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AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 47 1–4 7 6

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Clinical significance of orthostatic dizziness in the diagnosis of
benign paroxysmal positional vertigo and orthostatic
intolerance☆,☆☆,★
Eun-Ju Jeon, MD, PhD a , Yong-Soo Park, MD a , Shi-Nae Park, MD b , Kyoung-Ho Park, MD b ,
Dong-Hyun Kim, MD a , In-Chul Nam, MD a , Ki-Hong Chang, MD b,⁎
a
b

Department of Otolaryngology-HNS, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Department of Otolaryngology-HNS, College of Medicine, The Catholic University of Korea, Seoul, Korea

ARTI CLE I NFO

A BS TRACT

Article history:

Purpose: Orthostatic dizziness (OD) and positional dizziness (PD) are considerably common

Received 26 February 2013

conditions in dizziness clinic, whereas those two conditions are not clearly separated. We
aimed to evaluate the clinical significance of simple OD and OD combined with PD for the
diagnosis of benign paroxysmal positional vertigo (BPPV) and orthostatic intolerance (OI).
Patients and Methods: Patients presenting with OD (n = 102) were divided into two groups
according to their symptoms: group PO, presenting with PD as well as OD; group O,
presenting with OD. A thorough medical history, physical examination, and vestibular
function tests were performed to identify the etiology of the dizziness. Orthostatic vital sign
measurement (OVSM) was used to diagnose OI.
Results: The majority of patients were in group PO (87.3%). BPPV was the most common
cause of OD for entire patients (36.3%) and group PO (37.1%), while OI was most common
etiology for group O (38.5%). Total of 17 (16.7%) OI patients were identified by OVSM test.
Orthostatic hypotension (n = 10) was most frequently found, followed by orthostatic
hypertension (n = 5), and orthostatic tachycardia (n = 2). Group O showed significantly
higher percentage (38.5%) of OI than group PO (13.5%) (P = 0.039).
Conclusion: It is suggested that orthostatic testing such as OVSM or head-up tilt table test
should be performed as an initial work up for the patients with simple OD. Positional tests
for BPPV should be considered as an essential diagnostic test for patients with OD, even
though their dizziness is not associated with PD.
© 2013 Elsevier Inc. All rights reserved.

Conflicts of interest: The present study does not include any conflicts of interest.
This paper was presented at the oral session of 2012 Barany Society Meeting held in Uppsala, Sweden.

The authors did not have any commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing
arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. The authors did not have any financial
support provided by companies toward the completion of this work.
⁎ Corresponding author. Department of Otolaryngology-Head and Neck Surgery, Yeoeuido St. Mary’s Hospital, 62 Yeoeuido-dong,
Yeongdeungpo-gu, Seoul, Korea. Tel.: +82 2 3779 1061.
E-mail address: isment@naver.com (K.-H. Chang).
☆☆

0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjoto.2013.04.005

positional change. The questionnaire consisted of 13 items regarding the effect of various positional changes on their dizziness. Orthostatic intolerance was further classified as orthostatic hypotension. was performed on the patients. Questions 1 2 3 4 5 6 7 8 9 2. First six items were taken from the Dizziness Handicap Inventory [15]. Dizziness in this condition is resulted from abnormal changes in blood pressure. electrocardiogram. Also. The primary symptom of BPPV is rotational vertigo characterized by a sudden attack that is triggered by changes in head position in a specific direction. The tests included serology. and are important symptoms for diagnostic evaluation of the dizziness. Posterior canal BPPV was diagnosed by observation of torsional upbeating nystagmus following Dix-Hallpike test. which is a subcategory of dysautonomia. or rolling over in bed. Orthostatic dizziness is found in 2–19% of elderly population [4–6] and 4. we aimed to evaluate (1) the ratio of OI and its subtypes in patients with dizziness which is associated with orthostatic positional change (OD). Both PD and OD are considerably common conditions in dizziness clinic. positioning tests. do you avoid heights? Does turning over in bed increase your problem? Does bending over increase your problem? Does lying down on your back increase your problem? Does reaching for something on a shelf increase your problem? Does moving your head from side to side increase your problem? Does sweeping the floor increase your problem? Does picking something up from the floor increase your problem? Does standing up from a sitting position increase your problem? Does standing up from a supine position increase your problem? Yes No . orthostatic tachycardia. OC09FZZZ0037). or orthostatic hypertension [8]. such as oscillopsia. symptoms of BPPV can be provoked by rising up from supine position [11]. and (2) the disease entities for the group of simple OD and for the group with combined form dizziness (dizziness is associated with orthostatic position as well as changes in head position).8% of the adult population > 20 years of age [7]. However. Subjects who answered “yes” to only items 12 and 13 were placed in group O (simple OD). benign paroxysmal positional vertigo (BPPV) is the characteristic condition associated with typical symptomprovoking positions. asking patients to describe their symptoms is crucial step in evaluating patients with dizziness. Patients who could not tolerate orthostatic vital sign measurement test (OVSM) because of acute. Brain imaging study was performed for cases in which an etiology of central origin was suspected. OD is considered as a typical manifestation of orthostatic hypotension. thus most studies for orthostatic effect on dizziness via cardiovascular system involvement have been focused on orthostatic hypotension [9. Patients who answered “yes” to either 12 or 13 and “yes” to any of questions 1–11 were placed in group PO (combined OD. Thus. Patients and methods The protocol of this retrospective study was approved by the Institutional Review Board of Incheon St. vestibular tests. do you have difficulty getting into or out of bed? Do quick movements of your head increase your problem? Because of your problem. such as upright standing from a supine or sitting position. it was reported that a small group of BPPV patients experienced an unspecific sensation of dizziness. Thorough medical histories were taken and a complete physical examination. Vestibular assessment included an eye-movement examination. and the last seven items were composed by the authors (Table 1). audiometry. depending on the semicircular canal involved. Introduction Patients’ descriptions of their symptoms are one of the most critical factors in establishing the cause of dizziness [1. PD as well as OD). It can be caused by orthostatic intolerance (OI). and cerebral blood flow in response to upright posture. Anterior canal BPPV is diagnosed when Dix-Hallpike positioning produces a down-beating nystagmus with torsional component [16]. Table 1 – Patient questionnaire regarding aggravating factors related to positional change. In general. All subjects were asked to independently complete a questionnaire prior to an interview with the physician. imbalance. and caloric testing using video-nystagmography. Orthostatic dizziness (OD) is defined as dizziness provoked by orthostatic positional change. including the head and neck area and vestibular and neurological examinations. Mary's Hospital (approval No. The subjects were divided into two groups according to their answers to the questionnaire. This may complicate the diagnostic impression because dizziness caused by upright position is usually considered as a typical manifestation of OI. bending forward. severe vertigo and subjects who could not understand the questionnaire were excluded from the study. heart rate. and hematology. Dizziness caused by changes in head or body position is called positional dizziness (PD) [3]. Only a few studies have been conducted on the rate of OI and its subtypes in patients with OD [8]. such as looking upward. Questions 1–11 pertained to specific head position changes that aggravated dizziness.472 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 47 1–4 7 6 1. In this study. Horizontal nystagmus induced by supine roll test was considered as diagnostic sigh for lateral canal BPPV.2]. Among the various dizziness eitologies that are associated with positional changes. and nausea [11]. Reverse nystagmus and otolith organ dysfunction may account for OD in BPPV patients [12–14].10]. whereas questions 12 and 13 referred to the effect of orthostatic positional changes on dizziness (OD). The study included 102 patients whose dizziness was induced or aggravated by orthostatic 10 11 12 13 Does looking up increase your problem? Because of your problem. in more than half of patients. The causes of PD vary widely because any disease that affects the vestibular system can cause PD.

The percentage of patients with BPPV was similar in group PO (37. because the history was typical for orthostatic hypotension and thorough examination revealed no abnormal result. Finally. The characteristics of patients in each group are shown in Table 2. followed by peripheral vestibular diseases including Meniere’s disease (n = 17). Psycho: psychogenic dizziness). n = 33) and group O (n = 4. this difference did not reach statistical significance. representing five OI patients as most common etiology (38. The percentage of OI was highest in BPPV (−) patients (44. Discussion Positional dizziness is a frequently encountered symptom in dizziness clinics. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS. One patient in group PO was included into OI category in spite of normal OVSM test results. because vertigo of BPPV is usually more intense than that of OI. (Fig. and OI (n = 10. CVD: cerebrovascular disease. however. Kyoto. Orthostatic tachycardia was defined as an increase in HR of at least 30 bpm. MRV: migraine-related vertigo.3%).0% of BPPV(−) patients vs. OH: orthostatic hypotension.8%).039) (Fig. SPSS. respectively.05 were determined to indicate statistical significance. 1. When the patient is intolerable to the orthostatic challenge. Age and gender differences were not statistically Number 0% 20% 40% 60% Total 37 17 15 Group PO 33 15 10 Group O 4 2 BPPV CVD 80% 9 8 8 8 5 Cardio OI PV Psycho Cervico 473 100% 4 4 4 4 4 3 4 4 1 0 1 0 MRV Other Fig.18]. Inc. 37. The etiology of dizziness for the 102 studied subjects is shown in Fig. It can be caused by a number of conditions . followed by peripheral vestibular diseases (PV). significant between the groups PO and O. followed by orthostatic hypertension (n = 5). whereas no patient in group O showed hypotension. P values <0. which is performed by a nurse. 1 – Diagnosis of orthostatic dizziness according to its association with positional dizziness.0 years (range. Orthostatic hypotension (n = 10) was most frequently found. and other etiologies.5%) of OI than group PO (13. 39 had taken antihypertensive medication.2%).1%). The etiology of dizziness in group PO was similar to the distribution of etiologies for the entire patients. 3. 10.3%). PV: other peripheral vestibular diseases.8%).17. A history of hypertension (61. 2). Cardio: cardiovascular disease. Results The study included 30 male patients and 72 female patients with a mean age of 50. the patient was instructed to stand up with the forearm placed on a table at the height of the patient’s heart level (4th intercostal space). Group O showed different distribution of final diagnosis from that of entire patient and group PO. Vital signs were measured 2 and 5 min after assuming the standing position. 15–81 years). 36. 3 of whom had a history of antihypertensive medication. followed by peripheral vestibular diseases (n = 15.5%) and antihypertensive medication (61. in total) (Fig. or a maximum of 120 bpm was obtained in the upright position without profound hypotension.5%) and BPPV following it (n = 4. The majority of patients with OD were in group PO (n = 89. Cervico: cervicogenic vertigo.. or both at the standing position. The patient was then placed in the supine position on the bed. Three BPPV patients in group PO presented OI simultaneously. 11. This finding suggests that the OD symptom in BPPV is not associated with orthostatic hypotension. (BPPV: benign paroxysmal positional vertigo. with BPPV as the most common cause (n = 33. After a rest period in a quiet room. three were in group PO and one was in group O.4%) in group O. All the patients could finish the OVSM test.5%) was notably higher in group O than group PO. Chicago.5%) and BPPV following it.9 ± 16. Seven patients had a history of diabetes mellitus (DM). Hypotension was found in 12 patients in group PO (13. and OI (n = 15). A history of hypertension was found in 44 patients and of those. and they were classified into the BPPV etiology.8%) had concomitant BPPV and OI.AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 47 1–4 7 6 All patients underwent OVSM using an automatic sphyngomanometer (Omron 10 Series™. 87. orthostatic intolerance (OI). 30. the procedure is immediately discontinued. Group O showed significantly higher percentage (38. Criteria for positive orthostatic hypotension were defined as a decrease in systolic or diastolic blood pressure greater than 20 or 10 mmHg. OI was more frequently detected when the etiology was not associated with BPPV (20.5%). 3). IL). Orthostatic intolerance (OI) was identified in 17 patients (16. Omron Healthcare. Only 4 of the 37 BPPV patients (10. Hypotension was found in 12 subjects. MD: Meniere's disease. Benign paroxysmal positional vertigo (BPPV) was the most common diagnosis. with OI being most common cause (n = 5. 12. blood pressure and heart rate were measured with the patient’s arm placed at heart level in a sitting position.7%). and blood pressure and heart rate were recorded after a 2-min of rest period.5%) (P = 0. Japan). although no significant difference was found. BPPV was the most common (n = 37. followed by group O (n = 13. 30. 38. The etiology of dizziness in group PO was similar to the distribution of etiologies for the entire patients. orthostatic hypertension was defined as systolic BP increase ≥20 mmHg with orthostatic position [8.1%. Group O showed different distribution of final diagnosis from that of entire patient group and group PO. 16. and orthostatic tachycardia (n = 2).7%) from the 102 patients with OD. 1).8% of BPPV(+) patients.9%). 4. Statistical differences among groups were determined using analysis of variance (ANOVA) and the chi-square test.

7%) from the patients with orthostatic dizziness. n = 10) was most frequently found. 2 – Orthostatic intolerance (OI) was identified in 17 patients (16. but BPPV (37 patients. dizziness. including most peripheral vestibular diseases.3%) was far more common than simple OD in patients with OD.4%) in group O. had a history of hypertension.1) 39 (38.3%). Orthostatic intolerance is the development of symptoms such as lightheadedness and diminished concentration. 36.5) 6 (6. This compensatory mechanism. Orthostatic dizziness is also common symptom in dizziness clinic. and presbystasis.0% vs. 38. which are relieved when the subject adopts a recumbent posture.5%) compared to group PO (P = 0. showing that female patients were twice as many as male patients in patients with OD. Group O showed significantly higher percentage (38.063 0. *P < 0. Robertson [21] has described it as an epidemic.5%) of OI than group PO (13. Peripheral vestibular diseases followed (n = 17. with BPPV and peripheral vestibular diseases following it. orthostatic hypotension. 3 – Orthostatic intolerance (OI) was more frequently identified in the patients whose etiology was not associated with BPPV (20.000 Americans may suffer from some form of OI. known as baroreflex. upright posture. intractable motion intolerance. group O showed unique distribution of causes for OD. We found that combined form (87. and orthostatic tachycardia (OT.5%) (P = 0. headache.1) 0 1 5 4 (0) (7. The present study included patients whose dizziness was caused or aggravated by orthostatic positional change. While the cause of OD in group PO was similar to the distribution of etiologies for the entire OD patients.039). OI was most common problem (n = 5. in total).4) 31 (34. and OI (n = 15.751 0.7%) as second most common cause of OD.3) 12 (13.8) 13 49. However. BPPV+ 20% BPPVBPPV+ BPPV- 60% 4 BPPVBPPV+ 40% 80% 100% 33 13 52 3 30 9 47 1 3 4 5 OI(+) OI(-) Fig.129 0. because it is common. n = 2).5) 12 (11. BPPV was found at similar rate for each of group PO (37.456 DM: diabetes mellitus. is mediated by afferent and efferent autonomic peripheral nerves and is integrated in the autonomic centers of the brainstem [19].8) P value 0. vertebrobasilar insufficiency. OI: orthostatic intolerance.7) (38. This wide variety of etiologies makes identification of the cause of PD difficult.627 0.176 0.5%).9 27:62 (1:2.05. and is usually considered to be related with orthostatic hypotension.1%) and group O (30.1 ± 15.5) 8 (61. to evaluate the clinical significance of OD and if there is difference between simple and combined form of OD. Considering this result. and chest pain upon 100% 2 90% 10 0 2 3 7 5 2 80% 3 70% 60% 50% 40% 77 85 8 30% 20% 10% 0% Total Group PO OI(-) OH OHT Group O OT Fig. gravity causes a drop in blood pressure.7) 12 (13. Our findings were similar. Orthostatic hypotension (OH.039). even though their dizziness is not associated with PD. and used sedatives/hypnotics [7].5) 33 (37. 10.0 30:72 (1:2. It is noteworthy that the most common etiology of orthostatic dizziness was not OI. 14.3) 36 (40. followed by orthostatic hypertension (OHT.9) 17 (16. which trigger compensatory reflex tachycardia and vasoconstriction to restore normotension in the upright position.9 ± 16. When we stand up.474 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 47 1–4 7 6 0% Group O 102 50. n = 5).4) 44 (43. This result implies that positional tests for BPPV should be performed in patients with OD.5) (30.039* 0.7%) ranked the third. and estimated that as many as 500. fatigue.7) 37 (36. in group O.2) 89 51. 16. The demographic data did not differ significantly between the two groups. cervicogenic vertigo.8) 7 (6. The percentage of OI was most high in BPPV (−) patients (44.3) 8 (61. A previous study found that OD was prevalent in subjects who were female. although the difference between the two groups was not statistically significant. group PO: patients with OD combined with PD).8%.772 0. BPPV: benign paroxysmal positional vertigo. Similar distribution was found in each of group PO and group O. and the patients were further divided into two groups (group O: patients with simple OD.8%). The ratio of OI was significantly higher in group O patients (38. The true prevalence of OI is still unknown. It is thought that OI is caused by dysfunction of autonomic nervous system [20]. no significant difference was found in any of each comparison.6 ± 17. This is detected by arterial baroreceptors. We found that a history of hypertension and antihypertensive use was more frequent in group O.1 3:10 (1:3. Group PO Hypertension Antihypertensive use Hypotension DM OI BPPV Group PO Group O Number (%) Age (years) M:F Total Total Table 2 – Patient's characteristics. orthostatic .

heart rate. Because utricle and saccule are anatomically and histologically similar.26. 3.1%) of anterior canal BPPV (Fig. the usefulness of HUTT as a routine evaluation for OD is limited in dizziness clinic. and orthostatic hypertension (6%). The development of orthostatic tachycardia on OVSM test was very low. the degenerative process that affects the macula of the utricle and cause detachment of otoliths. each) compared with group PO (7. orthostatic hypotension was identified in 10 patients. An alternative explanation of OD in BPPV is the possible occurrence of OI in BPPV. The ratio of orthostatic hypotension and orthostatic hypertension was higher in group O (23. The primary pathogenesis of BPPV has been reported to be degeneration of the utricular macula [12]. with a prevalence of 9.14]. OI was most common etiology for the patients with simple OD.8%).4%) were posterior canal BPPV and 14 cases (37. such as HUTT or noninvasive continuous blood pressure monitoring with a larger number of study population. 4 – Posterior canal (PC) benign paroxysmal positional vertigo (BPPV) was found in 19 patients (51.7% of entire OD patients. and orthostatic tachycardia (n = 2). such as the baroreceptor reflex. Therefore. It involves continuous monitoring of blood pressure. Orthostatic hypotension was most common (n = 10. On the contrary. otolith organ dysfunction may account for OD in BPPV. However. In addition. Further investigations using a more sensitive diagnostic tool. The ratio of BPPV in each of group PO and group O was similar (37. which is comparable to previous studies. Anterior canal (AC). Orthostatic vital sign measurement is a simplified form of HUTT that involves measurement of blood pressure and heart rate in the sitting position. HUTT is considered the gold standard diagnostic test for OI [8. but increased to 10–20% in elderly people [4–7.2). and at 2 and 5 min after assuming the standing position. supine position. we found OI in only four patients from 37 BPPV patients (10. with 2 patients in total.4%. resulting in the development of OI in an orthostatic position.8%. The primary 475 10 8 6 4 2 0 Group PO PC Group O LC PC & LC AC Fig. followed by orthostatic hypertension (n = 5). In the present study. thus. and 40–50 min to perform.8%) were lateral canal BPPV. indicating a weak association between OI and BPPV. Conclusions BPPV was most common etiology for OD. belonging to group PO. 4).23]. Pappas et al investigated autonomic function test for the patients with symptoms of autonomic related vertigo [8]. Also. Although there are several forms of cardiovascular dysregulation producing OD. In their study. Under normal conditions. In our study. the otolith organ plays a primary role in vestibulosympathetic reflex (VSR). can induce movement of the canalith in the canal resulting in vertigo. a characteristic of posterior canal BPPV. and EKG while the patient is tilted to an 80-degree head-upright position and remains stationary for 20–40 min. We found that considerable number of patients with OD have an etiology of BPPV. There were 3 cases (8. most studies investigated the relationship of orthostatic hypotension and OD. an isolated room.4%) and lateral canal (LC) BPPV in 14 patients (37. Total of 37 patients (36. We used the OVSM test despite its low sensitivity because it is an easy and quick screening method for OI. may explain why patients with BPPV experience OD. positional tests for BPPV should be performed in patients with OD.1%. Furthermore. The prevalence of orthostatic hypotension in the general population has been reported to be 6% [22]. the test requires special equipment. When we included orthostatic hypertension and orthostatic tachycardia. 30. Although the HUTT has high sensitivity (70– 100%) for OI [28]. pathology of BPPV is thought to be otolith organ dysfunction.27].8%).3%) were finally diagnosed with BPPV in patients with OD. Therefore. each) (Fig.9%.4%. it is reasonable to assume that the VSR is also impaired in BPPV. in lateral canal BPPV. however its sensitivity is low (21%) [29]. 97% of patients showed positive finding of OI with orthostatic hypotension (38%) as a most common cause. Thus. will provide a clearer understanding of the relationship between OD and OI. vertical head movement as in the orthostatic position. a specialist such as a cardiologist or neurologist must observe the patient during the test. followed by orthostatic tachycardia (24%).AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 47 1–4 7 6 18 16 14 12 Number testing such as OVSM or head-up tilt table test (HUTT) should be performed as an initial work up for the patients with simple OD. even . The recently reported “lying down nystagmus” [24] and “Bow and lean test” [25] to localize the involved side of the lateral canal in BPPV are examples of vertical-head-movement-induced nystagmus in lateral canal BPPV. 19 cases (51. [9] They evaluated the presence of orthostatic hypotension using HUTT in 29 previously affected post-BPPV patients. BPPV should be considered as one of main etiology when evaluating patients with OD even though PD is not associated with OD. 5.1%. the total ratio of OI was increased to 16. This reflex occurs within seconds. Similar result was reported by Pezzoli et al. in total). before other cardiovascular mechanisms. and found no significant relationship between orthostatic hypotension and the persistence of unsteadiness after recovery from BPPV. 15.8%). might also affect the macula of the saccule. The specificity of OVSM (71%) for OD is acceptable. regardless of its association with PD. This hypothesis is supported with the recent reports that consistently showed abnormal findings of vestibular evoked myogenic potential in BPPV patients [13. occur and is thought to play a role in maintaining cerebral blood flow on abrupt head upright position [23]. Reverse nystagmus.

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