BPPV, 101 (89%) patients had posterior culvert BPPV, eleven patients were diagnosed with horizontal canal BPPV, and one patient suffered from inductive culvert BPPV. The patient with anterior canal BPPV was excluded from analysis considering multinomial logistic regression cannot be practical to a group of one.
Tabular array ii. Patient demographics.
Uni- and Multivariable Assay of Study-Specific Questionnaire
Univariable assay showed a correlation with all questions and the diagnosis of BPPV, except for the way patients perceived their dizziness (vertigo or instability, Q1) (Table iii). While the presence of light-headedness rather than vertigo reduced the chance of BPPV being nowadays [OR: 0.45 (95% CI 0.24– 0.87), p = 0.02], dizziness experienced either as instability or vertigo was not significantly associated with a BPPV diagnosis [OR: 0.67 (95% CI 0.40–1.1), p = 0.10]. A full of 91 (81%) patients with BPPV reported dizziness provoked by turning over in bed, compared to 243 (32%) patients without BPPV. This resulted in an odds ratio of 8.94 (95% CI 5.5–xiv.6, p < 0.01).
Table 3. Univariable and multivariable analysis for association between study-specific questions and diagnosis of BPPV (BPPV, n = 113; no BPPV, north = 772).
Multivariable analysis demonstrated that a duration of dizziness spells <1 min (Q2) [OR: one.8 (95% CI 1.ane to 2.8), p = 0.02] and dizziness provoked by turning over in bed (Q4) [OR 6.0 (95% CI iii.2–11.0), p < 0.01] were independently associated with the diagnosis of BPPV (Table three). The duration of the dizziness spell <1 min (Q2) had a sensitivity of 43% and a specificity of 75%. For dizziness provoked by turning over in bed (Q4), these percentages were 81 and 68%, respectively.
The manner patients perceived their dizziness (vertigo, light-headedness, or instability) was not independently associated with the diagnosis BPPV.
Subgroup Analysis
We observed no pregnant differences in the way of provocation (Q3–Q6) between the patients with posterior canal BPPV and the ones with horizontal culvert BPPV.
In a subgroup assay comparison the older to the younger patients, 324 (37%) patients were assigned to the elderly group (≥65 years). Of these patients, 55 (49%) were diagnosed with BPPV (Table 2). In the group of elderly patients, we did not find an association between the perceived blazon of dizziness and the occurrence of BPPV, while for the younger patients, BPPV was negatively associated with low-cal-headedness and instability compared to vertigo [OR: 0.37 (95% CI 0.16–0.87), p = 0.02; OR: 0.36 (95% CI 0.xv–0.84), p = 0.02] (Table iv).
Table iv. Subgroup analysis for elderly and younger patients regarding perceived type of dizziness and diagnosis of BPPV.
Validation of LP Model
We validated the LP model for BPPV of Friedland et al. (14). Using the cut-off value of ≥0.2 for the LP value, the sensitivity was 83% and the specificity 66%. The ROC-curve showed that the AUC of this model was 0.76 (Supplementary Effigy 1). Using the ROC-curve, we found that lowering the cutting-off point to ≥0.15 changed the sensitivity to 66% and the specificity to 83%.
Give-and-take
In this prospective cohort study, we determined the diagnostic value of several questions for the recognition of BPPV in patients with vestibular complaints. This would enable easy and fast assessment of patients presenting with dizziness, which can be valuable for otolaryngologists and neurologists, physicians working in emergency rooms, and general practitioners working in chief care. Early recognition of BPPV could reduce diagnostic delay and could forestall physicians from missing the diagnosis altogether, which puts the patient at an increased risk of falling, impairment of daily activities, and missing out on treatment.
Two symptoms showed a strong and independent association with BPPV: the specific trigger of rolling over in bed, and a dizziness spell with a duration of <1 min. These results are in line with several previous studies, which too establish that these symptoms had a positive association with BPPV (11, 13, 14, 17–21).
We found that whether patients perceived their dizziness as vertigo or instability was non a predictor of BPPV, whereas a perception of light-headedness conspicuously was a negative predictor for a diagnosis of BPPV. In subgroup assay, both light-headedness and instability in younger patients were negatively associated with the diagnosis of BPPV (p < 0.05). This effect is in accord with results reported by Batuecas-Caletrio et al. and Piker et al. who showed that elderly patients with BPPV nowadays less frequently with the archetype vertigo sensation (6, 22). This could be explained by a decreased sensitivity of the otolithic organ due to otoconial degeneration (23, 24).
The question concerning the blazon of perceived dizziness had a substantially higher number of missing entries (n = 61, 7%) than the other written report-specific questions (n = ane–four, 0.1–0.5%). Patients who did not reply this question either could not characterize their dizziness as one of the possible options or experienced multiple types of dizziness. The loftier number of missing entries shows that many patients notice information technology hard to describe the nature of their dizziness. This finding is consistent with the literature. Newman-Toker et al. establish that patients were inconsistent and unreliable in their answers when having to pick a single type of dizziness (25). Lxx-9 percent of the patients picked more than ane answer when given that option. In comparison, questions related to symptom duration and dizziness triggers were answered more than consistently, and Newman-Toker et al. concluded that these questions would prove more than useful for diagnosing BPPV (25). A possible caption for the difficulty patients have in characterizing their dizziness is lack of familiarity with dizziness-related symptoms, every bit well as the fact that the duration of symptoms frequently is too short to assess the quality (26).
Combining the high charge per unit of missing or inconsistent answers regarding the nature of the dizziness and our finding that in that location is no association betwixt the blazon of dizziness and the presence of BPPV, we suggest that the nature of dizziness should play a less prominent function in the diagnostic work-up of BPPV. Instead, the primary questions should be the ones focusing on triggers and on symptom duration. This change in priority will require a change in procedure and in instruction, as it has been shown previously that the majority of physicians endorse a main role for the nature of dizziness in determining of the etiology of dizziness (27).
We found no association between the type of head movement provoking dizziness and the affected semicircular canal of the vestibular organ. A possible explanation of this result could be the small number of patients diagnosed with horizontal canal BPPV in our study population (n = 11). To our knowledge, just ane article has previously examined this possible association (28). The authors investigated whether the trigger for the dizziness could predict which semicircular canal is affected, merely they did non observe an association between the two phenomena. Further research is required to elucidate the apparent discrepancy between known pathophysiology and clinical exercise.
Too establishing which questions should exist prioritized in the diagnosis of BPPV, we as well validated the predictive model of Friedland et al. (xiv) with the data of our study-specific questionnaire. Using a cut-off of ≥0.2 for the LP value, we found that the model had a high sensitivity of 82% and a specificity of 66% with an AUC of 0.76. Our findings are almost identical to the cross-validation past Friedland et al. who found a sensitivity of 79% and specificity of 65%, with an AUC of 0.76 (xiv). Changing the cut-off point to 0.15 in our population changed the sensitivity to 66% and the specificity to 83%. This cut-off point could be more useful for ruling out the suspected diagnosis of BPPV, and it would prevent patients with a negative consequence from undergoing unnecessary diagnostic tests. Comparing the diagnostic power of the model to the 2 predictors with the strongest association with BPPV (Q2—duration of the spell <1 min, Q4—provoked by rolling over in bed), the model performs similarly to "provocation by rolling over in bed," but does not seem to add any diagnostic value over the use of single questions. Nonetheless, the limitations of this upshot should be kept in mind, as we did non have all the data necessary for the length of spell variables (minutes to hours, days, days to weeks). The assumption that all vertiginous dizziness lasting longer than one min counts equally a positive interaction term ["ane.84 × (Vertigo) × (LOS: Days to Hours)"] almost likely results in an overestimation of this term. This overestimation results in a lower LP value and a structurally lower Pr(BPPV), resulting in fewer patients diagnosed with BPPV by means of this formula than is actually the case. It is therefore expected that our supposition results in an underestimation of the sensitivity constitute for the LP model.
A potential limitation of our written report lies in the fact that our results are not suited to exist extrapolated to starting time-line medical intendance as provided by emergency departments and general physicians. Because the data were gathered in a tertiary heart, at that place is a risk of selection bias, and the patient population most probable has dissimilar characteristics than a non-preselected population. However, similar results have been institute in studies fix in a general medical department and in a secondary emergency hospital (eleven, 13).
Another limitation concerns the generalization of the two questions which were found to associate most strongly with a diagnosis of BPPV. Because these questions were part of a ready of only half dozen questions instead of a broader set, they might accept erroneously been marked as correlated to BPPV. Nevertheless, considering the findings compare favorably with previously published literature (11, 13, fourteen, 17–21), the influence of this limitation is most probable minor.
In conclusion, a strong, independent association exists betwixt BPPV and the duration of a dizziness spell and the trigger situation of rolling over in bed. Interestingly, the nature of the dizziness was just of diagnostic importance in younger patients. We did not detect an clan betwixt unlike types of provocative head movements and the affected semicircular culvert. The predictive model of Friedland proved to perform well for confirming the suspected diagnosis of BPPV, but did not add together diagnostic value compared to dizziness provocation by rolling over in bed.
Information Availability Statement
The original contributions presented in the study are included in the commodity/Supplementary Materials, further inquiries tin be directed to the corresponding author/s.
Ethics Statement
The studies involving human being participants were reviewed and canonical past the Local Review Board of Gelre Hospital. The patients/participants provided their written informed consent to participate in this study.
Author Contributions
TB: inquiry idea. VD and BM: designed the written report. VD: analyzed the information and wrote the manuscript. TB, BM, and TS: revised the manuscript. All authors contributed to the article and approved the submitted version. They confirm that questions related to the accuracy of the work were adequately discussed and resolved.
Conflict of Interest
The authors declare that the inquiry was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgments
Nosotros thank Carla Colijn for the thorough data collection.
Supplementary Textile
The Supplementary Material for this commodity tin be institute online at: https://world wide web.frontiersin.org/articles/x.3389/fneur.2020.625776/full#supplementary-material
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