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Dossier Mode Un vent 60’s souffle sur la planete mode et la blogosphere, BB est de retour (ou presque).
Cervicocranial syndrome (Barre-Lieou syndrome) can also occur from injury to the cervical facet joints. Les amateurs de cafe ont de quoi se rejouir, les "coffee-shops" a l'americaine ont enfin traverse l'Atlantique pour s'installer en France. Madrid, le seul nom de la capitale espagnole suffit a evoquer soleil et tapas en terrasse ! Can be effective in many defined pathologies: when treatment of tinnitus is given to a medical conditions that have a known diagnostic procedure by objective means (such as audiograms, imaging and blood tests) and may respond to Surgery tinnitus treatment, Antibiotic medications or removal of medications that may cause tinnitus as side effect.
More details about treatment for tinnitus by the metabolic approach (that is my contribution to the severely affected sufferers) will be discussed at the end of this page.
Tinnitus is a sensation of sound when such ambient sound does not exist outside the head of the sufferer or may come from a structure near the ear of the patient, inside the head or neck.
Possible origins are: (1) contraction of a muscle, (2) turbulent blood flow inside a blood vessel. The subjective type of tinnitus is heard only by the sufferer, while the objective tinnitus can be heard also by others. Such tinnitus is typically a pulsating sound that can have the same counts per minute as the heart rate (when a blood vessel disease is the origin), or a different number then the heart rate of the sufferer (when involuntary muscle contraction makes the noise). When the intensity of the tinnitus becomes louder and annoying, it is called "acute on chronic".
When a sufferer is experiencing disturbance to his sleep-waking cycle (irregular biological clock), anxiety, irritability, hyperacusis (noise intolerance), Depression, less productivity at work, inability to derive pleasure from social life, sport, movies and family life – it is a severe medical condition. Treatment for tinnitus (with the metabolic approach) is very effective for severe tinnitus patients.
When the patient have a severe tinnitus (called also: intractable tinnitus or intolerable tinnitus), he is seeking for help.
When the patient have plans to start in legal processes against any medical insurance, the probability that effective tinnitus treatment will help him is very low.
Types of tinnitus that are considered as resistant to treatments, but may be cured by the metabolic approach are: 1) Chronic tinnitus without any known disease.
In patients with tinnitus that is considered treatable, but did not respond to the medical treatment: It means that if a sufferer has one of the above medical conditions and the medical treatment (with western approach) does not help him, he or she should be referred to a treatment with the metabolic approach (which is also a western medicine).
The expert should do re-assessment of the general health of the patient and his intra-cranial auditory pathways. Even in a group of people who are exposed to phonal trauma (such as high energy explosion, shooting of cannons, loud sound of speakers in rock concert) only few of them remain with chronic tinnitus. In daily clinical practice, it is seen that elderly patients complain most frequently of dizziness, tinnitus, and hearing loss.
With an increase in the elderly population, the pattern of diseases changes, and the age factor has to be considered in diagnosis and treatment. In daily clinical practice, the elderly patients seen complain most frequently of dizziness, tinnitus, and hearing loss.
In comparison to younger people, what is first noticeable about elderly people is that they have a good deal of body fat and a markedly low level of intracellular water.
Listed in Table 2 are the diseases involving vertigo, which we often encounter in daily clinical practice, specifically among elderly patients. The extension, flexion, or stenosis of a vertebral artery, cervical spondylosis, and cervical torsion due to the abnormality of cervical soft tissue induce rotary vertigo and sometimes a transient disturbance of consciousness. For oral drug treatment, it is important to use such agents as clonazepam, imipramine hydrochloride, and thyrotropin-releasing hormone.
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. How to cite this article Pawlak-osi&# K, Ska , Ka&# H, Mierczak , Kuczy&# R, Ska , Szaflarska-pop&# A, et al. The aim of this study was to search for the reason for vertigo in children who complain of it. Many children complain about vertigo but, in the majority of cases, vertigo seems to be a symptom accompanying other diseases and different from the strictly otoneurological phenomenon.
The normal situation in our study was that children would present to a pediatrician, and the physician would notice vertigo among numerous other complaints. The otoneurological study consisted of detailed anamnesis according to Claussen, otolaryngological examination, videonystagmography (VNG), and posturography. Apart from the otoneurological diagnosis, the pediatrician collected the data from the physical examination and additional tests. Table 1 demonstrates the results of anamnesis and the additional tests ordered by the pediatrician to facilitate the pediatric diagnosis.
The other problem was interpretation of positional nystagmus, present in 30% of our young patients. Middle-ear diffusion and otitis media are the mostoften discussed reasons for vertigo and balance disturbances in children [16-18]. Such pathological factors as previous head injury, diseases of the cervical vertebral column, hormonal disturbances, lack of micro- and macroelements in the diet, and side effects of drugs prescribed for other diseases might be responsible for vertigo syndrome in those we tested. Prolotherapy injections are the only documented treatment to restore joint, ligament, and tendon damage without surgery and can permanently cure the origin of referred facial, temporal, and jaw pain. Mais parfois, entre reve et realite il peut y avoir quelques differences dans le scenario, rapport aux attrapes touristes dont on se passerait volontiers. The objective tinnitus can be detected by a mini-high quality treatment for tinnitusmicrophone and amplified, transferred to a speaker in real time or recorded, and transferred to an amplifier and a speaker after the recording. Mild or moderate levels of this condition are not known enough in the out patient clinics of hospitals and audiological clinics because most of those who have it are non-help seekers. After the litigation process is over, there is a chance that the treatment will help, or even will become a "cure tinnitus treatment". When the interpretation of the objective tests is that there is no evidence for pathology that may cause tinnitus, it is possible to apply the metabolic approach. In many mild traumas such as small cut-wounds, miniature burns, or even obstruction of small vessels in the heart – the curative mechanisms of the body can cure the damage. After the beginning of the tinnitus, the curative mechanisms of the individual start to repair the damage. The principle of applying the metabolic approach is to identify the systems that failed to take part in the repair of the damage and enable them to take part in the healing process.
In the ear, nose, and throat field also, we are required to consider changes in organs and diseases associated with age and corresponding treatment approaches. In other words, elderly people are always at risk of dehydration and are liable to enter a shock state. Even if they have the same disorder as is seen in younger people, they are less likely to manifest typical symptoms. Hypotension produces rotary vertigo in patients, as it does paroxysmal positional vertigo (PPY).
Hyperlipidemia, ischemic heart disease, and diabetes mellitus require special attention in the elderly, as does orthostatic hypotension.
Cerebellar infarction, particularly in the bilateral or median portion, often produces vertigo (Fig.
The rare onset of this disease after the retirement age of between 60 and 65 years has to do with the decline of internal ear function with aging. Recall the familiar scene in which Robert Kennedy lay in the hotel lobby waiting for an ambulance immediately after he had been shot [4].
Of course, treatment should be provided on a case-by-case basis, but what is essential is to improve blood circulation. 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.
In discussing such typical vestibular childhood diseases as benign paroxysmal vertigo, benign paroxysmal torticollis, basilar migraine, kinetosis, and visual-cliff phenomenon, we must be very mindful of parents' observations regarding other conditions (congenital anomalies, drugs, previous head trauma, and diseases treated currently and in the child's past) that can affect the balance system [1].
Because the pediatrician would order a test battery, including otoneurological examination, affected vertiginous children came to our otoneurological laboratory. Spontaneous nystagmus with eyes closed, optokinetic nystagmus, eye tracking, positional nystagmus, cervical nystagmus, and gaze nystagmus were assessed. The posturographic test consisted of four sequences: with the platform moving backwardforward while the patient had eyes open and eyes closed, and with the platform moving side to side while the patient had eyes open and eyes closed.
The most frequent assessments were blood and urine examination, spirography, gastroscopy, radiological testing of the cervical vertebral column, computed tomography or magnetic resonance imaging of the head, and neurological, ophthalmological, and psychiatric examinations. The maximum amplitudes were greater than normal (estimated in healthy children) when the platform moved side to side and backward and forward with the patient's eyes closed. Duwel and Westhofen [2] recommended videooculography as a method of choice in testing children.
After excluding artifacts (repeating visuooculomotor tests several times), only 40% of the study group demonstrated a few pathologies. Many researchers question whether this kind of vestibular reaction is physiological in childhood and may be present in 20% of asymptomatic children [10]. We noted no pathology of the middle ear during routine otolaryngological examination in our children, nor did we observe any indication to perform tympanometry as a confirming test. The increase in maximum amplitude as compared with that in a normal sample in nearly each sequence of the entire examination may have been the effect of the changes in concentration; a small inattention may cause an abnormally greater deviation of the platform.
Further, we questioned why the majority of cases manifested no objective signs of vestibulopathy during otoneurological examination. Gastritis and respiratory infections were the most frequent diseases that were accompanied by vertigo. Un choix varie de cafes de toutes les origines prepare dans les regles de l'art, qui permet de gouter differentes saveurs.
Beaucoup, vraiment beaucoup (trop ?). Et parce qu'on y passe autant de temps, autant que notre telephone soit joli a regarder ! The duration of the tinnitus is not related to the tinnitus treatment when the metabolic approach is used (see later in this article: more about metabolic approach). If the sufferer experienced disappearance of his tinnitus for prolonged duration, and then a new onset of tinnitus started, it is a "relapse of tinnitus".
Examples are: frustration from ineffective tinnitus treatment that he had before, fear of the tinnitus treatment, the patient is in the middle of a process of litigation and he does not want to loose the opportunity to sue his insurance company, the sufferer has inability to finance the treatment or low expectations from the outcome. In most of the patients with sever tinnitus the expert is taking the anamnesis (medical history), examining the patient (ear nose & throat and Neurological examination) and referring him to objective tests (audiogram, ABR or BERA, MRI of the temporal bone and brain or fMRI). Soldiers who are exposed to the noise of shells report of having tinnitus that lasts few seconds to several hours.
Against this background, we review vertigo in elderly patients briefly and consider the key points of its treatment.
Using this as backdrop, we review vertigo in elderly patients briefly and consider the key points of its treatment. The dorsal root in the elderly is also degenerated, which ex-plains such diverse complaints as dizziness, tinnitus, ringing in the head, headache, neck and shoulder stiffness, and lumbago.
Special effort should be made to differentiate between not only benign PPY but pseudobenign PPY and malignant PPY. Atrial fibrillation, among others, can be one of the major causes for cardiogenic embolism [3]. The leftward conjugated deviation of the eyes and right facial palsy were due to a pontine lesion. The three keys are to facilitate blood circulation, prevent thrombosis, and improve blood rheology. 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. We performed the detailed protocol of anamnesis, videonystagmography, posturography, and additional tests ordered by the pediatrician and then compared the results of these procedures with those of a group of 30 healthy children. The goal of our study was to evaluate the reason for vertigo in children who complain of it. The caloric test was performed according to Brunings (with water at 30°C and 44°C) to search for unilateral labyrinthine weakness or directional preponderance (or both). During each sequence, we measured four parameters: (1) maximum amplitude, (2) mean amplitudes of the platform deviations, (3) mean velocity of the platform sway, and (4) mean velocity of the head.
Table 2 shows all the pathologies connected with the abnormal findings revealed by the pediatrician and other specialists and on the basis of additional tests. We used VNG and noted that the problem was with visuooculomotor reactions, during which not the equipment but both the immaturity of eye movement control and changes of concentration, smiling, and physical activity affected the recordings. In the literature, positional nystagmus is often connected with benign paroxysmal positional vertigo, but it must be emphasized that Hallpike's maneuver was not included in our VNG study, especially owing to the patients' lack of concentration and eye closing during position changes.
However, the other parameters-mean amplitude of the platform deviations, mean velocity of the platform sway, and head velocities-were in the normal range. Fewer than one-half of those in the tested group demonstrated objective signs of vestibular disability during VNG.
Caloric evaluation of the vestibular organ in the electronystagmography study determining dependence of vestibulo-ocular response.
Application of multivariate statistics to vestibular testing: Discriminating between Meniere's disease and migraine associated dizziness.
Sensory organization of balance responses in children 3-6 years of age: A normative study with diagnostic implications. In order to start treatment for tinnitus, the expert should start the medical evaluation from the beginning in the two types of patients. A help seeker can be a victim with acute onset, or someone who was non help seeker for long time, and recently became a sufferer of severe tinnitus. In comparison to younger people, what is first noticeable about elderly people is that they have a lot of fat in the body and a markedly low level of intracellular water. However, these complaints cannot be dismissed simply as an "unidentified syndrome." One or another organic disorder always is behind these complaints.
Because they are more or less conscious of death in daily life, they have a strong sensation of fear and thus visit with a variety of complaints. This tendency is particularly conspicuous among women, and their typical complaints include headache, vertigo, shoulder stiffness, palpitation, tinnitus, and lumbago (Table 1).
When this vertigo is induced and associated with PPY symptoms, it is important to differentiate between benign and malignant forms (Fig.
As compensation declines with aging, one usually becomes slower with age to recover from the same degree of disorder. This therapy should be continued for 10 consecutive days, followed by cessation for a subsequent 10 days. 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.
Respiratory system infections, gastritis, and spondylosis were diagnosed most often by pediatricians in young people with vertigo.
In one patient, epilepsy developed a few years later, and three were treated because of respiratory infections at the time of our study. In many of the VNG test results (discussed earlier), we observed only four pathological recordings: positional nystagmus, cervical nystagmus, pathological eye-tracking test results, and square waves regularly manifested during positional, cervical, and caloric nystagmus testing. This parameter was smaller than that in the healthy control group in nearly every sequence of the test. Our opinion on this topic was the same as that presented by Cyr [3] and Weeks [4], who stated that controlling the sinusoidal test, calibration, optokinetics, and gaze nystagmus in children is very difficult. In the cases in which the vestibular test results were abnormal, we searched for the causes, taking into consideration other test results collected during pediatric examination, and we observed a correlation between pathological VNG results and the presence of spondylosis. Uneri and Turkdogan [11] noted benign paroxysmal positional nystagmus together with spontaneous nystagmus in 59% of children with vertigo, which, in their opinion, suggested a peripheral vestibular pathology. In other words, elderly people are always at risk of dehydration and liable to enter a shock state. Therefore, when we examine elderly patients, we need to pay special attention to various factors [1]. Because of brain atrophy with aging, they are less likely to present, for example, symptoms of increased intracranial pressure even if they have a brain tumor.
Indeed, the eyes are the windows of the mind, they are more eloquent than lips, and they are a window for diagnosis.
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. From videonystagmography results, we observed only four types of pathological reactions: positional nystagmus, cervical nystagmus, abnormal eye-tracking test results, and square wave abnormalities. The children from the healthy group were never hospitalized, were never treated for otoneurological signs, and were examined regularly at school by balance testing (which is carried out according to each child's age and during which the child's weight, height, vision, hearing, and skin condition are checked). Claussen and Claussen [5] compared caloric examination in children 6-10 years old to that in children 11-15 years old. Sahlstrand and Petruson [8] and Asaka [9] observed an exact connection between idiopathic scoliosis of the cerebral vertebral column and abnormalities during electronystagmography study.
Zhang Zhao [12] demonstrated peripheral pathology in 95% of tested children younger than 13 years; benign paroxysmal positional vertigo or Meniere's disease was suspected in these cases. The dorsal root in the elderly is also degenerated, and this explains such diverse complaints as dizziness, tinnitus, ringing in the head, headache, neck and shoulder stiffness, and lumbago.
When such patients have cerebral infarction, in particular, they experience a dizziness that is unexpectedly transient; thus, it requires careful attention. Cerebellar or pontine hemorrhage causes severe rotary vertigo, nausea and vomiting, tinnitus, and headache. 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. They noted that in children in the younger group, the rotatory test is better accepted and is easier for clinical and statistical evaluation. However, in their studies, positional and spontaneous nystagmus were dominant; in ours, the cervical test was a good indicator of cervical pathology. Migraine was mentioned as the representative of nonspecific vestibulopathy in children, especially when positional nystagmus was accompanied by pathological eye-tracking test results and disequilibrium and when the typical episodic vertigo with headache sensitive to ergotamine appeared [13-15]. In our findings, the velocity of the platform was a paradox: It was smaller in patients with vertigo, confirming that they possessed a fairly good ability to control balance on a movable platform.
We agree with the opinion that not only organic etiology but functional complaints must be considered in treating children with vertigo [21].
However, these complaints cannot be dismissed simply as "an unidentified syndrome." Behind these complaints is invariably one or another organic disorder. By contrast, cerebral hemorrhage causes nonrotary vertigo and is sel-dom associated with tinnitus. In many cases, it progresses slowly after repeat transient ischemic attack and improves between episodes.
Kennedy, Robert Kennedy's fatal bullet penetrated through the right mastoid to the right cerebellar hemisphere. 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]. Posturography results did not provide specific findings as compared with those from the healthy children. In our data, one child demonstrated typical symptoms as mentioned-family history of migraine together with positional nystagmus and eye-tracking disability-so the diagnosis of vestibular migraine was suggested.
Additional evidence suggests that generally our tested group was free from objectively measured signs of vestibular system diseases. Such complaints may depend on posttraumatic symptoms (even mild sleep disturbances), depression, neurosis, diet, and the side effects of antibiotics, steroids, and other medication therapy being administered for primary diseases (in our children, consisting of gastritis, bronchial asthma, etc.) [22].
Subarachnoid hemorrhage, which occurs from various causes, produces headache, vomiting, and dizziness.
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. We discussed the probable reasons for vertigo, among which psychogenic origin, side effect of medications, hormonal disturbances, spondylosis, and diet errors had to be taken into consideration.
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].
Muckelbauer and Haid [7] pointed out the differences between the various parameters among children from 5 to 14 years old. 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]. Taking into consideration these suggestions, our study was unexpectedly free from problems with the interpretation of caloric responses to bithermal stimulation: Every child demonstrated clear symmetrical reactions. 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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