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05.02.2014
The Medical practice, which would evolve into Head and Neck Surgery Associates, began in July, 1977 when Dr.
Otolaryngology – Head and Neck Surgery was recently completed at the University of Mississippi.
Focus and expertise performing pediatric ENT surgeries, We have privileges at all Northern Kentucky Hospitals, our own outpatient Surgery Center and Children’s Medical Center. For those patients who are not controlled with avoidance or medications, allergy testing and immunotherapy are available.
Head and Neck Surgery Associates is a group of 10 board certified otolaryngologists devoted to the treatment of Adult ENT diseases.
Head and Neck Surgery Associates have received specialized training in the medical and surgical management of Sinus and Nasal Disorders. Certified Hearing Aid Consultants is staffed by fully licensed, certified and dedicated audiologists. Forty-five percent of normal adults snore at least occasionally, and 25 percent are habitual snorers. How to cite this article Otto V, Fischer B, Schwarz M, Baumann W, Preibisch-effenberger R. Thirty-seven patients suffering from vertigo associated with vertebrobasilar insufficiency participated in our prospective, single-center, double-blind, comparative study. The maintenance of balance is an essential condition for the management of daily activities. The vertebrobasilar system is responsible for the blood supply of 10 cranial nerves, all ascending and descending tracts, parts of the cortical hemispheres, and the endorgans of hearing and balance. A major concern of drug therapy in VBI is to improve impaired circulation and to restore normal perfusion of compromised areas [6]. Here we report on the efficacy and tolerability of a fixed combination consisting of the calcium channel blocker cinnarizine (20 mg) and the antihistamine dimenhydrinate (40 mg). The antivertiginous efficacy of the combination was demonstrated in a series of open studies [21-24] and in numerous controlled, double-blind, randomized clinical studies that included patients suffering from vertigo of central, peripheral, or combined central-peripheral origin.
Eligible participants were men and women who suffered from VBI and, in addition to the cardinal symptom vertigo, showed at least two of the following symptoms: impaired hearing, impaired vision, tinnitus, or headache.
We designed the study as a randomized, double-blind, reference- and placebo-controlled, single-center, phase III clinical study with three parallel groups. Patients were subjected to an entry examination (first visit, before start of treatment), an intermediate examination (second visit, after 7 ± 2 days), and a final examination (third visit, after 28 ± 2 days). The VBI symptoms-headache, tinnitus, impaired hearing, impaired vision, aural fullness, ocular muscle pareses, and bulbar symptoms-were rated by the patients.
In addition, the patients were asked about the intensities of vegetative symptoms that are often associated with vertigo.
We performed Unterberger's and Romberg's tests and registered the results by craniocorpography (CCG), as described elsewhere [3]. For an objective assessment of hearing function, we performed audiometric tests according to standard procedures using pure tones, words, and numbers as criteria for assessment of hearing loss.
Tolerability assessment was based on reports of adverse events that occurred after drug intake.
Confirmatory analysis of the primary efficacy variable SM was based on its change from baseline in hierarchical order: (first) 4 weeks after start of treatment and (second) 1 week after start of treatment. Thirty-seven white outpatients were enrolled in the study to receive either the fixed combination (n = 11), betahistine (n = 13), or placebo (n = 13). The primary efficacy variable was the reduction of the mean vertigo score (SM ) in the course of the 4-week therapy.
At the start of the study, all patients except one in the fixed-combination group complained about headache. The results of the parameter lateral sway in Unterberger's and Romberg's tests are shown in Table 6. Evaluation by Frenzel's glasses showed no clear evidence for spontaneous nystagmus in any patient either initially or in the course of the study. Also, no significant difference was seen between patients in the three treatment groups with respect to the caloric test variables, either at baseline or in the course of the study. Both in pure-tone and the speech audiometry, the proportion of patients presenting hearing loss remained unaffected in the course of therapy with any of the study medications.
The assessments by investigator and patients were similar and coincided with the decrease in vertigo symptoms observed under therapy with the fixed combination. A total of 7 of the 37 randomly assigned patients reported adverse events (AEs) in the course of the study. The investigator rated the tolerability of the study medication as good in all patients except for one patient in the betahistine group, for whom the tolerability was judged as moderate. Evaluating therapy success in patients suffering from vertigo is often difficult owing to the complexity of this disease and the lack of unambiguous apparatus-based parameters. The efficacy of the fixed combination and its superiority over betahistine can be explained by the pharmacodynamic properties of the two medications. The present results have proven that the fixed combination of cinnarizine and dimenhydrinate is an effective treatment option in treating vertigo due to VBI.
Owing to organizational and technical changes at the ear, nose, and throat clinic of the Otto-von-Guericke University, formerly the Medical Academy, Magdeburg, at the time of the study, the investigations had to be terminated prematurely. In conclusion, the fixed combination containing 20 mg cinnarizine and 40 mg dimenhydrinate proved to be a safe and effective antivertiginous medication in the treatment of patients suffering from vertigo due to VBI. Our Website is designed to offer the best homeopathy has to offer to help end the suffering of sinus sufferers worldwide. SinusWars Canada is one the best websites available for Canadians suffering with sinus conditions and provides Natural, Homeopathic and side-effect free Remedies together with an abundant array of information at ones fingertips. SinusWars Canada offers a full range of Homeopathic Remedies specifically designed to target sinusitis and sinus related conditions Safely and Naturally with the remedies being able to address all sinus complaints such as congestion, pain and headaches. The SinusWars Range of Allergy Remedies addresses allergies and allergy symptoms such as watery eyes, hayfever, rhinitis and all other allergy related symptoms. The SinusWars Post Nasal Drip Range of Remedies assists in regulating the flow and production of nasal mucus, ensuring adequate mucus production and flow.
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Our Center for Surgical Care has been active since 1992 and many of our surgical procedures are done here.
Problem snoring is more frequent in males and overweight persons, and it usually grows worse with age. Treatment of Vertebrobasilar Insufficiency-Associated Vertigo with a Fixed Combination of Cinnarizine and Dimenhydrinate. This complex physical performance is based on finely tuned brain processing of sensory inputs provided by the vestibular, visual, and proprioceptive systems and the cognitive system. Anticoagulant and antiplatelet therapies may serve to reduce the incidence of stroke after transient ischemic attacks [12].
This fixed combination has been used successfully in Germany for 25 years for the treatment of peripheral, central, or combined types of vertigo.
The results of these studies provided evidence for a synergistic effect of cinnarizine and dimenhydrinate at doses reduced by up to two and a half times as compared to the doses commonly used in monotherapy [25-30]. Diagnosis of VBI had to be confirmed by the presence of typical abnormalities in specific examination tests. It was conducted in accordance with the principles of good clinical practice and the Declaration of Helsinki (1989 revision). On the occasion of each visit, patients underwent an efficacy evaluation that was based primarily on the patients' assessments of the intensities of their vertigo symptoms. For evaluation purposes, the scores for the symptoms of nausea, vomiting, sweating, and tachycardia were integrated to a mean vegetative score (VM), which was analyzed in the same way as was SM. Briefly, CCG is a diagnostic procedure by which characteristic light patterns corresponding to the head-body sway of an affected patient are recorded. Gaze nystagmus was examined under the following conditions: glance to the right, to the left, straight ahead, and upward.
Nystagmus was induced by irrigation of the external auditory canal of the left and the right ear with 20 ml water at either 30  or 44  C. We performed pure-tone threshold audiometry at increasing frequencies, considering the left and right ears separately. The events were reported spontaneously by the patients, observed by the investigator, or reported by the patients in response to general questioning by the investigator.
Comparison between the therapy groups (the Kruskal- Wallis test) showed an imbalance in initial distribution at the 20% significance level. Change of the mean vertigo score, SM (primary efficacy variable), in the course of the study.
The three therapy groups were homogeneous with respect to initial distribution of headache as evaluated according to localization and type. Initially, all further symptoms were homogeneously distributed among the therapy groups, except for higher mean scores of tinnitus and impaired hearing in the placebo group (Table 4). Statistical analysis of the initial distribution of all parameters derived from CCG indicated comparability of the therapy groups.
More than one-half of the patients in each therapy group initially showed a positional nystagmus in at least one position. As to brainstem evoked response audiometry, no significant difference was noted between the therapy groups, either at baseline or in the course of therapy (not shown).


Accordingly, approximately 73% of the patients in the fixed-combination group, but only 36% of patients in the betahistine group, assessed their health condition as much improved or very much improved at the end of the study. Regarding the patients' judgments, statistical calculation showed a significant difference between the treatments (p = .019, Fisher's exact test), with the fixed combination showing the best ratings. Primarily, the crucial criterion for evaluating therapy success is the subjective severity of vertigo symptoms tormenting the patient. The antivertiginous effect of betahistine is considered to rely mainly on improvement of microcirculation in the inner ear [32,33].
These findings are consistent with those from previous studies, which demonstrated a high antivertiginous efficacy of the fixed combination in the treatment of patients suffering from vertigo of peripheral vestibular, central vestibular or-very common in medical practice-combined peripheral-central vestibular origin and Meniere's disease. By that time point, 37 patients had completed the study instead of 60, as initially planned. It showed a favorable benefit-risk ratio and a therapeutic success rate that significantly exceeded that of betahistine. This day was overcast, and by noon the sky had already begun to spit snow.fatigue exhaustion dizzinessest il possible que subjonctifThe Orions knew all the weaknesses of the vessels they had sold to the Falorians, and exploited them mercilessly.
Moving Kits and Packing Kits can be purchased for particular rooms or for entire households. There’s plenty of options when choosing a moving company, so you should know that the industry standard in Jupiter is All My Sons Moving and Storage. It has since grown to a 10 physician group providing premier Ear Nose and Throat care to the Northern Kentucky, Greater Cincinnati, and Southeast Indiana regions. The primary efficacy end point was the decrease of the mean vertigo score (SM), which was based on the patients' assessments of 12 individual vertigo symptoms after 4 weeks of treatment. Data mismatch induced by unusual and therefore unadapted stimulation of the intact sensory systems, or pathological dysfunction of any of these afferent components or of the brain centers integrating these signals, leads to vertigo [1,2].
Cerebrovascular disease is a common cause of vertigo symptoms, particularly in older patients [5]. Calcium antagonists are a useful alternative, especially in cases of atherosclerotic origin [13]. The rationale for using the combination is derived from the modes of action of its constituents: Owing to its calcium antagonistic properties, cinnarizine regulates calcium influx into vestibular cells of the labyrinth and improves cerebral circulation [16-18], whereas dimenhydrinate mainly exerts a regulatory effect on the vestibular nuclei and adjacent vegetative centers in the brainstem [19,20]. The ethics committee at the Otto-von-Guericke University, formerly the Medical Academy, Magdeburg, reviewed and approved the study documents.
As the primary efficacy end point, the change of the mean vertigo score (SM) after 4 weeks was used as a parameter for vertigo intensity. From these patterns, we determined deviation of the patient to the right or to the left (angular deviation), body spin, staggering of the patient's head and body (lateral sway), and longitudinal deviation using Unterberger's test, and anteroposterior shift and lateral shift using Romberg's test.
We determined positional nystagmus by monitoring the eyes for nystagmus in the following positions: supine with head downward, sitting up, and dorsal with head to the right and to the left, respectively. In addition, speech audiometry served to evaluate hearing loss for words and numbers and of speech discrimination capacity. The three therapy groups were comparable with respect to demographic variables and medical history. SM was defined as the mean of the patients' judgments of six vertigo symptoms and vertigo in consequence of six factors giving rise to vertigo (see Efficacy Measures).
Descriptive analysis of the effects of the therapy is based on the number of patients still reporting headache after 4 weeks of therapy (Table 3). As in the case of vertigo symptoms, the vegetative symptoms were reduced more effectively by the fixed combination than by the comparators. The patients judged the intensity of the four symptoms of nausea, vomiting, sweating, and tachycardia (see Efficacy Measures). Only patients in the placebo group initially showed slightly lower values for lateral sway (Unterberger's test) as compared to the fixed-combination group (p = .130). The number of patients with positional nystagmus decreased insignificantly in the course of therapy with betahistine and the fixed combination but increased under placebo (not shown). The ratings of slightly improved and not improved were each given by one patient in the fixedcombination group, whereas no patients in this group considered their health condition to be deteriorated. The reduction of symptom intensity is the most direct and important parameter for the evaluation of a patient's vertigo complaints in the course of an antivertigo treatment. In these randomized, double-blind, placebo-controlled or reference-controlled clinical studies, the efficacy and tolerability of the fixed combination was superior to various standard treatments, including betahistine [25-30]. From the observed results, it seems likely that the superiority of the fixed combination compared to betahistine would have been even more pronounced had the initially intended number of patients been investigated.
A direct effect of calcium antagonists in the inner ear: Blockade of abnormal calcium increase in outer hair cells of the guinea pig.
Effects of diphenhydramine and dimenhydrinate on vestibular neuronal activity of cat: A search for the locus of their antimotion sickness action. Fixed low-dose combination of cinnarizine and dimenhydrinate in the treatment of vertigo: A double-blind, randomized, single actives- and placebo-controlled 3-center parallel group 4-week clinical study in 246 adult patients. Fixed combination of cinnarizine and dimenhydrinate versus betahistine dimesylate in the treatment of Meniere's disease: A randomized, doubleblind, parallel group clinical study.
Efficacy and tolerability of a fixed combination of cinnarizine and dimenhydrinate versus betahistine in the treatment of otogenic vertigo-a double-blind, randomised clinical study. Treatment of vertigo due to acute unilateral vestibular loss with a fixed combination of cinnarizine and dimenhydrinate: A doubleblind, randomized, parallel-group clinical study. Efficacy and tolerability of a fixed combination of cinnarizine and dimenhydrinate in treatment of vertigo- analysis of data from five randomised, double-blind clinical studies. The effect of Serc (betahistine hydrochloride) on the circulation of the inner ear in experimental animals. Inhibitory effect of betahistine on polysynaptic neurons in the lateral vestibular nucleus.
Inhibition of voltagegated calcium currents in type II vestibular hair cells by cinnarizine. Effects of cinnarizine on calcium and pressure-dependent potassium currents in guinea pig vestibular hair cells.
Hang numbered signs on the doorposts of each room and write the same numbers on the appropriate boxes. Oh, I wouldn't worry much about him, Modra told her, so long as you didn't really kill him.difficulty breathing chest pain dizzinessdizziness when lying down early pregnancyarnold chiari dizzinessdizziness and neck pain and nauseaache in spine dizziness sleep disturbances1041 university avedizziness shortness of breath fatigue pregnancyawwa valve exercising standardswhat helps with the dizziness of vertigoWhen you move or relocate, to ensure your household goods arrive at your new destination without a scratch, our Jupiter Movers recommend that you start with a good packing list so you purchase the right packing and moving supplies. Do a comparison on total cost if items were purchased separately and watch out for any seasonal sales.
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Therefore, vertigo not only represents a cardinal symptom for vestibular disorders, but it can be associated with a wide spectrum of disorders, including internal diseases, or it may be of psychogenic origin [3,4].
Vertigo is one of the first and most frequent signs of vertebrobasilar insufficiency (VBI), with a relative incidence ranging from 50% to 80% [5]. Episodic, intense vertigo frequently represents the first and, in combination with neurosensory signs of brainstem dysfunction, the most important symptom in VBI [31]. Pregnant or lactating women or women without safe contraception during the study were also excluded.
All patients received oral and written information about the study and provided written informed consent before enrollment.
SM was defined as the mean of the intensities of six vertigo symptoms and vertigo as a consequence of six trigger factors, as evaluated by the patients. At the end of the final visit, patients and the investigator rated the overall tolerability using a 4-point verbal rating scale: very good, good, moderate, or poor. An analysis of covariance was performed with adjustment of means at the end of the study, using the initial values as covariate in cases of insufficient homogeneity of the initial distributions. Significantly greater reductions of SM found in the fixed-combination group became evident 1 week after the start of treatment (vs.
The symptom had subsided completely in two patients in each of the fixed-combination and betahistine groups by the end of the treatment but was still present in all patients treated with placebo. In the fixed-combination group, tinnitus progressively diminished in the course of therapy, with a significant decrease after 4 weeks (p = .016, Wilcoxon signed rank test with respect to baseline). Lateral sway in both tests progressively decreased in the course of the active treatments, more markedly under the fixed combination than under betahistine. In contrast, approximately one-half of the patients treated with betahistine stated a slight improvement, and two patients judged the efficacy with the ratings of not improved and deteriorated. As to the reports from the betahistine group, all AEs except one (vertigo) involved gastrointestinal system disturbances that represent known adverse drug reactions to this substance.
Nevertheless, apparatus-based methods are useful to corroborate the results of the vertigo diagnosis. There is some evidence for an inhibitory activity of betahistine on polysynaptic type-I neurons in the lateral vestibular nuclei [35]. Thus, as a superior efficacy of the fixed combination in treating vertigo of various origins has been repeatedly shown, the present results further underscore the broad efficacy of the antivertiginous fixed combination. Ein Leitfaden fur Praxis und Klinik zur Diagnostik und Therapie von Schwindel und Gleichgewichtsstorungen. The kitchen should be done at the very end though, because heavy appliances should go in the truck first. I know your belongings will be secure, so I feel great recommending them to be your movers in the Jupiter area. Thomas, Edgewood, Florence and Dearborn County Indiana, and 1 part-time office in Grant County, our physicians are conveniently situated to provide you with friendly, personalized medical and surgical care for your ear, nose, throat and allergic disorders. VBI is characterized by transient ischemic attacks, and it represents a heterogeneous disease entity with many potential causes [6-8].


Vertigo is most frequently associated with vision disturbances, patients often report nausea and vegetative symptoms, and perhaps one-third of the patients complain about severe headaches [3]. Other exclusion criteria were gastrointestinal ulcers, bronchial asthma, adrenal tumors, angle-closure glaucoma, prostate adenoma with residual urine, suspicion of compressive intracranial processes, Parkinson's disease, pheochromocytoma, alcohol abuse, acute intoxication, and convulsive disorders. We randomly assigned enrolled patients to 4 weeks of treatment with either the fixed combination of 20 mg cinnarizine and 40 mg dimenhydrinate (one tablet three times daily) or the reference medication betahistine (12 mg betahistine dimesylate per tablet, one tablet three times daily) or placebo (one tablet three times daily). The assessed symptoms at each visit were unsteadiness, staggering, rotary sensation, tendency to fall, lift sensation, swaying, and vertigo due to change of position, bowing, getting up, walking, head movements, and eye movements. Auditory brainstem responses were evaluated by means of brainstem evoked response audiometry. We performed homogeneity tests at the 20% level for the primary variable under consideration and for the parameters of age, gender, the Broca index, and body mass index.
Approximately 40% of the patients in each group were on drug therapy at the time of study onset (premedication), and some of them received more than one medication at a time. Mean scores for tinnitus showed a moderate, insignificant decrease under betahistine (p = .125) but remained nearly unaffected under placebo (see Table 4). In patients in the betahistine group, VM showed a minor, insignificant decrease (approximately 30%) within the first week but no further improvement until the end of the study. The judgments in the placebo group reflected the lack of efficacy of the treatment, with the rating of not improved given by eight patients and a rating of deteriorated given by three. Of the two patients reporting AEs in the fixedcombination group, one reported symptoms of an upset gastrointestinal tract (not likely to have been related to medication intake, in the opinion of the investigator, as the symptoms subsided after 2 days without interruption of treatment). In addition to thorough evaluation of case history, such tools are helpful for establishing the correct diagnosis for the individual patient. As a result of these effects, betahistine leads to a reduction of vertigo symptoms, and it is therapeutically useful particularly for the treatment of peripheral vestibular disorders and especially Meniere's disease [36]. Its dual central and peripheral mode of action represents a distinct advantage for its therapeutic use, leading to high responder rates. We service over 40 states, and I’ve received positive reports about the level of service you receive from every location. It usually results from atherosclerosis of the subclavian, vertebral, and basilar arteries with insufficient collateral circulation but may also be due to other causes, such as compression of vertebral arteries by cervical spondylosis or the subclavian steal syndrome [5,7]. In view of the pharmacological properties of the active substances in the fixed combination-in particular the cerebral selectivity of the calcium antagonist cinnarizine and the brainstem-regulating properties of dimenhydrinate-and encouraged by the positive results obtained in a previous open study [21], we performed this trial to investigate the antivertiginous effects of the fixed combination in VBI as compared to the effects of betahistine dimesylate. Further exclusion criteria were the concomitant use of monoamine oxidase inhibitors or aminoglycoside antibiotics. Randomization was based on a computer-generated block sequence that ensured equal distribution of patients among the treatment groups, according to Food and Drug Administration standards. Patients evaluated their vertigo symptom intensities on the basis of a standardized questionnaire using a graded 4-point visual analog scale ranging from 0 (no symptoms) to 3 (strong symptoms).
Confirmatory efficacy analysis was based on the changes in SM during therapy as determined for the collective of patients completing the study according to protocol (per-protocol analysis). The most frequently administered active substance was betahistine dimesylate, which had been taken by one patient of the betahistine group, three patients of the fixedcombination group, and two patients of the placebo group.
Despite the superiority of the fixed combination, the comparison with betahistine was found not to be statistically significant (p = .052, Kruskal-Wallis test). The second patient in this group reported an AE involving a strong response to the caloric test. Furthermore, three patients in the betahistine group (27.3%) judged the tolerability as moderate.
In our study, both subjective symptom-based and apparatus-based measures were used to measure therapy success. The combination, on the other hand, shows a dual mechanism of action acting both peripherally and centrally.
In addition to a higher efficacy, the fixed combination also showed a more favorable safety profile than betahistine. That’s because All My Sons is family owned and operated and take pride in moving every home with care. VBI presents with characteristic symptoms and signs owing to impaired perfusion of the cerebellum, the brainstem, and the occipital cortex [8]. For the treatment of VBI-associated symptoms, including vertigo, betahistine has been described as useful [15].
Previous antivertiginous medication had to be discontinued in a 2-week washout phase prior to the start of treatment.
The study medications were manufactured by Hennig Arzneimittel in accordance with good manufacturing practice. Treatment efficacy was analyzed by comparing SM changes from baseline resulting from either medication. The intent-to-treat collective was defined as those patients for whom the primary efficacy variable was at least determined at the entry and at one further examination. Because SM represents a parameter for the evaluation of vertigo severity and characterizes the intensity of an individual patient's vertigo sensations independently of the type of vertigo, it serves as a well-established and effective measure of therapeutic progress [25-30].
The calcium antagonist cinnarizine, similarly to betahistine, acts by enhancing circulation in the peripheral vestibular organ and in compromised intra- and extracranial areas [16, 17]. The prices are very competitive at All My Sons, and that makes me strongly recommend All My Sons. Its main symptom-vertigo-results from an insufficient blood supply in the vestibulocerebellar complex [9].
To guarantee double-blind conditions, test medication, reference medication, and placebo were indistinguishable with respect to appearance, taste, weight, shape, and packaging.
Secondary variables of efficacy were additional VBI symptoms (see later), vegetative symptoms, and vestibulospinal, vestibuloocular, and audiometric variables.
A separate intent-to-treat analysis was not performed because the two patient collectives were identical. Of the other symptoms evaluated, bulbar symptoms and impaired vision were the next most prominent, followed by impaired hearing and aural fullness. Statistical analysis showed a significant superiority of the fixed combination versus placebo after 4 weeks of therapy (p = .019).
No AE led to premature discontinuation of the study, and no serious or unexpected AE was encountered during the study.
Recently it was shown that cinnarizine directly affects calcium ion flux at calcium channels of vestibular outer hair cells [37,38]. Despite the absence of AEs, the tolerability judgments in the placebo group were more negative, which probably resulted from the lack of efficacy in patients receiving placebo.
Because vestibular pathways are widely distributed in the hindbrain and because the vestibular end-organ is supplied by vertebrobasilar circulation, in VBI the vestibular system may be affected at any level: the labyrinth, the eighth cranial nerve, or the vestibular nuclei [5].
In addition, the overall efficacy of the treatment was rated by both patients and investigator after 4 weeks on a 5-point verbal rating scale: very much improved, much improved, slightly improved, not improved, or deteriorated. All statistical tests carried out on secondary variables were strictly interpreted in an exploratory manner. Two patients each in the betahistine and placebo groups terminated the study prematurely between the entry and the follow-up examinations. Again, all the symptoms showed an improvement under the fixed-combination therapy, with decreases in mean scores of more than 50% after 4 weeks. The beneficial effects of this substance class in VBI have been demonstrated both experimentally and clinically [39,40].
This may explain why vertigo is the most frequent and sometimes the only symptom in VBI [10,11].
For analysis of the changes from baseline within a treatment group in the course of the study, we used the Wilcoxon signed rank test.
The patients treated with betahistine showed minor improvements, and almost no change occurred during therapy in the placebo group (see Table 4).
The antivertiginous efficacy of cinnarizine in patients with cerebrovascular disorders [14] is considered to rely on an increase in blood flow to the vestibular nuclei, which in turn results in improved neuronal responsiveness of polysynaptic neurons [41]. Typically, VBI-associated vertigo occurs in attacks, depends on position, and is frequently associated with nystagmus, nausea, vomiting, and severe imbalance [5]. The fourth patient (betahistine group) could not continue the study because of an internal disease. All 33 patients who completed the study (11 per treatment group) fulfilled the criteria for per-protocol analysis and were included in the efficacy analysis. By means of dampening the entire medial longitudinal bundle, dimenhydrinate inhibits the spreading of impulses at the medullar vestibular nuclei [19] that are closely associated with the vegetative regulatory centers [20].
Treatment compliance was confirmed by questioning the patients and by an investigator's checking of empty blister strips at the end of the study.
The vertigo symptoms and the concomitant vegetative complaints, particularly nausea and vomiting, are thereby reduced. The trigger zone at the base of the fourth ventricle in the brainstem is inhibited as well [20]. On the basis of these joined actions, the combination exerts a rapid and effective antivertiginous effect. Hence, the fixed combination not only effectively reduced the vertigo symptoms but decreased the concomitant vegetative symptoms to a statistically significant degree as compared to placebo. Particularly the distressing symptoms of nausea, vomiting, and tachycardia had ceased after the 4 weeks of fixed-combination therapy. Also, the scores of the concomitant VBI symptoms of tinnitus, impaired hearing, and impaired vision decreased significantly under the fixed-combination therapy as compared to placebo.



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