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Persistent Postural-Perceptual Dizziness
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
8 sections · 97 slides
Overview
- Scope of this presentation
Definition and diagnostic criteria
- Definition and classification of PPPD
- Predecessor concepts of PPPD
- Core symptoms: criterion A
- Exacerbating factors: criterion B
- Environments that provoke symptoms
- Precipitating conditions: criterion C
- Criteria D and E
- Reading the diagnostic criteria table
- Diagnostic criteria for persistent postural-perceptual dizziness (PPPD)
- Diagnostic criteria for persistent postural-perceptual dizziness (PPPD) (continued)
- Niigata PPPD Questionnaire
- Relative frequency of precipitants
- When no precipitant can be identified
Epidemiology
- Point prevalence in neurology clinics
- Prevalence in other care settings
- Rank among neuro-otologic diagnoses
- Age and sex distribution in adults
- PPPD in children and adolescents
- Incidence after precipitating events
- Kabaya cohort: risk after new vestibular symptoms
- Predictive value of the criterion B domains
Making the diagnosis
- First step in the clinical evaluation
- Role of examination and laboratory testing
- Membranous labyrinth of the inner ear
- Three trajectories of symptom development
- Trajectory after an acute vestibular syndrome
- Trajectory after an episodic vestibular syndrome
- Trajectory after a chronic precipitant
- Visual hypersensitivity as the key differentiator
- Niigata PPPD Questionnaire as a screening tool
- Dizziness Handicap Inventory thresholds
- Limits of self-report questionnaires
Differential diagnosis
- Where the full differential is published
- Common diagnostic stumbling blocks
- Features that argue against PPPD
Pathophysiological mechanisms
- Origins of the pathophysiological model
- Five processes in the first-generation model
- Second and third-generation models
- Anxiety-related personality traits
- Conflicting evidence on personality
- Acute body vigilance and illness perceptions
- Body vigilance and negative illness perception defined
- Stiffened postural control
- Open-loop versus closed-loop postural control
- Consequences of lower body stiffening
- Angular acceleration and the cupula
- Gait changes in phobic postural vertigo
- Visual dependence
- Evidence for visual dependence in PPPD
- Neuroimaging methods used in PPPD research
- Statistical activation maps on brain slices
- Insular cortex on coronal brain section
- Pooled neuroimaging findings
- Predictive processing of self-motion
- Misperception of motion in PPPD
- Cognitive findings in PPPD
- Optimal control hypothesis
Treatment
- Three primary therapeutic interventions
- Vestibular rehabilitation: early evidence
- Vestibular rehabilitation: prospective data
- Serotonergic drugs studied before 2017
- Serotonin molecule
- Response rates with serotonergic drugs
- Reading the serotonergic dosing table
- Guidelines for use of serotonin reuptake inhibitors for PPPD
- SSRI studies in defined PPPD
- Sertraline with and without CBT
- General dosing principles
- Sertraline dosing schedule
- Escitalopram and venlafaxine dosing
- Switching and duration of treatment
- Psychotherapy for PPPD
- Acceptance and commitment therapy
- Comparative effectiveness of the three modalities
- Combination treatment
Summary
- Key points: definition and burden
- Key points: mechanism and management
- References
- References (continued)
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- References (continued)
- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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